Inspection on 26/10/07 for Lawrie Park Lodge

This inspection was carried out on 26th October 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lawrie Park Lodge 21/02/07

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 Key Unannounced Inspection 26th October 2007 09:30 Lawrie Park Lodge DS0000025630.V344110.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.V344110.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.V344110.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.V344110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2007 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.V344110.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 was present for the inspection and facilitated the inspection process. Four service users were spoken to; case tracking methods were used in respect to two of the service users. One of the support staff was spoken to in detail and three were briefly consulted and a professional who visited the home at the time the inspection was held was also spoken to. Other methods used included inspection of records and a tour of the building. The Annual Quality Assurance Assessment (AQAA) completed by the home prior to the inspection will also be used to inform the report. At this inspection it was identified that eight of the previous requirements had been met. Four were partially addressed and one not met. The home has incurred repeated requirements that relate to staffs’ training needs, which need to be addressed otherwise enforcement action will be taken. Ten new requirements were specified as a result of this inspection. What the service does well: What has improved since the last inspection? Service users had been provided with a statement of terms and conditions to inform them of their rights living at the home that they had signed. Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 6 Improvements had been made in respect to care planning and risk assessments to make sure all service users’ needs were met effectively. Staff had received training in relation to medication as a measure to protect service users. Improvements to the environment of the home had been carried out. Staff were being supported better with regular supervision being provided. Measures had been taken to ensure the health, safety and welfare of service users were promoted and protected. 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.V344110.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.V344110.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. The service user guide for the home had still not been updated to include information regarding fees charged by the home and had not been made accessible to service users. The needs of service users who had moved into the home had been assessed prior to admission. Service users had all received and signed an updated statement of terms and conditions. EVIDENCE: At the last inspection the home’s statement of purpose and service user guide was generally found to include all the information required by regulation although the service user guide did not include a breakdown of fees charged by the home specified by a new regulation that came into force in September 2006. At this inspection it was found this information had still not been included in the service user guide. In addition, it was identified at this inspection that the Commission for Social Care Inspection’s (CSCI) contact details needed to be updated as these had changed. Furthermore, all service users needed to be issued or have access to a copy of the updated service user guide, as it was evident in discussions with the registered manager that service users had not had access to this (See Requirements). Since the last inspection there had been one new admission to the home. The personal file of the service user was inspected and there was evidence that the Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 9 home had obtained reports and information prior to their admission to ensure the home were able to assess that they would be able to effectively meet their individual needs. At the last inspection although the statement of terms and conditions had been updated to include information about the home’s visitors policy as previously required, the revised copy had not been issued to service users to read and sign. However, at this inspection there was evidence included in service users’ personal files that were looked at, of the statement of terms and conditions that had been amended and all these had been signed. Lawrie Park Lodge DS0000025630.V344110.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 good. This judgement has been made using available evidence including a visit to this service. Overall care plans were comprehensive in addressing service users’ needs and had been reviewed to reflect personal goals and changing needs. Service users had been supported to make their own decisions. Risk assessments had been drawn up and had been regularly reviewed. EVIDENCE: At the last inspection it was identified that although care plans were generally comprehensive in addressing service users’ personal support needs and health care needs in respect to social care needs service users’ individual cultural and religious needs had not always been adequately addressed. In addition, not all the care plans that were looked at had been signed by service users and not all of them had been reviewed six monthly as specified within the National Minimum Standards (NMS). At this inspection five care plans were looked at. These had been divided into three separate sections covering physical health needs, psychological needs and social care needs. All service users had a care plan in place including one that had only moved into the home a month Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 11 previous to when the inspection was held. Service users’ needs in respect to the three areas had been fully addressed with cultural and religious needs having been specified. In addition all the care plans had been signed and six monthly reviews had been completed and changing needs had been reflected. Service users confirmed that they do make their own decisions and they receive support from staff if and when required. The home holds a weekly community meeting at which all service users attend. This offers them an opportunity to give and receive information and have an input into decisions made about various aspects of living at the home. One service user stated they could talk about anything they wanted to at the