Inspection on 21/02/07 for Lawrie Park Lodge

This inspection was carried out on 21st February 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 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 13 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 20/06/06

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 21st February 2007 10:00 Lawrie Park Lodge DS0000025630.V331636.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.V331636.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.V331636.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.V331636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 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.V331636.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 took place over one day. The registered manager/owner of the home was present for the duration of the inspection. The inspection also involved speaking to four service users with case tracking methods being used for two service users that were spoken to. Discussion with three support staff also took place. Other methods used included inspection of care records and a full tour of the premises was undertaken. The outcome of the inspection was that some progress had been made with seven of the previous requirements having been met. However, some requirements have been carried over from previous inspections. In particular, an area of concern relates to the training of staff in adult protection, medication and mandatory training topics. These had either not been met or were only partially met. This needs to be addressed by the home, as continued non-compliance may result in enforcement action being taken. Five new requirements have been made as a result of this inspection. What the service does well: What has improved since the last inspection? There have been improvements to ensure service users are given the option of an annual holiday. Some improvements have been made to the home’s medication system. Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 6 Items of furniture have been replaced in service users bedrooms that were broken and the flooring in a few of the en –suite toilets have been replaced although this has to be addressed in all the rooms. Improvements have been made to the home’s recruitment practices ensuring service users are protected. The home has sought the views of service users, relatives and professionals involved in the home as part of quality assurance and drawn up a development plan for the home outlining aims and goals to be achieved over the year. 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. The summary of this inspection report can be made available in other formats on request. Lawrie Park Lodge DS0000025630.V331636.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.V331636.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. 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. Prospective and current service users generally have all the information they need about the home although details about the fees charged by the home needs to be included. The needs of service users have been fully assessed prior to admission. The statement of terms and conditions has been updated but service users have yet to receive a copy. EVIDENCE: The home has a statement of purpose and service user guide that generally meets with regulation although the registered manager who is also the owner/provider of the home reported they were not aware of the new regulation that came into effect in September 2006 that requires details regarding the fees charged by the home now to be included in the service user guide. This needs to be addressed (See Requirements). The home has had one new admission to the home since the last inspection. The personal file of the service user was inspected and detailed assessments and reports about the service users’ needs were found to be in place that had been obtained prior to their admission to the home. There was evidence that all service users had been issued with a statement of terms and conditions that had been signed. However, following a requirement Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 9 at the last inspection regarding information about the home’s visitors’ policy needing to be included in this document (For details see Standard 15), it was identified at this inspection this had been completed. However, the revised copy of the terms and conditions had not been issued to service users (See Requirements). Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users’ care plans had not all been reviewed six monthly and for individual service users their social/cultural needs had not been addressed. Service users have been supported to make their own decisions but information regarding advocacy services still needs to be made available. Detailed risk assessments were in place but had not been regularly reviewed. EVIDENCE: Care plans belonging to four service users were inspected, one of which belonged to a service user who had moved into the home three months previously. It was evident that the care plans were based on information contained in Care Programme Approach (CPA) summaries and other reports that had been obtained for service users. The plans were generally comprehensive and did cover areas relating to personal support needs and health care needs in detail. Some aspects of social care needs had also been included in the plans but it was noted that the individual cultural and religious needs of service users had not always been adequately addressed, for example within the CPA for one service user it stated they were a practising Muslim and Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 11 yet within the care plan in respect to this need only the service user’s dietary requirements had been specified. It is important that issues of culture and diversity are explored with service users and addressed in care plans to ensure service users’ welfare and individual needs are met. Furthermore, a previous requirement that care plans should be signed by either the service user, a relative or a representative to indicate their involvement, agreement and understanding of the contents and also that care plans should be reviewed six monthly, this was identified as having been partially met. Of the four care plans inspected all but one had been signed but none of the care plans where reviews needed to