Inspection on 20/06/06 for Lawrie Park Lodge

This inspection was carried out on 20th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lawrie Park Lodge 26/10/07

Lawrie Park Lodge 21/02/07

Lawrie Park Lodge 09/01/06

Lawrie Park Lodge 17/08/05

Lawrie Park Lodge 22/11/04

Lawrie Park Lodge 25/06/04

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

CARE HOME ADULTS 18-65 Lawrie Park Lodge 27 Lawrie Park Road Sydenham London SE26 6DP Lead Inspector Ornella Cavuoto Unannounced Inspection 20th June 2006 10:00 Lawrie Park Lodge DS0000025630.V300137.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 Lawrie Park Lodge DS0000025630.V300137.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. Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lawrie Park Lodge Address 27 Lawrie Park Road Sydenham London SE26 6DP 0208 778 5388 0208 778 5404 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) Mr Nundoo Nand Seeboruth Mr Nundoo Nand Seeboruth Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Lawrie Park Lodge is a large detached house located in a quiet residential road in Sydenham. A bus service passes the door and two railway stations are within walking distance as well as local shops, pubs and community facilities. The home is registered for 19 adults of either gender between 18 and 65 who have experienced mental health related issues. Accommodation is provided over three floors of the house. Communal space is provided on the ground and lower ground floor. The proprietors have extended the communal space with the provision of a large conservatory attached to the dining room on the lower ground floor. The home has an in house activity programme in addition to supporting people to access activities outside of the home. Lawrie Park Lodge DS0000025630.V300137.R01.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 that was carried out over one day. The registered provider/manager was present for the inspection and was involved with the process. Also, as part of the inspection eight service users were spoken to and two staff members. Other methods used included inspection of care records and a partial tour of the premises. What the service does well: What has improved since the last inspection? The home has introduced monthly key worker sessions with service users to monitor their progress and identify individual goals. Holidays have been arranged for some of the service users whilst negotiations are still being carried out with local authorities to ensure that other service users are offered a holiday. The registered manager has provided new and additional furniture items for those service users who have requested them. Visiting professionals to the home are now recording feedback about their visits in service user notes. Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 7 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 Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Prospective service users needs are assessed prior to admission. Service users have been issued with contracts/statements of terms and conditions. EVIDENCE: Two service users who have been recently admitted to the home had their needs fully assessed prior to admission to the home. There was evidence in both service users’ files of a recent Care Programme Approach summary report as well as additional information that included a psychiatric report and nursing summary for one of the service users and both had discharge summary reports that had been obtained. Service users’ files that were examined included evidence that service users had been issued with a contract/statement of terms and conditions that they had signed and which incorporated all the information specified within the National Minimum Standards (NMS). Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7& 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Service users’ care plans generally were comprehensive and did reflect their changing needs and goals although not all care plans had been signed by service users reflecting their involvement in the care planning process nor had they all been reviewed. There was evidence that service users are supported to make their own decisions but service users need to be given information regarding advocacy services to support them. Although risk assessments in place generally addressed service users’ needs they were in need of being reviewed. EVIDENCE: The six care plans examined were generally comprehensive covering the required areas to ensure that service user needs are addressed. It was evident that care plans were based on information contained in CPA summaries and other reports obtained and included interventions and procedures where service users may present with aggressive or self- harming behaviour. This has also been addressed in risk assessments that have been drawn up (See Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 10 Standard 9). Each service user had a care plan checklist in place that is initially used to help identify which care needs should be included in a care plan for individual service users. However, only one of the care plans had been signed by a service user and although there were review dates included in the care plans apart from one, three of the care plans had not had a six monthly review where dates indicated that they had been due to be carried out. Also, it was noted that on one of the care plans inspected it had been entered that the care plan should be reviewed in twelve months time. It was reported that the consultant psychiatrist had advised this. However, all care plans under National Minimum Standards (NMS) need to be reviewed six monthly. There was evidence of detailed daily recording for service users and that service users have attended regular CPA review meetings although minutes of the meetings had not always been obtained with two of the service users whose files were