Inspection on 16/08/04 for Lapworth Court, 17

Care Homes For Adults (18 ­ 65)Lapworth Court, 17Chichester Road London W2 6PLAnnounced Inspection16th August 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Lapworth Court, 17 Address Chichester Road, London, W2 6PL Email address Tel No: 020 7266 1694 Fax No: 020 7266 0631Name of registered provider(s)/company (if applicable) Southside Partnership Name of registered manager (if applicable) Ms Brigit Agnes Nevin Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number G090000171 Date first registeredDate of latest registration certificate 9th March 2004Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionYes NO 12/11/03 If Yes refer to Part CLapworth Court, 17Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 316th August 2004 09:30 am Miss Ffion JonesID Code120892Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionHarpreet Ghatora ­ Acting Care ManagerLapworth Court, 17Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementLapworth Court, 17Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Lapworth Court, 17. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Lapworth Court, 17Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 17 Lapworth Court is a registered care home providing care and accommodation for three women with a learning disability/mental illness. The care is provided by Southside Partnership and the home has an all female staff team. The home is situated on a small estate close to the shopping and transport facilities of Warwick Avenue, Bayswater and Paddington. A very good standard of accommodation is provided and each person living in the home has her own bed sitting room. The Kitchen, bathrooms and toilets are shared.Lapworth Court, 17Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The announced inspection took place over one day in August 2004. The inspector received a total of 2 completed comment cards from relatives/visitors. These provided positive feedback on the service. The inspector viewed the care plans of all three service users. A total of 9 requirements were made, two of which were repeated from the last inspection report. Choice of Home Of the total 5 standards in this section, 3 standards were met and 2 standards were not met. Each service user has a copy of the statement of purpose and service users guide. The guide indicated that the service provides 24 hour care to service users. Requirements were made from the last two inspections that copies of the statement of purpose and service users guide must be forwarded to the Commission. This remains a requirement. The latest admission to the home was approximately three years ago. It was confirmed that service users are only admitted following a full needs assessment and risk assessment carried out by the referring agent. Prospective service users are able to come to the house to have a look around and stay for a meal. This provides the service user with the opportunity to meet the staff and the other service users in the home. The trial visits gradually extend to overnight stays once the service user is comfortable with the environment. Emergency admissions are accepted but only following a full needs assessment and risk assessment. Individual Needs and Choices Of the total 5 standards in this section, 3 standards were met, 1 standard was not met and 1 standard was not assessed. Each service user has an individual plan in place outlining short and long term goals including details of who is responsible for ensuring that the need it met. The care plans were reviewed monthly and multi-disciplinary reviews were seen to be undertaken every 6 months. Service users receive a 1:1 key working sessions on a monthly basis. Care plans were signed by service users where appropriate. Two of the service users manage their own money and bank book. The staff look after the other service users money, and is kept securely in the homes safe. The financial records for this service user was checked and the balance was found to be correct. Where money is given to the service user, a staff signature and the service users signature is obtained. Risk assessments have been completed for all three service users. A policy was seen as part of one of the service users files to indicate that they could be left alone for a period of 2-3 hours initially. This was discussed with the Manager and an immediate requirement notice was made to ensure that this practice does not continue.Lapworth Court, 17Page 6 Lifestyle Of the total 7 standards in this section, 6 standards were met and 1 standard was not assessed. One of the service users was attending a day service at the time of the inspection and has a full timetable. During the summer term, the activities include art classes, outings to museum and cinemas, swimming, boat trip, theatre performance and bowling. A trip to Brighton was also scheduled to take place the day after the inspection. From September to June, the timetable includes a Womens group, social group, sex and relationships, travel and life skills and arts and crafts. This is aimed at developing social, communication and independent living skills. Service users who do not access the day service also have a timetable to encourage independence. Each service user has an allocated time for tasks such as attending to their laundry and cleaning their rooms and helping with preparing for dinner. Support to find and keep appropriate jobs and education/ training is provided. Service users have access to a range of leisure activities both inside and outside the home. Service users went to Eastbourne on holiday in July and one service user is going to a rock concert in the near future. Service users also have access to a community social club. Home activities include completing dot-to-dot books, movie nights, takeaway nights and games night. Service users rooms were seen to be equipped with TV and music systems. Service users are supported to maintain links with family members. The brother of one of the service users visits on a Sunday. One service user is currently in a relationship and has access to sex and relationships studies via one of the day projects. Personal and Healthcare support All 4 standards in this section were met. Service users personal care needs and the support required are identified in their individual care plans. No nursing care is provided in the home. The home has an all female staff team and therefore same gender care is provided. Specialist support is available for service users. The medication administration records were well completed and a running total of medications maintained. The medications were securely stored in a locked metal cabinet. No controlled drugs are currently in