Inspection on 07/08/07 for Latham House

This inspection was carried out on 7th August 2007.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Latham House 27/11/08

Latham House 01/07/08

Latham House 04/01/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Latham House The Lane Wyboston Beds MK44 3AS Lead Inspector Andrea James Key Unannounced Inspection 7th August 2007 12:00 Latham House DS0000060512.V347490.R02.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.V347490.R02.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.V347490.R02.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 psouthgate@brookdalecare.co.uk Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Brookdale Healthcare Manager post vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Latham House DS0000060512.V347490.R02.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 Service Users with a Mental Disorder may be accommodated where this is associated with a Learning Disability. 20th September 2006 Date of last inspection Brief Description of the Service: Latham House is 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. The home is split into 2 units for the people using the service aged between 18 and 65 years who have Autistic Spectrum Disorder and associated challenging needs. All of the bedrooms are single and en-suite. Each unit has a lounge and dining room. The laundry facilities were shared by the units. The home has recently changed the way meals are prepared. They are now cooked in the adjoining hospital, owned by Brookdale Healthcare, and delivered to Latham House. The fees for this service range from £2347.00 - £3108.00 per week. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 7th of August 2007 by Andrea James. It was the first inspection carried out for the year and as a result all the key standards were inspected. The inspection process lasted for 6 hours and the manager Paula Southgate assisted with the inspection process. The inspection process followed a case tracking methodology where a sample of people using the service were selected at random and their files inspected. Where possible these users were spoken to but it was not possible to obtain comprehensive information from the users due to their limited cognitive abilities. The inspector spent a lot of time observing the users of the service to gain an understanding of what it was like for them living at the home. A sample of care staff at the home on the day of the inspection was also interviewed. The inspection report also consists of information obtained from the AQAA (Annual Quality Audit Assessment) received from the home and surveys received from care staff. The Inspector would like to thank the people using the service, the care staff and the manager for their co-operation in the inspection process. What the service does well: The service provided a stable environment for people using the service, which reflected well in the way users anxiety, was kept to a minimum. The home solicited the professional input of various skilled professionals in order to provide consistent care provisions in enabling the people using the service to maximise their independence and live comfortably. The people using the service received satisfactory activities to ensure stimulation throughout the day and where possible this was carried out with 1 to 2 care staff depending on the need of the user. The people using the service were also able to access community resources such as swimming, shopping and other leisure pursuits. The home provided effective tools of communication for the users to ensure they were able where possible to make choices. The care plan documentations seen showed several documents that were in pictorial formats and showed that users views and choices were sought on admission and through their life at the home. The home ensured that where possible users kept in touch with their families and relatives. They were also enabled to visit whenever possible. People using the service were also protected by the robust recruitment procedures and staff received regular supervision and training. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 6 Safe systems for receiving, administering and disposing of medication were observed and staff spoken to were knowledgeable about the medication they were distributing to the users of the service. Whole life review meetings were held yearly with all disciplines including care managers, parents, psychologists and physiatrists. What has improved since the last inspection? What they could do better: The manager of the home have been in post for three months and informed the inspector that several of the areas for improvement identified in the report would be actioned in the near future. The home should ensure that: • All incidents that adversely affect wellbeing of people using the service are reported to the Commission and other governing bodies in accordance with the safeguarding procedures. All care staff receives up to date training on Safeguarding. All users privacy and dignity are maintained at all times. All risk assessments are dated and reviewed on a regular basis. All areas of the home are decorated to a satisfactory standard to promote homeliness to people using the service. All areas of the home are free from hazards. • • • • • Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 7 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.V347490.R02.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.V347490.R02.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 &5. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Satisfactory systems were in place to ensure new admissions to the home received as assessment by qualified professionals and information was provided to users and their representatives to make an informed choice of whether they wanted to live at the home or not. The contractual agreements however were of a generic nature and individual contracts were not available, as a result rights of users could be compromised. EVIDENCE: The home provided a Statement of Purpose and a Service Users Guide to all users and their representatives before they moved into the home. The users could not say if this was satisfactory due to the extent of their disabilities but information was seen on file to suggest this information was provided. The documentations inspected also showed that all users received a full preadmission assessment prior to users being able to live at the home and regular reviews were undertaken to ensure the suitability of the placement. The users were also able to move in on a trial basis before permanent residency was obtained. The home also ensured that risk assessments were undertaken for people using the service. It was noted however that some risk assessments failed to Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 10 have a date and as a result it was unclear how relevant the information was for the user. The inspector failed to find evidence to suggest that people using the service received individual contractual agreements. The inspector was presented with generic service agreements, which the home had with various placing authorities. The inspector was informed that the placing authorities provided a placement agreement with a schedule of annual prices, which is reviewed on users annual reviews to see if fees needed to be changed. One user file inspected showed a breakdown of the cost of his accommodation but this was not signed by the user/ representative or the home. Latham House DS0000060512.V347490.R02.