inspected not including minutes (See Requirements & Recommendations). In terms of supporting service users to make their own decisions monthly key worker sessions have been introduced by the home to discuss service users’ care plans their progress and to look at individual goals but these had not been held on a regular basis with some service users having no key worker sessions recorded. One service user also commented that they are not always sure when they are due to have a key worker session as they have not always been informed in advance. The majority of service users spoken to stated that they managed their own finances. Other service users are being supported to work towards taking responsibility for their own money. The home also holds a weekly community meeting to which all service users attend and offers them an opportunity to give and receive information and have input into decisions made about the running of the home. It was noted that the home did not provide service users information regarding advocacy services. The registered provider/manager reported that service users could access this information from the day centres where they attend or via their care co-ordinator. However, it is advised that this information is also made available within the home (See Recommendations and details regarding standard 22). All service users have a risk screen carried out with them. There was also evidence that detailed risk assessments had been carried out in respect to service users’ individual health needs, for example for those service users who are diabetic although one service user was identified as taking an anti coagulant medication that needs careful monitoring and this had not been included in their risk assessment. Yet, there was evidence within daily recording that staff were aware of the risks associated with taking this medication. Where service users presented with aggressive or challenging behaviour such as going missing this was also addressed within risk assessments. However, risk assessments had not been reviewed and were not all signed by service users, this needs to be addressed. In addition, in respect to service users’ mental health needs although service users did have crisis plans in place that were included in their CPA summaries including triggers and symptoms of relapse, these were not clearly addressed within a risk Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 11 assessment or individual care plans. It was evident in discussing these issues with staff that they were not fully aware of the crisis plans and the action needed to be taken stating they would contact the registered provider/manager if they had concerns about a deterioration in a service user’s mental health. Therefore, this information needs to be made more explicit within either a risk assessment or service users’ care plans (See Requirements). Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 &17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Service users are provided with opportunities to take part in valued and fulfilling activities although where appropriate the key worker system should be used to support service users to engage in individual activities. Service users are integrated into the local community. Although the home has arranged for some of the service users to go on an annual holiday further measures need to be taken to ensure all service users are provided with the opportunity to have a holiday and where service users refuse evidence of this needs to be provided. Although service users are supported to maintain contact with family and friends, restrictions in relation to visitors needs to be more clearly addressed within the service user guide and statement of terms and conditions or where appropriate individual care plans. Generally the home’s daily routines do promote independence, and freedom of movement. Service users are offered varied and nutritious meals. Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home has a comprehensive weekly activities programme that includes exercise to dance, relaxation therapy, social skills, assertive training, budgeting, cookery classes, arts and crafts, beauty sessions, bingo and quiz nights amongst others. The majority of service users stated that they did get involved in most of the activities provided but one service user commented that the activities are quite boring. Another service user stated they would like the opportunity to do things with their key worker and to go out on group outings. It was reported that service users are generally encouraged to be as independent as possible. However, where appropriate the key worker system should be used to support service users to engage with activities and to structure their time. Also, it is recommended that as part of the weekly community meeting the activities programme be periodically reviewed to ensure that all service users have an opportunity to contribute their ideas and preferences on activities they would like to be provided. A number of the service users attend local day centres where they get involved in a range of social activities. One service user spoken to stated they had attended adult education classes in the past where they did Maths and English whilst another service user said they are hoping to attend college. There was evidence within another service user’s care plan that with the support of an occupational therapist different training options were being explored with them (See Recommendations). The majority of the service users spoken to made good use of the local community with service users using the local shops, attending church, going for walks in the local parks. One service user stated they regularly go and play snooker and pool locally. At a previous inspection it was identified that service users had not been offered as part of the basic contract price the option of a