Inspection on 04/01/08 for Little Heath Lodge

This inspection was carried out on 4th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Little Heath Lodge 19/06/07

Little Heath Lodge 06/06/06

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

CARE HOME ADULTS 18-65 Little Heath Lodge 68 Little Heath Charlton London SE7 8BH Lead Inspector Maria Kinson Key Unannounced Inspection 4th January 2008 09:45a Little Heath Lodge DS0000064562.V351027.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 Little Heath Lodge DS0000064562.V351027.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. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Heath Lodge Address 68 Little Heath Charlton London SE7 8BH 020 8317 7542 020 8317 7534 enquiries@cognithan.com 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) Cognithan Ltd Ms Emilia N Endeley Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2007 Brief Description of the Service: Little Heath Lodge is registered with the Commission for Social Care Inspection to provide nursing care for five male or female service users, aged 18 to 65 years of age, with a mental health disorder. The home is located on a main road, in Charlton, which is served by several bus routes and is within 10 minutes walk of a train station. The property consists of a large Victorian terraced house with five single bedrooms, dining room, kitchen, laundry, office/meeting room and lounge. The fees charged by the home start from £900 per week. This information was supplied to the commission on 24.05.06. Further information about the home can be obtained by requesting a copy of the Statement of Purpose or by sending an email to enquiries@cognithan.com Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors and was unannounced. The inspectors spoke with all of the people who lived in the home and all of the staff that were on duty. The feedback that was obtained from people during the inspection forms part of this report. There were four people living in the home at the time of this inspection and arrangements were being made for another person to view the remaining vacant room. What the service does well: What has improved since the last inspection? This home struggled during its first year to meet some standards and to comply with The Care Homes Regulations. The findings from this inspection show that the manager and staff are developing a better understanding of their responsibilities and had addressed almost all of the previous requirements. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 6 Food supplies had improved and people were more involved in preparing and cooking meals. The Occupational Therapist had prepared a recipe folder for people to follow. Two of the bathrooms had been refurbished and tiled. This makes it easier to keep the area clean and provides a more relaxing experience for the people using the service. The maintenance issues identified in the previous report had been addressed. People had a key to their room and said staff respected their privacy. A photograph of the service user was obtained and kept with the medication records. Recruitment checks had improved. This will ensure that people are supported by suitable staff. The manager had introduced ‘carers meetings’. This provides support for carers and an opportunity to raise concerns about the service. Money records provided better information about how and when money was used. The management team had prepared written guidance for staff about the safe use of cleaning products. What they could do better: Some of the written information that was provided in the Statement of Purpose was not accurate and did not provide adequate detail about the service. People will not be able to make an informed choice if they do not have access to up to date information. Assessments and care planning had improved but did not always identify and address peoples social needs and hopes for the future. Risks were assessed but staff did not always consider issues from the persons past history. The management of medicines had improved but further work was required to meet this standard. The manager must ensure that records provide a clear audit trail and staff can account for all medicines used in the home. This includes homely remedy medicines. The complaints procedure did not provide adequate information for people that wanted to raise concerns about the service. The manager must ensure that the procedure is suitable and easy to follow. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 7 There was no soap or towels in any of the toilets. This is unhygienic and could lead to cross infection. The lock on the ground floor toilet was not working properly and the cover on the sofa in the lounge was split. The manager had recently advised the commission about the homes staffing arrangements. The staffing levels outlined by the manager were not always maintained. This could affect people’s health, safety and wellbeing. Some documents such as staff recruitment files, staff training records, the off duty roster and money records were not kept in an orderly manner, did not include adequate information or were difficult to read. It was not possible to assess whether the diet provided in the home was balanced, as food records were not maintained. Good records protect service users and will help to ensure the effective running of the business. The fire extinguishers had not been serviced since August 2006. The radiators were uncovered and felt hot when touched. The homes risk assessment stated that the radiators should be covered. The manager must ensure that she follows strategies to minimise the risk of people being harmed and develops a system to remember when health and safety checks are due. 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. Little Heath Lodge DS0000064562.V351027.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 Little Heath Lodge DS0000064562.V351027.