meeting. In addition, where appropriate service users are allowed to manage their own finances. Subject to a previous recommendation that information about independent advocacy services should be made available to service users, this had been addressed. A folder, which contained information about advocacy services, was available in the communal lounge area. In respect to risks presented by service users’ needs, it was identified at the last inspection that these had been addressed in detail with risks presented by their mental health needs having been covered within a risk assessment or as part of their care plan. Control measures to reduce risks had been put in place. However, six monthly reviews of the risk assessments had not been carried out. Subject to a previous requirement, at this inspection it was found that regular reviews of risk assessments had been completed. Also, a previous recommendation had been addressed. This specified that crisis and contingency plans contained within the Care Programme Approach (CPA) for service users in which triggers and symptoms of relapse in relation to their mental health is outlined and contact numbers of professionals to contact in the event of a crisis are given should be made more accessible to staff. At the top of care plans it had been stated that these plans should be looked at. A newly employed staff member was spoken to who was aware where to access this information. Also, a professional who was visiting the home at the time the inspection was held commented how the staff at the home were efficient in noting changes in individual service users’ mental health and taking appropriate action to intervene. Lawrie Park Lodge DS0000025630.V344110.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): 12,13,15,16&17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had been provided with opportunities to take part in valued and fulfilling activities including training and education and they were integrated in the local community. Links with family and appropriate personal relationships had been supported. The routines of the home had promoted independence and service users’ rights had been respected. Service users had received meals that were varied and nutritious. 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. The day the Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 13 inspection took place some of the service users took part in a quiz that was organised. Service users spoken to who had got involved stated they had enjoyed it. In addition, some of the service users living at the home attend day centres locally where they are engaged in social and educational activities whilst others attend college. Service users have also been engaged in doing some voluntary work, for example one of them does work at a local art gallery and another had previously done some work at a local museum. Service users spoken to, confirmed they have made use of the local community attending church, the local pub, leisure centres, local parks and also use the shops. It was evident from service users’ care plans and also in speaking to service users that they had been supported to maintain family links and to develop personal relationships. Service users regularly visit their families and spend weekends at home with their families. 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 had been given a key to their room and their rights to privacy were respected with staff always knocking before entering service users’ rooms. Since the last inspection the chef who was working at the home had left. An agency cook was being used at the time the inspection was held. Feedback from service users who were spoken to was generally positive about the food. One service user said, “ I like the food, you get a choice”. Another service user confirmed they were provided with foods they liked. The home has a four weekly rolling menu. Only one week of the menu was available on the day of the inspection but the other three weeks of the menu was sent to CSCI shortly following the inspection. From these it was evident that service users were provided with a choice of meals and that these were varied and nutritious. There was also evidence of meals on the menu to meet the specific cultural needs of service users. However, at the last inspection it was identified that one service user had been regularly buying takeaway meals, as often the meals provided by the home did not meet their individual cultural needs and tastes. Although the service user was not expressing any dissatisfaction about having to purchase their own food it was advised that ways of accommodating the personal tastes of the service user should be explored further with them. Yet, at this inspection the service user was spoken to again. They confirmed the registered manager had offered to cook food for them but that they preferred and were happy to continue buying takeaways. Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had received the personal support that they need. The physical and mental health needs of service users had been addressed. All staff had received training on the administration, handling and storage of medication resulting in the effective management of medication that generally protects service users but the home’s medication policy needed to be updated in areas. 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. 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. It was reported that the aim was to hold monthly key worker meetings with service users. Although there was evidence within personal files that key worker sessions had been held with service users these had not always taken place consistently on a monthly basis with gaps of Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 15 three and four months identified. Service users spoken to, did confirm that they have had meetings with their key workers and they also stated they were satisfied with the level of support they had received from staff. However, it is advised that key worker sessions are held monthly as intended (See Recommendations). It was evident from service users’ care plans and also in speaking to service users that their physical and mental health needs had been well met by the home. There was evidence that service users had their weight checked on a monthly basis and have had regular contact with mental health professionals. A mental health professional that was visiting the home at the time of the inspection commented that they considered service users’ mental health