minimum seven– day annual holiday. At the last inspection this had still not been arranged although the registered provider had written to commissioners to ask advice about meeting this requirement. At this inspection a holiday had been arranged for four of the service users to go on a holiday in August. In respect to the other service users living at the home it was reported that a list had been drawn up of some service users who had stated that they did not want a holiday. Although this list was not available for inspection one service user spoken to did state they did not want to go away. It is advised that for those service users who do not want a holiday that they sign a statement to clearly evidence their refusal and this is kept on their individual files. For other service users, the registered provider stated that negotiations are still in process with local authorities to try to arrange holidays (See Requirements). There was evidence from service users’ care plans that they do have regular contact with their family and friends, which was confirmed by those service Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 14 users spoken to who stated that they go to visit family and friends as well as family and friends being able to visit them at the home. However, one service user stated that they were not allowed to have visitors including family members in their bedroom. On addressing this with the registered provider it also became evident that restrictions had been placed on another service user being able to take their boyfriend into their bedroom for privacy. Reasons provided for these restrictions were not entirely appropriate. The home needs to avoid making a blanket policy on where service users can see visitors and circumstances where possible restrictions may have to be put in place should be made clear in the service user guide or statement of terms and conditions. Where individual restrictions are to be put in place these need to be addressed within a risk assessment or the service user’s care plan (See Requirements). Apart from the restrictions for service users’ visitors that have been discussed and restrictions on service users smoking in their bedrooms, which have been addressed within service users’ individual risk assessments following a requirement made at a previous inspection, the home’s daily routines and house rules do aim to promote independence and freedom of movement. Service users were seen to come and go freely from the home and were also able to choose when to become involved in an activity or not. The home has a four- week rolling menu that offers varied and nutritious meals to service users who are offered a choice. The menu is given to service users in advance so they can inform the chef which choice of meal they would prefer or if they would like an alternative. There are some foods included in the menu that cater for those with specific cultural needs. Service users spoken to were happy with the food. One service user reported that the chef who has recently started working at the home has made an effort to attend the weekly meetings to consult with service users about what they would like included on the menu. Lawrie Park Lodge DS0000025630.V300137.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Service users receive the personal support that they need. The physical and mental health needs of service users are addressed. The home has robust policies and procedures but there were areas of concern identified in the handling and storage of medication. EVIDENCE: Generally service users within the home are encouraged to be as independent as possible with regards to addressing their own personal care needs. The home offers a health and hygiene group to provide information and guidance in this area. Yet, there was evidence that for service users who are prone to self neglect this had been addressed within care plans and that service users are supported in the way of being prompted by staff to address their personal hygiene. The home also operates a key worker system to ensure consistency of support. There was evidence within service user care plans that individual physical and mental health needs are generally addressed and monitored for example where service users have a specific health condition such as diabetes this has been looked at in detail within care plans and risk assessments. Service users also Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 16 have regular contact with mental health professionals. On the day of the inspection a community psychiatric nurse visited the home to see one of the service users and in relation to a previous recommendation visiting professionals now provide written feedback in service users’ notes. Also, as mentioned previously there is also regular attendance of CPA review meetings although the minutes of these were not always available. The home has a medication policy that covers areas in relation to receiving and ordering medication, administration, disposal and procedures for issuing medication to service users whilst on leave away from the home. This was supplemented with more detailed documents including the UKCC Guidelines for the Administration of Medicines to ensure staff have comprehensive information to ensure service users are protected. Subject to a previous requirement the home has carried out weekly audits of the medication. However, in checking a sample of the Medication Administration Record (MAR) sheets several discrepancies were identified in relation to the stocks of medication/tablets recorded on the audit sheets to those that were actually in place. As a result of these findings a referral was made to the Pharmacy Inspector to carry out a more detailed inspection of the home’s medication system. Whilst this identified a number of strengths including MAR sheets being accurately completed with no missing signatures and that there is regular input from the Community Mental Health team, four requirements were stated in the report including one that relates to a previous requirement around staff receiving adequate medication training. For further details or to see a copy of the report please contact CSCI (See Requirements). Lawrie Park Lodge DS0000025630.V300137.