Inspection on 09/01/06 for Lawrie Park Lodge

This inspection was carried out on 9th January 2006.

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

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

Other inspections for this house

Lawrie Park Lodge 26/10/07

Lawrie Park Lodge 21/02/07

Lawrie Park Lodge 20/06/06

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 Kate Matson Unannounced Inspection 9th January 2006 09:30 Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 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.V276517.R01.S.doc Version 5.1 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.V276517.R01.S.doc Version 5.1 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.V276517.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 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.V276517.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 9.5 hours. The inspection included discussion with four service users, and the registered provider/manager, and examination of five service users files, staff records and other records. What the service does well: What has improved since the last inspection? Information provided to service users in the statement of purpose and service user guide now includes all of the information service users need. Service users’ files now evidence that an assessment of the service user’s needs is completed prior to them being offered a place at the home. The service user contract has been reviewed to ensure that it included the information needed to protect the rights of service users. Care planning at the home has been improved so that it was clear that all areas of need had been considered including communication, cultural and religious needs, they were more regularly reviewed and daily recording included essential information regarding service users care that was omitted at the previous inspection. Recording of the community meeting had been improved to evidence service users participation. Risk assessments had been included in service users files to indicate the need for any restrictions and that risks were assessed and managed safely. The registered provider had ensured that a new member of staff had undergone all of the appropriate checks before commencing work, one of Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 6 which he had not been aware at the previous inspection. However the format for interviews must be improved to evidence that the recruitment process is in accordance with equal opportunities policies. An induction training programme that complies with sector skills council specifications has been introduced though this will be assessed further at the next inspection. A training plan for the home is needed to evidence that training is based on an assessment of the needs of staff and service users and a record kept of how far the plan has been achieved. The frequency and recording of supervision has improved to ensure that service users are cared for be a well-supported staff team. Recording at the home has improved with records now being kept of all transactions of property kept for service users including cigarettes and daily money, which was not being done at the last inspection. Also a filing audit had been undertaken and service users files and files of maintenance and health and safety checks were now sorted into sections and indexed. Issues identified at the last inspection affecting the health safety and welfare of service users had now been addressed including the weekly testing of fire alarms, the testing of portable electrical appliances, and the implementation of environmental health department advice. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 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.V276517.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Prospective service users have the information they need to make an informed choice about where to live. The needs of service users are assessed before they are offered a place. Each service user has a contract with the home. EVIDENCE: Previous inspections had noted that the statement of purpose and service user guide, lacked some required information and at the last inspection the documents were not available. At this inspection the documents were seen to include all of the required information and the registered provider stated that copies are always made available on request. At the previous inspection there was little evidence available on service users files of the assessment they had undergone before being offered a place. At this inspection five service users files were examined including one newly admitted service users and these included evidence of a referral and accompanying documentation and an assessment checklist that is completed prior to a service user being offered a place and a full care plan being drawn up. Previous inspections had noted that the service users room number was not included in their contract and at the last inspection it was noted that other information was also missing. At this inspection the five service users files examined all contained a contract that included room numbers and all of the other required information. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Service users’ care plans reflect their individual needs and goals. Service users make their own decisions as far as possible. The community meeting encourages service users to participate in discussions on aspects of life in the home. Risks to service users are assessed and managed safely. EVIDENCE: Previous inspections had noted that more was needed within the plan of care to ensure it represents a more comprehensive picture of the individual and the introduction of clear objectives with clear targets; actions, timescales and responsibilities, would assist the monitoring and evaluation of progress and development. Also at the last inspection none of the care plans included cultural and faith needs, including a service user who spoke very little English and it was unclear what was being done to support this man with his communication, cultural and religious needs. Also some care plans had not been reviewed for over a year, rather than at least