use in the home. It is a recommendation that the home arranges for the pharmacist to visit the home to carry out a quarterly audit on their medication procedures. Concerns, Complaints and Protection. Of the total 2 standards in this section, 1 standard was met and 1 standard was not met. Complaints are logged by the Quality Assurance representative and are centrally monitored. The complaints policy was seen during the inspection and includes symbols to make the information more accessible to service users. The acting Manager operates an open door policy and service users are encouraged to speak about any issues they are unhappy about. Service users are also invited to take part in residents meetings. The acting Manager also explained to the inspector that a newsletter is currently being produced to explain to service users what is going on in the house and in the organisation. Staff are aware of the protection of vulnerable adults policy and were able to describe ways of identifying abuse. Staff are able to access training in dealing with physical and verbal aggression.Lapworth Court, 17Page 7 Environment Of the total 7 standards in this section, 6 standards were met and 1 standard was not met. The home is suitable for its stated purpose. The parts seen during the inspection were clean tidy and well decorated. New carpets have been fitted to the communal areas. The staff office has been repainted and some photographs have been put up. There is a patio area outside the home with plants and barbecue. The home is not accessible to service users with restricted mobility as the front door is at the foot of a flight of steps and there are internal stairs leading to two of the three bedrooms and bathroom. Staffing Of the total 6 standards in this section, 3 standards were met, 2 standards were not met and 1 standard was not assessed. The staff vacancies in the home are currently equal to 2.5 staff members. These positions are currently being filled by agency staff on long term placements. There is a need to ensure that the staff vacancies are covered by permanent staff. During the morning of the inspection, one staff member was out of the home supporting one service user, and another staff member was supporting one service user who was at home. One staff member started the late shift at 1pm and the staff providing the sleep-in cover started at 4pm. The human resources department are responsible to completing the pre-recruitment checks such as the two references and the CRB checks. A number of relevant training opportunities are available for staff. Conduct and Management of the Home Of the total 7 standards in this section, 3 standards were met, 1 standard was not met and 3 standard were not assessed. The registered manager is currently away from the project. An acting Manager has been in place since March 2004. The acting manager confirmed that they have been working in the care field for approximately six years both in a voluntary and paid capacity. The acting manager has obtained approximately 12 months experience as a deputy manager and has a social care qualification. She is currently studying for the NVQ level 4 and a Person Centred Counselling award. Staff feel that they work well together and that there is a friendly atmosphere in the home. The staff feel well supported by the acting Manager and felt that she is committed to staff development and motivation. Staff also felt that the acting Manager is proactive in involving other agencies for the benefit of service users.Lapworth Court, 17Page 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4&5 YA1 The Southside Partnership must provide the 30/06/04 NCSC with copies of the homes Statement of Purpose and Service Users Guide The CSCI must be informed of significant events affecting residents welfare. The recruitment of a permanent staff team must be a priority. 30/11/03 01/04/042 337 19YA23 YA32Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Lapworth Court, 17Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4&5 YA1 The Southside Partnership must provide the NCSC with copies of the homes Statement of 01/10/04 Purpose and Service Users Guide. This is a repeat requirement. 2 5 YA5 The licence agreements must be updated to contain all the required information as set out 01/11/04 in standard 5. Service users must not be left alone in the home at any time. Immediate 16/08/04313 [4]YA9437YA23 & YA42The CSCI must be informed of significant events affecting residents welfare. 01/09/04 This is a repeat requirement. Southside Partnership must ensure that the broken chest of drawers in service users 01/12/04 bedrooms are replaced. Agency staff who are placed on a contract, 01/11/04 must also receive regular supervision. Gas and Electricity certificates must be 01/11/04 obtained for the home The Manager must consult with the local fire authority to arrange an inspection of the 01/11/04 premises.516 [2] (c)YA266 718 [2] 13 [4] 23 [4]YA36 YA42 YA428Lapworth Court, 17Page 10 923 [5] 16[2] YA42 (j)The Manager must ensure that the authority responsible for environmental health for the 01/11/04 area is consulted with.RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 YA20 The home should arrange for the pharmacist to visit the home to carry out a quarterly audits on their medication procedures.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Lapworth Court, 17 YES YES YES YES YES NO NO NO YES NO YES YES YES YES NO YES NO YES NO YES Page 11 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)2 0 2 NO NO YES YES 6 0 16/08/04 09.30 7The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Lapworth Court, 17Page 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? Each service user has a copy of the statement of purpose and service users guide. The guide indicated that the service provides 24 hour care to service users. Requirements were made from the last two inspections that copies of the statement of purpose and service users guide must be forwarded to the Commission. This remains a requirement.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The standard was discussed with the acting manager and the operations manager. The latest admission to the home was approximately three years ago. It was confirmed however that should the home have a vacancy, Southside Partnerships policy would be adhered to. The policy stipulates that service users are only admitted following a full needs assessment and risk assessment carried out by the referring agent.Lapworth Court, 17Page 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Checking the service users personal files was evidence that their cultural needs have been assessed and noted. Discussion with staff was evidence that the acting Manager has made appropriate referrals to the multi-disciplinary team and as a result service users have been receiving a lot more input. There was evidence within the care plans to indicate that the service users needs were being met at the home. This was also confirmed by the staff team who commented positively on the progress made by service users. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The standard was discussed with the acting Manager and the Operations Manager. Prospective service users are able to come to the house to have a look around and stay for a meal. This provides the service user with the opportunity to meet the staff and the other service users in the home. The trial visits gradually extend to overnight stays once the service user is comfortable with the environment. Emergency admissions are accepted but only following a full needs assessment and risk assessment. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? The files of all three service users were seen during the inspection. Each service user has a licence agreement in place. The agreements seen were standard licence agreement and did not contain all the specification set out in sub standard 5.2. The licence agreements must be updated to contain all the relevant information.Lapworth Court, 17Page 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The personal files of all three service users were checked. Each service user has an individual plan in place outlining short and long term goals including details of who is responsible for ensuring that the need it met. The care plans were reviewed monthly and multi-disciplinary reviews were seen to be undertaken every 6 months. Checking the documentation was evidence that each service user receive a 1:1 key working sessions on a monthly basis. Care plans were signed by service users where appropriate.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Two of the service users manage their own money and bank book. The staff look after the other service users money, and is kept securely in the homes safe. The financial records for this service user was checked and the balance was found to be correct. Where money is given to the service user, a staff signature and the service users signature is obtained.Lapworth Court, 17Page 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not inspected.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? Checking all three service users personal file was evidence that risk assessments have been completed for all three service users. A policy was seen as part of one of the service users files to indicate that they could be left alone for a period of 2-3 hours initially. This was discussed with the Manager and an immediate requirement notice was made to ensure that this practice does not continue.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Service users records were seen to be stored in the staff office during the inspection. The acting Manager confirmed that a member of staff is always present in the office. There is also a lockable filing cabinet that can be used for storing confidential information. The acting Manager confirmed that service user have access to their personal files.Lapworth Court, 17Page 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? One of the service users was attending a day service at the time of the inspection and has a full timetable. During the summer term, the activities include art classes, outings to museum and cinemas, swimming, boat trip, theatre performance and bowling. A trip to Brighton was also scheduled to take place the day after the inspection. From September to June, the timetable includes a Womens group, social group, sex and relationships, travel and life skills and arts and crafts. This is aimed at developing social, communication and independent living skills. Service users who do not access the day service also have a timetable to encourage independence. Each service user has an allocated time for tasks such as attending to their laundry and cleaning their rooms and helping with preparing for dinner. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? On the day of the inspection, one service user was being supported to attend a food hygiene course. This enables the service user to maintain work with caterers on a regular basis. Checking the care plan of one service user was evidence that of their goals was to be supported to access an English class. Support to find and keep appropriate jobs and education/ training is also provided on an ongoing basis via the key-working sessions.Lapworth Court, 17Page 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was not inspected.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Discussion with the Manager and checking documentation was evidence that service users have access to a range of leisure activities both inside and outside the home. Service users went to Eastbourne on holiday in July and one service user is going to a rock concert in the near future. Service users also have access to a community social club. Home activities include completing dot-to-dot books, movie nights, takeaway nights and games night. Service users rooms were seen to be equipped with TV and music systems. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The standard was inspected by checking documentation and discussion with staff. Evidence was seen in the service users timetables and care plans that service users are supported to maintain links with family members. The brother of one of the service users visits on a Sunday. One service user is currently in a relationship and has access to sex and relationships studies via one of the day projects.Lapworth Court, 17Page 18 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The standard was inspected by general observation and checking documentation. Staff were observed to be interacting well with service users. Service users were seen to be able to choose when to be alone in their rooms and were observed to have access to all parts of the home. Service users responsibility for household chores were detailed in the care plans. House rules were outlined within the service users guide.