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Service users feel their views are listened to although the complaints policy needs to address how complaints against the home will be dealt with objectively. The home’s adult protection policy is comprehensive but staff still need to receive training in adult abuse. EVIDENCE: In respect to the home’s complaint policy although this included stages and timescales for the process, the policy does not clearly state how complaints made against the registered manager who is also the registered provider/owner of the home will be dealt with objectively. This needs to be addressed with information about where service users may access support for example from independent advocacy services being included in the policy (See Requirements). Service users spoken to stated they had not had any reason to complain but that were clear they would address any concerns with staff. One service user mentioned that they could bring issues/concerns to the weekly community meeting and in respect to this said, “If you put things forward they will try to get it done”. The home has had only one minor complaint since the last inspection that was dealt with appropriately. The home’s adult protection policy has not been reviewed since 2004 but it is robust and includes details about different types of abuse and action to be taken by staff in the event that abuse was identified or suspected. A previous Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 18 recommendation that the home obtain a copy of the local multi agency adult protection procedures to ensure staff have access to up to date information has not been addressed. In addition, a previous requirement in respect to staff receiving training in adult abuse has not been met. It was reported that training was arranged with Lewisham Council to be held in March but this was cancelled and as yet a new date for the training has not been set (See Requirements & Recommendations). Lawrie Park Lodge DS0000025630.V300137.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 28 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The home is generally well maintained and provides a safe and homely environment for service users. Service users bedrooms do generally meet their needs but some items of furniture are in need of being repaired/renewed and also flooring in en-suite toilets needs to be cleaned or replaced. Shared spaces complement and supplement individual service users’ rooms. The home is clean and hygienic. EVIDENCE: The home’s premises are suitable for its stated purpose, are accessible safe and generally well maintained. It is located in a residential area on a main bus route for the shops and facilities and other transport links in Sydenham. All of the accommodation is in single rooms and all of the rooms have en- suite toilets with a wash- basin. Previous inspections had noted that some of the service users did not have all the required items in their rooms and although the home had encouraged service users to personalise their rooms some did not want anything additional in their rooms but this had not been documented. Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 20 At this inspection there was evidence this has been addressed with letters on individual service users’ files of a letter asking service users if they want additional items of furniture and refusals noted. Although new bedroom furniture has been purchased for some service users inspection of a sample of service users rooms identified some items of furniture were still in need of being repaired or renewed, for example a wardrobe had one of the drawers at the bottom missing, another had a chest of draws with handles missing. In addition, a carpet in one of the rooms was frayed and taped used to repair it. Weekly audits of the premises should be completed in order to ensure that broken items are identified and repaired/ replaced efficiently in order that service users feel valued. Also, within all the rooms inspected the carpet in the en-suite toilets were badly stained and in need of being cleaned or replaced with a more suitable type of flooring that could be more easily cleaned and is more hygienic (See Requirements). The home has a number of shared spaces including a large communal lounge on the ground floor, which is bright and airy and has satellite television provided. There is a dining room in the basement and a conservatory that has a television but there is also a quiet room at the back. There is a large garden at the rear of the property. The home was clean and hygienic on the day the inspection was held. There are laundry facilities on each floor that are suitable and are sited away from where food is prepared. Lawrie Park Lodge DS0000025630.V300137.