six monthly to ensure that changing needs are recognised and addressed. It was also noted that although a daily record was completed for each service user, this did not detail all activity relating to that service user, for example one service user had been given notice to quit but there was no evidence on the file to explain this. It was also noted that although service users had regular reviews under the Care Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 10 Programme Approach (CPA), the minutes of these reviews were not always available. It was recommended that the registered manager write to the community mental health team to request minutes when they have been unacceptably delayed. At this inspection it was found that care planning had been greatly improved. A care-planning checklist was in place highlighting the areas where a care plan was needed. Evidence of the communication, cultural and religious needs of service users having been addressed was available and care plans had all been reviewed within the previous six months. The daily records also more accurately reflected all activity relating to that service user. Minutes of CPA meetings were also available apart from those held very recently. All of the service users spoken to confirmed that they made their own decisions with help where needed. Different levels of support are offered to service users depending on their level of need, for example some people manage their money completely independently, some manage it within a supportive framework i.e. managing it a day or two at a time and others have more support with staff buying things on behalf of service users. The home has a weekly “community meeting” to promote a sense of community and offer service users the opportunity to give and receive information and take part in decisions made about the running of home. At a previous inspection it was required that the format of the meeting must be developed to ensure that service users can more fully participate and that a more detailed and accessible record be kept of the meeting to ensure that those not present at the meeting can be clear about what was discussed and agreed. The record should be in an accessible format with copies posted on the service users notice board or provided individually to service users. It was noted at the last inspection that there was no continuation between meetings and some issues discussed were not followed up at subsequent meetings. It was recommended that consideration be given to reviewing the regularity of service user meetings as participation may increase if the meeting is held less often. At this inspection, it was found that the meeting day had been changed to Tuesday as some service users had not returned from weekend visits on a Monday and attendance at the meeting had increased. The meeting minutes were still recorded in a bound book as previously however all of the service users who were asked stated that they were happy with this and knew where to look to update themselves if they had missed a meeting. The minutes were recorded more formally and clearly evidenced discussion from the meeting as well as how previous matters arising had been followed up. At the last inspection none of the service users files examined included a risk assessment and it was required that these are in place to ensure that risks are identified and managed safely and to evidence why any restrictions may be in place. At this inspection, all of the files examined included a brief risk screen. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Service users have opportunities for personal development and take part in appropriate occupation and leisure activities in the home and the local community. A holiday is still to be offered by the home though the provider is taking steps to address this. Service users have appropriate relationships. Service users are offered a choice of balanced and nutritious meals. Restrictions at the home are appropriately documented though set meal times should be included in the service user guide so that they know about the routines in the home before moving in. EVIDENCE: The home has a weekly programme of activities that are reportedly well attended. The activities include, relaxation therapy, social skills, cookery class, art and craft, budgeting and planning, assertiveness and outdoor activities. Most service users were happy with the activities offered, but one commented that the activities had never changed and were a bit boring. It was recommended that in consultation with service users the activities programme be reviewed to ensure that it meets their needs and preferences as far as possible. At this inspection it was found that a quiz and exercise to music had Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 12 been added to the programme and services users spoken to reported to be happy with the activities on offer. The registered provider stated that the home has links with employment and retraining schemes and these are utilised as far as possible. In the past service users had attended courses at college but currently service users tended to attend day centres, take part in activities at the home or occupy themselves visiting friends and family. All of the service users spoken to made good use of the local community. One service user said, “I go out every day, I go to the day centre, a gardening group, shopping, to the pub and I like to go on a bus ride to a park or somewhere”. The registered provider stated that all of the service users may get a free travel pass and where appropriate, assistance is given with application. At the last inspection the registered provider was required to ensure that service users have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help choose and plan. At this inspection none of the service users had been offered a holiday by the home though some had gone with other groups. However the registered provider showed the inspector a letter he had sent to commissioners asking for advice on how to meet this requirement. The registered provider stated that most service users have regular contact with their families and they are supported in doing