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Checking the care plan of the service users was evidence that they are supported to participate in preparing and cooking a meal. This was also highlighted in one of the service users timetable. Dinner on the evening of the inspection was lasagne and salad, and the inspector observed one of the service users being supported to prepare the meal. Checking the pre-inspection questionnaire was evidence that breakfast is served between 8 and 9am, lunch served between 12pm and 1pm and dinner served between 5pm and 6pm. A communal roast dinner is prepared on a Sunday with the input of service users. Menus for the week are prepared on a Saturday with the service users input. The fridges and freezers were checked and the food within these were within date.Lapworth Court, 17Page 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Service users personal care needs and the support required are identified in their individual care plans. No nursing care is provided in the home. The home has an all female staff team and therefore same gender care is provided. Specialist support is available for service users (see also standard 19).Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Checking the personal files of the service users was evidence that they have received recent input from the Psychiatrist, GP, Optician, Dietician, Dentist, Speech and Language Therapist, Community Nurse and Community Psychiatric Nurse. Discussion with staff was evidence that the Manager is very proactive in obtaining professional advice from the multidisciplinary team.Lapworth Court, 17Page 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The standard was inspected by discussion with the acting Manager, checking medication and mediation records. Dosset boxes are filled on a weekly basis by staff on a Sunday with the involvement of service users to encourage independence. One of the service users currently self-medicates. A risk assessment had been completed to assess the suitability of this practice. Staff keep the service users ability to self-medicate under review. The medication administration records were well completed and a running total of medications maintained. The medications were securely stored in a locked metal cabinet. No controlled drugs are currently in use in the home. It is a recommendation that the home arranges for the pharmacist to visit the home to carry out a quarterly audit on their medication procedures. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? Checking service users personal files was evidence that some details about service users wishes regarding terminal care and death have been noted. The acting Manager has also contacted the advocacy department who are scheduled to come to visit the service users to further discuss issues around bereavement. Due to its layout, the home is not suitable for service users who have restricted mobility.Lapworth Court, 17Page 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 1 0 1 0 0 100 3 Key findings/Evidence Standard met? The standard was discussed with the acting Manager and documentation was checked. Complaints are logged by the Quality Assurance representative and are centrally monitored. The complaints policy was seen during the inspection and includes symbols to make the information more accessible to service users. The acting Manager operates an open door policy and service users are encouraged to speak about any issues they are unhappy about. Service users are also invited to take part in residents meetings. The acting Manager also explained to the inspector that a newsletter is currently being produced to explain to service users what is going on in the house and in the organisation.Lapworth Court, 17Page 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES02 Key findings/Evidence Standard met? The home has an adult protection policy in place. Discussion with the acting Manager was evidence that training has been arranged for staff next month. Discussion with staff was evidence that they are aware of the protection of vulnerable adults policy and were able to describe ways of identifying abuse. Staff are able to access training in dealing with physical and verbal aggression. Checking the accident/incident book was evidence that some incidents had occurred which fall under regulation 37. Any incident that adversely affects the well-being of service users must be reported to the Commission. Full details of these incidents, including details of any investigations undertaken, must be forwarded to the Commission.Lapworth Court, 17Page 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The standard was inspected by touring the building and the inspector viewed the rooms of 2 service users. The home is not accessible to service users with restricted mobility as the front door is at the foot of a flight of steps and there are internal stairs leading to two of the three bedrooms and bathroom. The parts seen during the inspection were clean tidy and well decorated. New carpets have been fitted to the communal areas. The staff office has been repainted and some photographs have been put up. There is a patio area outside the home with plants and barbecue.Lapworth Court, 17Page 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 3 0 0 0 3 00 0 0 03 Key findings/Evidence Standard met? There have been no structural changes made to the home. The bedrooms are spacious.Lapworth Court, 17Page 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? The inspector viewed the bedrooms of two of the service users. Each service user has their own bed sitting room. On the whole, the accommodation provided is of a very good standard and rooms are well equipped. The chest of drawers in both rooms are in need of replacement and is a requirement.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? There is a shower room and WC and wash hand basin on the ground floor. The work to this room has been completed since the last inspection. There is a bathroom with WC and wash hand basin on the first floor.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is no communal lounge in the home. Each service user has their own bed sitting room, which is spacious. There is an outside patio area, which provides adequate space for the current service users. Discussion with the staff team was evidence that service users can also come and sit in the staff office. There is a well equipped kitchen and a washing machine and tumble dryer for service users to use.Lapworth Court, 17Page 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? At the time of the inspection, none of the service users had a physical disability. No aids or environmental adaptations are currently needed.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? There are no cleaning staff employed in the home. The care staff are responsible for ensuring that the communal areas are clean. Service users are supported to clean their own rooms with staff support as required. The home was clean, tidy and free from offensive odours at the time of the inspection.Lapworth Court, 17Page 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not inspected.