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 &36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service The majority of staff working at the home have completed or working towards achieving a National Vocational Qualification (NVQ) in care. Although, generally the home’s recruitment practices do protect service users evidence of identification has not been obtained for all staff members and the home is still to evidence that the interview format complies with equal opportunities policies. Although there was some evidence that the home is carrying out an appropriate induction programme, a training plan to address the individual and collective needs of the staff and service users has still not been completed. Staff are appropriately supervised. EVIDENCE: It was reported that six staff members working at the home have completed or are working towards a NVQ Level 2 or Level 3. This ensures that the home has reached the required target as stated within the National Minimum Standards that 50 of staff working at the home need to have attained or are progressing towards attaining a NVQ. In terms of recruitment a sample six staff files were checked and the majority of these were found to include all the required information except for two that Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 22 did not include any documents verifying the identification of the staff members. This is required under regulation and needs to be addressed. In addition, at the last inspection it was identified that the interview format used by the home did not adhere to equal opportunities principles and this needed to be looked at with a new interview form being developed. At this inspection, the registered provider stated this had been completed but had not as yet been used. However, there was no evidence of this available for inspection (See Requirements). Subject to a previous requirement that a training plan should be drawn up based on an assessment of the individual and collective needs of the staff and service users has not been met. The plan must detail the training that is planned and to be provided for a twelve-month period including mandatory training of which was there was limited evidence within staff files that this had been completed and also NVQ training and other specific training to support staff to meet individual needs of service users. In respect to induction, the registered provider reported that this does meet with Skills for Care specifications and that new staff are issued with a work book that they keep and this is then looked at during supervision sessions. There was evidence of a letter on one of the staff files signed by the staff member and the registered provider that they have been issued with a workbook and the staff member confirmed they were presently working through it. However, it is also advised that a copy of the completed workbook is kept on staff files as evidence that a full induction programme has been undertaken (See Requirements and Recommendations). There was evidence that staff have received regular supervision which covers appropriate topics that includes looking at key clients and the key worker role, policies, training and general issues pertaining to the work environment. However, annual appraisals have not been completed with staff. These should also be used as a basis on which a training plan should be drawn up and therefore need to be completed (See Requirements). Lawrie Park Lodge DS0000025630.V300137.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service The registered provider/ manager is very experienced and holds appropriate qualifications to ensure that the home is well run. The home has some quality assurance systems in place but further improvements in this area are required. The health, safety and welfare of service users are protected. EVIDENCE: The registered manager/provider is very experienced having worked for many years in both hospital and community settings. He is a Registered Mental Health Nurse (RMN) and has also completed a Diploma in Management Studies (DMS). In addition he regularly has clinical and management supervision that is externally provided. In relation to quality assurance it was reported that that the home had completed a customer satisfaction survey with service users in June 2005 the Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 24 results of which were drawn together in a report and verbally fed back to service users. Evidence of the report detailing the results of the survey was seen but a copy of this should be made available to service users and any other interested parties including CSCI. It was explained that another service user survey is due to be completed in July 2006. However, as identified at previous inspections surveys, for the views of relatives and professionals involved in the service to be obtained, have not yet been compiled. This needs to be addressed. In addition, the home has not completed an annual development plan that is based on a systematic cycle of planning- action – review reflecting aims and outcomes for service users. The home has not addressed a previous recommendation that a more formal preferably external professionally recognised quality assurance system be implemented that would enable an improved overview of whether the home is achieving its aims and objectives in this area. This was discussed further with the registered provider/manager at this inspection who stated that at this point he would prefer to continue to address quality assurance internally. This will be reviewed at future inspections (See Requirements). Generally, there was evidence that the home does protect the health, welfare and safety of service users with policies and procedures being in place covering all aspects of health and safety. An up to date fire and building risk assessment being completed. Fire equipment had been inspected and maintained, fire alarm call points had been tested weekly, emergency lighting had been maintained and tested regularly and fire drills had been carried out at different times. There were also up to date maintenance certificates in place for electrical portable appliances and wiring, gas safety and boiler checks, lift maintenance. However, there was not an up to date certificate available regarding the testing for Legionella, the only one on file having been completed in 2003. Also, as mentioned all staff must complete mandatory training in areas such as food hygiene, infection control, manual handling and general health and safety training (See Requirements and details for Standard 35). Lawrie Park Lodge DS0000025630.V300137.