Inspection on 07/06/06 for Lampton Court

This inspection was carried out on 7th June 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 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 16/02/06

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 7th June 2006 10:00 Lampton Court DS0000026736.V297162.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 Lampton Court DS0000026736.V297162.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. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 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.V297162.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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.V297162.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of Lampton Court. The inspection took 8 hours over one day. The purpose for the inspection was to follow up requirements made at the last inspection and key standards covering: information;health and social care; leisure activitities, complaints and protection; environment; recruitment; management and health & safety. The inspector looked at records, policies and procedures. A tour of the building took place. Ten service users gave their views of the home to the inspectors. Surveys were sent to health and social care professionals and comments from those received are incorporated into the report. The inspector also spoke to four staff, the manager and a Director during the day. What the service does well: Lampton Court provides people with clear information that helps them decide whether they want to go through the programme of rehabilitation. Needs are discussed with service users before and during their stay at the home. Every service user has a keyworker who ensures that their needs are met. The philosophy of care at Lampton Court is inclusive, encouraging service users to fully engage in planning and reviewing their own care. Risks and quality of life issues are carefully managed so as to ensure that service users have few restrictions in the lives except those that are accepted in this type of care setting. The rehabilitation programme at Lampton Court enables service users to develop personally through education, leisure pursuits and daily routines. Some restrictions are in place with regard to relationships and freedom of movement outside of the home. These are acceptable restrictions, which are designed to prevent service users returning to behaviours associated with substance addiction. Service users fully participate in the preparation and choice of appetising and well-balanced meals at Lampton Court. Service users are encouraged to give feedback, which may include concerns, and the company acts this upon. Comfortable accommodation is provided for service users. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 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.V297162.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 Lampton Court DS0000026736.V297162.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users undergo a comprehensive assessment process to determine whether Lampton Court can meet their needs. In doing so, the home ensures that service user’s needs are well known and form the basis of each individuals rehabilitation programme. EVIDENCE: The inspector read the service users guide, which outlines the in-depth admission procedure. This consists of a three-stage assessment process. The first stage is a telephone interview with the service user. After which, the service user is invited to the home for a face-to-face interview. If the service user and team feel that the individuals needs can be met at Lampton Court, and agreed admission date is arranged. Two service user files were inspected. Comprehensive assessments had been completed and had been reviewed regularly with the individual concerned. Additionally, the home had obtained important information from the agency placing the service user at Lampton Court. The assessment steps taken by the home exceed the national standard. The Inspector was invited to join a group of 10 service users who wanted to give feedback about the service. All of the service users felt that the admission process was a positive experience and an important starting point from which to measure their motivation for wanting to be on the programme. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 9 The inspector was told that terms and conditions of residence and their ‘treatment plan’ had been discussed with them before their property was searched. The service users guide informs prospective service users that their property will be searched on admission and at anytime when the team suspect that the individual has used addictive substances banned at the home. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is an inclusive philosophy at Lampton Court that encourages service users to engage in the planning and reviewing of their own care. Risks are managed so as to ensure that service users have few restrictions in their lives except those that accepted in this type of care setting and made known to the service users on admission. EVIDENCE: Two care files were inspected. Lampton Court has employed a small team of nurses, as key workers, who have overall responsibility for managing the care of individual service users. Needs and risks that had been identified at admission were reflected in care plans. Care plans gave sufficient detail about the needs of each service user and it was evident that the individual had been fully involved in the process. Additionally, care plans had been regularly reviewed. The Inspector was invited to join a group of 10 service users who wanted to give feedback about the service. All of the service service users told Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 11 the Inspector that they had clear goals that they wanted to achieve during the programme and that these were reviewed regularly with