was well looked after and that the home ensured the Care Programme Approach (CPA) was adhered to. There was evidence CPA reviews had been held although as identified at previous inspections 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. In respect to liaison with other health professionals, there was evidence from the home’s diary of appointments booked for service users to see the GP, dentists, opticians, and chiropodists and to attend hospital appointments as required. However, this information was not very accessible and it is advised all contact with professionals be recorded on a form that is kept within service users’ personal files. This would also facilitate monitoring of appointments to ensure regular contact with health professionals is maintained as required (See Recommendations). In relation to medication, a small sample of medication record sheets were checked and all found to be accurate. Yet, prior to the last inspection of the home a pharmacist inspection took place that resulted in the home receiving four requirements and three recommendations. The last inspection identified that two of these four requirements had been met; medication had been audited weekly and at this inspection there was evidence that the audits had continued to be completed by support staff that are recorded on the medication record sheets (MARS). Also, in the sample of medication that was checked at the last inspection full instructions for use were seen to be in place as previously required although part of the requirement that stated there should be full instructions for use of benzodiazepines prescribed to be taken ‘as required’, this could not be assessed as none of the service users were prescribed these types of medication. Again, at this inspection this could not be assessed as it was reported none of the service users were taking benzodiazepines but as all medication seen again had full instructions for use this was assessed as met. One of the requirements that staff should receive training on medication that covers the points specified in 20.10 of the National Minimum Standards (NMS) was identified as having been partially met at the last inspection. However, at this inspection this had been fully addressed by the home. There was evidence within staff files that all permanent support staff had completed training. A pharmacist had delivered this but the course was comprehensive covering safe handling of medication including ordering, Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 16 checking, and receipt of medication, administration and recording, control and risk and awareness of responsibilities. In respect to the final requirement that the home should place more emphasis on supporting service users to manage their own medication particularly if there were plans for service users to move to less supported accommodation this was not able to be fully assessed at the last inspection or at this inspection. It was reported only one service user took some responsibility for administrating their insulin but there were no plans in place for this service user or others presently living at the home to move on from the home. This will need to be monitored at future inspections. However, in respect to the home’s medication policy, a copy of which was sent to CSCI shortly following the inspection although this stated the home encourages self medication and that service users have a locking facility in their rooms to store medication it did not outline procedures for how a decision would be made that a service user should take responsibility for their own medication apart from stating it would be discussed with the service user’s consultant psychiatrist. Neither did the policy outline how a service user would be monitored to ensure they were taking their medication as prescribed. This information needs to be added to the policy. In addition, although the policy did cover administration of medication in respect to procedures staff should follow using the monitored dosage system the home has put in place, issuing medication to service users on leave, receiving and ordering medication and cold storage of medication; there were gaps in the policy, for example it had not addressed the management of drug errors or what action should be taken in the event of a death of a service user. Therefore, the policy should be reviewed or advice sought about what needs to be included and the policy updated. Two of the three recommendations that were specified by the pharmacist inspector with regards to ensuring the medication fridge temperatures were recorded and within the limits of 2-8c and that photographs of service users were in place had been addressed. At this inspection both these areas were found to be in order although it was identified that the room temperature where medication was stored had not been monitored or recorded to ensure it did not exceed 25c. It is advised this is carried out. In respect to the last recommendation that controlled drugs should be identified as a controlled drugs declaration would need to be provided in the Annual Quality Assurance Assessment (AQAA) this had been addressed with the home stating within the AQAA that the home had not administered or stored any controlled drugs within the last year. The registered manager also confirmed this at the inspection (See Requirements & Recommendations). Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users spoken to considered their views would be listened to although the complaints policy still had not been amended to address how complaints against the home would be dealt with objectively. There was still not adequate evidence available to ensure staff working at the home had completed adult protection training and the registered manager must also ensure they are fully aware of their responsibilities in respect to safeguarding vulnerable adults. EVIDENCE: Subject to a previous requirement that the home’s complaint policy needed to address how complaints made against the registered manager who is also the registered provider/ owner would be dealt with impartially and without prejudice had been partially met. Although, this issue had been addressed in the statement of terms and conditions issued to service users, it had not been included in the complaints policy and this needs to be done. As mentioned in respect to Standard 7, information regarding how service users can access independent advice in terms of advocacy support, this had been put in place (See Requirements). Service users spoken to considered their views would be listened to and if they had any concerns or complaints they would speak to the staff or the manager. One mentioned they would speak to their care co-ordinator who works with the mental health team that is responsible for their overall care and to ensure the care programme approach (CPA) in place is adhered to. Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 18 The home’s complaint log was checked and two complaints had been made since the last inspection. One was an informal complaint made by a service user with regards to the service user in the neighbouring room playing their music too loud. This was dealt with appropriately. A service user alleging one of the staff had used their cash card to steal money made the other complaint. This was dealt with under adult protection procedures instigated by social services /South London and Maudsley (SLAM). The allegation, which was initially reported to the care coordinator, was a historical issue that reportedly occurred a year previously. The staff member was suspended and social services/SLAM informed the police. The home contacted CSCI about the matter. However, the allegation could not be fully substantiated due to a lack of available evidence. The staff member was reinstated in their post. The registered manager reported that the service user did not object to the staff member returning to work and no further problems had arisen. Furthermore in respect to adult protection, a previous requirement that all support staff should complete adult protection training had been partially met. On the day of the inspection four of the permanent support staff that were on duty reported they had completed training in this area; one staff member stated they had completed this prior to commencing work at the home. However, there was no documentation available to confirm this and this must be made available to CSCI. A staff member who had recently been recruited had yet to complete training but did have a good awareness of the different types of adult abuse and procedures to follow if abuse was suspected or identified. Finally, it became evident in discussions with the registered manager in relation to the home’s recruitment practices (For further details see standard 34) and following the inspection in respect to the adult protection investigation that they were not fully aware of their responsibilities under Protection Of Vulnerable Adults (POVA) procedures specifically they had not referred the staff member against whom the theft allegation was made to POVA for consideration that they be placed on the POVA list whilst the matter was being investigated. The list contains names of individuals under investigation and who have been found to be unsuitable to work with vulnerable adults. It is therefore important that the registered manager make themselves more familiar with POVA guidelines and undertakes a course around safeguarding of vulnerable adults for managers (See Requirements). As mentioned in respect to Standard 7 the home aims to support service users to manage their own finances. However, where service users have difficulties with budgeting the home does support them with managing their money for which records had been maintained. A small sample of these was checked and these were all found to be accurate. Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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 was generally well maintained providing a safe and homely environment although some repairs in the communal areas of the home was needed. Service users bedrooms did meet their needs. Overall the home was clean but it was not completely free from offensive odours. EVIDENCE: The home’s premises consist of a large detached house that is located in a residential area on a main bus route for the shops and facilities in Sydenham, Catford and Lewisham. Sydenham also has train links to central London. The home is suitable for its stated purpose and is accessible to all service users with a passenger lift in situ. Generally, the home was well maintained although it was identified that on the third floor of the home the paint on the wall by the passenger lift was flaking possibly a result of damp. This needs to be looked into and addressed (See Requirements). Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 20 All of the accommodation for service users consists of single rooms that all have an en- suite toilet and a wash- basin. Service users rooms contained all the required furniture and many had been suitably personalised. Subject to a previous requirement that the flooring in the en-suites should be replaced as the carpets that were in place had become badly stained, this had been addressed. All but four of the rooms had had the flooring replaced with lino that could be cleaned more easily. It was reported that two of the four rooms in which the flooring still needed to be changed had not been done as the service users had refused to have this done. The remaining two rooms were to be completed in due course. Overall the home was clean and hygienic on the day the inspection was held apart from one of the bedrooms, which smelt strongly of urine. The home needs to take measure to address this to ensure all areas of the home are kept free from offensive odours. Laundry facilities were situated on each floor and were sited away from the preparation of food (See Requirements). Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 &36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 50 of staff presently working at the home had completed or were working towards a National Vocational Qualification (NVQ). Service users had not been fully protected by the home’s recruitment practices. Not all newly recruited staff had been inducted and although a training plan had been completed this did not adequately detail individual training needs of staff. Staff had received regular supervision sessions and appraisals had been done but these were not sufficiently detailed in respect to how staffs’ development would be addressed. EVIDENCE: Of the five permanent support staff working at the home, two that were working on the day of the inspection reported they were working towards a NVQ Level 2 with the most recently recruited staff member having just commenced the course. Another stated they were in the process of completing a NVQ Level 3. In respect to one staff member who reported they had completed a NVQ Level 2 it was actually identified from records that they had done