Inspection on 22/09/06 for Lakeside House

This inspection was carried out on 22nd September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lakeside House 18/07/07

Lakeside House 07/12/05

Lakeside House 22/08/05

Lakeside House 23/03/05

Lakeside House 09/06/04

Similar services:

32 Beaumont Way

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Lakeside House Somerset Court Harp Road Brent Knoll Highbridge Somerset TA9 4HQ Lead Inspector David Kidner Key Unannounced Inspection 22nd September 2006 09:30 Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakeside House Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Somerset Court Harp Road Brent Knoll Highbridge Somerset TA9 4HQ 01278 760555 01278 760747 Vanessahalfacre@nas.org.uk National Autistic Society To be appointed Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Lakeside House is a large detached bungalow situated in the extensive grounds of Somerset Court. As part of Somerset Courts Modernisation Programme each previous accommodation area that comprised of Somerset Court, has now become a separate registered service. The National Autistic Society remains as the Registered Providers. There is a vacancy for the post of Registered Manager, however the Commission for Social Care Inspection has received an application to address this and this is currently being processed. The home was registered with the CSCI on 16/06/06 and is registered to accommodate seven services users. The home has a large lounge/dining room, kitchen, seven single bedrooms with wash hand basins, two bathrooms with overhead shower facilities and a separate shower room. There are adequate toilet facilities. The home has some laundry facilities but the majority of the laundry is sent to the main on–site facility. The home has a ‘fenced off’ garden area. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection conducted by the Commission for Social Care Inspection. This inspection was a Key Unannounced Inspection and was conducted by one Inspector. The inspection lasted one day (7.75hrs). The Inspector met a number of the service users and care staff. The Inspector was able to speak to one service user in more detail than others. Some service users did not wish to engage in conversation with the Inspector. Due to the complex needs of some of the service users feedback about the service they are receiving can be difficult to obtain. The majority of service users are unable to complete the comment cards. As part of the inspection process the Inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention, staff recruitment and viewed all areas of the home. Comment cards and telephone contact was made with relatives, care managers, GP and other health care professionals. The Inspector sent seven comment cards to relatives/visitors. Six were returned. All comments stated that they were made to feel welcome at the home, that they can visit their relative in private and the vast majority of comments stated that they are kept informed of important matters that affect their relative. All comments stated that they are satisfied with the overall care provided at Lakeside House. The Inspector would like to thank the service users for making the Inspector welcome in their home and for their contribution in the inspection process. The Manager and care team were very welcoming and presented themselves in a professional manner. As a result of this inspection the home has nine requirements and seven recommendations. What the service does well: Lakeside House provides a comfortable environment for service users. The home is furnished and maintained to a good standard and some areas of the home have recently been decorated and re-carpeted. Care and support plans are detailed and reflect individual needs and are regularly reviewed. The Manager advised that the format for these are in the process of being reviewed to ensure they contain explicit information. Risk assessments have been conducted where needed and any restrictions imposed are recorded. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 6 The home offers service users as much choice as possible. The home has clear management policies and procedures in relation to the protection of vulnerable adults. The episodes of behaviours are recorded and analysed by the organisations health and safety manager. All staff have received training in the management of challenging episodes and the protection of vulnerable adults. Contact with family members is good. Staff appear very motivated and committed to providing a quality service. The home is committed to providing a well-trained workforce. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The quality outcome group is Good The home has a detailed Statement of Purpose. The Service User Guide is being reviewed to reflect the service provided at Lakeside House following Somerset Courts Modernisation Plan. Key Standard 2 was not assessed at this inspection EVIDENCE: The Inspector was advised that the Statement of Purpose has been reviewed and that the Service User Guide is in the process of being reviewed. The Statement of Purpose is very detailed and contains the required information as listed in Schedule 1 of the Care Homes Regulations 2001. A copy of the Service User Guide must be forwarded to the Commission for Social Care Inspection once completed. There have been no new admissions to the home since the Inspectors last visited the services prior to each service becoming individually registered at Somerset Court. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 10 The quality outcome group is Good. The home has detailed care plans that reflect service user’s current needs. There are detailed risk assessments and any restrictions imposed on service users are documented. Service users are offered as much choice as possible and are encouraged to make decisions. Service users confidential information is kept secure. EVIDENCE: The Inspector viewed three care and support plans. The care plans viewed contained detailed information in relation to the care and support needed. Key Workers complete monthly summaries and daily records are kept of the care provided in the form of a monthly document. The Manager advised that the home is reviewing the format in which the care plans are presented. This is to make them more accessible and explicit. It was noted that the care and support plans have recently been reviewed. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 10 Some service users use Somerset Total Communication to assist in expressing their views and needs. Communication needs are very individual and care plans identified the manner in which staff should interact with service users. The Inspector observed care staff adapting their communication style as needed to meet the needs of individual service users. Staff offer service users with as much choice as possible. Any restrictions or limitations are identified in the individuals care plan. The Inspector noted that an alarm was to be fitted on a service users bedroom door. The Manager advised that this would be written into the service users care and support plan and risk assessed. At the time of the inspection none of the service users were able to manage their own finances. The Inspector viewed the documentation in relation to risk management and risk assessments. Each service user has a risk assessment in relation to the management of behaviours. The Inspector did not view any risk assessments in relation to the risks identified and protocols developed in order to support service users participating in independent living skills. The Manager stated that this is to be addressed in the very near future following the review of the care plan format. Service users records appear accurate and are kept secure and confidential. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 15 16 17 The quality outcome group is Adequate The home does not always ensure that there is adequate staff on duty to ensure that service users can participate in social and community activities, especially at evening and weekends. This must be addressed. The home supports service users to be involved in and are encouraged to participate in household activities. Contact with family members is good. The home provides menus that are varied and well balanced. Specific needs are identified and appropriate menus provided where needed. EVIDENCE: Service users have access to fulfil their spiritual needs. One service user is a practicing Christian and is supported to go to church. However, it appears that this is dependant on staffing levels, especially at weekend and evenings. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 12 All service users who live at Lakeside attend the on-site day service facility. The Manager and Inspector discussed issues relating to this and the Manager commented that a more ‘person centred approach’ would be taken as to the activities that service users partake in. Currently service users have access to a variety of activities including arts and craft, life skills, sensory room, gym, gardening and an IT Suite. One service user is accessing the local college. It is hoped that more service users may be able to access this resource in the future. Currently there are no service users accessing work placement, volunteer jobs or work-related training schemes. Lakeside House is located approximately three miles from Burnham town centre therefore there are very limited local community facilities that can be easily accessed. There is not a local bus service therefore all service user rely on the transport provided by the home. However, Service users are supported to access a variety of leisure and recreation facilities in the local and wider community. These include visits to the pub, cinema, swimming, bowling, restaurants and cafés. Records are kept of all activities that individual access. The Inspector was advised that due to recent staffing levels service users have not been able to access as many social and leisure activities especially at weekends and evenings. The Manager stated that there are some care staff vacancies at the home and interview dates are planned. However, the home must ensure that service users are able to access social and community based activities. However, the Inspector noted that the home has arranged some service user holidays. Two service users were due to go away that weekend, followed shortly by two other service users. The home encourages contact with family and friends. Records are kept of contact made. The Inspector sent relative comments cards to all the relatives prior to the inspection. All returned comment cards stated that the staff welcomes them to the home at any time and that they are able to visit their relative in private. The vast majority of replies stated they are kept informed of important matters. Service users have keys to their bedroom doors. Staff that the Inspector spoke to gave evidence on how they promote privacy and dignity and confirmed that staff knock bedroom doors before entering and wait to be invited in. Staff spoken to in private confirmed this. The Inspector observed care staff addressing service users in a polite and courteous manner and addressing service users in the name they wish to be called. This is also identified in the care plan. Service users have unrestricted access to the home. Each service user has a ‘home day’. This time is spent usually with their key worker and service users are encouraged to participate in the cleaning of their bedrooms laundry activities, basic cooking skills and other household activities. At the time of the inspection the Inspector observed one service user cleaning and Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 13 polishing their bedroom and completing laundry type tasks. The home records