Inspection on 22/02/07 for Lavenders (The)

This inspection was carried out on 22nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lavenders (The) 19/01/09

Lavenders (The) 06/12/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Lavenders (The) 145a Friern Park Finchley London N12 9LR Lead Inspector Jackie Izzard Key Unannounced Inspection 22 February 2007 09:30 Lavenders (The) DS0000065434.V325860.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 Lavenders (The) DS0000065434.V325860.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. Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lavenders (The) Address 145a Friern Park Finchley London N12 9LR 020 8445 9978 020 8445 9974 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) CareTech Community Services (No.2) Ltd No registered manager Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The bungalow is registered to provide two of the establishment’s eight places, the remaining six being provided in the main building. One bungalow (145b) can accommodate a wheelchair dependent service user. The call system within the bungalow must be fully functioning at all times. The second bungalow (145c) is not suitable for a wheelchair dependent service user. 6 December 2005 2. 3. Date of last inspection Brief Description of the Service: The Lavenders is a care home for eight adults who have learning and physical disabilities. There is an adjacent building which accommodates two of the eight people in self contained accommodation. The home is owned and managed by CareTech Community Services Ltd. The home which is located in a quiet residential street in North Finchley, is set back from the main road, and is within walking distance of shops and other amenities. The service users who live in the bungalow are also assisted by staff in the main building. The stated aim of the home is to work in partnership with the service users, their carers, purchasers and any other relevant agencies providing an individual support plan for each user of the service, with users being encouraged to attain their full potential determined by individual need. The current fees charged for living at The Lavenders ranges from £875.49 to £1762.45 per week. Following “Inspecting for better lives” the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The last inspection report was seen to be displayed on the wall in the home when the inspector arrived for this inspection. Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. THIS SUMMARY IS WRITTEN FOR PEOPLE LIVING AT THE HOME. This was an unannounced inspection, so nobody at The Lavenders knew the inspector was coming. The inspection lasted for one day. The inspector did the following ; • met seven of the eight people who live at The Lavenders and was able to speak with four of them. • • • • • • • Spent time talking to the manager Looked around the home Checked four people’s files Checked two staff files Looked at the home’s records Looked at people’s money Listened to the opinions of three relatives of people living at the home What the service does well: • • The Lavenders finds out and writes down people’s individual needs. People living in this home are encouraged to live an active life, going to college or daycentres and following their own leisure interests (going out for a meal, cinema, bowling, etc). There are clear risk assessments written down to keep people safe from harm but letting them be as independent as they can be. Staff spend time talking to people to find out what they want to do and help them make plans for each month Staff keep the home clean and comfortable for the people living there. Good records are kept so that other people can see what people living at the home have been doing DS0000065434.V325860.R01.S.doc Version 5.2 Page 6 • • • • Lavenders (The) • • Staff are given training to help them look after people better Three of the four people who talked to the inspector said that staff treat them well and they are happy living at this home. What has improved since the last inspection? What they could do better: At the last inspection CareTech was asked to • • include information about the manager and details of staff qualifications in the statement of purpose for the home to ensure that people living at the home are given a contract that is produced in a format they understand. Neither of these has been completed yet so they are repeated in this report. CareTech also need to do the following things • The staff need to keep records of people’s weight to help keep a check on their health and to see if they are eating the right kind of food for them CareTech must make sure this home knows who is supposed to pay when people go out for a meal, and pay people back if they are owed any money because they paid for their own meals out. CareTech need to ask for an investigation about how one person’s finances have not been looked after properly and tell the inspector the result of this investigation when it has been carried out. the broken scales in the activity room need to be removed to make sure nobody can hurt themselves if they fell on them. One staff member’s references need to stored in the home. staff should be advised what to write in the daily records about people’s cultural and religious needs. An Occupational Therapist should be asked to come and see one person to see if some new equipment could help him be more independent. • • • • • • Lavenders (The) DS0000065434.V325860.R01.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. Lavenders (The) DS0000065434.V325860.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 Lavenders (The) DS0000065434.V325860.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, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed and known to staff. They have an individual contract of the terms and conditions for living at the home but would benefit from a document that is more accessible to people who do not read well. EVIDENCE: A requirement was made at the last inspection to update the statement of purpose for the home. This had not been completed so the requirement is restated in this report. The file of the newest service user was inspected fro evidence of a thorough assessment of her needs. The assessment document was not in place. The manager said that this person had transferred from another CareTech home and the assessment had not been passed on. From examining the rest of the files, it was evident that the person’s needs were known to staff and clearly recorded in various documents. Three service user’s files were checked to see if they had a contract of the terms and conditions of the home. Each had a contract but this needs simplification as it is not written in a way that the service users can understand easily. Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 10 A requirement to make this document user friendly is at the back of this report. The contracts seen by the inspector were signed by relatives as the service users were not able to give informed consent to the terms and conditions. Lavenders (The) DS0000065434.V325860.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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are recorded and risks to their wellbeing known and acted on. Their views are sought and they are involved in decisions affecting their lives as much as possible. EVIDENCE: Three service users’ care plans were examined in detail as part of this inspection. Each had a person centred plan and support plan detailing the support they need from staff in all areas of their life. These are reviewed and daily records are kept so that it is possible to check whether their identified needs have been met. One person’s plan was not complete but the manager explained that this was in the process of being finished following a recent meeting held to review this Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 12 person’s care. Plans were reviewed regularly to ensure they were still relevant for that person. The inspector noted that staff were not clear what to record in the daily records regarding a service user’s religious and cultural needs. A recommendation is made at the back of this report to advise staff on what needs to be recorded for each service user. There was evidence that service users are consulted on day to day decisions regarding their lives. Each has a key worker and “talk time” is allocated each week, where the service user and their key worker sit together to talk about how the person is, discuss any concerns and make plans. The key worker records the session and the record is placed in the service user’s file. These were inspected for two service users and the inspector saw that they had made plans for the month ahead, with regard to activities and outings the person wished to do. The manager said that where a service user was not able to communicate their wishes and plans, the key worker still spent the “talk time” with them and involved them as much as possible in making their plans. The inspector talked to three service users about the key worker role. All knew who their key worker was and confirmed that they spent individual time together and that their key worker was helpful to them. One person explained in detail the level of support s/he received from staff to meet his/her needs. Risk assessments were looked at for two service users. These clearly recorded the risk to that person’s safety or wellbeing and what staff should do to minimise the risks. The risk assessments seen related to moving and handling a person who was non-ambulant, using a hoist, self harming behaviour and eating difficulties. Lavenders (The) DS0000065434.V325860.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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users follow their chosen activities and help to choose the food they eat. They are supported to go out in the community and maintain relationships with family and friends. EVIDENCE: The inspector looked at a sample of daily records and monthly summaries to see if the needs and preferences recorded in the service user’s care plans were being met. Each service user has an individual activity programme and monthly plan of activities. In the sample looked at, all the identified activities had taken place. In the daily records the person’s enjoyment level is recorded which is a good idea to ensure that the chosen activity is actually enjoyed. Activities recorded in the activity programmes (and that service users and the daily records confirmed had taken place) included trips to the cinema, Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 14 shopping, bowling and baking. Risk assessments were carried out where activities are taking place in the community. Seven service users go out to day services, college or employment during the week. One person is looking for daytime occupation at the time of the inspection. The manager said that all service users will be hoing on holiday in June 2007 in two groups of four, each with four staff. The holiday will be for three nights. The inspector observed two staff interacting with four service users and saw positive respectful interaction taking place. One service user told the inspector of his/her weekly programme of activities and said that it suited his/her needs and had helped him/her to become much more independent and happier. One person said they were currently unhappy at the home but continued to enjoy his/her activities. The other two service users spoken to said they were happy at The Lavenders. Service users said they enjoy relationships with their family and friends. Their choices of food are respected and they are involved in choosing the menu. Three service users confirmed that they were given food that they liked and the inspector saw written guidelines regarding one service user’s food preferences to help staff meet his/her needs. Another person had specific dietary needs due to his/her religion and records were kept to show that these were met. Some people need help with feeding and/or specially thickened food to help them swallow. Service users said they eat as a group . The scale used to weigh people who cannot stand up was broken. Records of monthly weights were therefore not up to date. Records showed this scale had been broken since at least May 2006. A requirement is made that all service users are weighed monthly or as often as considered necessary to ensure their nutritional needs are being met. Some service uses have assessed difficulties with eating and need regular monitoring. Those who need help to eat are assisted by staff. Lavenders (The) DS0000065434.V325860.