Inspection on 12/07/05 for Lemsford Road

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Lemsford Road 28/12/06

Lemsford Road 05/12/05

Lemsford Road 13/01/05

Lemsford Road 17/08/04

Lemsford Road 03/12/03

Lemsford Road 17/06/03

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

CARE HOME ADULTS 18-65 Lemsford Road 66 & 66a Lemsford Road St Albans Hertfordshire AL1 3PT Lead Inspector Jan Sheppard Unannounced 12 July 2005 10:00 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. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lemsford Road Address 66 & 66a Lemsford Road St Albans Hertfordshire AL1 3PT 01727 850 436 01727 810 723 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) United Response Ms Terri Matthias Care Home 11 Category(ies) of LD Learning Disability - 11 registration, with number PD Physical Disability - 11 of places Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13 January 2005 Brief Description of the Service: 66 Lemsford Road is a detached house divided into three separate living areas on three floors. 66a Lemsford road is a detached annex house standing in the large garden of the main building. In each of the four living areas there are single bedrooms, a lounge, a kitchen diner, a laundry and bathrooms. Lemsford Road is a busy road about one mile from central St. Albans but within easy reach of all amenities of the city. It has good access to major roads (M1 and M25) and has excellent public transport links. The home, which is owned by the Health Authority, is staffed and run by United Response. It offers care services for 11 adults with learning and physical disabilities. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of this inspection year and took place over one day when residents and staff were spoken with, records examined and a tour of the building undertaken. This was a positive inspection; the inspector was welcomed into the home by both the residents and the staff. One resident said, “Would you like to see my flat? I love it here its my home”. A number of the residents made time to have an individual talk or time of communication (many of the residents have no speech) with the inspector and to show off their rooms and the new garden patio areas. They appeared to be happy and relaxed in their home setting, they clearly knew their staff very well and were confident in their dealings with them. A satisfactory standard of care was seen to be delivered in a kindly calm and sensitive manner by the staff who showed good awareness of the potential problems that could be caused by the extremely humid temperatures prevailing on that day. The home had carried out a number of improvements to the building and its surrounds since the last inspection in line with requirements and good practice recommendations made so that the National Minimum Standards are met. One requirement and two recommendations are made following this inspection. What the service does well: Lemsford Road offers a warm secure and homely environment for its residents with facilities and equipment that are appropriate for their physical and emotional needs. All the residents appeared to be relaxed and happy and to be very much at home in their own personal spaces. Staff were observed to be delivering their care in an enabling manner and to be encouraging them to take as much responsibility for their own life style as it was safely possible for them to do. The particular care needs of one resident are being particularly well met since the successful recruitment of carerworkers from his ethnic minority group which have helped the service user to make progress in both the emotional and social skills aspects. The home prepares excellent care plans for each resident these are clearly set out in separate sections in the file enabling easy identification and accessibility. They contain good detail and clear instructions as to how each residents care needs should best be met. The home has achieved a very good training standard and has 92 of care staff holding an NVQ level 2 or 3 qualification with the manager having attained the NVQ level 4 Registered Managers Award. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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 Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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) 1,2,4 and 5. The home has a Statement of Purpose and a Service Users Guide which gives appropriate information for the service users and their families concerning how the home operates and what procedures are in place to meet their existing and changing care needs. Some sections of this document have been prepared in a visual format, which some residents may have a better understanding of. EVIDENCE: The atmosphere in the home on the day of this unannounced inspection was relaxed and happy with the service users needs being met in a caring and enabling manner by staff who clearly knew them well and had a good understanding of their care needs as well as their wants, wishes, likes and dislikes. The home has a pre-admission policy and assessment procedure that meets the requirements of these standards. As there have been no new admissions to the home since the last inspection it was not possible to examine any current records relating to these standards. However, the records relating to the last new admission to the home, some eighteen months ago, evidenced that the policy was followed with an introductory timetable that took some three months and involved several visits including weekend staying visits as well as participation in social activities with the existing group of residents, this to ensure their compatibility. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 9 This resident confirmed to the inspector that he remains happily settled at Lemsford Road and commented how much he liked his flat “ which is my home”. The contract of Terms and Conditions given to every service user gives details of their room, the fees payable, the care and services that they will receive and the terms and conditions of their occupancy including their rights in the event of any breach of contract. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 and 10. Personal care and assistance offered to the service users is of a high standard and is given in a manner that maintains their dignity and respect. The home keeps comprehensive and imaginative care plans, which are regularly reviewed so that changes to health and social care needs, are recognised and met quickly. Risk assessments are maintained for all residents and these reflect how the potential risks for some individual residents can best be avoided or managed as safely as possible. EVIDENCE: The care plans examined were found to be well organised to give clear and concise instructions as to how care should be delivered and to follow closely the steer given from the regular multidisciplinary review meetings. The recording on the care plans gave good detail as to the means of communication used by several of the residents who are non verbal with details of where their use of Maketon signing deviated from the universally accepted form. The records of both the residents and of the staff meetings gave good evidence of the detailed consideration given to the meeting of each residents needs. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 11 Separate residents meetings are held for each floor unit are so that residents know their staff well and were confident in making their comments and requests known. Risk assessments compiled individually for each resident were found on the care plans, these were seen to be regularly reviewed and to state clearly where a recognised risk had been judged to still be within acceptable limits. The records were found to be properly stored with good security either in the homes office or within a locked cupboard in the flats kitchen or dining areas. Staff were observed to be giving proper consideration to their confidentiality whilst handling these records. The manager discussed with the Inspector the regular checks made by the senior carerworkers and deputy managers to ensure that all the actions outlined on the care plans had actually been carried out for each service user, however these regular checks could not be evidenced and appropriate ways of achieving this evidence were discussed. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17. The residents day care and social activity programmes offer them the opportunity for personal development alongside peers of a similar age and ability. The home provides a regular evening and weekend leisure activity programme that is discussed regularly with the residents and changed to meet their wishes and abilities and to suit the time of year. For those residents with relatives good liaison with the home is maintained including for some a regular visiting pattern. A nutritious and varied menu, chosen by the residents and supervised by a dietician, is offered with fresh ingredients and home cooking being provided on a daily basis. EVIDENCE: The records demonstrated that all the residents have their individual day activity programmes covering either three four or five days each week as well as the weekend days. A local day centre and various college classes both recreational and life skills development classes are attended. These programmes are planned to meet the residents individual needs interests and abilities. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 13 Since the last inspection day classes and activity programmes for all residents have been reviewed with new programmes that better suit individual capabilities and meet individual social skills development needs being put in place. Activities have been arranged taking into account the residents particular interests and needs. One resident who recently purchased his own mountain bike is able to make short journeys alone but often, and this occurred on the day of this inspection. He accompanies another resident along with a member of staff to the local park where he rides on the cycle track. This activity is both recreational and assists with a healthy life style programme that has been recommended by the dietician. One resident has recently commenced doing a paper round whilst another has purchased a fishing licence and enjoys regular days out following this sport. All the residents have at least one staying away holiday each year although several prefer to take this as two long weekend breaks. Since the last inspection holidays have been taken in Cornwall, Dorset, to Disney World in Paris and one resident visited his relatives in Venice. One took a group holiday with the Local Mag-Pie Club and several had holidays visiting parents and other relatives. The manager explained that over the summer months various home outings and activities have been planned including day visits to the sea side, an inter home football tournament, and a trip on a canal barge. All the residents except one has contact with their families who are regularly invited to the home for parties and who are given the opportunity to complete quality feedback questionnaires. The dietician continues to visit regularly to supervise the menu planning, each of the four flats prepares its own menu this planned to reflect the needs and likes of the residents more individually and to monitor their weights. Two reducing and one increasing diet is planned to meet specific needs otherwise a normal healthy eating format is followed. Fresh fruits were seen freely available in all unit kitchens and where they are able to do so residents assist the staff with the weekly shopping in the local supermarket. On the day of this inspection one resident went alone to the local shop to purchase an item he particularly needed for the evening meal he was to prepare. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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 standard(s) 18,19 and 20 Personal Care and Health Care offered to the residents is of a high standard and meets their individual requirements. Many of the staff have worked with these residents for many years, some since they were children living in a residential hospital, and so they have an in depth understanding of their care needs and of their varying moods and can interpret their wishes as to how these needs should best be met on any particular day. The home benefits from having well established professional working relationships with their local GPs, the community nursing teams and with various specialist consultants at local hospitals this ensuring that the residents changing health needs are properly met. The home has a robust medication administration and storage system and an appropriate system for dealing with the aging or illness of any service user. EVIDENCE: Individual personal care practice observed was commendable. The needs of the residents were seen to be being individually met by kind sympathetic staff who intervened as little as possible thus ensuring the greatest level of self determination for the residents. The records demonstrated that since the last inspection several of the residents have required medical care and treatment in hospital, one treatment of a complex nature with needs that remain on going, was seen to be subject to regular review. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 15 There have been no changes to the homes medication administration system since the last inspection. This is supplied by a local pharmacist who carries out regular audits to check the management of the system within the home. The medication is stored in appropriate locked cabinets on each of the four units and the MAR sheets are checked regularly by other staff and separately checked by the homes manager with appropriate records to evidence this being kept. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 16 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 The home has the required complaints policy and procedures, a copy of which has been given to all residents and where possible to relatives and families as well. The home has policies and procedures concerning Adult protection and Whistle blowing which follow the guidelines given in the Hertfordshire County Council Adult Protection Joint agency procedures. EVIDENCE: There have been no complaints nor any incidents concerning adult protection since the last inspection. The home has prepared a copy of their complaints procedure in a pictorial format, which has been shared with the service users to ensure where this is possible that they have as best an understanding as possible of this. It was noted that several of the residents act in an empowered manner and are not slow in making their wishes or any complaints known to the staff who they trust. Staff spoken with demonstrated a good awareness of Adult Protection and Whistle Blowing and the records demonstrated that all had attended training on these subjects. Some staff spoke of the importance of their role in interpreting any non verbal signs of concern or distress that may be exhibited by the residents. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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 and 30 This spacious home and its surroundings offer a pleasant, comfortable and safe environment for its residents, it meets their needs and suits their life style and fits unobtrusively into the community in which it is set. The home is clean and very well appointed. The home has a planned routine maintenance programme but this is not being adhered to within any acceptable time frame. Tis resulting in some areas where repairs are needed deteriorating to a level which may be unsafe. EVIDENCE: The manager showed the inspector evidence of the recent maintenance plans that have been devised for the home to maintain it in good repair and to keep it as a safe building fit to be used as a care home. Unfortunately this planned programme of repairs, which was agreed with Aldwick Housing Association, has fallen far behind schedule. Items such as unfinished works of redecoration, an area of asbestos has not been surveyed to ensure its safety, works to fix extra lighting on the fire escapes as required following a recent fire officer survey remain out standing. The replacement of all the windows has been an agreed maintenance project, which the manager complained is constantly being deferred despite her protestations. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 18 This work is now urgently needed as the inspector found that the many rotten windows and doors are now detracting from the safety of the home. One small window in a ground floor W.C. was found to be so rotten that the glass was loose and the window restrictor had come away from its fittings making it non functional. An entrance door to house number 66A was very rotten so that its glass was unstable. A requirement is made that repairs are carried out promptly so as to maintain the home in good repair and ensure the safety for all the residents and staff. Non compliance with this requirement may result in enforcement action being considered. The residents all occupy generous single bedrooms some being very spacious and all being very well appointed with decorations and furnishings chosen by them to accommodate their tastes and reflect their interests. All residents have appropriate aids and equipment provided to meet their individual needs following an OT assessment. These bedrooms many of which are furnished as bed sitting rooms all had a very homely appearance and each was well personalised with personal items belonging to the residents. On the day of this unannounced inspection the home was found to be very clean and tidy. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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) 31,32,35 and 36. The home is run by a dedicated and well established staff team who are led by an experienced and qualified manager. The staff are appropriately trained to meet the needs of the service users and under take training on an on going basis. All the staff have job descriptions and clearly identified roles and responsibilities with in the home. EVIDENCE: On the day of this inspection the whole homes staff team were undertaking a group training course on Challenging Behaviour, and the presence of so many staff within the home enabled the inspector to speak to many of them. Without exception they all spoke positively about their work and the regular supervision and training opportunities afforded them. The home has already achieved a high percentage, approx 81 , of staff holding an NVQ qualification most at level 2 but several also at level 3. All the senior staff have level 3 and some are studying for the level 4 qualification. The training records evidenced that the home has an annual planned training programme with individual training needs identified during personal supervision meetings. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 20 The training for the core subjects is kept up to date with specialist training courses on Epilepsy, Medication Administration, Feeding Awareness, Continence Care and POVA training also being attended. Senior staff have also attended Management and Development training. At the time of this inspection the home was fully staffed and the manager explained that she was able to retain a few free day time staff hours to save for use at times of greater need, either to meet a specific residents higher needs or to cover unexpected and unforeseen staff absences.The recruitment records for the most recently employed member of staff evidenced that the correct procedures to ensure the protection of the service uses had been carried out. A number of relief or bank staff have been recruited recently and those who spoke to the inspector were all students studying some care related subject. They confirmed that they were enjoying their work and that it was helping them expand their horizons and assisting their studies. They also confirmed that they were treated as any permanent member of staff and made to feel one of the team. One commented at her surprise that the ethos of the home afforded the residents so much autonomy and encouraged them to be as self reliant as possible. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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) 37,38,39 and 42 The home is well run by a qualified, competent and experienced manager who leads a dedicated group of staff who work well together as a team. Close consideration to the health, safety and welfare needs of the residents is given and this results in a warm caring environment where the service users seemed happy and relaxed. EVIDENCE: Staff reported that in their opinion the home was well run; they said that clear procedures were in place for all aspects of their work and if something was not clear to them a senior worker was always on hand for consultation. The manager communicates a clear sense of leadership within the home and the records of the staff and of the residents meetings evidenced that good consultation processes are in place with staff actively being asked for their opinions and suggestions for improvements to the service. The aspect of extra consideration needed for the several residents who have no speech could also be evidenced from these records and from conversations with the staff. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 22 One said “we have to be extra careful with X as they cannot tell us, we have to observe carefully to see if they are happy with what we are doing, and sometimes this takes a little longer than it would if we could converse with them directly”. The homes records relating to staff and to residents meetings were found to be well kept with details of the agenda and of action points following the discussion. It was seen that these meetings were held regularly and are planned so that all staff including the night staff can attend and that a management team meeting is held before a general staff meeting. The manager is proactive in compiling Risk Assessments for both the service users and for the building and those examined were seen to be current and to be regularly reviewed. COSHE risk assessments were seen in each unit kitchen. It is recommended that an assessment of any potential risks for the new raised garden patio area is compiled. The records demonstrated that regular fire alarm checks are carried out during both day and night times and that daytime evacuations are occurring at monthly intervals. It is recommended that more detailed records of these evacuations are kept to include the time taken and any unusual occurrences during the process. The records relating to the personal monies held on behalf of the residents by the home were seen to follow the policy and procedures set down by the company, two staff make checks at each hand over, one such procedure was witnessed by the inspector during this inspection. The manager discussed with the inspector that where residents had very healthy financial surpluses that some, with their agreement and that of their families also, might possibly buy themselves a piece of garden furniture for the new raised patio areas. During this inspection it was noted that many of the more ambulant residents were using, clearly with great enjoyment, these new garden facilities. One service users discussed the gardening activities that he hoped to follow especially the growing of vegetables. Periodic quality questionnaires are sent to the service users relatives and to other stakeholders involved in the home. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 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 3 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lemsford Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 2 x I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 24 no 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 24 Regulation 23(2)(b) Requirement The works of repair and replacement to the rotten windows and door frames throughout the building must be carried out this to ensure that the safety of the home for its residents and staff is not compromised Timescale for action by 31st November 2005 2. 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 42 42 Good Practice Recommendations Fire evacuation records should include the time the drill took place and any comments resulting from the drill. The raised garden patio should be risk assessed. Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City AL7 3BQ 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 Lemsford Road I52 s19445 Lemsford Road v237100 120705 stage 4.doc Version 1.40 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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