Inspection on 01/11/06 for Lewisham Park, 40

This inspection was carried out on 1st November 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lewisham Park, 40 15/02/08

Lewisham Park, 40 10/03/06

Lewisham Park, 40 20/12/05

Lewisham Park, 40 28/02/05

Lewisham Park, 40 12/11/04

Lewisham Park, 40 21/01/04

Lewisham Park, 40 08/10/03

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 Lewisham Park, 40 40 Lewisham Park Lewisham London SE13 6QZ Lead Inspector Sean Healy Unannounced Inspection 1 November 2006 10:00 st Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lewisham Park, 40 Address 40 Lewisham Park Lewisham London SE13 6QZ 0208 3141877 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 Percival Fitzroy Drummond Ms Maise Melanie Bell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 Brief Description of the Service: 40 Lewisham Park is a large property offering residential care for up to 3 residents with learning disabilities. The house is located in a residential area opposite a park, and close to public transport links. It does not accommodate the needs of wheelchair users. The house is spacious and the care is provided by the proprietor and manager and who live in the house with their two children. The house has the appearance of a family home and the residents benefit from this environment. There was one vacancy at the time of the inspection. The two current residents are brothers and have lived at 40 Lewisham Park for a number of years. The residents spend their day in various planned activities such as day care and voluntary work. Their evenings and weekends are spent at home or in leisure pursuits. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. The recent CSCI report is currently kept in a file in the living room and is accessible to service users. At 1st November 2006, the homes fees are set at between £1,495.81 and £2,119.71 per month for accommodation, and for all support services. This charge includes food provided. This is paid for by the local authority. Residents have to pay for other personal expenses such as hairdressing, transport and personal shopping. The provider does not have an email address. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 1st November 2006. It was facilitated by the Registered Care Manager and his wife, both of who own the home and provide the care support. The two residents were present for part of the inspection and gave their views privately about how they felt living at the home. The method of inspection included discussion with the home owners, a tour of the building and inspection of records and other documentation. Care assessments and care plans were examined to ensure that care needs were being planned for and the owners and service users were questioned about these plans, to check that plans were being put into action. What the service does well: What has improved since the last inspection? Some work has been done to improve the information provided to service users about how the home is managed. Care plans have been improved and now include information about the activities service users most like to do and places they like to go. This helps to make sure they get to do favourite activities more often. The Adult Protection policy has been re-written and now has better information showing what staff need to do to protect service users from theft or abuse. The owners have now done some training so that they are better able to protect service users. There is now an Annual Budget, which shows how money will be spent to make the home a good place to live. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not yet have full information to make an informed decision about where they live, but their care needs are fully assessed. EVIDENCE: At the last inspection it was required that the registered person must complete the Service Users’ Guide to include the current position regarding the nonprovision of a screen and hand-wash basin in a service user’s bedroom. The manager has done some good work in reviewing the Service Users’ Guide and this is now included. Some further changes to the Service Users’ Guide are needed. Respite care is now not provided and should not be included in the Service Users’ Guide. The Guide also states that the home does not provide support for service users who may be frequently incontinent, but this is not the case and the home is able to provide this service, so this comment should be removed from the Service Users’ Guide. The home also needs to include the following information in the Service Users’ Guide: 1. There needs to be a clear reference to the fees to be paid and what these fees include. There also needs to be a brief description of how the fees are to be paid and by whom. 2. Staff training details should also be included showing the minimum levels of staff training including NVQ training. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 9 3. The system for carrying out care reviews including risk assessments should also be described. 4. The home should show in the Guide how it would provide a copy of the care plan to each service user and a representative. (Refer to Requirements YA1) There are currently two male service users resident in the home. Both of these service users have care assessments in place since they started living at the home. These were provided by Lewisham Partnership in December 2003. The assessments are full and comprehensive and fully describe the care and support needed. Care plans contain information from these assessments. Assessments overall were found to describe the needs of the service users. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Changing needs may not always be adequately reflected in care plans, which may result in needs not being met. Service users are helped to make decisions about their lives, and to take risks as part of their lifestyle. EVIDENCE: A Requirement was made at the last inspection for the Registered Person to develop a care plan for each service user, which describes their aim, goals and how residents’ choices are incorporated into care plans. While both service users have care plans in place, and work has been done to improve them as required, they do not yet fully describe how the routines in the home and how activities will meet the needs of each service user. For example, there is no reference in the care plan about whether service users have specific things they wish to achieve set out as goals, and therefore, no clear means of reviewing whether service users are getting to doing new activities. This Requirement is repeated. (Refer to repeated Requirement YA6 YA41 partially met) Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 11 The home needs to think about an alternative system for picking information about how service users’ personal desire to do new things can be incorporated in to the care plans. For example when speaking with service users on a daily and weekly basis they can regularly make suggestions about new things they would like to do based on their experiences, but these are not effectively picked up and recorded as goals for the future, and therefore some good opportunities may be missed to improve the care plan. (Refer to Recommendations YA6) Both service users have no family involvement out of choice and there is also no meaningful involvement from Social Services or Advocacy in the care planning process. Given the nature of the service user support needs it would be good practice for both Service user to be offered the opportunity to have other independent people such as a friend, advocate, social worker involved in care planning. The Manager suggested that both service users may have some support available to them from a family friend who has known them over many years and feels that this may be a possible means of addressing this problem. (Refer to Recommendations YA6). Social Services have not been involved in care planning for either of the two service users for a number of years. The home’s manager must ask Social Services for appropriate involvement in the next care planning review meetings. (Refer to Requirements YA6) Both service users are supported to make decisions about a range of areas on a daily basis. The staff who consist solely of the Registered Care Manager and his wife provide the support needed. They are both very respectful in how they speak with service users, and the service users said that they are treated well and that they like the staff. Service users said they have chosen how their rooms are decorated and that they choose what activities they want to do every day. As already mentioned they may benefit from advocacy support (Refer to Standard YA6). Service users’ money and finances are managed by the Registered Care Manager, and service users said that they are happy with this and that they can get money when they need it. Risk Assessments are included in the care plans for both service users. One service user’s risk assessment shows that there may be some risks in him using mini cabs, but there is no clear indication as to how this risk is managed. There are a number of ways this could be improved, for example asking that the same mini cab firm be used, or checking that the service user consistently carries personal identification that includes the home address or contact number. The Manager should review this risk assessment to ensure it’s more robust, and review whether other risks assessments may be needed to better support the service users. (Refer to Recommendation YA9). Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have opportunities for personal development, links with the local community and access to appropriate social and leisure activities. They are supported to have appropriate relationships, and have a healthy diet. EVIDENCE: Both residents have individual programmes of activities, which they said they enjoyed doing and also said that the staff are very good at helping them to go out and to do the things they like to do. Activities they are involved in include attending day centre, some voluntary work in the local community and educational and leisure activities. One service user attends Parkside Day Centre and has a voluntary job helping with cleaning and dishwashing. Each Wednesday, he helps at a local school doing similar voluntary work. He said he really enjoys doing this work. Both service users attend a local Catholic Church regularly and are supported to attend church services. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 13 Other activities services users enjoy are going to local pubs, going for walks, watching TV, helping with housework and maintaining the home, including doing the laundry. There was a Requirement at the last inspection that the Registered Person must include an assessment of services users leisure activities and social activities in their care plans and this has now been done. One service user helps distribute leaflets for the local church and said that he really enjoys visiting the church and meeting the people there. Both service users have little contact from family who leave in Australia and Portsmouth. The Manager said there might be a possibility of renewing contact with one brother to offer an opportunity of meeting again. A long-term family friend is involved and meets with both service users monthly. The service users said that they are pleased that he is involved and the Manager wishes to pursue more formal involvement in care planning with the services users’ permission. (Refer to Recommendations YA6) Service users have constant contact on a daily basis with the owners and Registered Managers of the home, who provide the care and support. No other staff are employed. There would seem to be a good relationship between the owners and both service users. Communications between the two were very respectful and the owner offered service users the opportunity to show the Inspector around the home. Service users said that they like and trust the owners of the home and are happy living there. Good and nutritious meals are provided for service users and both service users said they are involved in shopping and cooking, and always are given a choice of food at every meal. Menus are kept and service users said that the food is very good. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users do receive appropriate and sensitive personal care support, and physical and emotional needs are met. Support with medication is appropriate for the service users assessed needs. EVIDENCE: Personal care support plans are in place for both service users, which are adequate and up to date. The service users are supported with personal care by the homeowners. One is very independent and more support is required for the other service user, and this is reflected in the care plans. The care plan for each service user includes a good health care support plan, which fully meets their health care needs. Both are registered with a GP and dentist and have appointments with them at least every year. The homeowners know both service users very well, and are familiar with their needs. Neither is on any medication at present. Both are able to access the local GP and dentist as needed. Both the homeowners were able to demonstrate that they understood the residents differing emotional needs and Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 15 how to offer appropriate support to each. Both service users said that they are happy with the support they receive. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do feel their views and concerns will be listened to and acted on and are protected from abuse and self-harm. EVIDENCE: The home has an adequate written complaints policy and procedure, and no complaints have been received. Service users said that they have never complained and are happy living at the home. At the last inspection the home did not have any policy on the protection of vulnerable adults. One of the owners had been on training but this was some years ago. The home owners were advised that they need to attend training and that they ensure that they put in place a policy on vulnerable adults, in consultation with the Lewisham Partnership policy guidance. This has now been done and both of the owners have been on adult protection training as part of their NVQ training course. Both were able to clearly state how the policy worked and how to report any suspicion of abuse. It is recommended that a short, clear reporting instruction in how to report adult protection issues be included in the policy. (Refer to Recommendation YA23) The home have adequate procedures around safeguarding the residents money, as recommended at the last inspection they have a ledger with a running total. Receipts are kept to prove expenditure. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable clean and safe, and bedrooms are comfortable and personalised. The needs of the service users are fully met within the home. EVIDENCE: The home is situation in a large Edwardian house, situated in a crescent overlooking Lewisham Park. The service users have access to all the downstairs rooms and the garden. There is a large pleasantly fitted bathroom on the first floor that they share with the rest of the family. There is one bathroom with a toilet on the first floor and a separate toilet on the ground floor. The home is suitable for the needs of both service users who said that they like living with the family. It is homely and comfortable, well maintained and well heated and ventilated. It is not suitable for wheelchair users but none of the existing service users have this need, and there are no vacancies. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 18 Both service users share a room on the first floor. Both confirmed that it is their choice to share and they are very happy with this arrangement. Their room is large and pleasantly furnished, with a TV and two armchairs placed side by side for them to watch TV. Their were numerous personal items around and was a pleasant and homely environment. The home is very clean and well decorated with good natural light throughout. Laundry is done separately and the machine has a sluicing facility. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. Staff are adequately trained to meet service users needs. EVIDENCE: The owners of the home employ no staff, and provide all the support to service users themselves. The independence levels of the service users suggest that this staffing arrangement is adequate and appropriate. As the home employ no staff there is no rota, recorded of recruitment/employment, or supervision. The arrangements for staff cover is that one of the owners will always be at home when any of the service users are at home. Both of the service users said that there is always one of the owners available at the home when they are at home. Both of the owners, now have completed training to NVQ Level 2, and are awaiting their certificates. Both owners showed a knowledge and understanding of the needs of the residents. They are respectful in their approach to communicating with the service users, and maintain a professional boundary in sharing the homes Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 20 facilities. Both service users said that the owners respect their privacy and only go into their room with their permission. As the owners are the only staff working at the home, there are no recruitment records for inspection. The registered care manager said that the local authority, Lewisham Partnership, holds their own CRB documentation and there is not a copy available at the home. There is a training record in place for both of the owners, and a list of training is available showing training completed. However there is not a training plan in place, which would be beneficial especially as