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 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose did not provide accurate information about the range of services and care provided in the home. The arrangements for assessing people’s needs had improved but further work was required to ensure that staff obtained adequate information about people’s social needs and personal goals. People had an opportunity to view the facilities and meet staff and service users before making a decision to move into the home. EVIDENCE: The manager followed the advice given during the previous inspection to display the registration certificate in a more prominent position. The certificate was displayed in the entrance hall. Visitors could now see how many people the home could admit and who was responsible for managing the service. A copy of the revised Statement of Purpose was obtained during the inspection. The Statement of Purpose still contains very little information about the range of needs that the home can meet and the admission criteria, but had been amended to show that the home could not admit people that were detained under section three of the Mental Health Act. The home should Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 10 make it clear in the Statement of Purpose about the type of needs it can meet. It is not sufficient to state that the home admits people with a mental health disorder. The admission criteria should also include more detail. If, as the Statement of Purpose suggests the home is willing to admit someone in an emergency if they have a vacant bed and without obtaining any other information about the persons needs or potential risks they would not be acting responsibly. Information on page 7 of the Statement of Purpose, about the smoking area, was out of date and some information was more relevant to a care home for older people. For instance the Statement of Purpose states, “The home offers a wide range of activities to encourage the client to keep mobile”. The Statement of Purpose also indicated that the home employed a housekeeper. There was no evidence of this on the duty roster or during discussions with staff. See recommendation 1. The home had developed a new assessment form since the last inspection. The form prompted staff to obtain and record information about people’s mental and physical health, their personal and social history, details of any substance abuse, their current medication regime, forensic history and potential risks. A draft care plan was then developed using the information obtained during the assessment. This form will provide good information for staff about people’s needs, if completed in adequate detail. Two people were selected for case tracking. The first was a person that was admitted from hospital, but previously lived in the local community. Information about the persons needs was obtained from the hospital. The information was largely concerned with factors at the time of the hospital admission and although there was a long history of mental illness the assessment provided little information about this. This person was admitted prior to the introduction of the new assessment form. The second set of records were for someone with more complex needs who had a history of substance abuse and psychotic episodes. There was an abundance of psychiatric reports many of which were very detailed but there was very little information about the person’s social needs and background. See recommendation 2. One person that had recently moved into the home said they were invited to visit the home before they moved in and to spend time with staff and the other people that used the service. This person was happy with the placement and felt settled. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans provided good information for staff about the action they should take to meet people’s physical and mental health needs but did not always address other aspects of care. Staff identified potential hazards but did not always assess issues that were identified in assessments and histories. People said they were able to make decisions and felt they had control over their lives. EVIDENCE: Two support plans were examined. Care plans provided good information about mental health issues and medication but peoples social and rehabilitation needs were not always identified. See recommendation 3. The approach taken by staff appears to be based on a medical treatment model and was not person centred. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 12 Although people were satisfied with the care provided, the assessments, care plans and risk assessments seen during the inspection lacked some basic information and were incomplete in places. Peoples existing skills and strengths were not always identified and their personal goals were not always evident. Successful rehabilitation is dependent on people having clear goals and staff supporting people to achieve these. Although the records did not provide detailed information about what people wanted to achieve, the people that were using the service felt they were making good progress towards their recovery. Care plans were reviewed regularly. Care plans included little input from the multi disciplinary team. Individually ‘tailored’ care plans with clear mutually agreed objectives and goals as indicated by the after–care provision of the Mental Health Act 1983 are an essential element for providing the basis for care and the future integration of people back into the community. The manager should try to establish regular multi disciplinary reviews or obtain feedback from members of the multidisciplinary team and feed this information into the care plan. This was happening to some degree during CPA reviews. One person was still on a trial period. The history of the individual was not fully reflected by the provider in the risk assessments. This is necessary to ensure consistent safe working practices. See requirement 1. People told us they could go out when they wanted but had to notify staff before leaving the home. Although people had established regular routines they said they had plenty of time to do what they wanted such as visiting relatives and relaxing. People said they could help themselves to drinks and snacks and shower and bath whenever they wanted. People were aware of ‘rules’ regarding the use of alcohol and drugs, smoking areas and the times for returning to the home. Little Heath Lodge DS0000064562.V351027.