Inspection on 27/11/08 for Latham House

This inspection was carried out on 27th November 2008.

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

Other inspections for this house

Latham House 01/07/08

Latham House 04/01/08

Latham House 07/08/07

Latham House 20/09/06

Latham House 22/11/05

Latham House 23/08/05

Latham House 07/03/05

Latham House 21/12/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOME ADULTS 18-65 Latham House The Lane Wyboston Beds MK44 3AS Lead Inspector Andrea James Unannounced Inspection 27th November 2008 10:00 Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Latham House Address The Lane Wyboston Beds MK44 3AS 01480 470470 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) psouthgate@brookdalecare.co.uk na Brookdale Healthcare Limited Manager post vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Maximum number of service users: 12 Gender: Male and Female Ages: 18-65 Up to 12 people with a Mental Disorder may be accommodated where this is associated with a Learning Disability. 1st July 2008 Date of last inspection Brief Description of the Service: Latham House is registered as a 12-bedded house and its exterior is in keeping with the rural neighbourhood. It is situated on the outskirts of the village of Wyboston, close to the market town of St. Neots. There are good community facilities available and the home provides transport to staff and service users to travel from the village to nearby towns. Since the last inspection the home has reduced their occupancy from 12 to 5 people and as a result only one side of the house is used to accommodate people. The other side is used for activities to include art and craft and relaxation. The maximum fee for this service is £2978.00 per week. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a 1 star. This means that people who use the service experience an adequate quality outcome. This inspection was undertaken on the 27th of November 2008 by Andrea James and Nicky Hone. The inspection process was enabled by the acting manager who was present for the duration of the visit. Ten hours of inspection time was used in this site visit between both inspectors. The inspection process followed a case tracking methodology where samples of people using the service were randomly selected, their files and records inspected and where possible people using the service and their key workers were interviewed. The report consists of information received from people using the service, care staff, the management team and an occupational therapist. Limited information was received from people using the service because of the level of their disability. What the service does well: The service provides care and support to people with autistic spectrum disorder (ASD) who may also have a learning disability and who may pose challenges to the service. Staff spoken to said the home provides opportunities for people to be able to maximise their independence. One carer said the home is good. Another carer said Its brilliant now; people have a lot of activities. We observed that people in the home were actively participating in activities and 4 of the 5 people had left the home to access activities within the community on the day of the site visit. The needs of people using the service were also addressed using a person centred approach which reflects positively on people. The staff team appeared competent and able to meet the needs of people using the service. Staff were observed to interact positively with people using the service. The home ensured satisfactory recruitment procedures were in place for employing new staff and those spoken to were qualified and able to meet the needs of people using the service. The home ensured effective communication processes were in place for people using the service and their relatives to communicate. The home provided monthly reports to relatives about the progress of people and would telephone them to let them know any changes in peoples lives. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure that they identify all aspects of peoples health and implement satisfactory care interventions in order to meet peoples medical needs. The environmental standard needs further development to ensure all offensive odours are eliminated. There was also a need to ensure doors are not propped open by various pieces of furnishings and doors closed properly on their rebates. The home needs to ensure effective quality assurance policies and Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 7 procedures are implemented to ensure peoples views and concerns can be appropriately addressed. The staff rotas also need to be developed to be able to reflect accurately the staff members working in the home at all times. The training records for staff needs to be kept at the home to ensure peoples training needs can be assessed. The temperature for maintaining medication needs to be reviewed to reflect current guidance. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 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 Latham House DS0000060512.V373260.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People continues to receive sufficient information about the service and comprehensive needs assessments were in place for people using the service but further development was needed to ensure these assessment are reviewed to reflect current needs, as a result some peoples needs were not being met. EVIDENCE: The home ensured Statement of Purpose and Service User Guide that provides sufficient information for people using the service. This information was presented in a pictorial format tailored to meet the needs of people using the service. The home had needs assessments in place for people using the service which was based on assessing people with ASD but these documents needed development to ensure all the needs of people are identified. In one persons file inspected there was evidence from doctors notes that she was diabetic but this information was not reflected in the current needs assessment or care plan documentation seen. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 10 The manager said they were in the process of implementing this but due to computer failures had not put the information on file. It was concerning that this has been a long term medical condition and should have been addressed in a more proactive way. The assessment was printed off and placed on file before the end of the site visit. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The care planning procedures for people have improved and people have been assessed to be able to take more risks, but further development is needed to ensure all people have clear assessed needs recorded that reflect their individual circumstances, as a result some peoples lifestyles and care needs could be compromised. EVIDENCE: The home had worked hard to ensure the right information is recorded in peoples care plans. The care plans inspected suggested some had been developed to reflect the current new way of working but some still needed to be reviewed. The new care planning procedures reflected people in a person centred way and looked at peoples diagnostic information, mental health needs, physical health, activities and other areas of identified needs. There were also risk assessments associated with each care need in order to ensure Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 12 people are able to undertake a task safely. These risk assessments clearly identified the level of risk and the action staff were required to undertake. These care needs were collectively recorded with the input of the staff team and people using the service. The care plan files had also been reduced and contained just the information staff needed to care for people. There was evidence to suggest the occupational therapist had worked hard with the staff team to help them to understand the needs of people and several assessments were in place for reviews undertaken by the therapist. There was a need however to ensure all the needs of people are clearly recorded. In one persons care plan it was identified through diabetic check up forms that this person was diabetic. After further investigation found out she was a type 2 diabetic and this was controlled by diet but the care plan failed to show how this persons diabetes was being monitored and what staff should do in the event she had a hypo. Other aspects of medical needs for another person was also identified to be missing for example one person was due to have an opticians appointment on the 16/01/08 and it was recorded that a follow up should be arranged but no further action was recorded to have taken place. This was also the case for one person who was due to have a blood test on the 30/01/08. Records failed to show if this activity took place. The manager said with the implementation of the new Health Action Plans, this problem will be addressed more effectively in the future. There was evidence to suggest people were empowered to make decisions about their lives. People were able to move freely in their home and make decisions about what they wanted to do. One person decided to stay at home and do some baking on the day of the site visit. She was very vocal as to what she wanted to do and said to the member of staff supporting her come I want to do baking. This person was observed baking bread and actively undertaking the task. This person later decided to go and have a lie down later on in the afternoon. Care staff spoken to gave several examples of how people were actively empowered to make decisions about their lives. This was very obvious during the site visit where some people wanted to relax while other wanted to go out. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13,14,15,16 & 17. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home provided activities and stimulation that created opportunities for people to be able to develop, they were also able to have a balanced diet which offered choices and created self fulfilment for all. EVIDENCE: The home created opportunities for people to develop. Since the last inspection the occupancy have been reduced from 12 to 5 people which have created more living space for people and the environment is much quieter. One person moved out of the home on the morning of the site visit. The management team have been creative in identifying individual needs and ensuring staff are equipped in meeting them. One person who enjoyed computers was enabled to access this resource on a daily basis. While other people were able to attend snoozeloon sessions, horse riding etc. A small snoozellon room was provided for people in- house which proved productive in being able to diffuse anxiety Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 14 levels among people using the service. One person was supported to be able to use the kitchen facilities to bake. We were also informed that people were able to go on their first holiday together in 8 years this summer which proved to be a success and all enjoyed this activity. The home also employed extra staff on days when people needed to access community resources. There was evidence to suggest people were enabled to participate in community activities. Some people were able to visit family and friends and there was evidence that people were involved in the decision making processes. People were able to have a balanced diet with the exception of one person who had chicken nuggets and chips as his main meal every day. Staff said this was because he refused to eat anything else. The home had on display a menu in pictorial format and the manager was able to explain how people were enabled to make choices. The home had recently purchased a cooker and was preparing two of the meals in-house. There were plans in place to be able to provide all meals in house and stop having meals delivered from the main hospital canteen which is in the hospital next door. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People using the service had satisfactory health care support in terms of safe medication procedures and their emotional needs were met, further development was needed to ensure peoples medical needs are met, as a result some people failed to receive effective medical support. EVIDENCE: The home had developed the procedures for meeting peoples health care needs by implementing various care planning documentations which looked at peoples weight, diet and physical wellbeing. There was recorded evidence to suggest people visited doctors, opticians and clinicians when needed but this was not the case for all the people. The two care plan documentations inspected showed that the service failed to meet some of the medical needs of people. One person who was diabetic failed to have clear guidelines on how to manage this area of her need and as previously mentioned in the report no guidelines were in place for staff to adhere to. When asked how the home measured this persons blood sugars we were told that the person went to the Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 16 clinic but triggers of when the person may be ill due to diabetes was not in place. The second person case tracked had two appointments which he missed from January 2008 and there were no recorded evidence that a follow up visit was arranged. The home had worked hard to ensure the medication procedures in place protect people, as a result new guidelines for administering PRN medication was implemented. The medication administration sheets (MARS) were signed and dated and the medication stocks were satisfactorily maintained. There was a need to ensure the temperature of the medication room is comfortable for storing medication. The records seen suggested the temperatures were checked 8am each day and on a winters day still recorded temperatures on 22 degrees. Staff said it gets much hotter in summer months. It was also suggested that the time of recording be staggered to get a better picture of the room temperature at various times of the day. Records seen suggested staff received medication training and staff spoken to said they were competent in the administration of medication. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Policies and procedures were in place to protect people from abuse and to ensure all concerns can be dealt with satisfactorily. EVIDENCE: The home had in place effective policies and procedures for dealing with complaints. Since the last inspection the home has had no formal complaints but the manager informed us that one parent had voiced areas of concerns that were being dealt with. The manager said in order to reassure this relative weekly contacts were being made followed by letters to confirm conversations and they were working with other professionals to ensure this relative can be reassured of all the care been provided to her son. A simplified version of the complaints procedure was displayed on the notice board using symbols and plain language. The home have had no need to make any referrals since the last inspection but have in place the correct procedures to follow in the event people are at risk of abuse. Staff spoken to said they would know what to do in the event someone was being abused. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28 &30. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home was satisfactorily decorated to meet the needs of people but further development was needed to ensure offensive odours are eliminated to provide a welcoming environment. EVIDENCE: On the day of the site visit several of the people using the service were out on activities. The house on arrival was welcoming and most doors were open which created a light and airy feel to the environment. The home was clean and satisfactorily decorated and appeared to create a sense of comfort to people using the service. We were informed that improvements were made to the environment in regards to the new arts and crafts room and the relaxation room installed on the top floor. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 19 The communal areas of the home were in keeping with the needs of people using the service although some improvements could be had to make it more homely. For example in the dining areas all the chairs were secured to the floor and some of the upholstery was torn. Some chairs also needed re-varnishing and as a result detracted from the homely feel the home is obviously trying to create. The peoples bedrooms suited their needs but further development should be made to ensure bedrooms are more personalised. All personal belongings were locked away. The manager said this was because some users would destroy others property. The home had made efforts in trying to personalise peoples bedrooms by putting pictures on their bedroom walls. The doors of all bedroom doors were also propped open using various items of furnishings and when removed the doors failed to shut on their rebates. This was discussed as a fire safety hazard with the home. In one persons bedroom there was a strong smell of urine that permeated into the corridors once the door was open. The home was aware of this, as it was a behaviour displayed by the occupant on a regular basis. This was identified in the last inspection and remains an unmet requirement. The home had several communal bathrooms and toilets to meet the needs of people and bedrooms also had en-suite toilets to provide sufficient privacy, but on inspection none of these facilities had toilet paper available or facilities to dry your hands. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35&36. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include visit to the service. The home provided competent and skilled staff to meet the needs of people but further development was needed to ensure people are safeguarded through the use of agency staff. EVIDENCE: The home had a stable staff team and due to the level of need the people using the service required the minimum of 5 care staff to be on shift at all times. We were informed that the home employed 15 permanent carers. On the day of the site visit 4 extra agency staff were drafted in to support people. The home relied on agency staff on a daily basis in order to provide sufficient levels of staff. The home failed to record on the staff rota the names of these members of staff. The manager said she was not always informed before hand who the agency would send and as a result c0234ould only record the names of these staff members once they arrived. The names were not recorded on the rota but on a separate sheet on paper. The agency staff details in regards to satisfactory clearances were not available in the home and it was not routine for the manager to ask the agency for this information. We explained Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 21 the importance of this to the manager and she was able to get the information faxed through before the end of the site visit. The home had satisfactory recruitment procedures in place and a new member of staff spoken to said she felt her recruitment was in line with proper safeguarding procedures. Her file