Inspection on 28/06/07 for Linden Lodge

This inspection was carried out on 28th June 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Linden Lodge 18/05/06

Linden Lodge 12/12/05

Linden Lodge 06/09/04

Linden Lodge 24/05/04

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

CARE HOME ADULTS 18-65 Linden Lodge 38a Linden Way Southgate London N14 4LU Lead Inspector Wendy Heal Key Unannounced Inspection 28th June 2007 11:30 Linden Lodge DS0000010565.V333138.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 Linden Lodge DS0000010565.V333138.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. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Linden Lodge Address 38a Linden Way Southgate London N14 4LU 020 8447 9195 020 8447 9195 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) www.craegmoor.co.uk Parkcare Homes Limited ** Post Vacant *** Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of service users accommodated to not exceed 8 in Linden Lodge, 38a Linden Way and 3 at 38 Linden Way. One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 18th May 2006 Date of last inspection Brief Description of the Service: Linden Lodge is owned by Parkcare Homes Ltd. The home provides care for up to 10 people with mental health needs. Linden Lodge consists of two adjoining houses and is situated in a pleasant residential area of Southgate. The home is close to local shops and facilities and is near to public transport routes. 38 Linden Way has 3 bedrooms, each with en-suite facilities. There is a lounge and kitchen on the ground floor and a room upstairs for staff where they sleep in at night. 38a has 7 bedrooms, each with a hand basin. There is also a lounge and kitchen/dining room, bathroom and an office used by staff. There is an attractive garden at the rear with a patio area. People living at the home have their own bedroom. The staff team consists of a manager, one deputy, senior support workers and support workers. A minimum of 2 care staff are on duty in the daytime and 2 sleep in at night. Residents take part in a variety of activities, both within and outside of the home. The Purpose and Function Document and the last Inspection Report are on the homes notice board for interested parties to view. The organisations fees are approximately £800.00 per person. This report is also accessible on the CSCI website. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards. The inspection took approximately 7 hours. I undertook a tour of the building and spoke with the people who live in the home and members of the staff team. I gained further information by carrying out an inspection of the documentation kept in the home, including care plans and health and safety documentation. The area manager, manager and Deputy manager assisted me throughout the day. I would like to thank the people who live in the home for their openness and participation during this time. What the service does well: The manager and staff have a good relationship with the people living in the home, which makes them feel valued. People’s care plans are being kept up-to-date which ensures their individual needs are met. People’s risk assessments are being kept up to date which ensures that identified risks are minimised which protects the health and safety of the people living and working in the home. People are part of the community, which enriches their lives. People are assisted to maintain appropriate relationships, which assists their emotional wellbeing. A variety of food is available for people living in the home, which ensures their dietary needs are being met. People living in the home are protected from abuse neglect and self harm as all adult protection procedures are available within the home which ensures professional guidance and procedures are available to staff. Staff are receiving adequate training to ensure they have the necessary skills to meet people’s needs. People are protected by appropriate recruitment procedures. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 6 Staff are receiving regular supervision from the manager, which ensures that a consistent professional approach is maintained by staff in relation to people living in the home. What has improved since the last inspection? Staff have been provided with comprehensive guidance in the event of people experiencing complications such as hyperglycaemia or hypoglycaemia, as a result of their diabetes, which protects people’s health and wellbeing. The complaints book is now available in the home for inspection, which ensures people’s complaints are taken seriously. Improvements in relation to the environment have taken place. The oven has been replaced and is now functioning effectively which ensures peoples skills can be developed which assists to increase their independence. The conservatory door has been replaced which ensures there is no an effective exit in the event of a fire taking. The conservatory window has been repaired and it can now be opened by the people living in the home to allow fresh air into the conservatory, which ensures that they are living in a safe environment. The door to the laundry room has been replaced which ensures people living in the home have a safe exit to the garden which safeguards their health and safety. The doors to the identified persons bedroom have been replaced ensuring that the furniture in the person’s bedroom is well maintained. Staff have undertaken training in relation to food hygiene, first aid, and diabetes which ensures that staff have the opportunity to develop their knowledge to meet people’s individual needs. The COSHH cupboard door has been replaced which ensures that people’s wellbeing is safeguarded, as chemicals are appropriately stored. The pebble- dash exterior of the home has been made good which ensures the home is being maintained which provides a safe environment for people living in the home. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 7 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. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 8 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 Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 9 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, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People do have the information they need to make an informed choice about were they want to live as a service user guide is available. Assessments are appropriately undertaken prior to people moving into the home to ensure that people needs can be met. EVIDENCE: Since the previous inspection there have been no new admissions to the home. However one identified person is still in hospital. The service user guide is available in each persons file, which ensures that they are provided with sufficient information to make an informed choice about were they want to live. The statement of purpose is available on the homes notice board and was updated in May 2007. This ensures that accurate information is available in relation to the service. People assessment information was available in their files based on their daily living skills, which ensures that adequate information is available to ensure their individual needs can be met. Linden Lodge DS0000010565.V333138.