Inspection on 23/06/08 for Lexham House

This inspection was carried out on 23rd June 2008.

CSCI found this care home to be providing an Good 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

Lexham House 18/06/07

Lexham House 05/06/06

Lexham House 21/11/05

Lexham House 27/06/05

Lexham House 18/10/04

Lexham House 02/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Lexham House 28 St Charles Square North Kensington London W10 6EE Lead Inspector Sheila Lycholit and Jane Shaw Key Unannounced Inspection 23rd June 2008 10:30 Lexham House DS0000010845.V364461.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 Lexham House DS0000010845.V364461.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. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lexham House Address 28 St Charles Square North Kensington London W10 6EE 020 8969 8745 020 8696 8745 chtlexham-uk@yahoo.co.uk www.cht.org.uk Community Housing and Therapy 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) Amer Si Mohand Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 11 Key inspection on 18th June 2007 and a random inspection on 18th December 2007 and 2nd January 2008 Date of last inspection Brief Description of the Service: Lexham House provides support and accommodation for 11 people with mental health needs, including psychosis. The service is provided by Community Housing and Therapy, which runs 6 projects for people with mental health needs. The home is run as a therapeutic community, which aims to support service users to move on to live independently or in supported housing. There are 9 single rooms and 1 double. The building is a 4-storey Victorian house in North Kensington, which is close to shops, public transport and other services. It is unsuitable for wheelchair use, as there are steep steps to all floors. There is single staffing from 9PM until 9AM. Service users therefore need to be relatively self-managing. Lexham House DS0000010845.V364461.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 2 stars. This means that the people who use the service experience good quality outcomes. The unannounced visit took place on Monday 23rd June 2008 from 10.30am until 4.30pm. The Pharmacist Inspector joined the inspection. Her findings, which were discussed with the Manager and Deputy Manager during the visit, are detailed under standard 20. There were 9 people in residence, including 1 person on a respite placement at the project. Four feedback questionnaires were received from residents and the Inspector spoke in private with 2 of the people returning questionnaires during the visit. The Inspector also met with other residents who were around the building. The Deputy Manager was on duty with one member of staff at the start of the visit. The Manager, who had been at CHT’s head office, returned at lunchtime to meet with the Inspectors. A Senior Therapist came on duty at midday. One member of staff returned a feedback questionnaire and the Inspector spoke with one member of staff in private. The Deputy Manager made herself available until she had to leave to attend a meeting in the afternoon. The Manager had completed an annual quality assurance assessment (AQAA) form prior to the inspection. Fees are negotiated individually with the funding authority, depending on the amount of support needed by the prospective client. What the service does well: Lexham House provides support, therapy and accommodation to people recovering from severe mental illness. The residents, or clients as they are called at the project, receive good support to take part in all aspects of life of the home. Staff seek to ensure that a positive and therapeutic approach is maintained in all their interactions with clients, including the daily community meetings but also in the cleaning, cooking and other activities that take place. The project has been successful in supporting a number of people with severe mental illness to move on to more independent accommodation. Staff receive regular support through individual and group supervision and have access to a 3 year training course leading to the Diploma in Group Therapy. Senior staff at the project are experienced and well qualified and seek to continually improve the service. The Director and in particular the Deputy Director visit regularly and provide good management support. Records are well maintained. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Lexham House DS0000010845.V364461.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 Lexham House DS0000010845.V364461.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, 3, 4 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information about the project is regularly reviewed and updated. Well established assessment and admission procedures are in place, which fully involve the prospective client. EVIDENCE: Comprehensive information about the project is kept electronically and printed off as required. There are also leaflets and brochures about CHT and its approach that are available. The majority of clients who are referred to the project are from hospital, some of whom have been in hospital for a number of years. Three client files were looked at during the visit, including the files of the two most recently admitted people. Files showed that a thorough assessment process had been followed, with senior staff meeting with the client in their current placement and with the Care Co-ordinator and receiving a range of information from the multi professional team, including discharge notes and risk assessments. All prospective clients visit the project at least once and usually 2 or 3 times before moving in, meeting with other clients and staff. Placements are initially on a 4 to 6 week trial basis. Staff plan to implement a ‘buddy’ scheme for new clients – pairing them with an exiting client to help them settle in. In feedback questionnaires and in discussion clients confirmed that they had been fully involved in the admission process. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 9 Key workers go through a range of information with each new client, including a confidentiality agreement and the complaints procedure. Each of the files seen showed that the client had received information about the service. Clients are asked to sign to confirm they have received the information. The refusal of one client to sign any of the agreements was noted on his file. Copies of a licence agreement were available on each file. CHT is in discussion with the local PCT and Mental Health Trust regarding the admission of out Borough clients and clinical responsibility, including the funding of Clozapine therapy. When a protocol is in place, Lexham House’s admission procedure and assessment forms will need to be revised to reflect the changes agreed. Currently two thirds of clients are from neighbouring Boroughs, with 3 people from RBKC. Lexham House DS0000010845.V364461.