contained satisfactory references, application forms, Criminal Record Bureau checks, interview notes and offer letter. This person also said she was given an Induction pack but had not yet completed it. The home ensured training was provided for the staff team but the recorded evidence of this was not available. The staff did not have a development plan and it was not clear how the training needs of carers were met. The manager said the staff training records were kept centrally and not held in the home. Some staff spoken to said they received training such ad NVQ level 3 and mandatory training. Two staff members said they recently received training in Autism, ASD and confidentiality. Staff files seen suggested people received regular supervision and staff said they felt supported by the manager. They were also able to confirm that they received regular supervision. We observed staff and manager communicating effectively. We were informed that staff also received staff meetings on a regular basis but the minutes of the recent staff meeting was not available for inspection. One senior said they had a seniors meeting on the 26th of November but the only available meeting recorded was for the 20th of May 2008. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 &43. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The management of the home ensured the best interest of people were assured, but further development was needed to ensure effective monitoring of the service through quality assurance and door guards are implemented, as a result the interest and safety of people could be compromised. EVIDENCE: Since the last inspection the management of the home have proven to be effective in identifying the issues to be addressed and taking effective measures in ensuring the home is run smoothly. The organisation is currently restructuring to ensure the best interest of people both in the short term and the long term. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 23 The manager and team have worked hard to make the home more homely and welcoming and most importantly to ensure peoples best interests are assured. Staff spoken to said clients are given better care as they have more activities another staff said, service users are able to participate in more activities and they are given the opportunity to develop themselves, this is good. One staff said the thing is the team now works better together another staff said We interact well as a team and help each other. One staff member summed it up by saying Its brilliant now. An external professional spoken to said, Its really nice here now, Its so much better now than when I started in June 2008. We observed a calm atmosphere within the management team which created a good leadership ethos that staff appeared to respond positively to. The home needed to implement a quality assurance system to ensure effective monitoring of peoples views can be reviewed and used positively. The home had no evidence to suggest the people using the service had a forum in which to make their views known. The manager said she had some systems in place that sought the views of people but no formal procedures were in place to analyse information received. This was a requirement made in the last inspection and therefore remains unmet. The home had satisfactory health and safety procedures and fire procedures inspected suggested weekly emergency lighting checks were recorded and fire alarm tests. Fire evacuation was undertaken twice yearly. We were informed that the home was fitted with a new fire panel. We could not ascertain if all staff had been trained in fire safety due to the lack of available training records. The home had several doors propped open using various different furnishings. On the day of the site visit 5 of the people using the serve all had their doors propped open. This resulted in some doors not being able to close on their rebates and as a result contravenes the fire safety regulations. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 24 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 3 2 2 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 2 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 3 3 1 X X 1 3 Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14 Requirement All people using the service must be subjected to a full and comprehensive assessment that encompasses the holistic needs of care to be implemented. All care plans must accurately reflect the needs of people with clear interventions of care recorded. Arrangements must be made to ensure the health care needs of people are identified and procedures are in place to address them. All bedrooms must have sufficient furnishings and fittings suitable to meet the individual lifestyles of the people. Previous timescale: 05/11/08 Arrangements must be made to remove offensive odours from identified areas of the home. Previous timescale: 05/11/08 Arrangements must be made to ensure the staff rota encompasses the entire staff DS0000060512.V373260.R01.S.doc Timescale for action 30/01/09 2 YA6 15 30/01/09 3 YA19 12 30/01/09 4. YA26 23 (c) 30/01/09 5 YA30 23 30/01/09 6 YA31 18 30/01/09 Latham House Version 5.2 Page 26 7 YA34 19 8 YA35 18 9. YA39 24 (1) (a) (b) team on shift to include agency staff. Satisfactory clearances and proof 30/01/09 of identification must be obtained from all agencies before agency staff are exposed to people who use the service. The home must present evidence 30/01/09 to suggest all staff have satisfactory training to undertake their job roles. Effective quality assurance 27/11/08 systems must be implemented that seeks and monitors the views of the people using the service. Previous timescale 30/10/07 and 25/04/08. Arrangements must be made to ensure all doors held open are in line with fire regulations and does not compromise the safety of people using the service. 30/01/09 10 YA42 13 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 YA30 Good Practice Recommendations Arrangements should be made to employ a domestic staff to undertake the daily cleanliness of the home. 2. YA32 Arrangements should be made to ensure at least 50 of the staff team are trained in NVQ level 2 or equivalent. This could not be assessed on the site visit. Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Latham House DS0000060512.V373260.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!