Inspection on 25/01/06 for Langdon Foundation Clore House, 11 Norwood

This inspection was carried out on 25th January 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Langdon Foundation Clore House,... 23/10/08

Langdon Foundation Clore House,... 11/10/07

Langdon Foundation Clore House,... 04/12/06

Langdon Foundation Clore House,... 07/09/05

Langdon Foundation Clore House,... 03/02/05

Langdon Foundation Clore House,... 06/09/04

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Clover House

Parkside

Park Lodge

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St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Langdon Foundation Clore House, 11 Norwood Langdon Community Clore House 11 Norwood Prestwich Manchester M259WA Lead Inspector Sue Evans Unannounced Inspection 25th January 2006 09:35 Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.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 Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.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. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Langdon Foundation Clore House, 11 Norwood Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Langdon Community Clore House 11 Norwood Prestwich Manchester M259WA 0161 773 3015 Langdon Foundation Care Home 5 Category(ies) of Learning disability (6) registration, with number of places Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is registered for a maximum of 5 service users to include: Up to 5 service users in the category of LD (Learning Disabilities under 65 years of age). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 7th September 2005 Date of last inspection Brief Description of the Service: Clore House is part of The Langdon Foundation, a charitable organisation that was established to promote opportunities for young Jewish adults with learning disabilities. The home provides 24 hour support for up to 5 young Jewish female service users, most of whom eventually move on to a more independent setting. The house is situated in a quiet residential area of Prestwich, approximately three quarters of a mile from the village centre. It is within walking distance of bus routes, shops, and other local amenities. As the Prestwich area houses a large Jewish community, there is easy access to synagogues and kosher food shops. Clore House is a large detached home, similar to other properties in the area and it is not distinguishable as a care home. All the bedrooms are single. One resident is accommodated in a self contained flatlet within the building. Facilities in the home are domestic in style and provide a homely living environment. Residents have use of a lounge, dining room, and kitchen. Outside there are gardens at the front and side of the house. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took 6½ hours. Most of this time was spent watching what went on in the home, talking to the 4 residents and a visiting relative, and interviewing a staff member and the Care Manager. The inspector also looked round some parts of the house, and looked at some key records. This inspection was the second to take place in the current inspection year. In order to gain a fuller picture of the home, this report needs to be read in conjunction with the report of the previous inspection of September 2005. Following the previous inspection, the Pharmacist Inspector visited the home (on 26th September 2005) to look closely at the home’s medication procedures. Her findings were sent to the home in a separate letter. The letter has not been published but is available, on request, to members of the public if they wish to see it. The requirements and recommendations that she made were followed up at this inspection. The manager has been in post for approximately 4 months. She is not yet registered with the Commission for Social Care Inspection but has recently sent in an application. She was on a training course at the time of this inspection, so the inspector was assisted by an experienced support worker, and the Care Manager. The manager was spoken with later, by telephone, to discuss the findings from the inspection. What the service does well: The ethos of the home is centred upon the needs of the individual and the home is run in a very inclusive way. Residents were pleased with life in the home. One person said, “I love it here”. Residents confirmed that they were included in planning their support needs, and regularly reviewing them. They are able to make choices about their lifestyles, with help from staff if needed, in areas such as daily routines, activities and meals. Thus their rights to make choices and decisions about their lives are respected. Residents said that their privacy was respected, for example staff members knocked on their bedroom doors. They said that staff members were courteous and respectful. This was observed during the inspection. Residents are actively encouraged and supported to become involved in community activities such as employment, education, and leisure pursuits, which helps them to lead lives that are meaningful and fulfilling. Staff support Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 6 is provided where necessary. Residents also receive support to increase their skills in everyday life to help them become more independent. This includes menu planning, shopping, and household tasks. Cultural needs are supported, for example kosher meals are prepared, and Shabbas and Jewish festivals observed and celebrated. The home has arranged for someone to come in each week to help residents with new recipes. The home is clean, homely and well looked after, providing a safe, pleasant environment for those who live there. What has improved since the last inspection? What they could do better: Pre-employment checks for staff are carried out in order to protect residents, but the service was not aware that, since July 2004, CRB (Criminal Records Bureau) checks were no longer transferable. In the case of some staff members, new CRB checks need to be done. The home provides training to equip staff with the knowledge and skills that they need to meet the needs of the residents. However, there are still some gaps in staff training that need to be addressed, including medication training for the manager and one of the support workers. The home has not yet produced a development plan to show residents, and others, how the standards in the home are being reviewed and improved upon. The home needs to attend to a fire safety matter in order to promote the safety of residents and staff. Please contact the provider for advice of actions taken in response to this Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 8 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 Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 9 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 Residents’ inclusion in the assessment of their needs enables them to have a say about what they feel they need help with. EVIDENCE: Most of the people who came to live in Clore House had previously been at Langdon’s residential college. Records showed that the home obtained copies care plans and risk assessments from Langdon College, and that the home also carried out its own assessments. Residents were included in this exercise. The Care Manager said that people could come to Clore House for trial visits if needed. There was evidence of regular reviews and updating of assessed needs. Residents confirmed that they were included in planning their support needs and regularly reviewing them. They said that Clore House was a good place to live. One said, “I love it here”. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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 and 9 Residents know about their individual plans, and they are involved in reviewing their needs and goals. Care plans and risk assessments have improved and they contain more detailed guidelines for staff about how residents’ needs are to be met. Residents are able to make choices about their lifestyles, with help from staff if needed, to exercise their right to autonomy and individuality. EVIDENCE: Standards 6 and 9 were assessed in September 2005. As requested at the last inspection, residents’ records had been re-organised. Care plans and risk assessments had been improved and they contained much more specific information and guidelines for staff. Residents’ likes and dislikes, wishes, and future goals were taken into account when planning their support needs. The manager had introduced a new person centred booklet “My Lifestyle Plan” which residents’ were encouraged to complete themselves. Records showed that each resident and their key worker held regular discussions about the resident’s needs and goals. Each person had a daily diary in which any key information was recorded. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 11 There was also evidence of formal review meetings, to which relatives and social workers were invited. Residents knew about their written records and they confirmed that they had attended meetings to discuss their support needs and goals. Some of the residents were seen, throughout the inspection, coming and going from the home pursuing their chosen activities. They said that they could choose how they spent their time. Records and discussions showed that the staff team helped and encouraged people to make appropriate choices, for example when considering leisure, employment or educational opportunities. However, a visiting relative felt that there was sometimes too much choice offered. She said that she had discussed this with managers. Records and discussions showed that the home tried to help people to find independent advocates if possible. Where any restrictions on personal choice were necessary, for example for health and safety reasons, this was done only in the person’s best interests, and it was discussed and agreed with the resident and other significant people in their life, and recorded. The Care Manager said that, when recruiting staff to work at Clore House, interviewees were invited for an informal chat with residents prior to interview. He said that the interviewers’ observations plus the opinions of the residents, contributed to the final decision about whether a candidate was suitable. Risk assessments had been expanded since the last inspection and they contained more specific guidance. They showed that potential risks had been assessed, and balanced against the resident’s right to choice and independence. Residents were happy with the support given to them by staff. “Staff are good”. One said, Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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 and 16 Residents are encouraged and supported to take part in meaningful activities. They participate in the community, with staff support if needed, enabling them to lead fulfilling lifestyles. Contact with families and friends is encouraged and supported. Practices in the home respect residents’ rights to privacy, independence and choice. Cultural needs are supported. EVIDENCE: Standards 11, 12, 13, 16 and 17 were assessed in September 2005. It was clear from discussions, observations, and records that residents were encouraged to participate in fulfilling activities, with staff support as necessary. Residents described some of the community activities that they were involved in. These included work placements, college courses, and an art group. They said that they sometimes went out to the cinema, the pub, the library or shopping. On the day of the inspection, one resident went out on a work placement, and another went to college. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 13 Residents said that they kept in contact with family and friends. This was done in several ways including making and receiving visits, and by telephone. A visiting relative said that she always got a friendly welcome when she came to visit. A resident said that the home provided a staff escort to enable her to travel to London to see her family. Discussions, and examination of care plans, showed that residents were given support and information to help them make appropriate decisions about their relationships. Residents said that they had choices about their daily routines, for example what time they went to bed, what they ate, or what they did throughout the day. However, there was an expectation that residents would work towards gaining more independence. They gave examples of the ways in which staff members encouraged them to do things for themselves, for example planning menus, cooking, and cleaning their rooms. They were also supported to increase their skills in things such as budgeting. Cultural and religious needs were respected. For example kosher meals were prepared, and Shabbas, and Jewish festivals were observed and celebrated. Residents were particularly pleased that the home had arranged for someone to come to the home once a week to help them to learn how to prepare new recipes. Residents said that they were happy with the way that the manager and staff treated them, and the way they spoke with them. They confirmed that staff members were courteous and respectful. This was observed during the inspection when staff were seen speaking with residents in a natural way. Residents’ personal information was kept locked away. The staff member who was spoken with understood the confidentiality procedures, and was aware that they must not discuss residents’ personal information in front of others, or outside the home. Residents were satisfied that their privacy was respected, for example staff knocked on their bedroom doors. Locks were fitted to bedroom doors. Mail was given to them unopened. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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 and 20 Most residents attend to their own personal needs, with prompt and encouragement if needed. Any changes in health needs are dealt with in liaison with the appropriate specialist health services. Medication storage and procedures promote good health and safety but there is a need for accredited training for those members of the staff team who have not yet completed it. EVIDENCE: One of the aims of the service was to assist residents to be as independent as possible. Residents were fully able to express their wishes about the way they were supported. In respect of personal needs, most residents were generally able to manage for themselves. Staff said that sometimes prompt and encouragement was needed. Records showed that the home monitored any aspect of an individual’s personal care that needed closer supervision, for example dental hygiene. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 15 Discussions with residents and staff indicated that residents used community healthcare services such as dentists and GPs. Residents said that a staff member usually accompanied them to appointments. Records showed that the home requested assistance, as required, from specialist health workers, for example Consultants. In respect of one resident who was prone to falling, records were kept of each incident. These were passed to the residents’ consultant for analysis. One resident described how staff supported her to eat healthily to help her to keep her weight at a healthy level. Records showed that her weight was recorded every week. A staff member described how she looked for changes in residents’ that might suggest a health problem. The pharmacist inspector had visited the home on 26th September 2005 to look at medication procedures. Most of the requirements that she made had been addressed. Medicines that were kept in the home were securely stored. No one looked after their own medication. A risk assessment had been completed on behalf of one resident but it had been considered too risky for her to self-medicate. There were records of medication received, administered, and disposed of. However, there were two gaps in recordings on one of the MAR (Medicine Administration Record). The staff member on duty said that the medication had been given but not signed out. Training records showed that some staff members had undertaken medication training but one had not. The manager also needed to complete this training. The Care Manager said that both of them had signed up with Salford College for training. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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): None None of the above standards were assessed this time. EVIDENCE: Standards 22 and 23 were assessed in September 2005. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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, 25, 26, 27, 28 and 30 Clore House provides a clean, homely, well maintained environment for residents, suited to their lifestyles. EVIDENCE: Standards 24, 27, 28, and 30 were assessed in September 2005. The home is situated in a residential area of Prestwich, about three quarters of a mile from the village centre. It is close to bus routes, kosher shops, synagogues, and other local amenities. The house is a large detached home, similar to other properties in the area. It is not identifiable as a care home. All bedrooms are single. One resident lives in a self contained flat within the building. The communal areas of the home and two bedrooms were looked at this time. These areas were comfortable, homely, and well maintained. The home was furnished with domestic style furnishings and equipment. Bedrooms were individually decorated and furnished, and highly personalised with residents’ own possessions. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 18 There was a shower, bath and toilet on the upper floor, and a toilet on the ground floor. Both were lockable to provide privacy. Three rooms had ensuite facilities. Outside there was a garden at the front and side of the house, and a patio area at the back, where people can sit out. Gardens were much tidier than at the time of the previous inspection. Some fencing had been taken down and was being stored at the side of the house. The Care Manager explained that this might be re-used. He was asked to remove a computer monitor that had been left there. The areas that were looked at were clean. Liquid soap and paper towels were provided for hand washing. Residents, and the visiting relative, were pleased with the environmental standards in the home. One resident talked about some new bedroom furniture that she would be getting soon. It was noted that 2 window blinds needed repairing. The home had identified that this work was needed and the maintenance worker visited the home, whilst the inspection was taking place, to assess what needed to be done. The inspector was satisfied with the home’s ongoing work to maintain satisfactory standards. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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 and 35 Pre-employment checks are carried out in order to protect residents, but the service was not aware that CRB (Criminal Records Bureau) disclosures are no longer portable. Langdon Community provides training to equip staff with the knowledge and skills that they need to meet the needs of the residents. However, there are a few gaps that need to be addressed. EVIDENCE: Standard 35 was assessed in September 2005. Residents were pleased with the support they received from staff members. It was observed that residents had no hesitation in approaching staff members if they needed them. Residents felt that the staff team were approachable, and that they listened to them. Only one of the four support workers had done NVQ training. This did not represent 50 of the staff team. The home needs to continue to encourage and support staff members with NVQ training with a view to having at least 50 of workers with the qualification. Staff recruitment records, in respect of 3 support workers, were looked at. They contained most of the necessary records. However, two peoples’ CRB (Criminal Records Bureau) disclosure certificates had been obtained during the Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 20 person’s previous employment. Discussion took place, with the Care Manager, about CRB checks ceasing to be portable after the introduction of the POVA (Protection of Vulnerable Adults) List in July 2004. As these 2 people commenced employment after that date, the home should have arranged for a new CRB check, including a POVA (Protection of Vulnerable Adults) List check. One of the support workers gave examples of some of the training that she had done. This included NVQ level 3, moving and handling, food hygiene, fire training, medication, and the appointed persons first aid course. Since the last inspection staff training records had been brought up to date. The training matrix still highlighted a few gaps that the Care Manager was looking to address. Staff training will be looked at again during the next inspection. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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 and 42 Residents and staff benefit from the open management approach of the home and they are comfortable about expressing their wishes and opinions. However, the manager needs to be trained to NVQ level 4 in management. The home invites residents, relatives and staff to give their opinions about the quality of the service but has yet to produce a written plan that will show residents and others how their views are being used to improve the service. The health and safety of residents and staff is generally well promoted, but there is a need to arrange the annual service if the fire extinguishers. EVIDENCE: Standards 37, 39 and 42 were assessed in September 2005. The manager had been in post for approximately 4 months. She has recently sent in an application for registration with the CSCI. Before taking up this post, she had worked for Langdon Community doing quality performance reviews. She has a BA (Hons) degree in Learning Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 22 Disability Studies. The Care Manager said that it was planned that she would enrol for the RMA (Registered Managers Award). Since the last inspection, the manager had made improvements in a number of areas, for example updating risk assessments, and encouraging residents to prepare their own lifestyle plan. Residents and staff members said that she was approachable and supportive. At the time of the September inspection, it was noted that the manager undertook some senior support worker duties as well as her management tasks. Her office also doubled as a staff room, and residents’ money and medication were stored there. It had been observed throughout that inspection that there was steady stream of residents and staff coming and going from the room requesting information, personal money, medication, and other things, and that the manager also spent a fair amount of time answering the telephone. Whilst it was felt to be commendable that the manager was not a remote figure and was spending useful time with residents and staff, it was also felt that she needed to be able to set aside a number of hours per week in order to allow her to carry out management and development tasks. The manager said that, although she was managing to complete her management duties, she did not have set hours in which to do them. This will be looked at further as part on the manager’s CSCI registration process. The Care Manager said that the quality audit was currently being re-done, the previous survey having been done some time ago. He said that relatives’ questionnaires had been sent out and that the responses would be collated by one of the Trustees. The new Service Manager was to take responsibility for collating staff questionnaires. Discussion took place about the need to include these responses with views given by residents and any regular visitors to the home. Once the survey has been completed, the home must produce a written plan to show what action is going to be taken to improve the service as a result of the information gathered. A copy of the report needs to be made available to residents, and others, so that they know that their views have been noted and, where applicable, acted upon. A copy also needs to be sent to the CSCI. Several safety records were checked. These included the gas safety report, and servicing of fire alarms, and emergency lighting. Although 2 new fire extinguishers had been purchased, the old ones were still in use and had not yet had their annual service. This needs to be arranged. As requested at the time of the last inspection, the home had completed a fire risk assessment, and records showed that tests of the fire alarms, emergency lights, and means of escape were being done weekly. Portable electric appliance tests were carried out in December 2005. Records showed that 4 appliances failed the test. The Care Manager said that the failed appliances had been discarded. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 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 4 13 3 14 X 15 4 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 provider must ensure that 31/03/06 all carers handling medication complete assessed medication training. Medication must be signed out at 25/01/06 the time it is administered. The home must apply for a new 28/02/06 CRB (with POVA disclosure), for the identified staff members. The registered person must inform the CSCI, by the date in the end column, of the action taken to address this requirement. The ongoing programme of staff 30/04/06 training must continue so that all the staff team have received up to date training in all the mandatory topics. The responsible individual must 31/03/06 inform the CSCI, by the date in the end column, of the steps to be taken to ensure that the manager of the home receives appropriate management training. The registered person needs to 30/04/06 complete the quality audit, and produce an improvement plan which must be made available to DS0000008478.V265744.R01.S.doc Version 5.1 Page 25 Requirement 2. 3. YA20 YA34 13(2) 18 4. YA35 18 5. YA37 9,10 6. YA39 21,24 Langdon Foundation Clore House, 11 Norwood residents, and to the CSCI. 7. YA42 23(4) The home must arrange for the 28/02/06 servicing of the fire extinguishers. (Timescale of 30/09/05 not met) 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 YA32 Good Practice Recommendations The registered person must continue to encourage and support staff members with NVQ training with a view to having at least 50 of workers with the qualification. Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Langdon Foundation Clore House, 11 Norwood DS0000008478.V265744.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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