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, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A high standard of care planning has been established. Clients participate in all aspects of the life of the project. Additional steps to further increase client involvement in the service have been introduced since the last inspection. Risk assessments are generally comprehensive and are regularly reviewed. EVIDENCE: An up to date copy of the care plan/therapeutic curriculum was seen on each of the 3 files looked. Clients are fully involved in the development of their plans and normally chair their reviews. Files showed staff are working closely with the Care Co-ordinators and other colleagues to ensure that clients benefit from a multi professional approach. A key worker system is in place in the service. The therapeutic community model of support promotes the involvement of clients in all aspects of the life of the home. Clients are expected to attend the community meeting that takes place each weekday morning. Notes of meetings show that attendance is low, though steps have been taken to Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 11 encourage the current clients to attend more frequently, including reminder letters seen on file. Clients take part in cleaning, shopping and cooking with staff who participate alongside them. Further client involvement is being encouraged by having a regular slot for client representatives at the weekly staff meeting and 6 monthly reviews of the project, where clients’ views are formally sought by means of a questionnaire and attendance at a clients’ forum. The risk assessment format is comprehensive and risk assessments are updated monthly or more frequently if circumstances change, though steps must be taken to ensure that risk assessments regarding self-medication and clozapine are expanded (see standard 20). Risk assessments are signed by the key worker and the Manager. It is recommended that key workers go through risk assessments with their clients and ask them to sign to confirm that it has been discussed with them. If there are reasons why the risk assessment should not be discussed with the client, these should be noted. All clients sign an agreement to waive their right to confidentiality within the project, so that any issue can, if indicated, be raised in the community group and at other meetings. Lexham House DS0000010845.V364461.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): 11, 12, 13, 14, 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 personal development of clients is given a high priority, with support provided to manage their mental health problems and to acquire the skills to take part in the wider community. The project has been successful in enabling clients with long-standing mental health needs to move on to more independent accommodation. EVIDENCE: The programme at Lexham House is designed to provide clients with the opportunity for personal growth and to develop ways of managing their mental health problems. In addition to the daily community meetings, all clients meet with their key worker at least once a week for one to one therapy. In discussion with clients, it is clear that the relationship with their key worker is significant, providing psychological support, as well as helping to liaise with the Care Co-ordinator and acting as a source of practical advice. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 13 A range of task groups, in which staff participate, provide opportunities to acquire or re-learn daily living skills, as well as contributing to the maintenance of a pleasant environment. Two clients had moved onto the ‘flat’ programme and are catering for themselves and living more independently. Clients take part in a range of external activities, including adult education, day services and work placements. One client is attending college three days a week and one client spoken with is hoping to resume her studies later in the year. Staff have included more leisure activities in the programme, including trips out, individually with key workers and as a group. Photos of trips out are displayed in the house and one client spoke very positively about a visit she had made the previous day with her key worker to the V and A. Her key worker had taken some photos on her mobile phone as a record of the occasion. Clients choose the evening meal and help with shopping and cooking for the community. Discussion about that evening’s meal during the visit showed that clients are aware of other people’s likes and dislikes and also their cultural needs regarding food. Meals are taken in the pleasant dining room, which has a table large enough for all clients and staff to eat together. Staff try to promote healthy eating. The fridge, freezer and cupboards were well stocked with food, which was properly stored. A supply of fresh fruit and vegetables was available and the kitchen was clean and tidy. Lexham House DS0000010845.V364461.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): 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Clients receive good psychological support to manage their mental health needs and to develop emotional resources to take part in the wider community. The management of medication is generally good, though some further steps need to be taken. EVIDENCE: We inspected the handling of medication in the home. The medication policy had been updated in 2007 and it was noted that it did not to contain the home procedures for managing leave medications, managing medication errors and what to do if a resident refuses their medication. The home allowed some residents to administer their own medication but there was not a detailed procedure on how this was done. The list of specimen signatures and initials was printed so it was not possible to match them to those on the Medication Administration Record (MAR). The recording of receipts, administration and disposal of medication was good with no gaps noted. It was possible to audit several resident’s medication and Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 15 for each, signatures for administration could be reconciled against the stock held. This means that residents were receiving their medication as prescribed. The home held a small stock of controlled drugs, which were not stored securely as per the Misuse of Drugs Act. Since January 2008 all care homes must