a foundation course towards achieving the qualification but had not completed a course to fully achieve this. The registered manager also reported one of the other permanent staff and also a bank worker had done a NVQ Level Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 22 3. There were four other staff that the registered manager reported regularly worked at the home employed from an agency. Their qualifications were not clarified at the inspection and the registered manager had not completed this part of the AQAA requesting this information. As five of the ten support staff including the bank worker and agency staff had completed or were working towards a relevant qualification this met the 50 target of how many staff should be qualified as specified within the NMS. However, although a copy of a certificate for the bank worker was identified within their staff file there was not one on file for the permanent staff member. It is advised copies of certificates are obtained for all staff with relevant qualifications (See Recommendations). At the last inspection staff files that were checked included all the required information in relation to recruitment. At this inspection the recruitment documents for two staff members that had been recruited since the last inspection were checked. This included a staff member working with the support team and a domestic. All required documents for the support worker had been obtained. However, for the domestic it was noted that a full Enhanced Criminal Record Bureau (ECRB) check had still to be obtained. There was evidence that the application form for the ECRB had been completed and a check against the Protection of Vulnerable Adults (POVA) list that includes the names of individuals deemed to be unsuitable to work with vulnerable adults had been carried out. Although it is permissible to allow an individual to commence work based on a POVA check this should only be done in emergency situations and POVA guidelines specify that the employee if they have direct contact with vulnerable adults should be supervised when carrying out their duties until the full ERCB is obtained. On raising this with the registered manager they acknowledged they were not aware of this. The home would need to take measures to address this. Furthermore, as a result of the registered manager’s lack of awareness in respect to this matter and also as mentioned with regards to Standard 23 an issue relating to POVA where an adult protection investigation had to be carried out, it was evident that they needed to update their knowledge in this area and to do a training course that relates to manager’s responsibilities in respect to POVA. In addition, it was noted that the domestic had not provided any previous details of an employment history. This was discussed with the registered manager who stated that they had not worked for many years and a reason for this had been given. However, there was no evidence that this had been discussed with the domestic at the point of interview as the reason provided for the gaps in employment had not been recorded. Finally, as mentioned in respect to Standard 32 the registered manager stated in the inspection that four staff that worked at the home on a regular basis were agency staff. Consequently, all recruitment checks had been carried out by the agency and not held by the home. However, it was noted following the inspection that the AQAA specified that no agency staff had worked at the home in the past 12 months. This needs to be clarified by the registered manager with documentation verifying the staff are employed by the agency sent to CSCI (See Requirements). Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 23 There was evidence on the staff file of the support worker recruited that they had received a basic induction. The staff member who was spoken to confirmed this and also that they had been issued with the Skills for Care induction workbook. However, there was no evidence that the domestic had been inducted. The home needs to ensure all new staff receives at least a basic induction. In respect 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 this had still not been fully addressed. As identified at the last inspection the registered manager did have a training development plan for 2007/2008 in place that was sent to CSCI shortly following the inspection but this remained too generalised. It listed 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. Specific training topics to ensure service users’ needs could be effectively met, for example in relation to their mental health were limited and were to be completed in- house or staff had to inform themselves on areas rather than outside training courses sourced. The plan stated that a more individualised training programme would be developed through supervision and annual appraisal with timescales for training specified. However, records of supervision and appraisals did not indicate this had been addressed (See Standard 36 for further details). In relation to mandatory training covering areas such as food hygiene, first aid, fire safety training, infection control there was still limited evidence included within staffs’ records that this had been completed (See Requirements). At the last inspection 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. At this inspection, it was evident from records that staff had received supervision more regularly and should receive the required minimum six sessions within the year. There was also evidence that appraisals had been completed with staff although these were very basic. They did not indicate that a full appraisal process had been followed with staffs’ own comments being obtained about areas they considered they had performed well and not performed well and areas they felt they needed to develop and required training. Instead, the appraisal form simply stated individualised training needs and team training needs duplicating the training plan. Details of timescales of when courses should be completed or had been done were minimal (See Requirements). Lawrie Park Lodge DS0000025630.V344110.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. Generally the home is well run with the registered manager being very experienced and holding appropriate qualifications but they need to ensure their knowledge is updated in specific areas. Service user views had been sought as part of self- monitoring and a development plan had been drawn up. The health, safety and welfare of service users had been promoted and protected. 