Inspection on 16/05/05 for Leigham Lodge

This inspection was carried out on 16th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Leigham Lodge 18/02/08

Leigham Lodge 02/06/06

Leigham Lodge 20/12/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Leigham Lodge 64 Leigham Court Road, Streatham London SW16 2EL Lead Inspector Rehema Russell Unannounced 16/05/2005 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 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 Stationary 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. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leigham Lodge Address 64 Leigham Court Road, Streatham, London, SW16 2EL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 664 6640 0208 664 6640 leigham@beaconcaregroup.co.uk Leigham Lodge Ltd Imogen Maria Lucas CRH Care Home 6 Category(ies) of PC Care Home only registration, with number of places Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection n/a Brief Description of the Service: Leigham Lodge was registered on 31st December 2004 to provide care and accommodation to six people with learning disabilities with challenging behaviour/autism. It is owned by Beacon Care, a private company, which has other local and national homes. The home is a two storey semi-detached building entered via an electronically operated gate with entry phone. There is limited room for parking on the forecourt inside the front gate and there is a medium sized garden at the rear. On-street parking is available in nearby roads. The home is located on a bus route and within 5-10 minutes walk from a large shopping centre with full community facilities and bus and rail routes into central London and out to the coast. The home also has its own car for individual transport. Inside, the ground floor has two en-suite bedrooms, two lounges, a bathroom with toilet, a dining room and a kitchen. Upstairs there are four bedrooms, three of which are en-suite, a bathroom with toilet, a double laundry cupboard and a small office. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit to the home since it was registered. The inspection took place over two days because on the first unannounced visit the Manager was undertaking a study day away from the home and some information was unavailable. A second visit was therefore made a few days later when the Manager was at the home. The visits lasted for a total of ten hours, during which the building was toured, all three current residents were observed, staff were spoken with, staff handover was observed, and documents and records were inspected. The Area Manager was also met and spoken with. During the inspection written feedback on the service provided was seen from relatives and a Contracts Officer, and after the inspection the opinions of a relative and a Care Manager were obtained by telephone contact. What the service does well: What has improved since the last inspection? What they could do better: Although the home regularly reviews care plans and risk assessments, changes are currently communicated verbally within the staff team but must be recorded in future to ensure that all staff, including new and agency staff, have easy access to the most current care information. Some policies and procedures were found to be incomplete, inconsistent or not relevant to the client group of this particular home and the Registered Provider must rectify this so that staff have clear guidelines to follow. The Registered Provider must also adopt a clear policy on how it will ensure that the home meets the 50 NVQ Level 2 training target for staff and must also ensure that the Manager of the home receives regular supportive supervision, particularly as this is a new home. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 6 Although the home’s environment was generally good, only two of the three Dorguards recommended by the Fire Authority had been installed and an immediate requirement was left for the third to be installed as there was the potential for one resident’s safety to be compromised without it. 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. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 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 standard(s) 2 The organisation makes a thorough assessment of people being admitted to the home and obtains a copy of the placing authority’s care plan so that residents’ needs and aspirations are known and can be provided for. EVIDENCE: Two residents’ files showed that thorough pre-admission assessments had been made, in collaboration with the prospective resident and their care manager. The home’s assessments described all relevant areas of the prospective resident’s needs, preferences and behaviours and gave a clear and detailed picture from which a care plan could be devised. The different assessment sheets for one service user were extremely thorough but had not been dated and signed. Keyworkers spoken with were very familiar with the information provided in the assessments, which had given them a good basis on which to provide for individual care needs. A relative and the care manager of two different residents were both pleased with the placements, indicating that the pre-admission assessments had been suitable and successful. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 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 standard(s) 6,8 and 9 Care plans were thorough and reflected residents’ needs and goals but care plan reviews were not being recorded, so that there was the potential for up to date information to be missed. Resident participation in the running of the home had been facilitated where feasible and risk had been assessed on an individual basis to ensure resident safety. Risk assessment reviews were taking place but should be recorded with any changes noted so that new/agency staff would have easy access to this information. EVIDENCE: Care plans gave a thorough description of residents’ behaviours, reactions and preferences and how the resident was to be treated. There were immediate, medium term and long term goals but although these are reviewed monthly this is done verbally and not recorded. A keyworker spoken with was fully familiar with the conclusions of the verbal reviews but these must be recorded so that new members of staff/relatives/other relevant workers can access a record of any changes in the care given or the behaviours of residents. Very detailed and regular charts are kept of residents’ behaviours, household and community