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): 6,7,9, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s care plans are being kept up to date and they contain accurate information in relation to their assessed and changing needs. The service supports people to take risks as part of an independent lifestyle. EVIDENCE: People’s care plans were inspected and were clear to read. The care plans evaluate all aspects of living in the home. The needs are identified as well as the aims to achieve a care intervention and the care plans are being evaluated on a regular basis. The care plan considers areas such as depression, finances, independent - living skills and cultural needs. Staff had researched the Jewish faith and remind the relevant people when particular festivals are due to take place to ensure their particular beliefs are respected. The plan specifies the areas in which people make decisions about their lives. This assists people’s needs to be met in a consistent way by staff. There is a care plan consultation document, which is signed by the manager and the person living in the home, which further empowers people. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 11 I also noted an Illegal Substance Policy, Alcohol Policy and Room Search Policy which, were signed by only some people living in the home The manager has agreed these will be signed and dated by all parties to ensure that there are expectations placed on people in relation to how they conduct themselves whilst in the home which assists them to function within the expected boundaries. The care plans were informed by current risk assessments, which included compliance with medication, verbal abuse, aggressive behaviour and diabetes which ensures the identified risks to those living and working in the home are minimised which further safeguards their health and safety. I saw evidence of monthly meetings taking place, which allows people living in the home to express their views. I noted that people had discussed their holidays, health and safety issues, such as drinking within the home and one identified person had apologised to those living and working in the home with regard to their recent behaviour which ensures that respect between people living in the home is being recognised as a priority. Linden Lodge DS0000010565.V333138.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): 12,13,15,16,17, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged to take part in activities both within and outside the home to promote their personal development. Contact with family and friends is promoted which assists their emotional wellbeing. People’s rights are recognised which empowers them. People are supported to cook healthy balanced meals, which safeguards their health and wellbeing. EVIDENCE: People’s activity records were inspected. One identified person has been growing a range of vegetables in the garden, which include tomatoes, green beans, chilli peppers avocados, and has also planted sun- flowers and introduced a herb pot to the garden. This person has taken on the maintenance of the garden, which provides them with some responsibilities within the home. This person also likes to go and shop at charity shops daily. The garden now has a table and chairs and a bird table, which ensures people have a place, were they could sit and relax when they wish to and watch the birds, which has increased their opportunities within the home. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 13 Two people attend Jewish Day Centres three days per week and undertake activities such as art and music groups. One person has also been to the zoo with their key worker and on the day of the inspection they were going out to lunch with their Community psychiatric nurse, which expands the opportunities available for the person’s individual development. One person goes to their particular centre two days per week were they attend life skills classes, which increase their opportunity for personal development. The people living at the home had attended a party that was being held by one of the other homes within the organisation, which increases their social integration with their peers. I noted that at the recent meeting held for people living in the home to discuss their individual views that were asked the type of activities they wish to undertake and these include museums, picnics, BBQ’s, a visit to Kew gardens and meals out. The manager has said she will do her utmost to ensure these requests are met. I observed the interaction between the staff and the people living at the home and they were treated with respect. People have keys to their individual bedrooms and permission is sought before their bedrooms are entered unless a health and safety issue overrides their right to privacy. Contact for the people living in the home varies from personal telephone calls to individual visits to their home from family members. One person visits their girlfriend on a daily basis. One person had recently been to the cinema with their daughter, which increases their emotional wellbeing. On the day of the inspection the kitchen was clean and tidy, which benefits the health and safety of those living and working in the home. The menu of food available was wholesome and nutritious, which ensures that people’s dietary needs are being met which benefits their health and wellbeing. The fridge and freezer was inspected and all food was identified as being within its use by date and properly labelled which ensures that people’s health is safeguarded. One identified person who is Jewish is provided with kosher food of his choice which is being stored in a separate compartment in the fridge which ensures that his specific cultural needs in terms of diet are being catered for. Linden Lodge DS0000010565.V333138.