store their controlled drugs in an appropriate cabinet and record movement in a register. Other medication was stored securely and was well organised. Several of the residents were self-medicating and we looked at where they kept their medication. We noticed that they all kept their medicines securely in the lockable fixed boxes supplied. We were concerned though at the amount of loose tablets one resident was keeping in a locked drawer. Care workers were advised that part of the risk assessment was to check if there is any medication left at the end of the cycle before giving anymore. The risk assessment for this resident was not up-to-date. Care workers were also recording administration on the Medication Administration Record. If a resident is taking their own medication then only the supply given needs to be recorded by care workers. Two care plans were reviewed, one for the resident who was self-medicating and one for a resident prescribed clozapine. It was noticed that there were no guidelines available of what to do and who to contact if a resident missed a dose or was delayed in taking a dose of clozapine. Staff receive training in handling medication as part of their induction and during their Diploma in Group Therapy course. The Deputy Manager was meeting with the Pharmacy Company used by the home, for training in a new accredited training package, which would include distance learning undertaken on line. Lexham House DS0000010845.V364461.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 good This judgement has been made using available evidence including a visit to this service. Clients are encouraged to raise concerns and complaints in the daily community meetings and have the opportunity to use an established complaints procedure. Incidents are generally well recorded and relevant agencies, including CSCI, are informed. EVIDENCE: All clients receive a copy of the complaints procedure when they move to Lexham House. One client indicated on the feedback questionnaire that she had not received a copy of the complaints procedure, though her file showed that she had signed to confirm receipt. Notes of community meetings show that concerns and issues are regularly discussed. It is recommended that copies of the complaints procedure are displayed throughout the building. The Manager said that a copy had been put on the main notice board but may have been removed. No formal complaints were received in the past year. A number of issues about the project were raised with CHT and CSCI by the local CMHT. Action to address concerns for example regarding security and medication have been taken and an inter agency meeting took place earlier this year. Any remaining issues are likely to be resolved by the establishment of a protocol regarding admissions, as noted at the beginning of this report. Incidents are well recorded and generally reported promptly to other agencies, including CSCI. Delays in reporting 2 incidents regarding medication have been taken up by the Deputy Director of CHT and action taken. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 17 Staff, who have recently attended safeguarding training provided by RBKC, are aware of the vulnerability of clients, for example regarding financial abuse. Risk assessments seen include strategies for reducing the risk of abuse. Since the last inspection, staff have also attended training on the Mental Capacity Act. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 18 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, 26, 27, 28 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. While steps have been taken to create a more attractive and pleasant environment, the building is in need of refurbishment to provide more up to date facilities for clients and for staff. Security has been improved since the last inspection. The standard of cleanliness has improved considerably. EVIDENCE: There are two large communal rooms, the sitting room and dining room, which are spacious and attractively furnished and decorated. Staff have made the rooms as attractive as possible with pictures and soft furnishings. New carpets have been fitted on the stairs and in the basement. There is a bathroom on each floor with a lavatory and washbasin. The bathroom on the ground floor is kept solely for the use of staff (and visitors) in lieu of en suite facilities in the sleeping-in room. Replacement of the floor coverings in the bathrooms has been agreed and the Manager confirmed that the work will take place shortly. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 19 The lavatory bowls would benefit from de-scaling. The Deputy Manager said that she would refer this work to the maintenance officer, who visits regularly. One client showed the Inspector her room, which she had personalised to a high degree. She confirmed that she had all the furniture that she needed. The Deputy Manager said that the window restrictors have been checked and refitted where necessary, after a client was seen sitting on a windowsill in a ground floor room. There is new outdoor furniture in the back garden and staff have arranged for volunteers to help clear the remaining overgrown shrubs and bushes next month. CCTV has been installed, with the monitor located in the staff sleeping-in room. The Deputy Manager said that consideration is being given to installing another camera at the back of the house, following a recent incident when intruders were seen in the garden. The cleanliness of the building is of a much higher standard than at the last inspection, when staff were finding it difficult to motivate clients to help. The maintenance officer visits regularly undertaking redecoration and repairs. Although staff have made commendable efforts to create a more attractive and pleasant environment, the underlying fabric of the building and the layout is poor and detracts from the professional service provided. The double room provides little privacy for occupants; staff have no en suite facilities when sleeping-in and the office is in the basement, with access via external steps. CHT’s senior managers agree that the facilities need updating but are restricted by the conditions of the current lease. A plan needs to be in place, with timescales, for the upgrading of the building when the lease expires. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff training and support is given a high priority. Staff have access to an excellent training programme, which includes the Diploma in Group Therapy. EVIDENCE: The staff team consists of 8 posts, including the Manager and Deputy Manager. Interviews have been arranged for the one vacant post. The Manager and another staff member are leaving the project later in the summer. Rotas and discussion with staff show that the vacant post is not being fully covered, resulting in staff having to work extra hours and do additional sleep-ins. All posts at the project need to be covered in this already small team, to ensure that sufficient staff are available to support clients and that staff do not become over-stretched. Interactions observed during the inspection visit between staff and clients were positive, professional and showed warmth and concern. Staff are recruited by CHT’s HR team together with the project Manager. Prospective candidates visit the project, meeting with clients and staff, who feed back their observations to CHT’s head office by means of a structured report. One candidate had visited the project the week before the inspection. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 21 No new staff have started at the project since the last inspection. Recruitment checks are undertaken by the HR team, with confirmation sent to the Manager. The Manager confirmed in the AQAA that satisfactory pre-recruitment checks have been received for all staff. CHT has a well established training programme that includes a 3 year part time course leading to the Diploma in Group Therapy. The course is accredited by Middlesex University. In addition to working at CHT’s projects, staff have placements in other mental health settings. New staff are expected to have a relevant degree and/or previous experience and must enrol on the Diploma course. A regular training programme, including induction training, is run at CHT’s head office in Fulham, which gives staff an opportunity to meet colleagues from other projects. Team meetings are also used as training workshops. The Manager, Deputy Manager and Senior Therapist have completed or are studying for an MA at the Tavistock Clinic or the Institute of Group Analysis. In discussion, staff confirmed that they receive good support through weekly supervision and staff business and practice meetings. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 22 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, 41, 42 and 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Lexham House has an experienced and qualified senior staff team. Steps have been taken to further increase client involvement in the development of the service and to seek feedback from referring agencies. CHT’s senior Managers regularly visit the service, providing good support to staff and ensuring that standards of practice are maintained. EVIDENCE: The Manager and Deputy Manager are experienced in working in the mental health field and have qualifications in psychology and group therapy/analysis. The Manager and Deputy Manager have implemented a number of improvements in the service, including changes to the programme and increased client involvement. A range of quality assurance systems are in place. As discussed earlier in this report, client representatives now attend part of the staff meeting each week Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 23 to discuss client issues. Clients’ views are formally sought by means of a questionnaire before the twice yearly client forum. The project recently had a peer group review, though the report was not yet available. Records seen were in good order. Since the last inspection, recording in the daily log book has improved, with a fuller account available of action taken. All staff receive training in health and safety as part of their induction and receive refresher training. Fire safety records were up to date. The maintenance engineer from the fire systems company was testing the system during the inspection visit. Fire drills are carried out at least 4 times a year and along with other incidents that set off the alarm are recorded in detail. Since the last inspection, the Manager has arranged for a contractor to assess the building for the risk of legionella. As a result of the assessment the water tanks and system have been cleaned and a system of checks to be carried out by staff implemented, including testing the temperature of the water monthly and regular cleaning of the showerheads. In view of the physical vulnerability of one new client, staff should include the temperature of the hot water used by him in their monthly schedule. Good support is provided by the Deputy Director visits the project at least monthly and completes a report on behalf of the provider. The Manager also meets with senior Managers at weekly meetings. Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 24 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 3 4 3 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score N/A 3 2 X 3 3 3 X 3 3 3 Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13(2) Requirement That the home’s medication policy is updated and expanded to include the home’s procedures for self-medication, managing medication errors, leave medication and what to do if a resident refuses medication. When completed there must be a list of specimen signatures and initials to demonstrate understanding and for audit purposes. That the home has a controlled drugs cupboard to safely store temazepam. That risk assessments/care plans are expanded and regularly reviewed for residents who are self-medicating and who are prescribed clozapine. This is to prevent error and to safeguard the health of the resident. Plans for upgrading the building must be developed, with timescales available. Vacant posts must be covered to ensure that the staff team does not become over-stretched. Timescale for action 01/09/08 2 3 YA20 YA20 13(2) 13(2) 01/10/08 10/08/08 4 5 YA24 YA33 16 18 31/10/08 31/07/08 Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 26 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 YA1 YA2 Good Practice Recommendations Once a local protocol regarding clinical responsibility for out Borough clients is agreed, the statement of purpose and admission procedure and related forms will need to be revised. Clients should be asked to sign their risk assessments unless there are clear indications otherwise. The complaints procedure should be displayed in the home. The lavatory bowls would benefit from de-scaling. In view of the physical vulnerability of one client, checks of the hot water used by him should be included in the monthly temperature tests, to ensure that the hot water is not running at too high a temperature. 2 3 4 5 YA9 YA22 YA27 YA42 Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Lexham House DS0000010845.V364461.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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