so. Service users spoken to stated that they may have visitors at any time and at the last inspection, one service user stated he could take his girlfriend into his bedroom for privacy if he wished. At the last inspection it was noted that although service users were seen to come and go freely from the home and move around freely within it, there were some restrictions in place such as service users not being allowed to smoke in their bedrooms and having to hand over their cigarettes to staff at night. No records were kept of these transactions, leaving service users vulnerable to abuse, and staff vulnerable to allegations of theft. The registered manager was required to review the no-smoking policy and if it is still believed to be necessary a risk assessment was to be carried out for each service user. The home was reminded that service users property must not be kept by the home without records of their consent (or a risk assessment) and required to keep records of each handover between staff and service users. At this inspection the registered provider stated that the smoking rule had been imposed as a result of advice from the fire brigade and this is clearly included in the service user guide and the service user contract. Also not all service users have to hand their cigarettes over. Risk assessments/consent forms were available on the files of those service users who did. Service users gave positive feedback about the food; comments included “The food is good”, “The food is genuine, always fresh and the vegetables are good”, and “The food is nice, it’s healthy and there are always 2 choices”. At the last inspection the inspector was invited to sit with the service users whilst they had lunch and the choice of two meals provided looked appetising and nutritious. However it was found that meals were served at set times and Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 13 unless the service user was diabetic, if they missed breakfast they may only have a hot drink. The registered provider was required to ensure that service users are provided with food at times that suit them. At this inspection the registered provided stated that set mealtimes were essential for the routine of the home and confirmed that service users were able to have meals saved for them, giving examples of such occurrences. However it is recommended that the service user guide include reference to the set meal times to ensure that service users are aware of the routines in the home. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Service users receive the personal support that they need. The physical and mental healthcare needs of service users are addressed and monitored. Errors in medication administration indicated that more regular auditing is required in addition to more suitable training. EVIDENCE: Care plans indicated that service users needed a varying amount of support with personal care. A key worker system is in operation to ensure consistency. Service users confirmed that they were given the help that they need. Service users attend four different GP practices. All have support from a psychiatrist and a social worker and/or community psychiatric nurse. Service users are supported to be independent in looking after their own health and there is a health and hygiene group offered. Exercise has also been offered more recently. Service users are weighed monthly. The medication supply and administration records were examined. A few errors in recording were found and the registered provider stated that medication is audited monthly. However in order to identify errors more quickly this should be done weekly. Also it was found that although staff have to be assessed as competent before being allowed to administer medication, the training given is usually provided in house and does not include all of the areas required. The registered provider must ensure that medication is audited weekly and that staff are given adequate medication training. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users feel that their views are listened to. The home has appropriate policies in place regarding abuse but more staff need to be trained in order to better protect service users. EVIDENCE: Only one of the service users spoken to had made a complaint and this was resolved to their satisfaction. Other service users stated they would feel able to complain if they needed to. The registered provider stated that the community meeting served as a forum for raising concerns and the minutes indicated that issues were addressed satisfactorily. The home has some appropriate policies in place on adult protection and whistle blowing including the local multi agency procedures though it is recommended that the home access the most recent review of the document to ensure up to date information. Some staff had undergone training in adult protection but the registered provider must ensure that all staff have adult protection training to ensure that they are able to spot signs and symptoms of abuse and know what action to take if they do. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 and 29 Service users have pleasant, good quality and well-maintained accommodation though some rooms still lack standard items and records of service users refusal were not available. The home does not offer a service to people with physical disabilities. EVIDENCE: Previous inspections had noted that some service users did not have all of the required items, for example two comfortable chairs. At this inspection the inspector was informed that service users had been encouraged to personalise their rooms but some did not want anything additional in their rooms, however this had not been documented as required. Service users had been provided with a safe and easy means of opening and closing skylight windows and blinds on the top floor as required at the last inspection. The home does not offer a service to people with physical disabilities. It was noted at the last inspection that although the home has a passenger lift, on the day of the inspection it was full of cleaning equipment and materials. The manager was required to ensure that the lift is available for use and that it is kept clear of all items. At this inspection the registered provider stated that service users are encouraged to use the stairs for health reasons but confirmed that the lift is always available for use and kept free of cleaning equipment and materials. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Service users are supported by sufficient numbers of staff, of whom a high proportion have or are completing relevant basic qualifications. The homes recruitment practices protect service users, though current interview records do not evidence recruitment practices comply with equal opportunity policies. Although an appropriate induction-training programme has been introduced, a training plan is needed to ensure that staff have the appropriate training to meet mandatory requirements and the changing needs of service users. Staff are appropriately supervised. EVIDENCE: The home has 7 permanent staff excluding managers. Three staff had already achieved NVQ qualifications and another two were currently completing courses. The home is therefore on target to have at least 50 of staff with NVQ qualifications. This should ensure a competent workforce. The rota showed that there is at least three staff on duty during the day and at night one waking and one sleeping staff. There is also a cook and a cleaner. The staffing level appears to be sufficient to meet the needs of service users. It was noted at the previous inspection that staff meetings were not taking place at least six times per year and that minutes of meetings were only very brief. The inspector was invited to attend a handover meeting where staff going off duty, inform staff starting duty of any significant issues relating to each service user. It was noted that no records were used to hand over information and staff starting duty did not take any notes. Whilst the inspector was impressed Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 18 by the capacity of staff to store information, this practice is likely to lead to information getting missed and does not make staff accountable for information passed on. At this inspection it was noted that a communication diary was in place and staff were now being encouraged to use a notebook and write fuller notes in service users records. Also the meetings were now taking place every two months, and the minutes had been improved. At the last inspection it was found that a new staff member had started employment before a new check with the criminal records bureau and a check against the list of people considered unsuitable to work with vulnerable adults (POVA) had been made. This practice potentially leaves service users at risk of abuse. At this inspection the registered provider admitted that he had not been aware of the obligations placed upon him by the POVA list but was able to provide evidence of appropriate checks being made on a staff member who had started following the last inspection. However the notes of the interview did not evidence that the interview was conducted in accordance with equal opportunity principles and a format must be developed to evidence this. Previous inspections had required that the registered provider must introduce a more formal induction programme, which meets Sector Skills Council specification. At the last inspection it was recommended that the manager contact the local office of the National Training Organisation, “Skills for Care” for advice about training. At this inspection it was found that the registered provider had accessed information about induction from the Skills for Care website and stated that he had given his new staff member a workbook and would be working through this with her during her supervision sessions. This will be examined at the next inspection. In addition the registered provider must develop a training plan for the home, based on an assessment of staff needs and the needs of service users. The plan must detail the training that is planned and provided for a twelve-month period including mandatory training and NVQ’s as well as training specific to the service user group. Previous inspections had noted that although staff were supervised, this did not take place at least six times per year as required and the recording of the sessions did not include staff signatures to indicate their involvement in the discussion agenda and supervision did not cover all of the required areas. At this inspection it was found that all staff were regularly supervised however it was only the most recent sessions that had been signed by staff and included the required areas. The requirement is considered met on the basis that the new format continues to be used. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The manager is qualified and competent to run the home. Quality assurance systems are being developed though a professionally recognised tool should ensure their effectiveness. The homes record keeping has improved and it is recommended that visiting professionals provide written feedback in service users files. The health, safety and welfare of service users are protected. EVIDENCE: The registered provider/manager is dually qualified in general and mental health nursing. He has many years experience of working in hospital and community settings. He has owned and managed Lawrie Park Lodge for over 5 years. He informed the inspector that he updates his knowledge by using the Internet and reading nursing journals and that he received external supervision. Previous inspections had noted that although service users had been surveyed the home needed to implement an effective system for inviting and recording the views of staff, service users relatives and visiting professionals and for documenting internal monthly audits. It was required that the manager implement a more formal, preferably professionally recognised, quality Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 20 assurance system, which would enable an improved overview of whether the home is achieving its aims and objectives. It was also recommended that the survey form be redeveloped with a view to eliciting more useful and detailed feedback on a variety of