activities, contacts etc. however, the recording of reviews would also help to summarise this information and indicate any behavioural trends. Due to residents’ cognitive limitations it is not feasible for them to participate in the overall daily running of the home, but one resident, who has limited Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 10 verbal communication, has been encouraged and supported to attend staff meetings and participate in staff recruitment, demonstrating the home’s commitment to user participation. Individual risk assessments had been carried out and staff spoken with were familiar with the updates from verbal reviews of the risk assessments. However, risk assessments reviews should be regular and recorded, especially during the current period when the home is new and there are changes in regard to residents being admitted and new members of staff joining the team, both of which are likely to impact on the behaviours of the service group. This would ensure that all members of staff caring for residents users have up to date knowledge to ensure their safety. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 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 standard(s) 13, 14, 15 and 17 Residents are supported and encouraged to access community facilities and take part in appropriate leisure activities, both inside and outside the home, so that they take part in enjoyable and fulfilling activities and mix with the general community. Residents are supported to have appropriate personal and family relationships, and are offered a healthy diet in a relaxed and cheerful atmosphere. This contributes to residents’ emotional and physical health care needs. EVIDENCE: Residents are supported to be part of the local community by shopping at local shops, eating at local cafes, attending local health facilities, being taken on walks in the local neighbourhood and to the park. These activities ensure that residents become part of the local community and were observed on both days of the inspection. Within the home television, video, dvd and music are provided, both communally in the lounges and individually in residents’ own bedrooms. A range of daily activities are also provided, including residents’ known interests (such as puzzles and bead making) and activities commissioned by outside specialists such as reflexology, aromatherapy, drama therapy etc. One resident attends a day centre regularly and another attends Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 12 a weekly lunch club. In this way residents are supported and encouraged to take part in activities that are enjoyable, beneficial to their mental and physical health and which give them the opportunity to develop skills within their cognitive and physical abilities. The home has its own car, which can be used to take residents on individual or paired outings. Staff support service users to maintain family links and friendships by facilitating visits (currently one of the lounges is designated as a quiet lounge where visitors can be entertained), inviting relatives to care plan meetings and consulting with them on issues such as religious needs and preferences. All residents have been assessed for advocacy and are currently on the Mencap waiting list so that they can have an independent outside representative who is unaffected by family or staff interests. One relative told the inspector that they were very pleased with the friendship that had developed between two of the residents at the home. The home operates a four-weekly menu programme. Menus were seen and demonstrated that residents are given varied and healthy meals, with a takeaway choice once per week. The menus had been devised by a nutritionist who had been asked to visit and compile an individual report on each service user after staff observed that residents were having bowel and water problems. Residents were observed to enjoy the lunch provided, with staff providing a relaxed and happy atmosphere, and staff said that residents’ behaviour indicated that they enjoyed the new menus, with the exception that breakfast was not very popular so far. Staff believed that this was because residents were previously used to having toast daily and still expected this although it is now only on the menu for two days per week. Staff deal with this sensitively, either providing alternative foods, or activities as a distraction but providing toast if the resident is adamant. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18, 19 and 20 Staff provide sensitive and flexible personal support and residents’ physical and emotional health needs are met. Administration of medication was generally in good order with the exception of some issues in regard to ‘as required’ medication which could result in medical personnel being unable to ascertain its exact usage. EVIDENCE: Residents require prompting to carry out personal care and in some cases require support. Speaking with staff and observation of practices demonstrated that support and prompting is carried out sensitively and in a way that ensures residents’ privacy and dignity. This was particularly evident in the toileting practice at the home, observed during the inspection, where particular sensitivity and care needs to be shown as all service users require help with toileting. Same gender personal care is given whenever possible but it is particularly ensured for one resident whose behaviour indicates that she only wishes to receive personal support from female staff. Staff demonstrated how residents who are able to are supported to choose their own clothes and how they are gently persuaded to choose more appropriate clothes if their initial choice does not suit the weather. Residents were dressed and groomed according to their interests and personalities and photos displayed in their rooms indicated that staff ensure they are appropriately and stylishly dressed when they attend outside activities, day trips and events. A wheelchair has been appropriately assessed and provided for one resident who is fully mobile Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 14 indoors and for short distances outside but who cannot always manage the walk down to local shops. Documentation in assessments and care plans shows a detailed understanding of individual residents’ preferences and needs, which helps to ensure consistency and continuity of care and with which keyworkers were familiar. Documentation and verbal evidence from staff also demonstrated that residents are supported to access the full range of health care professionals and facilities and that appropriate consultation and support had been sought from specialist teams. There was evidence from staff and relatives that, with appropriate medical specialist input, residents’ medication had been reduced since they had been at the home – one relative was particularly pleased about this and said that this had made a great difference to the resident “who is off her medication and a completely different person”. Storage and administration of medication was checked and found to be in good order with the exception of one ‘as required’ (PRN) medication. One of the doses of this medication had been taken from the wrong blister and had therefore disrupted the administration of the remaining blisters and the traceability of administration of this medication. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 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 standard(s) 22 and 23 Service users views are sought where possible or otherwise indicated by their behaviours, which are closely monitored so that staff can interpret their views and choices. However, the documentation outlining the complaints procedure for the use of staff, relatives and others is unclear, which could prevent them from accessing the complaints procedure. The manager and staff act appropriately to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The service users’ handbook explains the process of complaint in an attractive and appropriate format and through speaking with staff and looking at documentation it was evident that residents’ “complaints”, in the form of challenging behaviours, was closely monitored and acted upon, using specialist advice as appropriate. However, for staff, relatives and other interested parties the complaints procedure was less clear. The inspector had access to three documents – “Your Right to Complain”, “Complaints Policy/Procedure” and “Complaints Procedure” – and although all three cited appropriate timescales, they described different and sometimes contradictory processes. The home must have a cleared accessible complaints procedure which also includes a suitable assurance for service users and their families. A copy of the procedure should be made available to residents’ families/friends/visitors. The Manager and staff spoken with were familiar with the steps to be taken in the event of suspected abuse and the home held a copy of the local authority’s Vulnerable Adults Policy. There was verbal and documentary evidence that physical and verbal aggression by residents was understood and dealt with appropriately. When a former resident’s behaviour had drastically deteriorated, appropriate specialists had been contacted and consulted with, and the safety of other residents had received appropriate attention. A Care Manager spoken with confirmed that the management of the home was efficient, staff were Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 16 eager to respond to suggestions and were receptive to ideas and that a potential adult protection issue had been appropriately dealt with and reported. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24,25,27,28, 29 and 30 The home is homely, comfortable and safe, with appropriate personal and communal space, and a clean and hygienic environment. However one of three recommendations made by the Fire Authority had yet to be implemented and as this had the potential to compromise the safety of one resident. EVIDENCE: As the home provides for residents with autism and/or challenging behaviours there are therefore necessary restrictions in communal areas and relevant resident bedrooms – for example there are very few ornaments and extraneous furniture in the lounges and dining room, residents’ toiletries are kept in locked cabinets in bathrooms, toilet paper is not left out in communal and relevant en-suites due to shredding and chewing behaviours – but nevertheless, communal areas have been made homely and attractive and all areas of the home are well decorated and furnished. All occupied residents’ bedrooms are personalised, and although this is restricted in two bedrooms due to the occupants particular behaviours, staff have made adaptations where possible (such as raising picture frames high on the wall and fixing them down) to ensure as much comfort and safety as possible. The third residents’ bedroom, where there are few behavioural restrictions, is attractively personalised according to the resident’s interests and preferences, which Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 18 includes television, radio, karaoke machine, framed photographs, ornamentation etc. All but one of the resident bedrooms have en-suite facilities, but both floors have communal bathrooms which can be used by service users, staff or visitors as convenient. None of the current residents require adaptations or specialist equipment for indoors, but as previously mentioned a wheelchair is provided for one resident who cannot manage to walk outside for lengthy distances. On both days of inspection the home was found to be clean and hygienic throughout. All staff had had food hygiene training, and those spoken with were familiar with infection control and other cleanliness issues. There are several minor maintenance works that need to be done in the home, some arising from the challenging behaviours of a former resident who has just been moved on, but the inspector was assured that all of these are in hand and expected to be repaired shortly. The Manager undertook to check whether Environmental Health had visited the home and to send a copy of the resultant report to the inspector. The Fire Authority had recommended the installation of Dorguards to three of the communal doors in the home so that these could be left open without compromising the safety of residents in regard to fire. It was found that only two of these had been installed and that the lack of the third for the dining room meant that a safety system installed to the front door could not be heard by staff if they were in the dining room or kitchen. As this had to potential to comprise the safety of one of the residents an immediate requirement was left for the third Dorguard to be installed as a matter of urgency. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 and 36. The home has an effective and well supported staff team, but does not have a clear staff training and development programme that would enable the 2005 NVQ Level 2 training Standard to be met. EVIDENCE: In speaking in depth with a Senior support worker and the Manager, and observing support workers interacting with residents, staff demonstrated accessibility, approachability, a good knowledge of the disabilities and specific needs and behaviours of service users, and good professional relationships with external health and social care workers. A care manager spoken with reported that the manager of the home was efficient and effective and that the staff team was eager to respond to advice and suggestions and was always receptive to ideas. A relative spoken with said that staff “are superb”, the relatives’ keyworker “is marvellous” and that he was very happy with the home and the care given. The home has a structured, thorough induction programme, including weekly meetings with goals set for the first four weeks of employment and all goals dated and signed. Induction training includes all basic training needs (health & safety, food hygiene, manual handling, fire safety, epilepsy awareness etc.), all LDAF accredited; however it is recommended that infection control and abuse training is added, and also autism training for this particular home. The latter would ensure that all staff begin work at the home with a preliminary Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 20 knowledge of the type of behaviour/needs that some of the residents may exhibit, mitigating any disruption that a new member of staff may have on the behaviour of an autistic resident. Staff stated that they receive 5 days paid training per year; however the parent company does not appear to be supporting NVQ Level 2 training, and only one member of staff has completed the course (by self-funding and supporting). Hence the home has not met the 2005 NVQ Level 2 training target (Standard 32, National Minimum Standards). All staff are given bi-monthly supervision, which is signed and dated as good practice, and which helps to maintain a well supported staff team and highlight any training or other needs, so that residents can benefit from suitable and consistent care. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,40, 41,43 The Manager is sufficiently knowledgeable and competent to run the home in a way that ensures the care and safety of residents and an effective staff team. Records are generally in good order but several policies and procedures need to be updated. No problems were found with the overall management of the service but the parent organisation should ensure that the manager is regularly and sufficiently supported to enable her to deal with the demands of a new service. EVIDENCE: The Manager is a trained instructor in on Violent Crisis Intervention, which is very relevant to the behaviours of the resident group. She is due to complete the Registered Manager’s Award later in the year and is also studying for a Master of Science in a subject relevant to the home, which will ensure that she has the required knowledge to run the home and care for the resident group. Due to a vacancy in line management personnel, the manager had not received supervision since January 2005. The vacancy had recently been filled, but the parent organisation must ensure that the Manager receives regular supervision at which she can discuss issues arising at the home in an open and Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 22 supportive atmosphere, particularly as this is a new home, with a new staff team, and with a client group displaying challenging behaviours. A range of records were seen and were generally in good order, ensuring that residents’ rights and best interests are safeguarded. The parent organisation has provided the home with a large range of policies and procedures but several of those seen needed to be updated or were not relevant to the home’s category of resident. For example, the medication policy must be updated according to current practice, the complaints procedure must be updated with the correct CSCI address, the adult protection procedure must be updated according to current adult protection procedures, the restraint policy needs to be updated, and several other policy refer to an elderly client group rather than one suitable for the home. If policies and practices are not up to date and relevant to the home, the parent organisation cannot ensure that staff have adequate knowledge of the polices and procedures that are intended to safeguard residents’ rights and best interests. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 1 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leigham Lodge Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x 1 3 x 2 G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 24 n/a 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. 2. 3. 4. 5. Standard 2 6 9 20 22 Regulation 17 (3) 15 (2) 13 (4) 13(2) 22(1) & (5) Requirement The Manager must ensure that all records are signed and dated where relevant. Changes to care arising from reviews must be recorded Changes arising from risk assessment reviews must be recorded Staff must ensure that medication is administered correctly The home must have a cleared accessible complaints procedure which also includes a suitable assurance for service users and their families. A copy of the procedure should be made available to residents’ families/friends/visitors. An Immediate Requirement was made for a Dorguard to be installed to the dining room door, as recommended by the Fire Authority The Registered Person must ensure that all policies and procedures for the home are up to date and relevent to its client group The Registered Person must ensure that the Manager Timescale for action 30/06/05 30/06/05 30/06/05 30/06/05 31/07/05 6. 24 23 (4) 03/06/05 7. 40 12(1) 30/09/05 8. 43 18(2) 30/06/05 Page 25 Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 9. 35 18(1) receives regular supportive supervision Training in autism, infection control and abuse should be added to induction and on-going training. 30.9.05 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 32 Good Practice Recommendations The Registered Person should have a clear policy on how it will achieve the 50 NVQ Level 2 training target. Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Southwark Area Office Ground Floor 46 Loman Street London SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Leigham Lodge G52-G02 S44234 Leigham Lodge V226578 160505 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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