Inspection on 15/02/08 for Lewisham Park, 40

This inspection was carried out on 15th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lewisham Park, 40 01/11/06

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 Lewisham London SE13 6QZ Lead Inspector Sean Healy Key Unannounced Inspection 15th February 2008 11:30 Lewisham Park, 40 DS0000025599.V348877.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.V348877.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.V348877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lewisham Park, 40 Address Lewisham London SE13 6QZ 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) 0208 3141877 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.V348877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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 business status is that of a sole trader. 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 £2,019.67 and £2,599.45 per month for accommodation, and for all support services. This charge includes food provided. The local authority pays this for. Residents have to pay for other personal expenses such as hairdressing, transport and personal shopping. The provider email address is percival.drummond@Gmail.com Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality Rating for this service is 1 Star. This means that the people who use this service experience adequate quality outcomes. This unannounced inspection took place on 15/2/08. The registered manager facilitated the inspection. Two residents were present for part of the inspection but choose not to give detailed views about how they felt living at the home. They did make some comments, which are included in this report. The method of inspection included discussion with the home’s manager and his wife, both of who provide the support for residents. The building was also inspected for health and safety, suitability for residents and for cleanliness. Resident’s records and other documentation about how the home is run were examined. Care assessments and care plans and risk assessments were examined to check that care needs were being planned for, and the registered manager and other main carer spoke with me about these plans, and about the plans for development of the service provided for residents. What the service does well: What has improved since the last inspection? The Service Users Guide has been updated to provide better information about fees, staff training, and the system for carrying out care reviews and risk assessments. This has helped to show residents how staff will help them to makes plans for doing things and how they will get the training they need to do their job. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 6 Care plans have been much improved and now show clearly the help that residents need and how staff will support the residents. Improvements include showing all the activities that residents like to do and how the home will help them to do these activities. The manager has now enrolled on an NVQ 4 course in care and management and the health and safety at the home has improved. All the electrical equipment has now been checked and is safe and all of the other equipment such as fire equipment and gas are also checked for safety. Improvements have been made to the homes Adult Protection policy and the way any concerns are to be reported is now much clearer. 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.V348877.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.V348877.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have the information they need to decide whether to live at the home and their care needs are fully assessed. Each resident has an up to date written contract with the home showing the care to be provided. EVIDENCE: At the last inspection a requirement was mad effort the home to make the following changes and amendments to 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. 3. The system for carrying out care reviews including risk assessments should also be described. 4. Respite care is now not provided and should not be included in the Service Users’ Guide. 5. Remove the statement from the Service Users Guide, which currently states that the home does not provide support for service users who may be frequently incontinent. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 9 6. The home should show in the Guide how it would provide a copy of the care plan to each service user and a representative. All of these changes have now been made and this requirement is now met. There are currently two male residents living in the home. Both of these 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. One resident has since developed a health issue related to his heart, which has now been included in his assessment and care plans. Both residents have been given a contract between themselves and the home, which shows the room they will have, the service and support they will receive, and the cost of the service. Lewisham local authority is responsible for paying fees and this is noted in these contracts. Overall the information provided about the service the home provides, the cost of this service, how residents are to be supported and the staff qualities and training are included in all the relevant documentation for the home and care is taken to help the residents to be aware and understand this information. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are reflected in their care plans. The residents are supported to make important decisions about their lives and risk assessments do adequately protect residents and staff. EVIDENCE: Both residents are supported to make decisions about a range of areas on a daily basis. The staff consisted solely of the Registered Care Manager and his wife provides the support needed. They are both very respectful in how they speak with residents, and I observed the residents being treated well and involved in discussion about what they did with their day when they returned home, and about what they would like to eat for tea. Residents have chosen how their rooms are decorated and the activities they want to do every day. Both residents’ money and finances are managed by the Registered Care Manager, and when residents were spoken to about this at the last inspection they said that they are happy with this and that they can get money when they need it. I was not able to speak with them about this subject at this inspection. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 11 There was a requirement made at the last inspection for the home to develop residents care plans to include: residents aims and goals for their future activities and personal development, progress made in achieving these goals, and how residents choices are incorporated into the care planning process. This requirement is now met and the home has done considerable work to improve care plans for both residents. The home has introduced a new care planning system over a number of months, and while the old care plans are still in use, the information is in the process of being transferred onto the new system. The new system includes a very comprehensive assessment system for all areas of health and social care needs, with the section for including goals and objectives for each category of the assessment. The home has started to include goals for development of social activities and for healthcare needs of both residents. Warn residents care plan shows that he likes exercising, holidays, music, outings to local parks cinemas and pub, watching TV, going to the zoo and going to friend’s parties. The home has now got a system in place for setting objectives about all of the assessed