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. People were supported to learn new skills and to work towards achieving greater independence. People said they liked the food provided in the home and were supported to cook. EVIDENCE: The people that lived in the home provided feedback about the service and were asked about personal choice, meals and how they liked to spend their free time. The home employs a part time Occupational Therapist. The Occupational Therapist visited the home at least once a week to develop an individual activity programme for each person, to complete assessments and to support Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 14 people to learn new skills. The records completed by the occupational therapist provided good information about people’s interests. People were supported to establish a regular programme of activities based on their personal interests and goals. Some people said they attended ‘First Step Trust’ a local organisation that provides work experience and training opportunities for people with a mental health disorder. One person was undertaking an office administration course and hoped to complete a work placement in a court and another person was undertaking a computer training course. During their free time people said they liked to visit their family and friends, watch television and relax. Records showed that some people were supported to take local walks, paint, play games, listen to music and keep their bedroom clean and tidy. One person said that they did not like to go out very often. People said they had a key to their room and one person that had expressed concerns during a previous inspection about their privacy confirmed that action was taken by staff to address this issue. People said they attended ‘community’ meetings and were able to make suggestions or raise concerns during meetings. The minutes from some of the recent meetings showed that people were asked to put forward ideas for a group outing and had discussed the homes drug and alcohol policy. People said they had requested a pay phone, and the manager confirmed that this suggestion was being explored. There were good supplies of fresh and frozen food in the refrigerator and freezer and people said there was always had plenty to eat. Although the home had a menu there was no evidence that the menu was followed and it was difficult to establish exactly what people had eaten in recent weeks. See requirement 2. The manager said that a number of the people that lived in the home enjoyed cooking, so a decision had been made to complete a cooking rota. Staff and service users will each be responsible for preparing and cooking some meals. People confirmed that this issue was discussed and agreed at a ‘community’ meeting and said they were happy with the decision. The occupational therapist had developed a folder that included people’s favourite dishes and recipe ideas and suggestions. Little Heath Lodge DS0000064562.V351027.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. Staff worked in partnership with other professionals to promote people’s health, safety and wellbeing. The management of medication had improved but did not fully comply with safe practice guidelines. EVIDENCE: Most people did not require assistance with personal hygiene and were able to choose how and when they had a bath or shower and how they dressed. One person that required prompting to wash and dress said staff were kind and supportive. The Occupational Therapist had developed a series of visual prompts to assist this person to get dressed and to become more independent. The signs were displayed in the person’s bedroom. Records showed that one person was supported to attend an Opticians appointment and people said staff assisted them to make or attend medical appointments if necessary. Staff recorded if people attended planned appointments in the community to receive medication. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 16 The home had received some information from the Department of Health about the Mental Capacity Act. The manager was not aware of the code of practice that accompanies this legislation and had not provided training for staff. See standard 35. Two medication records were examined. Records about the receipt of medicines had improved and people confirmed that they received their medicines regularly. The manager had developed a new form to record information about medication changes and staff used a code to show why some medicines were not given. Stocks of medicines were difficult to audit, as staff did not carry forward some medicines that were left over from the previous cycle and record this information on the new medication chart. This meant there were more medicines in the home than the records suggested. See requirement 3. The medicine room temperature was monitored and there was adequate space for the storage of medicines. Some ‘over the counter’ medicines were used but it was not possible to assess whether the stock level was correct, as there were no records to show when or how many homely remedy medicines were received in the home. See requirement 4. Although most of the people that lived in the home were quite independent, there was no evidence to suggest that people were assessed to see if they could manage their own medicines. As the home provides rehabilitation it should ensure that it has adequate systems in place to identify and support some people to take their own medicines. Little Heath Lodge DS0000064562.V351027.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 adequate. This judgement has been made using available evidence including a visit to this service. People did not have access to suitable information about the process they should follow if they wanted to make a complaint. The arrangements for safeguarding people’s money had improved and staff were aware that they should report allegations or poor practice to the manager. EVIDENCE: A copy of the homes revised complaints procedure was supplied to the commission in October 2007. Although the manager had added information about the contact details for the Commission for Social Care Inspection (CSCI) and timescales for responding to complaints, the procedure was not suitable. The procedure indicated that people could “seek advice and help from the local Community Health Council” (which was abolished in 2003) and said complaint forms were available “on each ward”. See requirement 5. The home had not received any complaints since the last inspection. The people living in the home said they would speak to the manager or staff if they were unhappy. The homes adult protection procedure was assessed in June 2007. It stated that concerns would be reported to the manager who would then contact social services or the police, depending on the nature of the allegation. References to the Registered Homes Act in the safeguarding procedure and the chief executive in the whistle blowing procedure had been removed. The Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 18 commission are not aware of any complaints or safeguarding issues relating to this home and the manager had not made any referrals to the Protection of Vulnerable Adults (POVA) list. One member of staff was questioned about the homes safeguarding procedure. The staff member said they had attended protection training with another employer and were aware that they must report concerns to the manager. Most of the people that lived in the home were able to manage their own money but staff were responsible for safeguarding some money for one person. Records were kept about money that was handed to staff for safekeeping. Receipts were obtained where possible or an explanation regarding how the money was used was recorded. Entries were checked and initialled by staff. Some information was difficult to read, this was possibly due to the lack of space provided for staff to record information. The manager was advised to maintain separate records for each person and to ensure that all records were legible. Little Heath Lodge DS0000064562.V351027.