Inspection on 27/09/05 for Lambert House

This inspection was carried out on 27th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lambert House 04/09/07

Lambert House 20/04/06

Lambert House 28/02/06

Lambert House 03/03/05

Lambert House 14/06/04

Lambert House 12/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 LAMBERT HOUSE 36 NOTRIDGE ROAD BOWTHORPE NORWICH NR5 9BE Lead Inspector CLIVE LUCAS Announced 27 SEPTEMBER 2005 10:00 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 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 Stationary 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. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lambert House Address 36 Notridge Road, Bowthorpe, Norwich, Norfolk, NR5 9BE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01603 749845 01603 749460 Norfok Autistic Community Housing Association Limited Mr Michael George Patterson Care Home 11 Category(ies) of LD Learning disability registration, with number of places LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 03 March 2005 Brief Description of the Service: Lambert House is situated in the middle of a residential area. It is a large, detached, two storey building with parking to the front. There is a secure garden to the front of the Home and a secure paved area to the rear. Accommodation is provided to up to eleven adults with a learning disability with autistic spectrum disorders. All service users have a single bedroom, either on the ground or first floors. The Home does not have a passenger lift. There are several communal rooms including activity rooms and a swimming pool. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. Comment cards were sent out to relatives and the local general practitioner. The deputy manager and responsible individual were spoken with, as were three members of staff. Records were examined, practice was observed and there was a tour of the accommodation. 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. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: There have not been any new service users who have moved into the home in the last 12 months. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 8 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 standard(s) 6, 7, 9 Service users have their individual needs assessed and care plans are used to help meet these needs. EVIDENCE: Service users have comprehensive care plans. They are involved in drawing up the plan as much as their communication ability allows. Staff will use observation of service users and their knowledge of them to inform the care plans. Care plans are reviewed regularly. All service users have allocated key workers. Service users are able to be involved in decision making about their lives as far as their communication allows. Staff provide service users with assistance and communication support to help them take part in decision-making. Risk assessments are used to help ensure the service users safety. There appears to be some duplication in risk assessment, which could cause some confusion and so detract from the efficacy of the system. Risk assessments are kept on the “quick access” files and also on the main files, one file was LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 9 found to have a slightly different risk assessment on each, as one had been updated, but the other had not. In addition to this, so many areas are risk assessed that there could be duplication. In one case there were five risk assessments that all had some element of risk related to potentially aggressive behaviour toward others. The home is to be commended for their comprehensive approach to risk assessment. However, it is recommended that consideration be given to whether the system would benefit from a review to simplify it. Dates for reviews of risk assessments are not always met, a number of risk assessments which were recorded as being reviewed every three months were going five months without review. It is recommended that risk assessments be reviewed within the timescales recommended in the assessments themselves. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13 and 15 Service users are supported in taking part in activities, using community facilities and maintaining relationships with relatives. EVIDENCE: Service users are supported and encouraged to take part in various activities. Staff spoken with showed a good understanding of the need to balance consistency and structure with new experiences, including educational activities. The service user plans contain detailed activity plans for service users. Some of the service users attend formal day centres around Norwich and others have day services provided from the Home. Additional staff are on duty to ensure that activities take place as planned. Good use is made of local community facilities. The service users are encouraged to take part in daily household tasks as appropriate. The service users who are at home are encouraged to make their own lunch with assistance. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 11 The service user plans contain details relating to the arrangements that are in place for each of the service users to enable them to maintain contact with family and friends. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19 and 20 Service users’ health needs are met. EVIDENCE: Records evidenced that service users’ health needs are met, appointments are made for routine medical and dental check ups and where appropriate specialist medical advice is sought. Discussions with staff supported this. The Home uses a monitored dosage system and medication is stored appropriately. Records are kept of the orders of medication, its receipt (added to the total on the MAR sheets), the administration of medicines and any medication disposed of. Only senior staff handle medication. They are instructed in the handling of medication and assessed before they administer medication. The previous inspection found that the medication for one of the service users, who attended for day services only, was provided to the staff in a dosset box rather than in the original packaging. This meant that staff were “secondary dispensing” which is not a safe system. During this inspection the deputy manager stated that no medication comes into the home now unless it is in appropriate packaging. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 13 LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22 and 23 There is a system for service users and others to express their views on the way the home is run. Staff are aware of issues of adult protection, but recruitment practices gave cause for concern about the protection of service users. EVIDENCE: There had been six complaints recorded in the previous 12 months. All of these had been responded to appropriately and within the timescales. Staff said that complaints procedure was explained to service users, made available in a simple language format and a TEACCH format and that copies of the procedure are given to families. In their responses to the comment cards, only one relative indicated that they are unaware of the complaints procedure, all others indicating that they are aware of it. Staff spoken with showed an understanding of adult abuse, including an understanding that they had a duty to report any concerns, and how they could report concerns outside of the home if necessary. One member of staff who had only begun work two weeks before had covered adult abuse in his induction and had received a copy of the procedures. Recruitment practices gave cause for concern about the protection of service users. Please see comments for Standard 34. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24 For the most part accommodation is appropriate: some areas require attention. EVIDENCE: The home was purpose built in 1994. For the most part it is adequately decorated, furnished and maintained; the exceptions to this are the upstairs bathroom and the downstairs WC located by the cloakroom. The bathroom is in need of re-decoration as the ceiling is in a poor state of repair and the bath panels are badly scratched. In addition this on the day of the inspection the seat had been broken off of the WC. The WC smelt strongly of urine and requires redecorating. The registered person must ensure that these matters be addressed. Bedrooms were personalised and some had been decorated with murals, or for one blind service user, with a range of textured materials. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 16 There is a lounge, art room sensory/music room for communal use. The lounge contains 11 seats and is rather crowded at that. The home has an indoor swimming pool. There are male and female changing rooms, which as well as having doors leading out to the main corridor, are linked by a corridor at the rear of the changing rooms. The doors to this rear corridor do not have any locks. It is recommended in order to ensure privacy that consideration be given to the need to provide locks for these doors. The locks to bedroom doors, which could only be operated from outside, and were used to secure a room when it is empty, have been removed as required in the inspection report of March 2005. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 Statutory employment checks are not being carried out and consequently service users are not being protected from abuse. EVIDENCE: Three previous inspection reports since February 2003 have identified that the registered persons must obtain full evidence of the “fitness” of staff they propose to employ and retain the statutory records, (to ensure that service users are protected by a thorough recruitment and checking process before staff are appointed). This inspection found that this is still not happening. An examination of a selection of staff files showed that staff had been employed for 23 weeks before a Criminal Records Bureau check was requested and that other recruitment checks as set out in schedule 2 of the Care Homes regulations 2001 were not completed. This is a major failing and places service users at risk. Immediate requirements were left on the day of this inspection that: • No new staff to commence employment before references have been received and POVA first clearance obtained. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 18 • Staff currently in post for whom checks have not been completed must be rostered to work under supervision of named and appropriately checked/inducted members of staff. An audit of personnel files must be carried out for all staff recruited since 26 July 2004. ‘Missing’ statutory staffing records to be obtained. • • The responsible person must ensure that these matters are addressed. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 There are systems in place to promote the health and safety of service users, but some work is required to ensure that they operate appropriately. EVIDENCE: Fire equipment is regularly tested. The fire maintenance report of July 2005 states that the system requires an upgrade. The registered person must ensure that this matter be dealt with. Hot water temperatures are controlled. The risk assessment requires that they are checked weekly, but the last recorded checks were 11 September for upstairs and 14 August for downstairs. The registered person must ensure that checks of the water temperature are undertaken weekly in line with the risk assessment. A report from the Environmental Health officer dated 14 June 2002 lists a number of actions that were required in respect of the swimming pool. As the manager was not present during the inspection, and records were not clear LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 20 about what had been addressed (indeed some records cast doubt on the work having been done) it was not possible to confirm what matters had been addressed. This matter will be followed up separately. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x x 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 LAMBERT HOUSE Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 22 No 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 24 Regulation 23 Requirement The registered person must ensure that the bathroom on the first floor be redecorated and that work be done to the WC on the ground floor to eliminate the smell of urine and to redecorate it The registered person must ensure that no new staff commence employment before references have been received and POVA first clearance obtained. Immediate requirement left at the time of the inspection. The registered person must ensure that staff currently in post, who do not have all of the checks required by the Care Homes Regulations 2001, be rostered to work under supervision of named and appropriately checked/inducted members of staff until the checks are completed. Immediate requirement left at the time of the inspection. The registered person must ensure that an audit of personnel files must be carried out for all staff recruited since 26 July I55 S27475 Lambert House V246371 270905 Stage 4.doc Timescale for action 31 December 2005 2. 34 19 27 September 2005 3. 34 19 30 September 2005 4. 34 19 5/10/05 LAMBERT HOUSE Version 1.40 Page 23 5. 34 19 6. 7. 42 42 23 23 2004. Immediate requirement left at the time of the inspection. The registered peson must ensure that missing statutory staffing records to be obtained. Immediate requirement left at the time of the inspection. The registered person must ensure that the fire alarm system is satisfacory. The registered person must ensure that checks of the water temperature are undertaken weekly in line with the risk assessment. 28 October 2005 31 October 2005 With immediate effect upon receipt of this report. 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. Refer to Standard 9 9 24 Good Practice Recommendations It is recommended that consideration be given to whether the system for risk assessments would benefit from a review to simplify it. It is recommended that risk assessments be reviewed within the timescales recommended in the assessments themselves. It is recommended in order to ensure privacy that consideration be given to the need to provide locks for the doors linking the changing rooms. LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 LAMBERT HOUSE I55 S27475 Lambert House V246371 270905 Stage 4.doc Version 1.40 Page 25 - 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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