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The acting manager is currently studying for their NVQ level 4. The Manager is also nominating one of the permanent carers to undertake NVQ level 2. The need for staff with NVQ level 2 qualification will be considered when recruiting new staff.Lapworth Court, 17Page 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 0 1 2 156 2 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 156 Nursing X X X002 Key findings/Evidence Standard met? The standard was inspected by discussion with the acting Manager and checking the duty rotas and general observation of staff on duty. The staff vacancies in the home are currently equal to 2.5 staff members. These positions are currently being filled by agency staff on long term placements. There is a need to ensure that the staff vacancies are covered by permanent staff. During the morning of the inspection, one staff member was out of the home supporting one service user, and another staff member was supporting one service user who was at home. One staff member started the late shift at 1pm and the staff providing the sleep-in cover started at 4pm.Lapworth Court, 17Page 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The standard was discussed with the acting Manager and documentation was checked. The organisation advertise their vacancies in the local papers and internal adverts for secondment opportunities are also made. The human resources department are responsible for completing the pre-recruitment checks such as the two references and the CRB checks. Evidence was seen during inspection to confirm that CRB checks had been completed on all staff. The HR department are also responsible for obtaining clarification that staff supplied by agencies have obtained the relevant checks prior to working in the home. It was confirmed during the discussions that service users have recently been involved in interviewing prospective staff members. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The Southside Partnerships training manual was available and seen during the inspection. This contained a number of relevant training opportunities for staff. The organisation has a training monitoring system, which highlights when training updates are required. Training undertaken by staff include the TOPSS training, LDAF, mental health awareness, medication, data protection, key-working training, cultural needs, medication, managing aggression and crisis intervention. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 2 Key findings/Evidence Standard met? The standard was discussed with staff and the Acting Manager. The permanent staff confirmed to have regular supervision on a monthly basis by the manager. The Manager also confirmed that she receives monthly supervision by her senior managers. There is a need to ensure that agency staff who are placed on a contract, also receive regular supervision and is a requirement. The format for recording the supervision sessions were seen. The format indicated that discussions during supervision sessions include general health and behaviour of service users, developmental needs, organisational issues and general house/environmental issues.Lapworth Court, 17Page 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? The registered manager is currently away from the project. An acting Manager has been in place since March 2004. The acting manager confirmed that they have been working in the care field for approximately six years both in a voluntary and paid capacity. The acting manager has obtained approximately 12 months experience as a deputy manager and has a social care qualification. She is currently studying for the NVQ level 4 and a Person Centred Counselling award. She keeps herself updated and has attended TOPPS induction, LDAF, mental health awareness training, Data Protection, autism and working with people with learning disability. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The acting Manager was found to be very enthusiastic and positive about their current role and about working with the client group. Discussion with the staff group was evidence that staff feel that they work well together and that there is a friendly atmosphere in the home. The staff feel well supported by the acting Manager and felt that she is committed to staff development and motivation. Staff also felt that the acting Manager is proactive in involving other agencies for the benefit of service users.Lapworth Court, 17Page 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not inspected.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not inspected.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? A range of documentation was checked during the inspection including health and safety records, accident incident records, care plans and medication records. The overall standards of record keeping in the home was good.Lapworth Court, 17Page 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The health and safety documentation was checked and the inspector discussed the standard with the acting Manager. Weekly fire alarm tests and emergency lighting tests are carried out and regular fire drills are performed. The fire equipment was seen to have been recently tested. The Acting Manager is currently attempting to obtain a gas and electricity certificate for the home and is a requirement. The date of the last visit by the local fire brigade was unknown and must be contacted to arrange a visit. The date of the last visit from the environmental health officer was not known and so the home must liaise with this agency to arrange a visit. Risk assessments for safe working practices were in place including a fire risk assessment. Accident and incidents were recorded in the book. some incidents had occurred which fall under regulation 37. Any incident that adversely affects the well-being of service users must be reported to the Commission. Full details of these incidents, including details of any investigations undertaken, must be forwarded to the Commission. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not inspected.Lapworth Court, 17Page 33 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Regulatory Inspector Date Regulation Manager DateFfion JonesSignatureJulian SainsburySignatureLapworth Court, 17Page 34 Public reports It should be noted that all CSCI inspection reports are public documents.Lapworth Court, 17Page 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Lapworth Court, 17 Page 36 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Lapworth Court, 17Page 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Lapworth Court, 17Page 38 Lapworth Court, 17 / 16th August 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000010886.V168817.R02© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!