their key worker during one-to-one meetings. The group of service users told Inspector that they are encouraged as individuals to make decisions on a day-to-day basis about their lives. At the same time, decision-making is also group based and this was illustrated when they chose to call an impromptu group meeting to give the Inspector feedback about the home. The head service user introduced him and told the Inspector that the group democratically elected a head service user every week. The role of the head service user was said to involve the delegation of therapeutic duties each week and being the chairperson of the community meeting held every evening. Comprehensive risk assessments were seen on two files inspected. Each one clearly laid down action to be taken to minimise identified risks and hazards. Service users told the Inspector that these had been discussed with them on admission. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 12 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): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The rehabilitation programme at Lampton Court enables service users to develop personally through education, leisure pursuits and daily routines. Some restrictions are in place with regard to relationships and freedom of movement outside of the home. These are acceptable restrictions, which are designed to prevent service users returning to behaviours associated with substance addiction. User participation in the preparation and choice of appetising and well-balanced meals at Lampton Court is an integral part of the programme. EVIDENCE: The Inspector was invited to join a group of 10 service users who wanted to give feedback about the service. One service user who had been staying at the home for a few weeks said youre fine no problems with this place and showed the Inspector their journal. The group told the Inspector that they had been focusing on the content of their journals during the morning group. During a tour of the building, the Inspector saw that the weekly program was Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 13 displayed on a notice board. The program was therapeutic and activity based and provided service users with one-to-one counselling, Reiki, life skills, group work, tai chi, relaxation and physical activity. This was discussed with service users who verified life skills training happens on a Tuesday morning and Wednesday afternoon. There are three courses which provide you with a inhouse certificate. Additionally, BTEC certificates are issued for some other courses for which all of that of the service users said they had signed up for. Art produced by service users during their art therapy sessions held twice weekly was displayed throughout the home. The head service user told the Inspector about therapeutic duties which involved amongst other things preparing and cooking the evening meal for the group. The Inspector was told that an important part of the programme was to learn how to be more responsible and accountable, which being involved with therapeutic duties formed an important part. Lampton Court initially precludes service users from having contact with family and friends and has strict restrictions in place in terms of independence, choice and freedom of movement. The rationale behind this is to prevent the service user from returning to behaviours associated with substance addiction. The group of 10 service users verified that they have been made aware of these restrictions prior to their admission to the home. The Inspector joined service users for the buffet meal at lunchtime, which was appetising and well-balanced. The meal was served in large dining room, to which the entire community-service users and staff-attended. A new cook had been appointed and in consultation with service users had revised the six weekly rolling menus. The inspector observed the cook seeking feedback about the meal from service users and staff. A record of meals provided was seen and demonstrated that menus were varied and provided good choice for service users. In addition to this, the Inspector was shown records that verified that dietary preferences had been accounted for. Lampton Court DS0000026736.V297162.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users at Lampton Court are enabled to be independent within a structured programme of rehabilitation. Service users personal and social care needs are well met. However, The manager had significantly improved the way medication is administer, stored and recorded thereby ensuring that service users are protected and are given the right medication, at the right time by competent staff. EVIDENCE: Lampton Court is completely independent with regard to personal care matters. Individuality is encouraged as part of the rehabilitation process for service users. NHS legislation precludes the service users who reside at the home on a short-term basis from registering with a GP during their stay. However, the organisation has a contract with a local GP who holds a weekly surgery at the home. The inspector saw GP records for service users, which were kept secure. Ten service users verified that this was a very useful service that is held at the home every Friday evening. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 15 Significant improvement was seen in respect of the way medicines are handled in the home. Since the last inspection, the manager had changed the procedures for storing keys to ensure that the were kept securely at all times. The records for the receipt of medicines into the home were well kept. Records showing where medication had been administered had been totally revised to avoid duplication as highlighted by the pharmacist inspector at the previous inspection. MAR charts has been signed and dated. A separate secure storage facility had been purchased for controlled medication and a separate register obtained showing the current balance of medication held. Staff administering medication told the inspector that they are shown the procedures during induction and assessed as being competent. The manager had undertaken a formal ongoing review of competence and review policies and procedures. The inspector tracked medication administered to two service users. Medication that was being administered by the service user had not been recorded as being ‘self medicated’ on the MAR chart. Since the last inspection, the manager had set up a contract with a local pharmacy for all medicines to be in monitored dosage form. Lampton Court DS0000026736.V297162.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are able to voice concerns about the service safe in the knowledge that their views will be respected. Policies and procedures are in place to protect service users from abuse. Shortfalls in adult protection training were in the process of being addressed by the manager who had booked training for July 2006 for all staff. EVIDENCE: Pre-inspection questionnaire dated 8/6/06 (received by fax on 12/06/06) stated that no complaints or pova referrals had been made in the last 12 months. Additionally recognised POVA training had been planned for staff in July 2006. The complaints procedure was clearly displayed on the service user’s notice board. The Inspector was invited to join a group of 10 service users who wanted to give feedback about the service and their comments included: “You’ll find no problems with this place” and “the staff are very approachable” and “this has been a very positive experience for me, I’ve learnt a lot about myself” and “the complaints procedure is outlined in the information that you receive before coming here” and “they are always asking for feedback, there are good structures in place at Lampton Court”. Interactions between staff and service users were friendly. Lampton Court DS0000026736.V297162.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Lampton Court provides an environment suitable to the needs of those who reside there. The safety of service users has been promoted by the fitting of window restraints since the last inspection. EVIDENCE: The responsible individual for the company told inspector that a maintenance person had been appointed. Maintenance certificates for the gas electrical and fire installations verified that external contractors had inspected all of these. The tour of the premises was carried out. Window restrictors had been fitted to all rooms above the ground floor. Maintenance staff told inspector that they had prioritised work for example bedroom six needed to be repaired and painted. All areas of the home were clean and comfortably furnished. The Inspector was invited to join a group of 10 service users who wanted to give feedback about the service. There had been some redecoration since the last inspection. Most service user said that they were in single rooms, however others shared with one other person. The inspector was told that they had been encouraged to personalise their rooms during their stay and did so with Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 18 posters, pictures or items of sentimental value. All of the service users verified that bedroom doors could be locked and that their privacy assured. The home has an appropriate number of wcs and bath/shower rooms. These are suitable to the needs of service users and to ensure their privacy, are lockable. The laundry area is situated across the courtyard and can be accessed without going through areas where food is prepared or eaten. Service users told inspector that they were discouraged from taking their laundry through the kitchen. Each person had been given a specific day to do their laundry. Lampton Court DS0000026736.V297162.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home has an effective staff team, however to ensure that the right people are recruited the manager must ensure that two written references and PIN checks are obtained to protect service users. A lack of supervision of care workers and qualified staff has meant that capability and consistency of professional practice when working with service users has not been monitored. EVIDENCE: Copies of the rotas were provided prior to inspection. These showed that there is a registered nurse on duty at all times during the day. In addition to this there are three salaried staff that work between 9am and 5pm on Monday to Friday. In addition, there is an administrative officer and a director who works the same hours as the salaried staff. Staffing levels had increased since the last inspection in preparation for the reinstatement of the nursing category that would enable the home to provide a low-key detoxification service. Minutes of staff meetings showed that these are held regularly and in discussion it was shown that there is good communication between shifts. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 20 Pre-inspection questionnaire dated 8/6/06 (received by fax on 12/06/06) stated that 95 of the staff hold the NVQ level 2. Three registered nurses had been appointed and are working at the home, all hold the Registered Mental Nurse qualification. Qualified staff that was spoken to held additional qualifications for example cognitive behavioural therapy. Additionally, three support workers had completed the NVQ level 3 in care. Inspector spoke to four staff all of which felt that the recruitment process was excellent and very thorough. Four staff files were examined. Two written references had not been obtained for the staff concerned and there was no evidence that PIN numbers had been verified for the qualified nurses employed by the home. All other checks, including CRB and POVA, had been carried out. The inspector was told that the induction training lasted two weeks and that staff had felt very well looked after. Records of induction and other training were seen on this staff files examined. However, there was no written evidence that the staff had received one-to-one supervision since their employment. Newly pointed staff spoken to also verified that they had not received supervision. A group of ten service users told the inspector that they had confidence in the skills, knowledge and experience that staff had who were working with them. Lampton Court DS0000026736.V297162.