how each home day was spent. Smoking is not allowed in the home. As previously stated all service users attend the on-site day service. When attending day services all service users access the main dining facilities at Somerset Court. This is a refectory style service. There is a varied and nutritious menu on offer with a number of choices. Lakeside House has a Two-week menu. Service users are encouraged to contribute to the development of these menus. This was evidenced in the minutes of the service users meetings. The dining facilities are domestic in style. The Manager advised that the home caters for the dietary needs of service users with specific medical and cultural needs. The Inspector viewed the documentation in relation to one service user’s dietary needs. Records are kept of meals taken. Another service user ‘s dietary needs are being further explored and these were discussed in more detail with the Manager. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 The quality outcome group is Adequate Care staff are aware of service user’s needs in relation to personal care and support. Service users have access to a variety of healthcare professionals. The home needs to improve in some areas of the management of medicines. EVIDENCE: Wherever possible, intimate personal care is provided by a person of the same gender. The service users have very differing care and support needs. Some service users require more support other than general prompts. The Manager stated that the personal care and support plans are being reviewed to ensure that they explicitly reflect the needs of the individual. Times for meals and getting up and going to bed are as flexible. On the day of the inspection service users appeared well attired. Service users have access to all other health care providers. The Inspector was able to view the records that are kept in relation to visits to a variety of health care professionals. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 15 The Inspector viewed the arrangements for the management of medicines. The home has a policy for the management of medicines and designated staff are nominated to dispense medicines and have been assessed as competent. The home’s policy is that two staff dispenses medicines the second person signs to witness the administration. The MAR sheets were viewed. It was noted that not all hand transcribed medicines were supported by two staff signatures. It is recommended that two staff signatures be obtained. The Inspector noted that the home had entered three medicines on the MAR sheet but did not record the quantity of the medicines bought into the home. This must be addressed. The home keeps a fridge for the storage of insulin. Good records are kept of the temperature of the fridge with the use of a minimum and maximum thermometer. Insulin that was in current use was not being stored in the fridge as per guidance. Discussions took place in relation the current regime adopted for the recording of the administration of insulin, following the advice of the diabetic nurse. The Inspector recommends that the Manager review the arrangement directed to staff to ensure that the protocol is robust. The home maintains a record of medicines that are returned to the pharmacy. The home does not have Controlled Drugs. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 The outcome group is Good. The home has a robust Complaints procedure but it appears that not all interested stakeholders are aware of the process. The home has policies and procedures in relation to the protection of vulnerable adults. EVIDENCE: The home has a Complaints Policy and Procedure. There have been no recorded complaints at the home. The feedback that the Inspector received from relatives is that not all relatives were aware of the complaints procedure. The Manager should ensure that all interested stakeholders are aware of the process. The home has policies for the protection of vulnerable adults including policies for adult protection and the management of service user’s finances. Care staff that the Inspector spoke to was aware of the home’s Whistleblowing Policy. All staff at Lakeside have received training in the Protection of Vulnerable Adults. The home is in the process of training all staff in the use of the SPELL approach and the Studio 111 procedures for the management and defusing of challenging situations. The training records viewed indicated that some staff have received training in Studio 111. The Manager stated that dates have been arranged to address this to ensure that all staff have received the appropriate training. The home keeps records in relation to incidents that occur at the home as a result of challenging situations. The Inspector was able to view detailed care plans, behaviour management guidelines, risk analysis and risk assessments in relation to the management of behaviours. It was noted when Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 17 viewing some incident reports that these had not been supported by the completion of accident reports. This is further highlighted in National Minimum Standard 42 under Conduct and Management of the home. The Manager must ensure that accident records are completed following an incident that has resulted in an injury. The home has a system for auditing accidents / incidents. The Inspector discussed the arrangements for the management of service user’s finances. The National Autistic Society has corporate appointeeship for all the service users living at Lakeside. Service users have individual bank or building society accounts. The Inspector sampled the records kept on the behalf of two service users. Records are kept of the transactions undertaken via the building society and the home also maintains records of financial transactions of monies spent from personal spending. The Inspector was able to follow an audit trail for transactions sampled. Receipts are kept of all transactions and balances were correct. The Inspector recommends that wherever possible two staff signatures be obtained for all financial transactions. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 27 29 30 The quality outcome group is Adequate Most areas of the home are homely and comfortable. The home does not ensure that privacy and dignity is promoted in bathing areas. Most areas of the home are clean and hygienic however some areas need further attention. EVIDENCE: Lakeside House has a large lounge/dining room with adequate seating and dining facilities. There is a television and DVD player and a HI-FI for communal use. There is a good-sized kitchen, seven single bedrooms with wash hand basins, two bathrooms with overhead shower facilities and a separate shower room. There are adequate toilet facilities. The home has some laundry facilities located in the kitchen area and this is mainly used for the washing of tea towels. The majority of the laundry is sent to the main on–site facility. The home has a ‘fenced off’ garden area and patio area with garden furniture. The home has recently been redecorated and new carpets fitted in some areas. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 19 The Inspector viewed all areas of the home with the exception of service users bedrooms. It was noted that the boiler is located in the kitchen and is not covered. There are exposed leads from the boiler that may pose a hazard. The kitchen is also kept locked to promote health and safety, as all service users need support in accessing the kitchen area. The Manager should review the need to keep the kitchen locked at all times and to review the need for the boiler to be covered in order to promote health and safety. It was also noted that some flooring in the kitchen has been removed and not replaced or made good. This must be addressed. The home has a planned maintenance and renewal programme. As previously stated the home has two bathrooms with shower facilities and a separate shower room. These facilities were viewed. One bathroom did not have a shower curtain, it appeared that small amounts of mould were present around the bath sealant and the sink did not have a plug. The door lock on the second bathroom door was not working. This does not promote privacy and dignity. The shower room also appeared to have small amounts mould on sealant areas, the light did not work and a pungent smell was present. It was also noted that these areas were not personalised to promote a homely environment. All service users are fully ambulant and at present do not require any specialist aids and adaptations. On the day of the inspection most areas of the home was clean and hygienic. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 The quality outcome group is Adequate. Staff demonstrated their awareness in the support required to meet service user’s individual needs. Although all the care team do not have an NVQ qualification the service is proactive in addressing this matter and has developed an action plan. Staffing levels are adequate but need constant reviewing to ensure adequate staff are on duty at all times. The home is committed to providing a well-trained workforce. EVIDENCE: It was evident at the time of the inspection that the care team are aware of the service users individual needs. Staff were able to inform the Inspector of how complex needs are met. Staff were observed to be interacting with service users in a professional manner and using alternative methods of communication. Staff appeared motivated and committed. Training records viewed indicated that staff have received specialist training in areas such as diabetes, SKIPP, autism awareness, Studio 111 and Somerset Total Communication (STC). Some staff are waiting for refresher dates to be set. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 21 The Manager has stated that 45 of the workforce has an NVQ qualification. The National Minimum Standards state that 50 of the workforce achieves a minimum of NVQ qualification. It is acknowledged that the home has an action plan to address this and that the home is committed to providing a wellqualified workforce. The home usually has three staff members on duty of a morning to assist service users with personal care and breakfast. All service users then attend the on-site day services facility unless they are on a home day. If on a home day the service user is supported on a 1:1. Service users return mid afternoon. Depending on the activities planned there are usually two staff on duty of an afternoon / evening. However, staffing levels are adjusted as needed to reflect planned activities. There is waking night staff presence. The Inspector was advised that there are currently vacancies within the team and interview dates have been arranged. Until appointments have been made staff are working extra hours and relief staff are being used from other teams based on-site. Minimum staffing levels are being maintained but at times this compromises the ability to provide activities and opportunities for service users at evenings and weekends. This has previously been identified in this report. The Manager continues to review the staffing levels to ensure minimum staffing levels are maintained. Regular staff meeting are being held. The Inspector viewed the minutes to these meetings. The Inspector viewed three recruitment files of the most recently appointed staff. All files contained the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. However, it is recommended that full employment histories are obtained and any gaps recorded and references received are dated to confirm when they were written. The service has a Training and Development Manager and each staff member has a training and development plan. Records are kept of each staff member training. The staff spoken to confirmed that they receive regular mandatory and specialist training. Records viewed confirmed this. The staff have received a variety of training including, diabetes, SPELL, Studio 111, Protection of Vulnerable Adults, manual handling, STC, first aid, food hygiene and epilepsy. The home has a detailed Induction programme. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 40 41 42 The quality outcome group is Adequate. National Minimum Standard 37 was not fully assessed at this inspection, as there is a vacancy of Registered Manager. The home has detailed policies and procedures. The home promotes health and safety, however some areas need addressing. EVIDENCE: Following the Modernisation Programme. The home has appointed a new Manager Mr Julian Morse. Mr Morse has applied to become the Registered Manager and the CSCI is processing this application. The home has a vast number of policies and procedures that have been developed by the National Autistic Society. Staff have unrestricted access to these policies, as they are located on the home’s Intranet. All Polices and Procedures are available to interested stakeholders on request. The home Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 23 complaints policy is written in STC. Service users have access to their records. Individual records are kept safe and secure. The Inspector viewed a number of documentation in relation to health and safety. Fire Safety: The home has an appointed fire safety officer and a Fire Risk Assessment. The fire alarm system and emergency lighting system had an annual service on 31/05/06. Fire fighting equipment was serviced on the 21/09/06. The emergency lighting and the homes torches are tested monthly and were last tested on the 21/09/06. Weekly fire alarm checks are conducted; these were last tested on the 21/09/06. The home conducts monthly fire drills. All staff have received regular fire training. Hot Water/ Legionnella: The home conducts weekly checks of the hot water. Records confirmed that the temperature is within suggested guidelines by the Health and Safety Executive. It is uncertain that the home has received a certificate in relation to complying with Legionella. This must be addressed. Electrical Hardwiring Certificate: This must be forwarded to the CSCI. Portable Appliance testing was conducted on the 11/08/06. Gas Safety Certificate: This is dated 27/07/06. Accidents / Incidents: The Inspector viewed the accident and incident records. It was noted that some accidents had not been formally recorded following an incident. This was discussed with the Manager at the time of the inspection. The Manager must ensure that accident records are completed following an incident that has resulted in an injury. The home has a generic system for auditing accidents / incidents. However, the inspector recommends that the Manager should countersign all accident and incident records as part of the audit process. COSHH: The home has a policy in relation to this. All products are stored securely. Fridge/Freezer: The home keeps daily records of fridge and freezers. Records viewed indicated that the temperature of the fridge had not been recently recorded. This was addressed at the time of the inspection. Food was stored appropriately in the fridge. Risk Assessments: The home has a detailed risk management policy. Radiators throughout the home have been risk assessed as not needing to be covered. First Aid: Staff receive training in first aid. Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 24 Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X X 3 3 2 X Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA13 Regulation 4 (2) 5 (2) 16 (2) (m) Requirement The Manager must forward a copy of the Service user Guide to the CSCI. The Manager must ensure that service users are provided with opportunities to participate in social and community activities, especially at evening and weekends. The Manager must ensure that the quantities of all medicines that enter the home are recorded on the MAR sheets. The Manager must review the need to cover the boiler and make safe the wires leading from the boiler to ensure health and safety is promoted. The Manager must ensure that shower room is well light and free from offensive odours. The Manager must ensure that bathing and showering facilities are kept clean. The home must ensure that a certificate re Legionella has been obtained to ensure prevention of infection at the home. Timescale for action 31/12/06 27/10/06 3. YA20 13 (2) 20/10/06 4. YA24 13 (4) 31/10/06 5. 6. 7. YA24 YA24 YA42 13 (4) 23 (2) (p) 23 (2) (d) 13 (3) 20/10/06 20/10/06 30/11/06 Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 27 8. YA42 17 (1) (a) Schedule 3. The Manager must ensure that accident records are completed following an incident that has resulted in an injury. 20/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA20 YA20 YA23 YA24 YA32 Good Practice Recommendations The Manager should ensure that two staff signatures support all hand transcribed medicines. The Manager should review the arrangements directed to staff to ensure that the protocol for the administration of insulin is robust. The Manager should ensure that two staff signatures are obtained for all service users financial transactions. The Manager should explore possibilities in promoting a more homely appearance of the bathing and showering facilities. The Manager should ensure that the home continues to ensure that 50 of the workforce achieves an NVQ qualification. The Manager should ensure that full employment histories are obtained and any gaps recorded and references received are dated to confirm when they were written. The Manager should countersign all accident and incident records as part of the audit process. YA34 YA42 Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lakeside House DS0000015975.V303433.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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