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. Yet as mentioned in respect to Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 25 Standards 23 and 34 the manager does need to update their knowledge in respect to Protection of Vulnerable Adults (POVA) (See Requirement in relation to Standard 23). Evidence was seen at the last inspection that an annual survey 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. A copy of a development plan for the home for 2007/2008 was also sent to CSCI. This outlined goals and aims to be achieved over the forthcoming year. This was not checked at this inspection to assess progress in achieving goals that were identified but this will be looked at the next inspection. Subject to a previous requirement the home had ensured that the home’s building/ environmental risk assessment had been reviewed and this included that the home did not need to test hot water temperatures as service users were able to do this themselves and so were not at minimal risk of scalding. An updated fire risk assessment was sent to CSCI shortly following the inspection, which was adequate. In addition, fire alarm call points had been tested weekly and fire drills had been carried out regularly. There was evidence of up to date maintenance certificates for electrical wiring and portable appliances (PAT) within the home and an up to date gas safety certificate was sent to CSCI following the inspection. Lawrie Park Lodge DS0000025630.V344110.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 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 2 25 X 26 3 27 X 28 X 29 X 30 2 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 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 3 X Lawrie Park Lodge DS0000025630.V344110.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 Timescale for action 30/04/08 2. YA1 5(2) &(6)(a) 3. YA20 13(2) 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. (Previous timescale 30/06/07 not met) The registered manager must 30/04/08 ensure that the present service user guide is updated to include the new contact details for CSCI’s local office and that a copy of the updated service user guide is provided to all current and prospective service users to fully inform them about the service. The registered manager must 30/04/08 ensure that the home’s medication policy is updated to include more detail around the home’s procedures to assess and support service users with selfmedication to ensure their welfare is fully protected and promoted. Also, to ensure that DS0000025630.V344110.R01.S.doc Version 5.2 Lawrie Park Lodge Page 28 4. YA22 22(2) 5. YA23 13(6) 6. YA23 10(3) &13(6) 7. YA24 23(2)(b) 8. YA30 16(2)(k) the policy is more comprehensive with gaps as specified within the report are addressed to protect service users and for staff to be aware of all issues relating to administration, handling and storage of medication. 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. Timescale of 30/06/07 partially 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. Timescale of 30/09/07 partially met) Continued non- compliance with this requirement may result in enforcement action being taken. The registered manager/provider must ensure they undertake training to become fully aware of their responsibilities in relation to the Protection of Vulnerable Adults (POVA). The registered manager must ensure that all areas of the home are kept in a good state of repair specifically that the area by the lift in which the paint was flaking is looked into and repainted. The registered manager must ensure all parts of the home including service user bedrooms are kept free from offensive DS0000025630.V344110.R01.S.doc 30/04/08 30/04/08 30/04/08 30/04/08 30/04/08 Lawrie Park Lodge Version 5.2 Page 29 odours. 9. YA34 19 & Sched 2 The registered manager must ensure all gaps in employment are fully accounted for prior to employing persons to work at the home and reasons given in respect to any gaps are recorded to fully safeguard those living at the home. 19 Sched The registered manager 2 /provider must provide evidence to CSCI to verify those staff reported to be employed via an employment agency and therefore no recruitment documentation was required by the home. 19 Sched The registered manager must 2&13(6) provide details to CSCI of how the employee that was recruited based on a POVA check only whilst awaiting the results of the full ERCB will be adequately supervised as POVA guidelines specify. 18 (1) (a) 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 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 & 31/01/07 not met. Timescale of 30/09/07 partially met) Continued non- compliance with this requirement may result in enforcement action being taken. 18(1)(c)(i) The registered manager must ensure all newly recruited staff receive an induction and a record of this is maintained DS0000025630.V344110.R01.S.doc 30/04/08 10. YA34 15/12/07 11. YA34 30/11/07 12. YA35 30/04/08 13. YA35 30/04/08 Lawrie Park Lodge Version 5.2 Page 30 within their staff file. 14. YA35 18(1)(c) The registered manager must ensure that that all staff complete training in mandatory topics with any gaps addressed and evidence that training has been completed obtained and kept within individual staff files The registered provider/ manager must ensure that annual appraisals are carried out with all staff. (Previous timescale of 31/03/07 not met. Timescale of 30/09/07 partially met). 30/06/08 15. YA36 18 (2) 30/04/08 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 YA18 YA19 Good Practice Recommendations The registered manager should try to ensure that monthly key worker sessions are held monthly as the home specifies. The registered manager should try to ensure service users appointments with health professionals are recorded on a form to be kept in their personal file for easier accessibility and monitoring. The registered manager/provider should try to ensure that copies of CPA review meetings are obtained The registered manager should try to ensure that the room temperature where medication is stored is monitored daily and recorded. The registered manager should try to ensure that copies of certificates for qualifications achieved by staff are kept on their individual staff files. 3. 4. 5. YA19 YA20 YA32 Lawrie Park Lodge DS0000025630.V344110.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup 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. 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