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 &10. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Satisfactory care plan documentation was seen that reflected changing needs and personal goals of people using the service and evidence was available to suggest users were consulted about their care package, as a result users were able to maximise their independence. EVIDENCE: The home ensured all users had a full documented care plan that was presented in a pictorial format and reflected their changing needs. The information also reflected that from the admission assessment. The documents showed that users were consulted about their likes and dislikes and from observation users were able to undertake activities in accordance with their preferred lifestyles. One user who enjoyed going out said she was able to go shopping and listen to music. All users of the service received annual reviews, which were undertaken with external professionals. The inspector observed a team leader preparing for one user review and said that external professionals Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 12 including social workers and relatives were invited to the review. Lists of dates for other users reviews were seen on the wall in the manager’s office. One if the users care plan did not reflect the others in that it failed to have evidence of recorded goals or staff intervention. The manager said she was due to audit the documentation to ensure they are all up to date. The manager said users were also consulted about their holiday destinations and staff enabled users to enjoy this time of the year. The users were able to visit the seaside the day before the inspection and users spoken to said they enjoyed it. All users access varied amount of activities throughout the day. Care staff spoken to informed the inspector of some of the activities undertaken for the day to include reflexology, cooking, swimming and other activities within the community. The information for all users were seen to be kept confidentially and in locked facilities. Staff were observed to be confidential when speaking about a user and treated all users with respect and dignity. Latham House DS0000060512.V347490.R02.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 the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Good systems were in place to ensure users are involved in meaningful daytime activities in accordance with their individual interests and capabilities. They were encouraged to develop and maintain important personal and family relationships, and the practice of staff promotes individual rights and choice, and also considered protection of individuals, supporting people to make informed choices. EVIDENCE: People who use the service experience good activities from the service. Care staff are employed on a high ratio to ensure users are able to undertake activities. On the day of the inspection 10 staff were on shift to work with 12 users, as a result most activities were undertaken on a one to one basis. All users files showed that individual activity programme was in place for all users. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 14 The care staff said the activities were flexible to accommodate users moods and whether conditions. The manager informed the inspector that users were able to have regular contact with their families. There was also evidence that some families played a large part in users lifestyles. Some users were also able to have home visits. Relatives were invited to annual reviews and made contact via telephone to users when possible. Care staff were observed to respect users rights but due to the capability of the client group some restrictions existed to protect users. For example some users clothes and personal belongings were locked away as users would tear and destroy if the opportunity was presented to them. The inspector was able to view a users bedroom that had very basic furnishings as he would destroy his own property but in contrast to that some users bedrooms were furnished and decorated to a very high standard with personal belongings around. The inspector was informed that this user was responsible for choosing all her own furnishings. The nutritional needs of the users were provided by the main kitchen that catered for the near by hospital. The care staff informed the inspector that choices in the mornings for breakfast was limited but the manager said users were able to order cooked breakfast from the kitchen should they wish. The users also received a choice of meals at lunch and dinner times but these choices were limited to two meals. There was evidence that users could be provided with hot and cold beverages should they wish but limited stock of snacks existed. The manager said care staff were able to purchase some snacks in addition to the meals provided. The meals seen appeared to be of a nutritional balance. The inspector was informed that some users were also able to undertake cooking as a part of an activity using facilities provided for them. One user had recently baked some cakes. The diverse needs of people using the service were also met in regards to their nutritional needs and cultural preferences. One non-European user was able to prepare his own cultural meal with the assistance of care staff. The kitchen staff also catered for users with different cultural needs and diabetics. Care staff said one user was able to have halal meat. Latham House DS0000060512.V347490.R02.