the home is a small individual concern, which does not avail of the benefits of larger organisations training provision. It is recommended that there be a training development plan in place for both of the owners. (Refer to Recommendations YA35) Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run, but the manager needs to achieve appropriate qualifications. More work needs to be done to ensure service users views are fully included in the homes development plans. Health and safety needs are largely addressed but some improvements are needed. Management is competent and accountable. EVIDENCE: The home is well run and both owners were able to demonstrate a positive and committed approach to the residents that they provided care and support to. The ethos of the home is very much that of offering a care service within the setting of a family home. The manager is experienced in the learning disabilities area of care provision, and communicates very well with the service users. He has completed NVQ level 2/3 in care and is awaiting a placement on an NVQ level 4 course. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 22 (Refer to Requirement YA37) At the last two inspections there was a recommendation that the homeowners liaise further with the Commission and Lewisham Social Services to explore whether the home would be more appropriately registered as an adult placement scheme. The homeowners were concerned that if they returned to the adult placement scheme they would not longer be able to offer a home to the present two residents, who originally come to them via the placement scheme. The owners now have stated that they wish to remain fully registered with CSCI as a care home, as they may wish in the future to expand the home. This recommendation therefore no longer applies. The nature, structure and size of the home is such that the service users have complete daily access to the owners and registered manager, who include them in day to day decision making. Both service users said that they speak with the owners every day and when we want something they listen to them and get what they need. However there is no formal system for asking service users for their views on how the home is managed and there is no formal involvement from anyone else to represent the views of service users, should they feel unable to express their own opinions. The home needs to put a system in place for asking service users and their representatives for their views in confidence and for ensuring that a development plan is in place for including necessary action, together with any other staffing training or environmental improvements needed. (Refer to Requirements YA39) All health and safety systems and working practices are in place to safeguard service users and the homes owners. Fire equipment is in place and fire practice drills are being done. There have been no reports under RIDDOR, and no serious incidents have been reported. However the homes portable appliances are not being tested annually and this needs to be addressed. (Refer to Requirement YA42) At the last inspection there was a requirement that the home draw up an annual budget for the home to identifies money being paid into the service and how this is allocated. This has now been done. Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 2 2 X X 2 3 Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4 (1,2)5,6 Requirement The registered person must ensure that the service users’ guide is completed to include all of the issues outlined in this report under Standard YA1. The Register Person must develop with each resident an individual care plan that includes information about their aims, goals, information about progress made, as well as how residents choices are incorporated into the care planning process. This was a requirement of the last inspection, Timescale 01/08/06 partially met, and now revised. The registered owner and manager must request in writing, involvement from social services in the annual care reviews for all service users The registered manager must enrol on an NVQ level 4 course in care and management. The registered manager and owner must put in place an effective quality assurance and quality monitoring systems, based on seeking the views of DS0000025599.V291978.R01.S.doc Timescale for action 28/02/07 2 YA6 YA41 15 28/02/07 3 YA6 15 28/02/07 4 5 YA37 YA39 18.1 a 24 1,2, 3 28/02/07 31/03/07 Lewisham Park, 40 Version 5.2 Page 25 6 YA42 23.2 c service users, to measure success in achieving the aims, objectives and statement of purpose of the home, as discussed in this report YA39 The registered manager must ensure the health, safety and welfare of service users and staff, by ensuring that all of the homes portable appliances are checked by a person qualified to do so. 31/12/06 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 Refer to Standard YA6 Good Practice Recommendations The registered manager should consider introducing a system for regularly recording when service users bring up ideas or requests for new activities or personal aims for development, and included these in the care planning system. The registered manager should consult with service users about involving friends or advocacy in the care planning system The registered manager should review risk assessments to ensure they are robust, and review whether other risks assessments may be needed to better support the service users. The registered manager should include in the homes Adult Protection policy a short description of how the reporting of adult protection issues should happen and who is involved The registered manager should consider making improvements to the training and development planning for both of the owners, which is in written form and reviewed annually 2 3 YA6 YA9 4 YA23 5 YA35 Lewisham Park, 40 DS0000025599.V291978.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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