be undertaken had taken place on a six monthly basis as specified within the National Minimum Standards (NMS). Instead, reviews had had been carried approximately annually with one care plan not having been reviewed with the service user since their admission to the home. To ensure care plans reflect service users’ changing needs and progress care plans must be more regularly reviewed (See Requirements). There was evidence that service users had been supported to make their own decisions through key work sessions held. At this inspection records indicated these had been carried out on a more regular basis with service users. Also, the home hold 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 various aspects of living at the home. Where appropriate service users are encouraged to manage their own finances whilst others are supported to work towards this. A previous recommendation that information on independent advocacy services should be made available to service users had not been addressed and is restated in this report (See Recommendations). The files of service users that were checked all included detailed and comprehensive risk assessments. Risks presented by service users’ mental health needs had been addressed either within a risk assessment or as part of their care plan. However, as was identified with service users’ care plans although reviews of the risk assessments had taken place these had been carried out after almost a year rather than six monthly as required. Also, at the last inspection, it was identified that support staff were not aware of the information included in crisis plans contained in service users’ CPA review summaries. These outline triggers and symptoms of relapse in relation to service users’ mental health and contact numbers of professionals to contact in the event this occurs. At this inspection staff spoken to were knowledgeable about the plans and where the information was to be found. Consequently, the previous requirement in this area is deemed met. However, it is advised that this information is made more accessible to staff within the personal files of service users (See Requirements and Recommendations). Lawrie Park Lodge DS0000025630.V331636.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. 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 have been provided with opportunities to take part in valued and fulfilling activities including training and education. Service users are integrated in the local community. Arrangements have been put in place for those service users who wish to, to go on holiday. Service users have been supported to maintain family links and personal relationships although information regarding the home’s policy on visitors still needs to be given to service users. The routines of the home do promote independence and service users’ rights are respected. Although generally service users are provided with varied and nutritious meals, the home needs to ensure the specific cultural needs of all service users are adequately met. Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 13 EVIDENCE: In respect to service users being provided opportunities to partake in fulfilling and valued activities, the home has a comprehensive activities programme in place that includes social skills, assertive training, music and exercise, budgeting and planning, relaxation, cookery class as well as more recreationally based activities such as bingo and beauty sessions. Service users can choose the activities they attend and service users spoken to all confirmed they had attended different parts of the programme. A previous recommendation that the activities programme is periodically reviewed within the weekly community meeting held with service users so they can contribute their ideas and preferences on activities, this had been addressed. In addition, some of the service users living at the home attend day centres locally and/or are involved with the Community Opportunities Service (COS) team in Lewisham that involves engaging service users in a range of social and educational activities. Service users spoken to confirmed that they do make use of the local community attending church, the local pub, leisure centres, local parks and also use the shops. A previous requirement that service users should be given the option of a minimum seven- day holiday that they choose and plan is deemed met. A holiday was arranged last summer attended by four service users and it was reported that it is aimed that the same location will be used again this year. Some of the service users had refused the option of going away last year and they had all signed a statement clearly stating this, which was included within their personal files. Some of the other service users had gone away with family. The registered manager reported that where it has been possible negotiations have taken place and an agreement has now been agreed with referring authorities that they will pay for an annual holiday as part of the basic contract price for any prospective service users admitted to the home. It was evident from service users’ care plans and also in speaking to service users that they have been supported to maintain family links with family and to develop personal relationships. One service user stated how they visit their girlfriend on a weekly basis. However, at the last inspection, it was identified through discussion with one service user and also the registered manager that in certain circumstances restrictions would be imposed on service users being able to see visitors in their bedrooms but this had not been specified in the homes’ statement of terms and conditions or the service user guide. Subject to a previous requirement that this matter should be clarified to service users by addressing this in either or both documents, it was found at this inspection that this had been met. As mentioned in respect to Standard 5 the home’s statement of terms and conditions had been altered to include information Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 14 about the policy on visitors but the updated copy had yet to be issued to service users (See Requirement in respect to Standard 5). The home’s routines and house rules do promote independence, individual choice and freedom of movement. Service users were seen to come and go freely from the home and to spend their