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 the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Systems were in place to ensure people using the service received personal and emotional support and adequate systems for medication was available for all users but further development was needed to ensure all medications administered are accounted for, as a results users health care needs could be compromised. EVIDENCE: People using the service received personal support in varied ways in meeting with individual needs. One user was able to say she liked music and enjoyed staff taking her shopping. She said she was happy at the home but did not like another one of the user who often displayed behaviours that challenged the service. Care staff were also observed to accompany users to activities of their choice. The users had recently chosen their annual holiday to go to Blackpool and Waymouth. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 16 The care plan documentation seen suggested user physical and emotional needs were met. The reviews undertaken showed how the home would attempt to meet the health care needs of users. The home had regular monthly visits from the GP and their medication and other health care needs were regularly assessed. The inspector observed the manager trying to resolve one user who had an epileptic seizure and subsequently had to have blood tests. Records also showed that other users medical needs were reviewed on a regular basis. The privacy and dignity was maintained for most of the people using the service but one user had no form of protection at his windows and as a result his privacy and dignity was compromised. The inspector was informed that this user continued to remove his curtains when he became anxious. It was advised that other forms of protection could be used to maintain his dignity. The home had clear medication procedures and care staff were observed to administer medication confidently and in line with company procedures. There was however a need for staff to be more vigilant as on two occasions staff failed to sign for medication administered. Only staff trained to administer medication were able to do so. Staff explained to the inspector the processes for ordering, receiving administering and disposing of medication. Latham House DS0000060512.V347490.R02.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 poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Some systems existed for users views to be listened to but further development is needed to ensure users complaints are satisfactorily recorded, staff understand safeguarding procedures and all incidents that affect users safety are reported in accordance with the Care Homes Regulations 2001 and local safeguarding protocols. EVIDENCE: The home made efforts to listen to the views of people using the service. The home’s most recent residents meeting was held on the 27th of July 2007 and surveys were undertaken using questionnaires for people using the service. However further development was needed in this area to make residents meeting more frequent and to ensure the results of the questionnaires are evaluated and where necessary changes made to reflect the best interests of people using the service. The home failed to satisfactorily report incidents using the correct Safeguarding procedures that happened to people using the service. The manager said she was not aware that all incidents should be reported as several incidents could happen to users due to the severity of their disability and some users would self-harm. It was noted that from the three users files inspected there were 16-recorded body charts detailing marks on people’s bodies but only 2 of these events were reported to. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 18 The care staff spoken to said they understood how to report incidents of suspected abuse but when challenged were not able to demonstrate knowledge in this area. 19 of the 26 staff training records showed that staff had undertaken abuse training in 2006 but only 2 care staff had this training in 2007 to encompass the new Safeguarding regulations. The complaints procedures also needed further development to ensure the procedures followed in the event of a complaint can be audited. Since the last inspection the home received two complaints and although some correspondence was seen it was not clear what the outcomes were for the complainant. The manager said some information was held by the area manager and as a result was not available in the home. The inspector was informed that one of the complaint was resolved satisfactorily and not upheld. Three of the users finances were audited and all found to be satisfactorily recorded with receipts for all transactions. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 19 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): 24,25,26,27,28 & 30. People who use the service experience a poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Systems were in place to ensure users bedrooms suited their needs and life styles but further development was needed to ensure a homely and comfortable environment was provided for the users and that their dignity and privacy is maintained at all times as a result users did not have a welcoming home in which to live. EVIDENCE: The home was split in two units each catering for 6 users. Some users were less challenging and the inspector was informed that because of this they did not damage furnishings as much as other users. It was evident that one unit was in more need of decorating than the other. The inspector observed that several areas including bathroom’s toilets, communal area and bedrooms were in need of redecorating. There was deterioration and discolouring of walls and ceilings and some furnishings were old and needed revarnishing or replacement. Some walls had holes and walls Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 20 were cracked, door framed shaken, door handles broken and large cracks appeared throughout. The manager and area manager provided information to suggest works to improve the decorative state of the building was due to commence in 4 weeks time. The manager also had an inventory of all the jobs required to be completed. Some bedrooms inspected showed that users took pride in their bedrooms but the majority of the bedrooms showed that users when anxious would demonstrate their anger by destroying personal belongings and as a result a wholesome environment appeared difficult to maintain. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 21 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 the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff were satisfactorily recruited, skilled, trained and supervised to meet the needs of people using the service, as a result users were protected. EVIDENCE: The staff at the home were well developed for their job roles through proper induction training and development plan. There was a key workers system and clear job descriptions available for all care staff. The homes recruitment procedures were robust and included satisfactory clearances and references prior to commencement of employment. Staff spoken to said they felt skilled and competent in meeting the needs of people who use the service. All staff felt supported by the manager but some felt that there was a lack of teamwork, which resulted in discrepancies within the team. The staffing levels had been reduced from 12 staff being on shift to 10 but the inspector was reassured that this was still adequate in meeting the needs of people using the service as not all users required 1to 1 care. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 22 All care staff spoken to had achieved their NVQ level 2 in care and said they were able to access other courses on a regular basis. It was calculated that 79.3 of the staff team had achieved this qualification. It was observed however that refresher training was needed in some areas to ensure all staff had the skills and competency required. For example not all staff had received training in medication, abuse, risk assessments and Infection Control. Staff spoken to said they received regular staff meetings and supervisions. The files inspected suggested that this was undertaken. Last meeting was recorded in July 2007. The manager had a rota to show that all staff had a date for their supervision to be undertaken. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 23 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): 37,38,39,41,42 & 43. People who use this service experience a poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Some systems were in place to ensure the running of the home but further development was needed to ensure users views are monitored and health and safety for users are maintained, as a result people using the service were at risk. EVIDENCE: The manager had been in post for just over 12 weeks. She appeared competent and knowledgeable about the needs of the people using the service. She was a qualified nurse and midwife and had embarked on her Registered Managers Award. She had made changes that reflected positively for both the people using the service and the care staff. All spoken to said they felt confident in approaching Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 24 the manager should they have a problem. The inspector observed staff entering the manager’s office during the inspection. She said she operated an open door policy. There were procedures in place to ensure the home was run in the best interest of people using the service. The home had made efforts in finding out the views of people living at the home by having residents meetings and questionnaires, but further development was needed to ensure the monitoring of these views are evaluated and used positively to benefit the users. The home did not have a cyclical development plan for aspects of quality assurance. He home had a health and safety policy and procedures were in place to protect people using the service, however further development was needed to ensure all aspects of the home protects the people using the service. For example the hot water distilled from one hand basin was of the extreme temperature that could cause scalding. The maintenance person said he isolated the water immediately and would ensure that it would be fixed. It was also noted that none of the electrical appliances in the home had been tested for safety. The home carried out regular fire evacuations and tests of all fire equipments. There was evidence to suggest all alarms were tested by external professionals on a regular basis. The home needed to ensure they had an up to date risk assessment for the environment. The inspector was provided with an assessment, which was completed in 2004 but had not been reviewed. Since the inspection the home forwarded a more recent assessment carried out on the 7th of August 2006. The manager provided accountable service to people using the service. She was also supported by an area manager. She had applied for registration and was awaiting her interview date. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 3 2 X 3 1 2 Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement Arrangements must be made to ensure records of all medication administered is signed and accounted for. Arrangements must be made to ensure clear and effective complaints procedures are implemented that includes the stages, timescales and the process to enable users to know how and who to complain to. A clear audit trail must be evident. The manager must ensure ‘Safeguarding’ training is included in the mandatory training programme. Previous timescale: 31/10/06 All areas of the home must be decorated to present a welcoming and homely environment that meets the collective needs of people using the service. Arrangements must be made to ensure all staff are trained in Risk Assessments and Infection Control. The manager must ensure CSCI DS0000060512.V347490.R02.S.doc Timescale for action 30/09/07 2 YA22 22 (1) (3) (4) 30/09/07 3. YA23 13(6) 30/10/07 4 YA24 23 (2) (a) (b) 30/10/07 5 YA35 18 (1) © (i) 37(1)(e) 30/10/07 6. YA37 30/09/07 Page 27 Latham House Version 5.2 7 YA39 24 (1) (a) (b) 8 YA42 13 (4) (a) 9 YA42 13 (4) (a) 10 YA42 13 (4) (a) is notified of any event in the home that may adversely affect the wellbeing or safety of any service user. Previous timescale:31/10/06 Further development must be made to ensure satisfactory systems are implemented in monitoring the views of people using the service. Arrangements must be made to ensure all hot water distilled from taps are at a safe temperature for users and will not cause scalding. Arrangements must be made to ensure all electrical appliances are tested for safety at least annually. Arrangements must be made to ensure an updated fire risk assessments is available for the home. 30/10/07 30/09/07 30/09/07 30/09/07 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 2 3 4 Refer to Standard YA5 YA9 YA18 YA20 Good Practice Recommendations Arrangements should be made to ensure a written costed contract/statement of terms and conditions is obtained between the home and individual users. Arrangements should be made to ensure all risk assessments receive regular reviews and dates are recorded on assessment documentation. Arrangements should be made to ensure all users privacy and dignity is maintained at all times. Arrangements should be made to ensure all staff are trained in the procedures to follow for controlled drugs. Latham House DS0000060512.V347490.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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.V347490.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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