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): 18,19,20, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive support in a way they prefer and require which ensures their wishes are respected. People’s physical and emotional needs are not being fully met due to insufficient recording. The process for the recording and administration of medication is not effective and does not promote the good health of people living in the home. EVIDENCE: People have access to Primary and specialist healthcare appointments, which safeguards their health and wellbeing. People’s records of medical appointments indicated that people have access to General Practioners, opticians, diabetic nurse and psychiatrists, which ensure their health care needs, are being monitored. However the health care records are not being fully and appropriately recorded for example health care information had not been recorded on the health record. The information had been recorded on the back of the CPA Care plan with no cross reference used. This does not ensure that effective recording of people’s health care needs is being undertaken which does not assist staff to work in the most effective way to ensure that peoples individual health needs are being met. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 15 Some people living in the home refuse to attend medical appointments this must be identified in the person’s risk assessment and information must be noted when they refuse to attend their medical appointments. The manager started to complete this at the time of the inspection therefore no requirement has been made, as I will look at this further during the next inspection. The medication was inspected and this is stored appropriately in a medication cabinet, which ensures that professional practice is being followed which safeguards the wellbeing of people living in the home. At the previous inspection the medication had not been appropriately signed for on the medication administration record. Medication had been signed for as given but was still in the blister pack. This member of staff was suspended from administering medication and the manager undertook an investigation, appropriate action was taken. The staff member also attended further medication training to ensure the people in the home were protected from potential harm. On the day of this inspection the medication for one identified person had not been administered and was still within the blister pack no written record had been made to inform fellow colleagues why this was the case. The manager has been asked to undertake a full investigation to ensure that professional practice is followed and put robust procedures in place to monitor the administration and recording of medication, which will ensure that the well being of people living in the home is safeguarded. People were appropriately dressed at the time of the inspection, which promotes their self-esteem. Linden Lodge DS0000010565.V333138.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): 22,23, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure people are listened to and protected from abuse and neglect. EVIDENCE: The complaints book was examined. There have been no complaints made since the previous inspection. The company policy on whistle blowing was satisfactory and the manager was familiar with its use, which ensures that policies are in place, which supports people to inform the organisation when unprofessional practice is being undertaken. The home had available the necessary Adult Protection Procedures and Multi Agency documentation which ensures that staff have the necessary documentation available to follow professional procedures and protect people from potential abuse. Linden Lodge DS0000010565.V333138.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): 24,30, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made. Further action is needed to ensure the home is comfortable, clean and homely for all of the people living in the home. EVIDENCE: I undertook a tour of the home. In relation to the kitchen the oven has now been replaced and is working effectively which means people living in the home can maximise their independence skills. A sharps box has recently been obtained to ensure that knives are effectively stored which minimises the potential risk of harm to people living and working in the home. The pebbledash exterior of the home has now been repaired, which ensures that people are living in a home that is being maintained. The patio door which also acts as a fire door within the conservatory is now functioning correctly which means that people living in the home are being Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 18 provided with an effective exit in the event of a fire taking place. The window in the conservatory has been repaired which means that people’s health and safety is safeguarded, as the window is now secure. The Laundry room door, which provides an exit to the garden in the event of a fire- taking place is now working effectively which further safeguards people living in the home as they can exit the home at speed in the event of an emergency taking place. The COSHH cupboard door has now been replaced and was locked on the day of the inspection, which ensures that chemicals are stored appropriately and people living in the home have been safeguarded from potential harm. The hall has been decorated which ensures that people are living in a home that is pleasant to live in. I inspected people’s bedrooms with their permission. One person has obtained a new bed, desk, new curtains, a chair has been ordered which has made their bedroom more comfortable. A fridge for the food items they wish to buy for themselves has been obtained and the fridge is kept in their bedroom therefore their wishes have been respected. The lounge in number 38 has been decorated and new furniture has been obtained which ensures that people have a comfortable place to relax. One identified person needs to have their carpet replaced to ensure it is clean and hygienic. I have been informed that the flooring is going to be replaced with wood flooring by August 2007. Another person is obtaining a new bed, bedside cabinet, television cabinet, television and chair by August 2007 in order to personalise their bedroom. One person in the smaller home has requested that the bedroom carpet is replaced as it is dirty and the person has difficulty keeping it clean and does not want to be assisted by staff. The manager has therefore agreed to replace the carpet with wood flooring by August 2007.This action will ensure the person’s wishes are respected and their request to be independent is therefore being supported. The fridge in the conservatory is going to be thrown away as it is showing signs of rust on the doors and is no longer needed as the home has alternative fridges that can be used elsewhere. Two identified people’s bedrooms were dirty on the day of the inspection and I had a discussion with the manager and area manager who requested that staff cleaned them immediately, which ensures people live in a hygienic environment. The manager is going to raise the standard of cleaning in the Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 19 staff meeting with the area manager present to ensure that people are living in a clean environment. One identified person’s hot water supply was not working effectively as very little hot water was passing through the hot water tap which does not ensure that the persons individual needs are meet. The toilet needs to be decorated and the flooring replaced to ensure it is hygienic for people to use. Linden Lodge DS0000010565.V333138.