Inspection on 16/02/06 for Lampton Court

This inspection was carried out on 16th February 2006.

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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lampton Court 05/03/09

Lampton Court 25/01/08

Lampton Court 12/09/07

Lampton Court 07/06/06

Lampton Court 21/12/05

Lampton Court 08/03/05

Lampton Court 23/07/04

Lampton Court 05/01/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Lampton Court Lampton Court Littleham Bideford North Devon EX39 5HT Lead Inspector Susan Taylor Unannounced Inspection 16th February 2006 11:00 Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 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 Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 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. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lampton Court Address Lampton Court Littleham Bideford North Devon EX39 5HT 01237 470280 01237 425040 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) Health & Care Partnership Limited Vacancy Care Home 19 Category(ies) of Past or present alcohol dependence (19), Past or registration, with number present drug dependence (19) of places Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: Lampton Court provides 24-hour care for 19 younger adults aged 18 to 65 years with past or present alcohol and/or drug dependencies. The home is registered as a care home. The program provides group work, and an activity program. External to the registered home, the program also provides an experience of community living and day program. There are 5 single bedrooms and 5 are shared. The grounds are extensive and are landscaped. There is a swimming pool on site. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took four hours over one day. The purpose for the inspection was to follow up requirements made at the last inspection and key standards covering: medication; environment; recruitment; management and health & safety. Two inspectors looked at records, policies and procedures and spoke to residents and staff. Additionally, the pharmacist inspector carried out a thorough audit of the medication systems. A tour of the building took place. Eleven residents gave their views of the home to the inspectors. Three staff and a Director were spoken to during the day. The people staying at Lampton Court told the inspector that they preferred to be referred to as ‘residents’. This term is used throughout the report. What the service does well: Lampton Court provides comfortable communal areas for residents. Since the last inspection, steps have been taken to promote safety in respect of window restraints and risk assessments. Recruitment procedures are consistently failing to protect residents. Management arrangements had been put in place. However, these had yet to be formalised with the Commission to ensure that there is a registered manager who is qualified, competent and experienced to run the home and meet the stated aims and objectives for residents. Health and safety had been prioritised to safeguard residents and staff. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 6 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. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 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 Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 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): None EVIDENCE: Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 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): None EVIDENCE: Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 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 the following standard(s): None EVIDENCE: Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 11 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): 20 The way that some of the medication administration records are kept and the storage of medicines has the potential to place service users at risk of harm. EVIDENCE: The regional pharmacist for CSCI followed up requirements made at the last inspection in respect of standard 20. Medicines storage keys were not to be kept securely at all times. The records for the receipt of medicines into the home are incomplete. The Medication Administration Record (MAR) charts in use at the home are confusing and sometimes have information relating to the administration of medication in three different places for the same day. Also the records appeared to show that medication administration had been duplicated. The reason for non-administration of medicines was not always recorded. When hand-written entries on the MAR charts are made by the staff at the home they are not signed and dated and also not checked and signed by a second person. Non-medicinal items requiring secure storage are stored within the medicines cupboard. For those controlled medication stored at the home there is not separate secure storage available and a separate register is not maintained with a current balance of medication held. Staff administering medication are shown the procedures during induction and assessed as competent, but there is no formal ongoing review of competence or the following of policies and procedures. Also the current policy and procedures Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 12 are not reflective of the practices undertaken. The current audit sheet for the MAR charts does not indicate what has actually been monitored. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 13 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): None EVIDENCE: Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 14 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 Lampton Court provides an environment suitable to the needs of those who reside there. Since the last inspection, steps have been taken to promote safety in respect of window restraints and risk assessments. EVIDENCE: Requirements made in respect of standard 24 were followed up at this inspection. The inspector toured the building and saw that window restraints had not been fitted. Risk assessments were seen, which identified that restraints needed to be fitted. The inspector was told that these were scheduled to be installed on the following Saturday. This information was confirmed by a discussion with another member of staff. The Commission has since received written confirmation that window restraints have now been fitted. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 15 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): Recruitment procedures are consistently failing to protect residents. EVIDENCE: Requirements made at the last inspection in respect of standard 34 were followed up and had not been met. Five staff files were inspected. None of the files met the requirements of schedule 2. Two written references had not been obtained for two out of five new staff. None of the files contained evidence that a CRB check had been obtained sent for. Immediate requirements were issued on 16th February 2006. The Commission has since received written confirmation that these have been met. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 16 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, 42 Management arrangements had been put in place. However, these had yet to be formalised with the Commission to ensure that there is a registered manager who is qualified, competent and experienced to run the home and meet the stated aims and objectives for residents. Health and safety had been prioritised to safeguard residents and staff. EVIDENCE: The Commission had written to the company requesting clarification about the management arrangements of the home. The inspectors met a director for the company who said that he would be writing to the CSCI to clarify what management arrangements had been put in place. After the inspection, the Commission was notified of the name of the person responsible acting on behalf of the company as the ‘responsible individual’. A senior person is responsible for Health and Safety issues relating to Lampton Court. Fire records are appropriately maintained with a drill scheduled for the day of the inspection. A Health and Safety file was inspected, which contained Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 17 evidence that there is a weekly safety check covering all areas of the home and encompassing the safety of electrical installations and appliance, furniture and fittings and the physical environment of the home. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 18 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 x 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 x 23 x ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x 2 x x x x 3 x Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 19 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 YA20 Regulation 13(2) Timescale for action The registered person shall make 31/05/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This requirement had not been met since the last inspection and is repeated. The registered person shall not employ a person to work at the care home unless - subject to paragraph (6), (8), (9) her has obtained in respect of that person the information and documents specified in (i) paragraphs 1 to 9 of schedule 2. This requirement had not been met since the last inspection. Immediate requirements were issued on 16/2/06 and have been met. 16/03/06 Requirement 2 YA34 19 (1)(b)(i) 3 YA37 CSA 2000 S9(1) Care Standards Act 2000, S11(1) 06/03/06 Any person who carries on or manages an establishment or agency of any description without being registered under DS0000026736.V283899.R01.S.doc Version 5.1 Page 20 Lampton Court this Part in respect of it (as an establishment or, as the case may be, agency of that description) shall be guilty of an offence. The Care Homes Regulations 2001 – SI 3965 A person shall not manage a care home unless he is fit to do so. This requirement had not been met since the last inspection and is repeated. 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 Refer to Standard YA20 Good Practice Recommendations Policy and procedures for medicines in the home should be reviewed to take account of the National Minimum Standards and also the Royal Pharmaceutical Society “Guidelines for the control and administration medicines in care homes and children’s services.” All controlled medication in the home should be stored in a cabinet complying with the Misuse of Drugs (Safe Custody) Regulations 1973. A separate register should be kept for the receipt, administration and disposal of these medicines. When hand-transcribed entries are made, these should be written, signed and dated by the first person and then checked and signed by a second person. The style of Medication Administration Record chart in use should be reviewed, to enable the clearer recording of information regarding the administration of medicines. The assessment of competence of all staff administering should be regularly reviewed and that this review is documented. Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Lampton Court DS0000026736.V283899.R01.S.doc Version 5.1 Page 22 - 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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