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health needs are recorded and are met. They are given the support they need to access external health services and specialist support. Service users are protected by careful medication procedures and practices. EVIDENCE: The inspector looked at the support plans and daily records of three service users to see if their health and personal care needs are recorded and met. There was evidence of their health needs being addressed and appointments to GP, dentist and any other health professional were recorded clearly. All appointments were up to date for these three people. One person had requested a dental assessment and there was evidence that this request had been met. One service user needed a piece of equipment for health and safety reasons. A referral had been made for her. One person’s health action plan was inspected and found to be detailed regarding their medical and health needs and how staff should support her. Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 16 Three relatives gave their views on personal care and the overall standard of care. Two relatives considered the standard of care at the home to be good and one thought it was adequate. One service user told the inspector that s/he was happy with the personal care provided and that staff carried out these duties according to his/her wishes. There are two baths but no shower in the home. There is a shower attachment. The manager said that all current service users like baths so the current bathing facilities meet their needs. The inspector asked two service users if they preferred a bath or shower. Both said they preferred a bath and their support plan also stated this. After inspection of a service user’s bedroom and discussion with the service user and the manager of the home, a recommendation is made for one person to request an assessment by an Occupational Therapist for adaptations to his/her room to facilitate more independence. The manager said she would request this as soon as possible and that some handrails had already been requested. Medication was stored securely and the temperature of the storage space recorded regularly to ensure medicines were stored at safe temperatures. A sample of medication records for service users were checked and found to be recorded properly. All staff giving medication have attended training before doing so. Lavenders (The) DS0000065434.V325860.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ views are listened to and appropriate complaints and adult protection procedures used. Service users are protected from risk of abuse by trained staff. Their financial interests need further safeguarding. EVIDENCE: The inspector spoke with two service users about complaints and asked if they knew how to make a complaint and whether they felt confident to do so. Both said they felt able to make complaints. One person told the inspector that s/he had made a complaint and was not happy with the outcome. This was discussed. The complaint procedure is clear. The home has a whistle blowing policy and adult protection policy. The majority of staff have been trained in adult protection, ie recognising abuse and dealing with any allegations and /or suspicion of abuse. The staff who have not attended this training will do so in March 2007. The inspector looked at the home’s record of adult protection investigations. From the records, it was evident that appropriate procedures had been followed. The inspector looked at CareTech’s policies regarding service users’ finances to see if they protect service users from risk of financial abuse. Two areas of Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 18 concern were found during inspection of records for four service users. One concern was that one service user who was unable to make informed decisions about financial matters had incurred bank charges. A requirement is made to refer this matter to Barnet Council for investigation as this person is owed money. There was no evidence from preliminary inspection of the records that CareTech were at fault. The other concern was that practice in the home regarding service users having meals out is not in accordance with Care Tech’s written polices. The policy dated 1/8/06 entitled , “Use of service users’ monies” indicated that if a meal out replaces a meal that would have provided at the home, then Care Tech contribute £2 towards the cost of the meal. In practice, records and receipts showed that service users pay for their own meal if they went out for lunch or dinner. The manager said that she was not aware of the written policy. This discrepancy needs to be clarified, clear guidance given to the home and the policy made known to service users and their representatives. A requirement is therefore made on this matter. This appeared to be lack of clarity rather than abuse of service users’ finances. Although there are two requirements regarding service users’ finances, safeguards in place for the protection of service users from abuse are otherwise good which results in this area being judged as good. CareTech’s response to the requirements made will be monitored by the CSCI. Lavenders (The) DS0000065434.V325860.R01.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, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a clean and comfortable home with all the facilities they need. EVIDENCE: A tour of the building was undertaken, including all rooms used by the people living there. There are sufficient bathing and toilet facilities. People are allowed to personalise their bedroom and bedrooms in the main house have enough space for their personal belongings. All rooms other than one bedroom in the “bungalow” are wheelchair accessible. There are adequate bathing facilities for people who have a physical disability. A broken scale for weighing people who are non-ambulant was stored in the activity room. This was a potential hazard as a service user could potentially Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 20 fall on it so a requirement is made to remove it from the room and store it in a safe place. The home was clean and the condition of furniture and décor was good. The kitchen and laundry facilities were satisfactory to meet service users’ needs. There is a secure walled garden to sit in. Lavenders (The) DS0000065434.V325860.R01.