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): 32,34,35,36, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are adequately trained to support people living in the home. People living in the home are protected, by the homes recruitment policy and practices. Staff are supervised which assists their personal development. EVIDENCE: The staff rota was examined and there were an adequate number of staff on duty to ensure the needs of the people living in the home were met. The staffing records were inspected and staff had been provided with some of the essential training which included COSHH, fire safety, infection control, first aid, equality and diversity, manual handling, health and safety, protection of vulnerable adults which assists the staffs personal development. Staff are undertaking their NVQ level 2, which will further improve the quality of care provided to people living in the home. I noted that one particular member of staff had limited information available on their file. It is believed that this person had taken their training certificates home. I have requested that the manger obtains copies of these certificates and places them on the staff file. The manager has agreed to inform me when this has been completed. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 21 One new member of staff has been appointed since the previous inspection and the relevant documentation was available at the time of the inspection in relation to references, criminal records bureau check. This ensures that people living in the home are protected from potential abuse as the correct recruitment procedures are being followed. Staff supervision is taking place, which supports staff to work in a professional consistent way with people living in the home to ensure their needs are met. Linden Lodge DS0000010565.V333138.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): 37,39,42, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not run effectively in particular areas which to ensure it is run well. People can be confident that their views underpin all self-monitoring and development within the home. All appropriate health and safety measures are not in place to ensure that health and safety and welfare of people living in the home are maintained. EVIDENCE: The manager is not registered, and has not undertaken the Registered Managers Award and this training will have to be undertaken to ensure that they are fully equipped to effectively manage the home. The service has undertake a quality assurance audit and compiled this information into a report, which ensures that the quality of the service provided to people living in the home is being monitored. Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 23 The record of fire alarm tests, emergency lighting, and fire fighting equipment were inspected and found to be in order. All fire doors were effective and free from obstruction. Fire notices contained all of the information to indicate were people need to meet in the event of a fire taking place. The record of fire evacuation drills could not be inspected, as the records could not be provided to me on the day of the inspection. I brought this to the attention of the area manager and have requested that a clear record is maintained and available for inspection to ensure that people living in the home are safe and fully protected in the event of a fire- taking place by ensuring professional procedures are being followed. I requested a fire evacuation test was undertaken on the day of the inspection to ensure that the system was working effectively and people living in the home were safeguarded by an effective fire alarm system. As I had a record of fire drills being undertaken from my previous inspection and the area manager had a record of a fire drill in her regulatory visit having been undertaken in May 2007 I have made the decision to place the rating at adequate. The gas certificate was seen and found to be in order. The electrical certificate was seen and found to be in order, which safeguards the wellbeing of people living in the home. I need to see the service recording information and working with people living in the home in a consistent way over a period of time before the overall rating of the service can be improved. Linden Lodge DS0000010565.V333138.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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 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 2 2 X 3 X 3 X X 2 X Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 13 Timescale for action The Registered Person must 10/07/07 ensure that people’s health care appointments are fully and effectively recorded and include the outcomes of the appointments undertaken. The Registered Person must 06/07/07 ensure that that an investigation is undertaken in relation to the medication that was not administered and was still contained, within the blister pack. No record had been made as to why this medication had not been administered to the identified person. The Registered Person must 06/07/07 ensure the hot water supply in the identified persons bedroom is working effectively to ensure their needs can be met. The Registered Person must 20/08/07 ensure that the toilet is decorated and new flooring is obtained to ensure that it is hygienic. The Registered Person must 10/09/07 Version 5.2 Page 26 Requirement 2. YA20 13 2 (c) 3. YA24 23 2(b) 4. YA24 23 2(b) 5. YA33 18 (1) Linden Lodge DS0000010565.V333138.R01.S.doc 6. YA42 23 (4) (c) ensure that they make an application for registration to ensure they are trained effectively to manage the home. The Registered Manager must 06/07/07 ensure that there are clear records available of the fire evacuation procedures available in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Linden Lodge DS0000010565.V333138.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Linden Lodge DS0000010565.V333138.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!