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service user’s needs are at the centre of this well run home. Quality assurance systems of the home ensure that service users participate fully in a formal process to bring about improvements to the service. However, to meet regulatory requirements the management team need to produce a quality assurance report reviewing the service and outlining any action that is necessary for improvement. Health and safety for service users, staff and visitors alike is prioritised at Lampton Court. EVIDENCE: At the time of the inspection the commission was processing an application for registration of a new manager who is a qualified nurse with counselling work experience in the drug/alcohol rehabilitation services. Her portfolio was Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 22 examined and certificates seen for the following qualifications: State enrolled nurse, Registered Mental Nurse,ENB 998. ENB 943, the Registered Manager’s Award and NVQ level 4 in management. In addition to this, she had completed First Aid training and also holds the ‘Manual handling instructor’ qualification. Evidence reported upon under other sections indicated that the new manager had made significant improvements in a number of areas including the management of medication and day-to-day maintenance in the home. A healthcare/socialcare professional wrote in a survey card “the home is very well run”. As previously reported, care plans had been regularly reviewed with service users.Ten service users gave feedback about the quality of the service and the overall management of the home. All were satisfied with the service and comments were “Lampton Court is a positive experience” and “there are good structures in place” and “they’re [staff] very approachable”. Completed quality assurance surveys were seen demonstrating that the home has sought the views of service users at the end of the programme. Views were encouraged on whether the programme met their expectations and whether the therapeutic models, the environment, food and accommodation met their needs. Staff told the inspector that the manager had set up regular meetings with them to seek their feedback, communicate changes to the programme and training opportunities. The responsible individual told the inspector that work was in progress to produce a quality assurance report and it was agreed that the timescale for completion of this requirement would be extended to facilitate this. Pre-inspection questionnaire dated 8/6/06 (received by fax on 12/06/06) stated that fire training had been provided for staff in the last 12 months on 5/8/05. This was also verified in discussion with staff. In addition to this Health and safety hygiene in the kitchen had been addressed. Additionally, that food hygiene and first aid training was planned for staff. The last recorded fire drill was 10/5/06. The inspector examined a range of maintenance certificates including the electrical wiring [23/8/05], Gas installation [6/3/06], Fire equipment [17/3/06]. Four staff told the inspector that the induction programme was thorough and that they felt well equipped with knowledge about the service, Health and Safety issues and quality procedures, and had been given an ‘Employee Handbook’ that summarised all the main policies and procedures. Lampton Court DS0000026736.V297162.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 x 2 3 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 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Lampton Court DS0000026736.V297162.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(2) Requirement The registered person shall ensure that— (a) persons working at the care home are appropriately supervised Timescale for action 28/02/07 This relates to regular supervision that is recorded. 2 YA34 19(1)b Sch 2 The registered person shall not employ a person to work at the care home unless— (b) subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2 31/01/07 This relates to preemployment checksthat must be carried out and includes obtaining: 2 written references Details of registration with Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 25 professional body Statement of physical and mental health CRB, POVA certificate Proof of identity Evidence of qualifications and training A full employment history 3 YA39 24(2) At the request of the 28/02/07 Commission, the registered person shall supply to it a report, based upon the system referred to in paragraph (1), which describes the extent to which, in the reasonable opinion of the registered person, the care home— (a) provides good quality services for service users; (b) takes the views of service users and their representatives into account in deciding— (i) what services to offer to them, and (ii) the manner in which such services are to be provided; and (c) has responded to recommendations made or requirements imposed by the Commission in relation to the care home over the period specified in the request. This relates to the production of a quality assurance report summarising measures taken and action identified. Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 26 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 Lampton Court DS0000026736.V297162.R01.S.doc Version 5.2 Page 27 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.V297162.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!