issues, including inspection requirements and recommendations. At this inspection the registered provider showed the inspector a summary of a recent survey. The survey had been redeveloped, however the same questions were asked of service users, their relatives and professionals so it is recommended that surveys are developed for each group separately as different questions need to be asked of each. The requirement is considered met as surveys are completed annually and other auditing systems are in place, however a professionally recognised system is not in place and this is still recommended to ensure a more formalised and effective approach is taken to quality assurance. Previous inspections had required that all service users are made aware of their rights in relation to accessing records. At the last inspection it was found that eight service users had assistance in managing their money. It was not clear whether service users had purchased things themselves or whether staff had made purchases on their behalf as there were receipts available for both instances. It was required that this is clearly stated in the record in order to fully protect service users interests. It was also found that daily amounts of money were kept for service users but there were no records for these, leaving service users vulnerable to financial abuse. Personal files of service users and the file for maintenance and inspection certificates were poorly organised and the manager was required to conduct a filing audit and ensure that files are sorted into sections and properly indexed. It was also required that single sheets be used in order to record accidents and incidents to maintain confidentiality. At this inspection it was found that the service user contract states that service users may access their records and all of the service users who were asked were aware of this right and one had exercised his right to see them. Records were now being kept of all transactions, and files were much better organised with sections and indexes. Also an accident book from the Health and Safety Executive was being used as recommended. A visiting professional stated that he was never asked to write in service users notes and it would be good practice to implement this. At the last inspection records of inspection and testing of fire equipment, gas and electrical safety were seen to be up to date though fire alarm tests had not been completed for over a month and portable electrical appliance tests had not been inspected for over two years. Also a recommendation made by the Environmental Health Officer in October 2004 had only partially been implemented. This was to check temperatures of the fridge and food as it is being cooked. A serious concern letter was sent to the registered provider following the inspection to ensure that electrical appliances were safe and evidence of this was sent to the inspector as required. At this inspection it was found that all records of inspection and testing of fire equipment, gas and electrical safety were seen to be up to date and the advice of the EHO was being fully implemented and temperatures of food were tested as well as the fridge. Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 2 27 X 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X 3 3 X Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA14 Regulation 12 (1) (a) Requirement The registered provider must ensure that service users have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home, which they help choose and plan. (Previous timescale of 31/12/05 not met) The registered provider must ensure that medication is audited weekly. The registered provider must ensure that medication training for staff is adequate covering the points listed in Standard 20.10. The registered provider must ensure that all staff have adequate training in adult abuse. The registered manager must discuss with service users whether they would want any of the standard items of furniture not currently provided and if so these must be supplied. Details of the consultation and decision must be recorded in their care plans (previous timescales of 30/09/04, 31/03/05 and DS0000025630.V276517.R01.S.doc Timescale for action 31/05/06 2. 3. YA20 YA20 13 (2) 18 (1) (a) 31/03/06 30/04/06 4. YA23 13 (6) 31/05/06 5. YA26 16(2)(c) Sch 4(10) 30/04/06 Lawrie Park Lodge Version 5.1 Page 23 6. YA34 17 (2) schd 4,6 (f) 7. YA35 18 (1)(a) 30/11/05 not met). Continued non-compliance with this requirement may lead to consideration being given to enforcement action. The registered provider must 31/05/06 develop an interview format in accordance with equal opportunities and ensure records of interviews are kept on staff files. The registered provider must 31/05/06 develop a training plan for the home, based on an assessment of staff needs and the needs of service users. The plan must detail the training that is planned and provided for a twelve-month period including mandatory training and NVQ’s as well as training specific to the service user group RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA17 YA23 YA39 Good Practice Recommendations It is recommended that the service user guide include reference to the set meal times to ensure that service users are aware of the routines in the home. It is recommended that the home access the most recent review of the local multi agency adult protection procedures to ensure up to date information. It is recommended that the registered provider use a professionally recognised quality assurance and monitoring system to more effectively measure success in achieving the homes aims and objectives. It is recommended that separate quality assurance questionnaires be developed for service users, relatives and visiting professionals to reflect their differing experiences of the service. It is recommended that visiting professionals be DS0000025630.V276517.R01.S.doc Version 5.1 Page 24 4. YA39 5. YA41 Lawrie Park Lodge encouraged to provide written feedback of their visit in the notes of service users Lawrie Park Lodge DS0000025630.V276517.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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