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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(2) Requirement The registered manager/provider must ensure that all care plans that are drawn up are signed by service users to indicate their involvement and understanding of the care planning process and that these are reviewed on a six monthly basis. The registered manager/provider must ensure that all risks presented by individual service users are included in a risk assessment and that these are regularly reviewed. The registered manager/provider must ensure that where crisis plans are in place for service users indicating action to be taken when service users mental health deteriorates that these must clearly be addressed within a risk assessment or care plan to ensure staff are fully aware of their content. The registered provider/provider must ensure that service users have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which DS0000025630.V300137.R01.S.doc Timescale for action 31/01/07 2. YA9 13 (4) (c) & 14 (2) 31/01/07 3. YA9 13 (4) (c) 31/01/07 4. YA14 12 (1) (a) 31/01/07 Lawrie Park Lodge Version 5.2 Page 27 5. YA15 16 (2) (m) 6 YA20 13(2) 7. YA20 18(1) (a) 8. YA22 22(2) 9. YA23 13(6) 10. YA26 16(2) (c) they help choose and plan. (Previous timescale of 31/12/05 not met and previous timescale of 31/05/06 partially met) The registered manager/provider must ensure that circumstances where restrictions on visitors may be imposed is clearly specified within the service user guide and statement of terms and conditions and individual restrictions should be addressed in either a risk assessment or care plan. The registered manager/provider must ensure that medication is audited weekly. (Previous timescale of 31/03/06 partially met discrepancies not investigated) The registered manager/provider must ensure that medication training for staff is adequate covering the points listed in Standard 20.10. (Previous timescale of 30/04/06 not met Continued noncompliance with this requirement may result in enforcement action being taken). The registered manager/provider must ensure that the complaints policy addresses how complaints made against the home’s management/owners will be objectively investigated and that information is included where service users can seek independent advice/support. The registered manager/provider must ensure all staff have adequate training in adult abuse. (Previous timescale of 31/05/06 not met) The registered manager/provider must ensure that broken DS0000025630.V300137.R01.S.doc 31/01/07 31/08/06 31/08/06 31/01/07 31/01/07 31/03/07 Lawrie Park Lodge Version 5.2 Page 28 11. YA34 19 (1) (b) Sch 2 12. YA34 17 (2) schd 4,6 (f) 13. YA35 18 (1) (a) 14. YA36 18 (2) 15. YA39 24 furniture is repaired or replaced and that weekly audits of the premises rooms are carried out to ensure awareness of any breakages. Also, that carpets in the en -suite toilets are cleaned or replaced with flooring that can be more easily cleaned. The registered manager /provider must ensure that all documents including evidence of identification are obtained prior to allowing staff to commence working within the home. The registered manager/ provider must develop an interview format in accordance with equal opportunities and ensure records of interviews are kept on staff files. (Previous timescale of 31/05/06 not met) The registered provider must develop a training plan for the home, based on an assessment of staff needs and the needs of service users. The plan must detail the training that is planned and provided for a twelve-month period including mandatory training and NVQ’s as well as training specific to the service user group (Previous timescale of 31/05/06 not met) The registered provider/ manager must ensure that annual appraisals are carried out with all staff. The registered provider/manager must ensure that as well as surveys conducted with service users that the views of relatives and professionals involved in the home are also obtained and the results of all surveys are compiled in a report that is accessible to service users and DS0000025630.V300137.R01.S.doc 31/01/07 31/01/07 31/01/07 31/03/07 31/03/07 Lawrie Park Lodge Version 5.2 Page 29 16. YA42 13 (4) (c) other interested partied including CSCI. Also, that the home draws up an annual development plan. The registered manager 30/09/06 /provider must ensure that an up to date certificate for the testing of legionella is obtained. 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 YA7 Good Practice Recommendations The registered manager/provider should try to ensure that copies of CPA review meetings are obtained. The registered manager/provider should try to ensure that service users receive monthly key work sessions and that they are informed in advance of the date and time of when the sessions are to be held. The registered manager/provider should try to ensure that information on independent advocacy services is made available within the home. The registered manager/provider should try to ensure that the key worker system is used effectively to engage where appropriate service users in leisure activities and to structure their time. Also that the weekly community meeting is used to periodically review the activity programme. The registered manager/provider should try to ensure that the home accesses the most recent review of the local multi agency adult protection procedures to ensure up to date information. The registered manager/provider should try to ensure that a copy of the induction workbook is kept on staff files once completed as evidence that a full induction programme has been undertaken. 3. 4. YA7 YA12 5. YA23 6. YA35 Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lawrie Park Lodge DS0000025630.V300137.R01.S.doc Version 5.2 Page 31 - 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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