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, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a comfortable environment for the people using the service and their visitors. Hand washing facilities were not provided. This will prevent the spread of infection. EVIDENCE: The home is situated in a three storey Victorian house close to shops and a local bus route. There are five single bedrooms located over three floors and a shared toilet and bath or shower each floor. On the lower ground floor there is a laundry room, lounge, dining room and kitchen. At the back of the property there is a good size garden with a patio and seating. This area was well maintained and tidy. The maintenance issues identified during the previous inspection had been repaired or replaced. The only issues that were identified for repair or replacement during this inspection was the lock on the ground floor toilet and the sofa cover, which was split. See recommendation 4. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 20 One of the people that lived in the home showed us their bedroom. The room had a double bed and was very spacious. There were a number of family photographs displayed on the chest of drawers and Christmas presents from friends and family. The person said they liked their room but preferred to spend time in the communal areas during the day. The lounge and dining room were comfortable and warm. Since the last inspection two of the bathrooms had been refurbished and retiled. This made the rooms look cleaner and much more welcoming. The home was clean and tidy. Refrigerator and freezer temperatures were checked and recorded and there was a daily cleaning schedule. A sign in the ground floor toilet reminded people to wash their hands but there were no hand washing facilities in any of the toilets. See requirement 6. Little Heath Lodge DS0000064562.V351027.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, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a stable and competent team of staff. Staffing levels were not always maintained, this could affect peoples quality of life and wellbeing. Training records were poorly maintained, this made it difficult to assess if staff received adequate and suitable training. EVIDENCE: The home indicated in the annual quality assessment (AQAA) that 75 of care staff had a vocational qualification or equivalent qualification in care. We spoke with one member of staff that worked in the home. The staff member had a nursing qualification and had experience of working with people with a mental health disorder in hospitals and in the community. The manager was the only staff member on duty during the morning shift. The off duty indicated that the carer that was due to work between 10am and 4pm was sick. Although this did not have a significant impact on most of the people that lived in the home one person does have a short attention span and Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 22 requires support to undertake most activities of daily living. This person was not engaged in any therapeutic activities during the inspection. See requirement 7. The duty roster indicated that there were other occasions when there was not a second member of staff between 10am and 4pm. The current duty roster was examined. The Occupational Therapist was not included on the rota but had recorded her hours in the diary. The manager must ensure that all staff that work in the home are included on the duty roster. See requirement 8. Two staff files were examined. The homes recruitment practices had improved and now provide better protection for the people using the service. The files included a application form, enhanced criminal record bureau (CRB) disclosure, two written references, which were company stamped or verified, proof of identity, a statement about the person’s mental and physical health, a recent photograph, proof of training and qualifications and interview notes. Some information was difficult to locate, as the files were not indexed. See recommendation 5. Most of the staff that worked in the home were employed on a sessional basis and had other jobs in the NHS or private sector. Some staff had undertaken relevant training courses in connection with their other jobs. Certificates were kept on staff files and a separate record was maintained about ‘in house’ training sessions. ‘In house’ training records were a little vague in parts, for instance it was not clear where some of the sessions occurred, who the trainer was and what the session covered. See recommendation 6. There was no evidence that induction training for care staff covered the common induction standards. See recommendation 7. The manager said she was arranging food hygiene and safeguarding training sessions for 2008. We recommend that staff also receive Mental Capacity Act training. See recommendation 8. Records indicated that there were regular staff meetings and staff said they could obtain advice or support if required. Little Heath Lodge DS0000064562.V351027.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, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This service has improved but further work is required to meet some key standards. The manager must be able to demonstrate that she has adequate systems in place to maintain peoples safety. The home obtained regular feedback from people that used the service and used this information to improve the service. EVIDENCE: The manager is registered with the commission. The manager has a degree in education, a Post Graduate Diploma in Counselling and is a Registered Mental Health Nurse. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 24 Staff and service users said that the manager was approachable and listened to their views. There were regular opportunities for staff and service users to contribute ideas and make suggestions about the management of the service. Although the management of the service had improved further work is required to meet some key standards and to ensure that some basic procedures and records are in place. In particular the home does not have a suitable complaints procedure for people to use and does not provide up to date information in its Statement of Purpose. The manager of the service must have a system in place to ensure that basic health and safety checks are carried out. The home had developed some systems to monitor and assess the quality of care provided in the home and to obtain feedback from the people using the service. Senior staff completed medication and record keeping audits and one of the directors had started to complete monthly visits to assess the conduct of the service. People’s views were obtained during community and carers meetings and a satisfaction survey was completed in May 2007. There was little evidence that the results were formally collated but action was taken to address a concern raised by one individual. The home should ensure that information obtained during quality assurance work is included in the homes annual development plan. The manager had recently set up ‘carers meetings’ to obtain feedback about the service and to keep relatives informed about new developments. The minutes from some of the recent meetings were viewed. The records showed that attendance was good and people were given feedback about action that the manager had taken to address issues raised at previous meetings. The home had completed a fire risk assessment but the assessment was not dated. Fire exits were clearly marked and free from obstruction. The alarm, and emergency lighting system were tested and serviced regularly but there was no evidence that the fire extinguishers had been serviced since August 2006. See requirement 9. Fire drills were taking place regularly and advice given during the previous inspection about making the drills unannounced was followed. Health and safety records were sampled during the previous inspection. Hot water temperature checks were examined during this visit and were found to be satisfactory. The risk assessment for hot surface temperatures stated that the home should fit radiator covers to minimise the risk of burns and scalds. The radiators that were seen during the inspection were not covered and felt very hot. See requirement 10. The manager said she spoke with the local fire officer about locking the front door and was told it was up to people to decide what was in people’s best interests, locally. The idea of closing the front door but leaving it unlocked was Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 25 discussed with service users during a recent community meeting. The minutes were not available as the meeting had only taken place on the previous day but the manager said that some people expressed concerns about security. The inspectors discussed this issue with the manager and provided information about the action staff could take to minimise risks. The manager agreed that the home would work towards providing unrestricted access to and from the home for people that used the service. Progress with this issue will be assessed during the next inspection. There were no records of any accidents or incidents in the period since the last inspection. Information about potentially harmful cleaning substances was recorded and kept in the home. COSHH assessments provided clear information for staff about the action they should take to protect themselves and what treatment was required if someone swallowed or splashed a substance in their eyes. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 2 X Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA9 Regulation 13 Requirement The Registered Person must ensure that when information is received about potential hazards or risks a risk assessment is completed to make staff aware of the risk and to advise them about the action they must take to maintain peoples safety. The Registered Person must ensure that adequate records are maintained about the food provided for service users. The Registered Person must ensure that medicines that are leftover from the previous months supply are carried forward onto the new medication chart. This will provide a clear audit trail. The Registered Person must ensure that adequate records are maintained about the receipt of ‘homely remedy’ medicines. The Registered Person must ensure that the home has a clear and effective complaints procedure. Timescale for action 22/04/08 2. YA17 17 22/04/08 3. YA20 13 22/04/08 4. YA20 13 22/04/08 5. YA22 22 20/05/08 Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 28 6. YA30 13 7. YA33 18 8. YA33 17 9. YA42 23 10. YA42 13 The Registered Person must ensure that adequate steps are taken to prevent the risk of cross infection within the home. Restated requirement, as the previous timescale of 13/09/07 was not met. The Registered Person must ensure that there are adequate staff on duty at all times, to meet peoples needs. The Registered Person must ensure that all staff that work in the home are included on the duty roster. The Registered Person must make adequate arrangements for the maintenance and servicing of all fire equipment. The Registered Person must ensure that strategies to reduce the risk of burns and scalds are followed. 22/04/08 22/04/08 22/04/08 20/05/08 24/06/08 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 Good Practice Recommendations The Registered Person should completely review and update the Statement of Purpose to ensure that information is up to date, relevant and specific. A copy of the revised Statement of Purpose should be supplied to the commission. The Registered Person should ensure that adequate information is obtained during the assessment about people’s social needs and aspirations. The Registered Person should ensure that care plans specify the action that should be taken by staff to meet people’s health, personal and social care needs. The Registered Person should ensure the lock on the ground floor toilet door is working properly and the sofa cover is repaired or replaced. DS0000064562.V351027.R01.S.doc Version 5.2 Page 29 2. 3. 4. YA2 YA6 YA24 Little Heath Lodge 5. 6. 7. 8. YA41 YA35 YA35 YA35 The Registered Person should ensure that staff recruitment records are kept in an orderly manner and are indexed. The Registered Person should ensure that staff training records are properly maintained and provide adequate information about training sessions. The Registered Person should provide structured induction training for support staff. The training should cover all of the common induction standards. The Registered Person should provide Mental Capacity Act’ training for staff. Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 30 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 Little Heath Lodge DS0000064562.V351027.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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