needs of the residents, and the homes paperwork shows that these are now being reviewed on a monthly basis. There was a requirement made at the last inspection for the home to involve social services in care planning and carrying out care plan reviews. The home has contacted social services and has now received confirmation of the attendance of a social worker at scheduled care plan reviews in March 2008. This requirement is now met. There was a recommendation made at the last inspection for the home to introduce a system for resident’s ideas for activities to be included in their care planning. The home is now doing this, and records this information as goals in the new care planning system each time a resident comes up with a new idea. Currently issues recorded include: health care intervention, going out for regular walks, and going out socially to pubs and social clubs. Both residents have learning disabilities and the local authority receive their benefits and are responsible for managing their finances. The home receives monthly payments from the local authority for the support to be provided under residents receive weekly amounts by cheque for personal spending which is lodged in their own bank accounts. Both residents have support from a long-term friend works as an advocate and is involved in care planning and decision-making. This individual is not currently included in this system for carrying out surveys of resident’s views about how the home is managed, and it is recommended that he be included in service carried out in future. (Referred to Recommendation YA7) There was a recommendation made at the last inspection for the home to review residents risk assessments to ensure that they are robust and also to decide whether other risk assessments were needed to fully protect residents. There are risk assessments in place, which identify risks such as: residents Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 12 using minicabs, walking to the corner shop, walking home from the barbershop. These risk assessment shall risk to be minimal and well managed. In discussion with the manager and the main carer about how the risk assessments work it was clear that they were well understood by both these people. However it is important that some further work is done to further clarify the details of these risk assessments so that it would be more easily understood by a new worker should the need arise. (Refer to RecommendationYA9) Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents 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 showing the things they like to do, which have been updated since the last inspection. The new system for care planning, (Refer to standard 7) includes clear description of the activities residents like to engage in, and also shows how residents own ideas are included in new care plans. The staff are help the residents to go out and there are activities clearly identified that residents can do without staff support. Activities they are involved in include attending day centre, some voluntary work in the local community and educational and leisure activities. One resident attends Parkside Day Centre and has a voluntary job helping with Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 14 cleaning and dishwashing. Each Wednesday, he helps at a local school doing similar voluntary work. At the last inspection he said he really enjoyed doing this work. Both residents attend a local Catholic Church regularly and are supported to attend all church services. Other activities they enjoy include going to local pubs, going for walks, watching TV, helping with housework and maintaining the home, including doing the laundry. Contact has been made with a long lost family member of one resident and good work has been done to forge a new relationship between them. As a result this relative has extended an invitation to the resident to visit him at his home in Portsmouth. Residents have constant contact on a daily basis with the owners and Registered Manager 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 residents. Communications between the staff and residents is good and staff are very respectful in how they communicate with and about residents. Good and nutritious meals are provided and both residents are involved in shopping and cooking, and always are given a choice of food at every meal. Menus are kept and residents said that the food is very good. Hall offers residents a choice of food a daily basis using a pictorial menu, which shows pictures of all of the meals on offer. These pictures have a number beside them and this is used to record what has been eaten. The use of pictures seems to greatly help residents to make quick and easy choices. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 15 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. Residents do receive appropriate and sensitive personal care support, and physical and emotional needs are met. Support with medication is appropriate for the residents assessed needs. EVIDENCE: Personal care support plans are in place for both residents, which are adequate and up to date. The residents are supported with personal care by the homeowners. One is very independent and more support is required for the other and this is reflected in the care plans. The care plan for each resident 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. There is not involvement from many other healthcare professionals but this is appropriate to the assessed needs of the residents. More recently one resident has developed a heart condition and his care plan and health care records show that he is receiving appropriate treatment for this. The homeowners know both residents very well, and are familiar with their needs. Neither resident is on any medication at present. Both are able to Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 16 access the local GP and dentist as needed. Both the homeowners were able to demonstrate that they understood the residents differing emotional needs and how to offer appropriate support to each. Both residents said that they are happy with the support that they receive. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents 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, which was reviewed in 2007. No complaints have been received since the last inspection. Residents said that they have never complained and are happy living at the home. The residents have daily contact with the registered manager who provides support for them, and communications seems to be very good between staff and residents. Both residents have support from a long-term friend who is in regular contact with them and who can provide support to complain to the home should the need arise. The home has an adult protection policy in place, which was reviewed in 2007. There are adequate procedures around safeguarding the resident’s money, and the home is not responsible for any of the residence bank accounts or benefits. These are managed by the local social services. Receipts are kept for all transactions and good written records are kept of all expenditure on behalf of residents. There was a recommendation made at the last inspection for the home to include a brief clear reporting instruction in the adult protection policy, about how to report adult protection issues quickly to social services. This is now been done in this requirement is met. The home now has a simple guidance for Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 18 how to identify and report and protection issues, which includes a list of contact details for social care professionals in the Borough of Lewisham. Social services are now involved in annual care reviews for both residents. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 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 residents are fully met within the home. EVIDENCE: There have been no significant changes to the premises since the last inspection. The home is situated in a large Edwardian house, situated in a crescent overlooking Lewisham Park. The residents 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 residents who have 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. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 20 Both residents share a room on the first floor. Both have 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. The home is very well maintained and there are no outstanding repairs required. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff and are protected by the homes recruitment policy and practices. Staff are not yet adequately trained to meet residents needs. EVIDENCE: As at the last inspection the owners of the home employ no staff, and provide all the support to residents themselves. The independence levels of the residents suggest that this staffing arrangement is adequate and appropriate. As the home employ no staff there is no rota, record of recruitment/employment. The arrangements for staff cover is that one of the owners will always be at home when any of the residents are at home. One of the residents 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 them, and maintain a professional boundary when sharing the homes facilities. At the Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 22 last inspection both residents said that the owners respect their privacy and only go into their room with their permission. One resident spoken to said that this is still what happens. It was not possible to discuss this with the other resident at this inspection. As the owners are the only staff working at the home, there are no recruitment records for inspection. The local authority, Lewisham Partnership, holds the CRB documentation for the care manager and his wife and copies were available for inspection. These were updated on the 13/12/07 and 3/1/08 and showed no issues for concern. 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. There was a recommendation made at the last inspection for this to be done but although some progress had been made, the individual training plans are not yet in place. Examination of the training recorded for both owners showed gaps in training, which must be addressed. For one there was no current record for the following training: Health and safety, fire safety, first aid, care planning, and medication. For the other Learning Disability training and basic food hygiene training needs to be brought up to date. It is now required that there be a training development plan in place for both of the owners addressing the gaps in training described and any additional training the registered manager feels appropriate. (Refer to Requirement YA35) The home has an induction system in place and is in the process of reviewing the homes training and induction programme in consultation with Skills for Care. This is a positive step in bringing the core training for the home up to date. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 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 residents views are fully included in the homes development plans. Health and safety needs are now being fully addressed by the home. EVIDENCE: As at the last inspection 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 there was a requirement made at the last inspection for the registered manager to enrol on an NVQ 4 course in care and management. He Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 24 has now done this having commenced on a course in November 2007 and was able to show the coursework file he uses for accumulating the necessary coursework evidence. The manager must now complete this course in order to fully meet the registered care management requirements. (Refer to Requirement YA37) There was a requirement made at the last inspection for the home to put in place a quality assurance system based on seeking the views of the residents. The home does not yet have a formal quality assurance system in place, but has begun developing questionnaires for residents and has now secured the services of a quality assurance consultant to help develop the quality assurance systems for the home. They showed commitment to working towards meeting this requirement, and a requirement is now partially met but is repeated. (Refer to Repeated requirement YA39 partially met) Although there is not a formal quality assurance system in place, the home has begun developing questionnaires for residents and has discussed relevant other means of gathering views of residents and a daily basis. The owners have consistent daily contact with both residents, and provide very good opportunities for conversations and communication about all aspects of care with the residents. The owners demonstrate a strong emphasis on quickly responding to residents changing needs and both residents have varied weekly activities including work for one residents voluntary work for one resident at a local care home, contact the local church, and enjoying music and TV. There is involvement from two long-standing friends of the residents who can if requested support the residents in independently making their views known. The registered care manager said that he wished to include this option in the quality assurance system for the home. There was a requirement made at the last inspection for the home to ensure the health and safety and welfare of residents and staff, by having to homes portable appliances checked by a qualified person. This has now been done and this requirement is met. The health and safety policy for the home was reviewed in 2007 and is up-to-date. The full range of health and safety documentation for the home was checked and was found to be in order. Fire safety equipment is in place and complete records are kept of all fire drills and fire equipment maintenance. The residents had risk assessments also adequately protect them from risk or harm, and a reviewed by the home monthly. Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 26 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 YA35 Regulation 18.1 a Requirement The registered provider and manager must make improvements to the training and development planning for both of the owners, as discussed in this report YA35. This must be in written form and reviewed annually The registered manager must complete 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 residents, to measure success in achieving the aims, objectives and statement of purpose of the home, as discussed in this report YA39. This is a repeat of a requirement from the last inspection Timescale of 31/3/07 partially met and now repeated. Timescale revised. Failure to meet this requirement may result in enforcement action Timescale for action 30/06/09 2 3 YA37 YA39 18.1 a 24 1,2, 3 28/02/09 31/08/08 Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 27 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 YA9 Good Practice Recommendations The registered manager should review risk assessments again to ensure they are robust, and review whether other risks assessments may be needed to better support the service users. This is a repeat of a recommendation from the last inspection Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lewisham Park, 40 DS0000025599.V348877.R01.S.doc Version 5.2 Page 29 - 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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