Inspection on 25/01/07 for Lakeside House

This inspection was carried out on 25th January 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lakeside House 12/07/07

Lakeside House 19/06/06

Lakeside House 02/02/06

Lakeside House 01/08/05

Lakeside House 19/03/05

Lakeside House 08/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Lakeside House 21 Chadwick Road Leytonstone London E11 1NE Lead Inspector Rob Cole Unannounced Inspection 25 January 2007 10:00 th Lakeside House DS0000007278.V322988.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 DS0000007278.V322988.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 DS0000007278.V322988.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakeside House Address 21 Chadwick Road Leytonstone London E11 1NE 020 8923 6841 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) Mr Siddicq Yadallee Adeola Oshuwa Imode Care Home 8 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a service user who has both learning disability and mental disorder may continue to reside at the home. The CSCI must be informed when this service user no longer resides at the home. 19th June 2006 Date of last inspection Brief Description of the Service: Lakeside House is a residential care home registered with the CSCI to provide accommodation and support to eight adults with learning disabilities. The home is situated in a residential area of Leytonstone, in the London Borough of Waltham Forest. The home is situated close by to shops, transport networks and other local amenities, and is in keeping with other homes in the area. The home is privately run. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 25/1/07 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home. The homes manager was also present throughout the inspection. The inspection also included a tour of the premises, and an examination of records and documents. The inspector was pleased to note that there has been considerable improvement to the home since the last inspection, and feedback from service users was generally positive. There are however some issues that still need to be addressed, as highlighted within the report. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 6 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 DS0000007278.V322988.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents have been written in plain English, and are dated and subject to regular review. The Statement includes details of the services and facilities provided, the organisational structure of the home and of the staff team and their qualifications. The Statement is now in line with National Minimum Standards (NMS). All service users have access to their own copy of the Service Users Guide. This includes a summary of the Statement of Purpose and details of the homes complaints procedure. However, the Guide does not include details of the fees charged by the home, what they cover and what is extra, and this must be addressed. Contracts/statement of terms and conditions are in place for each individual service user. These cover services provided and the rights and responsibilities Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 8 of both parties. They have been signed by the service user, or a relative where appropriate, and by a representative of the home. There have been no new admissions to the home since the previous inspection. The homes manager outlined the admission procedure, this included pre admission assessments, visits to the home before moving in, and a placement review meeting after an initial trial period of six weeks. The home had a written admissions procedure, and this was in line with the procedure outlined by the manager. Lakeside House DS0000007278.V322988.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users have a large degree of control over their daily lives. Risk assessments and care plans are of a satisfactory standard, but both need to be subject to regular review, at least once every six months. EVIDENCE: Care plans are in place for all service users. These have been drawn up with the involvement of the service user, their family, key worker and the homes manager. Care plans were of a satisfactory standard, they covered needs associated with culture, social and leisure needs and personal care, and were clear and comprehensive. Daily records are also maintained. At the previous inspection a requirement was set that the home arranges for each service user to have a review of their care in conjunction with their placing authority. The inspector was pleased to note that these reviews have taken place for six of Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 10 the eight service users, and the home was able to demonstrate they have made efforts to try to arrange meetings for the remaining two service users. The manager informed the inspector that they are implementing an in-house system so that each service user has a review of their care needs at least once every six months, however, at the time of inspection only one service user has had such a review. It is required that the care needs of all service users are subject to regular review, at least once every six months. As with care plans, risk assessments are of a satisfactory standard. Since the last inspection they are now clear and comprehensive, covering risks such as around smoking, epilepsy and accessing the community. Assessments identify risks, and include strategies to manage and reduce those risks. However, several risk assessments have not been reviewed within the past year, and it is required that all service users individual risk assessments are subject to regular review, at least once every six months. Some service users on occasions exhibit challenging behaviour, there were clear guidelines in place around how to manage this. Through