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): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by vetted, trained staff in sufficient numbers to meet their needs. EVIDENCE: The statement of purpose of the home states that there are four staff on duty. The manager said that this is the case. On the day of this inspection there were four staff on duty. The bungalow has a call system so that the two service users there can call staff for assistance when needed. Supervision of service users, who have varying needs, was discussed with the manager. She said that the home’s policy is that the lounge is always supervised. Although all the service users who can walk are allowed to go to their bedroom or toilet without staff supervision, when people are in the lounge there is always a staff member present to supervise them. Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 22 Two staff files were inspected for evidence of a thorough recruitment procedure, adequate induction, training and supervision. The files indicated that both staff had a CRB disclosure and two references. The references for one were not in the file and the manager sad this was because they were held at head office. A requirement is made to give copies of the references to the home so that they are available for inspection there. Both staff had completed an induction programme to train them for the job. Both had attended other relevant training. One had completed NVQ level 2 and the other was in the process of this training. All staff are studying for NVQ level 2 if they have not already achieved this qualification. This is very positive and exceeds the national requirements for 80 of staff to have this level of training. Training records for the whole staff team were offered to the inspector to look at but were not inspected on this occasion. Both staff had records of regular supervision in their file. This is where they meet individually with the manager to discuss their work and progress. Lavenders (The) DS0000065434.V325860.R01.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, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home which strives to know and meet their needs and wishes. EVIDENCE: There has been change of manager since the last inspection of The Lavenders. The new manager was previously the deputy manager so is familiar with CareTech and the home’s practices and knows all the service users. The manager has NVQ level 3 training and is shortly to start NVQ4 which is required for a manager of a home. A new deputy is starting in March 2007 to support the manager. manager is supervised by the area manager. The Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 24 CareTech monitor the conduct of the home on a monthly basis and write a report of their own unannounced inspection,, as required by The Care Homes Regulations 2001. Service users’ views are listened to. Regular meetings are held as well as individual “talk time” on a weekly basis to ascertain service users’ views. For those who are unable to express their views in this way the manager explained how records of their enjoyment of activities helps staff to determine their views on how they spend their leisure time, which is very positive. Two service users told the inspector they feel fully involved in the running of the home and that their wishes were respected by staff. One service user undertakes the fire tests for the home and has other responsibilities which he said made him feel independent. One service user had been involved in interviewing potential new staff. Two relatives of service users told the inspector that they would like to be more involved in decision making and planning for the service user. The manager told the inspector that families were welcome to be part of the monthly review of each service user. A health and safety tour of the home was undertaken and a requirement made to remove a broken scale (see Environment section of this report). There were no other health and safety concerns. Fire doors were closing properly, medication and hazardous substances were stored securely and fire equipment had been inspected for safety. The home’s hoists had been serviced. Health and safety records were not inspected on this occasion as CareTech had undertaken a health and safety audit in January 2007 and the inspector was able to read this report. Lavenders (The) DS0000065434.V325860.R01.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 2 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 X 3 X x 3 X Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) (c) Schedule 1 Requirement The registered person must ensure that the statement of purpose contains the name of the registered manager and details of qualifications of staff in the home. This requirement is restated. Previous timescale of 30/01/06 not met. 2. YA5 5 (b) (c) The registered person must ensure that service users are given a contract that is produced in a format they understand and where necessary representatives are available to assist. This requirement is restated. Previous timescale of 30/01/06 not met. 3. YA17 17(1) sch 3 (3)(m) The registered person must ensure that all service users are weighed regularly and a record kept, to help ensure their health and nutritional needs are being met. 30/03/07 30/06/07 Timescale for action 30/04/07 Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 27 4. YA23 13(6) 5. YA23 13(6) 6. YA29 13(4)(a) 7. YA34 19, sched 2(5) The registered person must ensure that the home’s policies and practices regarding service users paying for meals are clarified and any reimbursements made to service users where needed. The registered person must ensure that an investigation is requested into the finance arrangements for a service user who has unknowingly incurred bank charges and report the outcome to the CSCI. The registered person must ensure the broken scales in the activity room are removed to ensure there are no hazards to people’s safety. The registered person must ensure that copies of a named staff member’s references are stored in the home available for inspection. 30/04/07 30/04/07 30/03/07 30/03/07 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 Refer to Standard YA6 YA18 Good Practice Recommendations Guidance should be given to staff on how to record whether service users’ cultural and religious needs have been met in the daily records. An assessment by an Occupational Therapist should be requested for a named service user to maximise his independence. Lavenders (The) DS0000065434.V325860.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lavenders (The) DS0000065434.V325860.R01.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. 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