time as they prefer choosing when they want to become involved in activities or not. Service users spoken to also confirmed that they all have been given a key to their room and their rights to privacy are respected with staff always knocking before entering service users’ rooms. Feedback from service users about the food provided by the home was generally very positive. One service user said, “The food is nice” whilst another said, “He is an excellent chef and the food is excellent”. The home uses a four -week rolling menu and a choice is offered. However, although the home does include some meals and foods in the menu to cater for the culturally specific needs of individual service users, it was identified that one service user has been regularly buying take away meals as often the meals provided by the home did not meet their individual cultural needs and tastes. This was discussed with the service user, the chef and the registered manager and although the service user was not expressing any dissatisfaction about having to purchase their own food it is advised that ways of accommodating the personal tastes of the service user should be explored further with them (See Recommendations). Lawrie Park Lodge DS0000025630.V331636.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users receive the personal support that they need. The physical and mental health needs of service users are addressed. Improvements had been made in relation to the way medication is managed by the home although some of the staff have still not received adequate training in this area. EVIDENCE: Generally service users living at the home are supported to be as independent as possible with regards to addressing their own personal care needs although some do require prompting and monitoring that they are attending to their personal hygiene and this had been addressed in individual service users’ care plans. The home also offers as part of its weekly programme a health and hygiene group to service users to provide information and guidance in this area. To ensure service users receive consistency of support the home operates a key worker system. Service users spoken to confirmed they had met regularly with their key workers and also stated they were satisfied with the level of support they had received from staff. Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 16 It was evident from service users’ care plans and also in speaking to service users that their physical and mental health needs have been well met by the home. There was evidence that service users have their weight checked on a monthly basis and have regular contact with mental health professionals. CPA reviews have been held although as identified at the last inspection reports of the reviews were not always available. It is advised the home try to ensure a copy of the reports for all CPA reviews are obtained (See Recommendations). Since the last inspection the home has changed the medication system. A blister pack system is now in place. Staff spoken to confirmed they had received training on this. A sample of Medication Administration Record (MAR) sheets were checked and all were found to be accurate. The pharmacist inspector also carried out following the last inspection a separate inspection of the medication system. At this inspection it was identified that two of the three recommendations made in respect to the pharmacist inspector’s report had been addressed. The medication fridge temperatures had been recorded and were within the limits of 2-8C. In addition, photographs of service users were in place to enable identification of residents prior to administration. The final recommendation regarding a Controlled Drugs declaration to be provided in the home’s Annual Quality Assurance Assessment by April 2007 could not be assessed. None of the service users were prescribed controlled drugs. In respect to the four requirements specified, two had been met. There was evidence that the home had carried out weekly audits of the medication. Furthermore, the sample of MAR sheets and blister packs containing medication that were checked had full instructions for use. In addition, the requirement stated that it was particularly important that full instructions should be in place for PRN use of benzodiazepines. It was reported that none of the service users were being prescribed benzodiazepines so this could not be assessed but will be checked, at future inspections. A requirement in relation to the home placing more emphasis on supporting service users to manage their own medication particularly if there were plans to move to less supported accommodation also could not be fully assessed. It was reported only one service user was being supported to administer their insulin and there were no plans in place for any of the service users to move on from the home. Again this will be looked at, at future inspections. Finally a requirement that medication training should be provided to staff that is comprehensive had been partially met. One staff member spoken to stated that they had completed a City and Guilds Safe Handling of Medication course and the registered manager showed evidence of a course that it was reported one of the support workers had attended that covered areas of administration and management of medication and also looked specifically at medicines used in the mental health field and their side effects. There was also evidence that the registered manager had undertaken medication competency assessments with two staff members. However, not all staff spoken to had undertaken additional Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 17 accredited training in medication apart from that provided by the local community pharmacist and this needs to be addressed (See Requirements). Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to although the complaints policy still needs to address how complaints against the home will be dealt with objectively. Service users are not being fully protected from abuse, as staff still need to receive training in this area. EVIDENCE: It was identified at the last inspection that although the home’s complaints policy included the stages and timescales for the process, it did not clearly state how complaints made against the registered manager who is also the registered provider/owner would be dealt with objectively nor did it provide information where service users may access independent advice and support if required. At this inspection it was found that this issue had still not been addressed within the policy (See Requirements). No complaints had been received by the home since the last inspection. Service users spoken to also confirmed they did not have any complaints about the home but were clear if they had concerns they would speak to either a staff member or address the matter with their care co-ordinator/ social worker. A previous requirement that all support staff need to receive training in adult abuse had not been met. None of the staff spoken to had yet to attend training on adult abuse although they did demonstrate that they had some knowledge about the different types of abuse and action to be taken if they suspected or identified abuse occurring in the home. There was evidence that some staff Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 19 would be attending a training day provided by Lewisham Partnership in March 2007, which, was confirmed by staff spoken to but for remaining staff this was still to be organised. Also, a recommendation that the registered manager should try to access a copy of Lewisham’s Interagency Guidelines on adult protection had still not been addressed (See Requirements and Recommendations) Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 20 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): 24,26 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and provides a safe and homely environment. Service users’ bedrooms do meet their needs although flooring in the en-suite toilets still need to be replaced. 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 an ensuite toilet and a wash - basin. At the last inspection it was noted that the carpets in the en-suite toilets were badly stained and were in need of being cleaned or replaced. At this inspection, the flooring in a small number of the en-suites had been replaced. However, the majority of the en-suites were still carpeted and although the registered manager reported that they had been Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 21 cleaned they remained quite badly stained. Therefore, the flooring in all the en-suites needs to be replaced. Also, at the last inspection despite new bedroom furniture having been purchased it was noted that some items of furniture in service users’ rooms were still in need of being repaired or renewed. At this inspection, this had been addressed. No broken items of furniture were identified in service users’ bedrooms. Finally, one of the service user’s bedrooms was in need of being re-decorated. The registered manager reported that there were plans for this to be completed but explained the service user writes on the walls and this would be difficult to prevent making the condition of the room difficult to maintain (See Requirements). 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 the preparation of food. Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. 50 of staff presently working at the home have completed or are working towards a National Vocational Qualification (NVQ). Service users are protected by the home’s recruitment practices. All staff have been appropriately inducted although a comprehensive training plan had still not been completed. Not all staff have received at least six supervision sessions in the past year and appraisals have still not been undertaken. EVIDENCE: It was reported that at present four of the support staff working at the home have completed or are working towards a NVQ Level 2 or 3. Of the three staff spoken to one confirmed that they had achieved an NVQ Level 2 whilst the other stated they were in the process of doing a NVQ Level 3. This meets the specified target stated within the National Minimum Standards (NMS) that 50 of staff working at the home need to have attained or are working towards achieving a NVQ. Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 23 At the last inspection it was found that staff files checked included all the required information in relation to recruitment except two did not include any appropriate identification documents. At this inspection this had been addressed with identification documents included in the files for all staff working at the home. The home had recruited one new support worker since the last inspection. The staff member’s file was looked at and this included evidence of all the necessary documents. Subject to a previous requirement there was also evidence of the interview process undertaken in accordance with equal opportunities included in the file. There was evidence on staff files that staff had completed an induction that meets with Skills for Care specifications. There was also evidence that the Skills for Care induction work book had been issued to the new staff member who had commenced working at the home a week prior to the inspection. 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 had still not been fully addressed. The registered manager did have a training development plan for 2007/2008 in place. However, this was generalised. It listing training that staff would be expected to complete including mandatory topics but it did not identify areas that had already been completed by staff, those gaps in training that needed to be addressed or any dates arranged for this training to be completed. Nor did it list any specific training topics that may need to be covered. In relation to mandatory training, there was still limited evidence included within staffs’ records that this had been completed. Staff spoken to stated they had undertaken food hygiene and a health and safety course at Croydon College but only one certificate confirming a staff member had completed food hygiene could be identified (See Requirements). There was evidence that supervision had taken place but records indicated that not all staff had received a minimum of six supervision sessions a year as specified within the NMS. In addition, a previous requirement that annual appraisals for all staff working at the home should be carried out had still not been completed. This is important in respect to the drawing up of a training plan (See Requirements). Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 24 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. The registered manager is very experienced and holds appropriate qualifications to ensure the home is well run. Service users’ views have been sought as part of self- monitoring and a development plan for the home has been drawn up. Generally the health, safety and welfare of service users are promoted but fire and building risk assessments need to be reviewed. EVIDENCE: The registered manager /provider is very experienced having worked for many years in both hospital and community settings and has appropriate qualifications to ensure the home is well run. He is a qualified 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 provided externally. Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 25 There was evidence that customer satisfaction surveys had been issued to service users, relatives and professionals involved in the home at the beginning of the year, 2007. A report outlining the results had also been completed. The report specified areas on which feedback was requested included accommodation, meals, daily activities, support provided, respect and privacy. The results were generally positive. Also, following the inspection the registered manager sent a copy of a development plan for the home for 2007/2008 to CSCI. This outlined goals and aims to be achieved over the forthcoming year. In relation to health and safety there was evidence of up to date maintenance certificates for gas, electrical wiring and portable appliances (PAT) within the home. Fire equipment had been serviced and checked and fire alarm call points had been tested weekly and fire drills carried out regularly. Subject to a previous requirement a certificate for the testing of legionella was in place. However, it was noted that the fire and environmental risk assessments in place for the home had not been reviewed since March 2005 and January 2006 respectively. The home had also not tested hot water temperatures for the purpose of the prevention of scalding of service users. This was discussed with the registered manager who stated that service users at the home are able to test the temperature of the water for themselves leaving a minimal risk of scalding. However, this still needs to be risk assessed and included in the home’s environmental risk assessment (See Requirements). Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 26 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 2(3) Requirement The registered manager/ provider must ensure that the service user guide includes information about the fees charged by the home, what is included in the total fees payable and when and how service users will be notified about an increase in fees. The registered manager/ provider/ must ensure that a copy of the revised statement of terms and conditions is issued to all service users living at the home, which the service users, a relative or a representative should read, and sign indicating their understanding and agreement of the contents. 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. (Previous timescale of 31/01/07 partially met). The registered manager/provider DS0000025630.V331636.R01.S.doc Timescale for action 30/06/07 2. YA5 5 (1)(b) 30/06/07 3. YA6 15(2) 30/06/07 4. YA6 12(1)(a) 30/06/07 Page 28 Lawrie Park Lodge Version 5.2 5. YA9 13 (4) (c) & 14 (2) 6. YA20 18(1) (a) 7. YA22 22(2) 8. YA23 13(6) 9. YA26 16(2) (c) must ensure that the cultural needs and issues of diversity are explored and addressed in the care plans of individual service users. 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. (Previous timescale of 31/01/07 partially met) 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 and timescale of 31/08/06 partially met.) Continued non- compliance 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. (Previous timescale of 31/01/07 not met) The registered manager/provider must ensure all staff have adequate training in adult abuse. (Previous timescale of 31/05/06 and 31/01/07 not met) Continued non- compliance with this requirement may result in enforcement action being taken. The registered manager/provider must ensure that carpets in the DS0000025630.V331636.R01.S.doc 30/06/07 30/09/07 30/06/07 30/09/07 30/09/07 Lawrie Park Lodge Version 5.2 Page 29 10. YA35 18 (1) (a) 11. YA36 18 (2) 12. YA36 18(2) 13. YA42 13 (4) (c) en -suite toilets are replaced with flooring that can be more easily cleaned and maintained. (This is an updated requirement. Additional part of the requirement regarding broken items of furniture had been 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 to be provided for a twelvemonth period including mandatory training and NVQ’s as well as training specific to the service user group (Previous timescale of 31/05/06 & 31/01/07 not met) Continued non- compliance with this requirement may result in enforcement action being taken. The registered provider/ manager must ensure that annual appraisals are carried out with all staff. Previous timescale of 31/03/07 not exceeded. New date for compliance set) The registered manager/provider must ensure that all support staff working at the home receive a minimum of six supervision sessions a year. The registered manager/provider /provider must ensure that the fire and environmental/building risk assessments are reviewed annually. Also, hot water temperatures are tested regularly unless a risk assessment of service users deems this unnecessary. 30/09/07 30/09/07 30/09/07 30/06/07 Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 30 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 YA7 YA9 Good Practice Recommendations 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 information included in the crisis plans for service users is made more easily accessible and visible in their personal files. The registered manager/provider should try to explore further with the chef and the service user who is purchasing take away meals ways in which their individual cultural needs and tastes can be met more effectively. 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 the home accesses the most recent review of the local multi agency adult protection procedures to ensure up to date information. 3. YA17 4. 5. YA19 YA23 Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 Lawrie Park Lodge DS0000025630.V331636.R01.S.doc Version 5.2 Page 32 - 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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