observation and discussion there was evidence that service users have control over their daily lives. For example service users are able to get up and go to bed as they choose, and have choice over what they wear, mealtimes etc. On the day of the inspection service users were offered a choice of activity for the day. The inspector was pleased to note that since the previous inspection mechanisms are in place to seek and record the views of services users on the day to day running of the home. For instance, the home now holds monthly service user meetings, these are recorded, and the agenda is set jointly by service users and staff. Meetings evidenced discussions on menus, activities and holidays. The home has a policy in place on confidentiality. This makes clear that under certain circumstances a confidence may have to be broken in the health, safety and welfare interests of service users and others. Confidential information is stored securely, staff and service users can access their confidential records as appropriate. Lakeside House DS0000007278.V322988.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are supported to live valued and fulfilling lives, and that they have regular access to the community. EVIDENCE: Service users have access to various facilities within the community. One service user attends IT classes at a local college. One service user attends an Asian drop-in centre, which arranges various social activities and day trips. One service user attends an African-Caribbean centre, which gives them an opportunity to develop and maintain friendships. Another service user attends an activities group run by MENCAP, which arranges various sporting activities. Service users regularly visit local shops, markets, the post office and parks etc. Service users have access to public transport, including buses and tubes, and Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 12 the home has its own unmarked vehicle, which service users use to access the community. On the day of inspection one service user visited local shops. Service users have access to a variety of social and leisure needs, both inhouse and in the community. In house service users have access to TV, DVD, music, cards, darts, table football and various board games. Service users are able to watch TV and listen to music in their rooms if they so wish. The home has developed an activities programme for service users. This indicated that service users go swimming, bowling, play pool and visit the cinema. Indeed, on the day of inspection four service users went out to the cinema and for lunch. Staff were observed to discuss with service users which film they wished to see. Service users are offered a weeks holiday annually away from the home as part of the basic contract price. Last year, service users went to Blackpool, those spoken to informed the inspector that they very much enjoyed this holiday. Service users are able to maintain contact with family and friends, including visiting relatives for overnight stays. Relatives are able to visit the home at any reasonable hour, and see service users in private if they so wish. Service users are given their own mail to open, and have access to use a telephone in private. Records are kept of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users are involved in food preparation, including buying food. Mealtimes were observed to be relaxed and unhurried. The kitchen was clean and tidy, and food was stored appropriately. Care plans indicated that four service users prefer a Halal diet, this was seen to be catered for. The home checks and records fridge and freezer temperatures on a daily basis. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is generally meeting the health and personal care needs of service users. However, the home must ensure that service users have routine access to eye care, and that Medication Administration Record charts are appropriately maintained. EVIDENCE: There were clear guidelines in place around the provision of individual personal care, included in service users care plans. Service users are encouraged to manage their own personal care as much as possible. On the day of inspection all service users were dressed appropriately. The home has sought and recorded the views of service users on their wishes in the event of their death. These have been recorded. The manager informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 14 All service users are registered with a GP. Records are maintained of medical appointments. These indicated that service users have access to a variety of health professionals including district nurses and CPN’s, and since the previous inspection all service users now have regular access to dental care. However, the home could not evidence that all service users have had access to routine eye care over the past two years, and this must be addressed. The home has a clear and comprehensive policy in place around medication, and all staff undertake training before they are able to administer medications. Medications are stored securely in a locked cabinet within the office. No service users are on any controlled drugs, and none currently self medicate. Records are maintained of any medications entering the home and of those that are returned to the pharmacist. Guidelines are in place on the administration of medications prescribed on a PRN basis. Medication Administration Charts are maintained. On occasions a dash (-) had been entered on the Charts, yet there was no corresponding mark on the key code of the charts. Thus it was impossible to be clear on what any particular dash meant. It is required that only symbols that are on the key of the MAR charts are used. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that appropriate systems are in place to help reduce the risk of abuse to service users, although the complaints procedure must make appropriate reference to the CSCI. EVIDENCE: The home maintains a complaints log. This evidenced that complaints have been appropriately recorded and investigated, although the manager informed the inspector that the home had not received any complaints since the previous inspection. There was also a complaints procedure, which was on display within the home. However, although this procedure made reference to the CSCI, it stated that complaints should only be made to the CSCI after the homes internal complaints procedures had been exhausted. The policy should make clear that people can complain at any time to the CSCI. Further, the policy did not include contact details of the CSCI, and this too must be addressed. The inspector was pleased to note that since the previous inspection the home has now obtained a copy of the Local Authorities adult protection procedure, and that it also has produced its own policy on adult protection. This appeared to be in line with current legislation. All staff except the most recent person to start working at the home have undertaken training in adult protection issues. The manager informed the inspector that it is planned that this person will Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 16 attend relevant training within the near future. Staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. The home holds money on behalf of service users in a locked cabinet. Records and receipts are maintained of transactions involving service users monies, those checked by the inspector appeared to be satisfactory. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, both internally and externally, and service users are provided with adequate communal and private space. EVIDENCE: The home is situated in a residential area of Leytonstone in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities, and is in keeping with other homes in the area. The home was generally well maintained both internally and externally, and on the day of inspection was clean and tidy. The communal space consists of a dining/sitting room, kitchen and garden. The home has garden furniture, which was of a suitable standard. The home has Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 18 two bathroom/toilets and three toilets on their own. All bathrooms had working locks fitted (including an emergency override device) and were clean, tidy and free from offensive odour. All service users have their own bedrooms. Bedrooms have hand basins in them, and adequate natural light and ventilation. Bedrooms have been personalised to service users individual taste, for instance with televisions and family photographs. Bedding, carpets and curtains were generally well maintained and domestic in character. Rooms had appropriate furniture, and meet National Minimum Standards on size requirements. The inspector was pleased to note that since the previous inspection all service users have now been offered keys to their bedrooms, subject to the completion of satisfactory risk assessments. However, a strong odour of urine was noticeable in one of the ground floor bedrooms, and this must be addressed. The home has a policy in place on infection control. Protective clothing such as latex gloves are available to staff. The home has separate laundry facilities, and hand-washing facilities are situated throughout the home. COSHH products were stored securely. Service users have been provided with individual laundry baskets for their bedrooms, to help ensure they only ever wear their own clothing. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is staffed in sufficient numbers to meet service users needs, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including a waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the actual staffing situation on the day of inspection. Since the last inspection it now also indicates who is in charge of the home at any given time. The inspector was pleased to note that staffing levels have increased since the last inspection, and are now satisfactory. All staff have been provided with a copy of the General Social Care Council codes of conduct, and since the last inspection they have now all been provided with a copy of their job description. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and that they have built up good relations with Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 20 individual service users. Staff were seen to interact with service users in a friendly and respectful manner. Of the nine care staff employed at the home, five have achieved a relevant care qualification. The manager informed the inspector that the other four staff will be given the opportunity of obtaining such a qualification in the near future. All staff undertake a structured induction programme on commencing work at the home. This includes the physical environment and service user issues. At the last inspection requirements were set that all staff undertake training around learning disabilities, mental health and epilepsy. The inspector was pleased to note that all staff have either now received this training, or are scheduled to attend it in the near future. Likewise, progress has also been made with regard to health and safety training. Staff have now undertaken training in fire safety, first aid and manual handling. However, not all staff have had training in food hygiene, including staff who have responsibility for food preparation within the home. It is required that all staff who have responsibility for food preparation in the home undertake appropriate food hygiene training. Other recent training attended by staff includes adult protection and oral hygiene. Since the last inspection all staff now have regular formal supervision. Records are maintained, and staff receive a copy of their minutes. Supervision covers such topics as performance, training needs and service user issues. The home has policies in place on recruitment and selection and also equal opportunities. The inspector checked several staff employment files at random. These were found to contain all required documentation, including proof of ID, references and satisfactory CRB checks. Since the last inspection the home also now has a full written record of staff’s employment history. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that this is generally a well run home, although greater attention needs to be paid to health and safety management. EVIDENCE: Since the previous inspection the home has now appointed a permanent manager who has been registered with the CSCI. The manager has an NVQ Level 4 in Care, and is currently working towards the Registered Managers Award. Staff and service users spoken to informed the inspector that they found the manager to be approachable and accessible, and on the day of inspection staff were observed to interact with the manager in a relaxed manner. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 22 The home has policies and procedures in place in line with National Minimum Standards. Those checked by the inspector, including admissions, medication and adult protection appeared to be satisfactory. Record keeping in the home was generally of a good standard. All confidential records are now stored securely, and staff and service users can access their records as appropriate. Service user meetings, staff meetings and staff supervisions all contribute to the quality assurance within the home. Since the previous inspection, monthly unannounced Regulation 26 visits take place, and a copy of these reports is kept in the home. Previous inspection reports are also available to view in the home. The home has recently introduced a system of questionnaires to gain feedback from service users on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback. The manager informed the inspector that it is planned that questionnaires will soon also be issued to relatives to gain their feedback. Since the last inspection the home now has a fire risk assessment and fire safety procedure in place, and all staff have undertaken training in fire safety. The home has also arranged for a visit by the Local Fire Authority, who visited the home to provide advice on the placing of fire extinguishers around the home. These are now situated around the home, and were last serviced in June 2006. Fire alarms are tested weekly, and were last serviced on the 13/10/06. However, as at the last inspection, the home is still not holding regular fire drills, further, on the day of inspection a fire door leading into the kitchen marked “keep closed” was found to be wedged open. This must be addressed. The home tests fridge/freezer and hot water temperatures, and COSHH products were stored securely. The home had in date certificates for landlords gas safety and PAT testing. However, there was no evidence that the home has had an electrical installation safety check within the past five years, and this must be addressed. The home had in date employer’s liability insurance cover in place. Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 23 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 “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 3 3 3 1 3 Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 24 Yes 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. Standard YA35 Regulation 18 Requirement The registered person must ensure that all staff receive all statutory health and safety training as appropriate, including food hygiene training. (Timescale 31/10/06 not met) The registered person must ensure that service users have access to all health care professionals as appropriate, including eye care. (Timescale 31/10/06 not met) The registered person must ensure that the home carries out regular fire drills, at least once every three months. (Timescale 31/10/06 not met) The registered person must ensure that the homes Service User Guide contains all information in line with the National Minimum Standards and the Care Homes Regulations 2001. The registered person must ensure that all service users care plans are subject to comprehensive review, at least once every six months. Timescale for action 30/04/07 2. YA19 13 31/03/07 3. YA42 13 and 23 31/03/07 4. YA1 5 31/03/07 5. YA6 15 31/03/07 Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 25 6. YA9 13 7. YA20 13 8. YA22 22 9. 10. YA26 YA42 23 13 and 23 11. YA42 13 and 23 The registered person must ensure that all service users individual risk assessments are subject to regular review, at least once every six months. The registered person must ensure that only symbols that are on Medication Administration Record charts key codes are actually entered on the charts. The registered person must ensure that the homes complaints procedure includes contact details of the CSCI, and that it makes clear that complaints can be made direct to the CSCI at any time. The registered person must ensure that all bedrooms are free from offensive odours. The registered person must ensure that designated fire doors are not left wedged open within the home. The registered person must ensure that a safety check of the electrical installation within the home is carried out at least once every five years, by persons so qualified to do so. 31/03/07 28/02/07 30/04/07 30/04/07 28/02/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lakeside House DS0000007278.V322988.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000007278.V322988.R01.S.doc Version 5.2 Page 27 - 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. 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