Inspection on 14/11/07 for Lodge Hill (145)

This inspection was carried out on 14th November 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lodge Hill (145) 30/11/06

Lodge Hill (145) 17/02/06

Lodge Hill (145) 05/07/05

Lodge Hill (145) 01/03/05

Lodge Hill (145) 06/09/04

Lodge Hill (145) 28/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Lodge Hill (145) 145 Lodge Hill Abbey Wood London SE2 0AY Lead Inspector Keith Izzard Unannounced Inspection 14th November 2007 10:30 Lodge Hill (145) DS0000006764.V350847.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 Lodge Hill (145) DS0000006764.V350847.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. Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lodge Hill (145) Address 145 Lodge Hill Abbey Wood London SE2 0AY 020 8312 4865 020 8312 4865 145lodgehill@tiscali.co.uk londonroad@tiscali.co.uk Milbury Care Services Ltd 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) Mrs Saraspady Dullip Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: This home is one of a group of six homes for adults with learning disabilities. All of the homes are situated in the London Borough of Greenwich and are managed by Milbury Community Services Limited. 145 Lodge Hill is located in the grounds of what once was Goldie Leigh Hospital. The house is divided into two self-contained flats, each with their own lounge, kitchen, dining room, bedrooms, toilets and bathrooms. Service users have use of a large hall on the ground floor that has been converted into a shared lounge and dining/ activity area. The home is registered with the CSCI to provide personal care for eight service users with a learning disability, all, have their own large single bedrooms that are personalised to suit individual preferences. The current fee charged per week for residents’ care and accommodation is £1438.81. Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed over seven hours on 14/11/07. Two members of staff and the manager assisted the Inspector. Six of the eight residents were seen on the day of inspection. The service was last inspected in February 2006. The inspection included a review of information received about the service, a tour of the premises, inspection of records, talking to, but mainly observing residents’ interaction with members of the staff team. Following the inspection, contact was made with relatives and other interested parties to get their views of the service. Responses received were positive about the service provided by the home. There was a happy and positive atmosphere in the home on the day of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. What the service does well: Staff members support residents to participate in a range of social and recreational activities in the local community. Residents are provided with a varied nutritious diet. Staff members ensure residents have access to appropriate health care professionals. Residents and their advocates are provided with clear information regarding the organisations complaints procedure. The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional. Lodge Hill (145) DS0000006764.V350847.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. Lodge Hill (145) DS0000006764.V350847.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 Lodge Hill (145) DS0000006764.V350847.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures were in place to comply with the Standard. EVIDENCE: Standard 2 No new residents had been admitted to the home since the introduction of the National Minimum Standards, therefore this Standard was not assessed. However, evidence has been available previously that the home had complied with the requirements of this Standard. Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 9 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. Residents in the Home are treated as individuals, and their care plans reflect their individual needs and wishes. EVIDENCE: Standard 6 Two care files and individual plans were examined in respect of two residents. Individual plans were comprehensive and involved residents and their representatives, including family or advocates and other professionals involved. These plans are reviewed with outcomes clearly stated and agreed by all participants and are conducted on a six monthly basis. Records seen were comprehensive and up to date and included monthly summaries completed by key-workers that contribute to the review process on individual residents; this is good practice. Residents’ records included risk assessments. In view of the dependency of the residents in the home they required staff to assist them with all aspects of Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 10 their lives. Where risks were identified procedures and care plans reflected how these were being managed. Standard 7 Interaction between staff and residents, observed by the Inspector, demonstrated that choices for residents was being encouraged by staff members in relation to the activities taking place. The level of disability and communication difficulty of service users is such that staff members find it very difficult to meaningfully engage residents in participating in the running of the home and contribute to policies and procedures. On a daily basis staff do make attempts to involve residents, for example, in small domestic tasks and this was evidenced in the daily diaries, the activities file and within tasks for staff listed in the shift planners. Enabling residents to express their choice in relation to outings, meals and activities are promoted by showing pictures and direct reference to specific items and the historical knowledge built up by staff members about individuals recorded in their care files. Specifically, three residents have been provided with large pictorial books that have photographs of a range of different activities and these are now being developed for the other five residents. It was noted that one resident had recently indicated that she would like to bake a cake by pointing to the picture book and another on the day of inspection, had seen another resident receiving a foot massage and indicated by pointing to her feet that she would also like one, this was responded to by the newly appointed activities coordinator and thoroughly enjoyed by the resident. Standard 9 Risk assessments are available in all residents’ care files and are readily accessible for all staff members, particularly, those who may be less familiar with individual residents’ needs. Any restrictions placed are few and would be for the safety and welfare of residents, for example not leaving the home unaccompanied or the provision of a stair gate restricting access the stairs for one resident with mobility difficulties. Evidence was available from the residents’ records examined that they are enabled to express choice in what they do and staff record these occasions. Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 11 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): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social needs of the residents but staffing should be reviewed to assess whether the input required can be adequately met with existing staffing levels. Meals provided were varied and planned to meet the resident’s choice and preferences, and special requirements in respect of diet and nutrition were well catered for. EVIDENCE: Standard 12 Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 12 Evidence was available from the care files of residents that opportunities are being made available for the personal development although, owing to the level of learning and physical disability and associated communication difficulties, none of the service users have been identified as being able to participate in employment or further education. Two service users attend day centres four days a week and one five half days per week. The other five have an activity plan. This is provided on a daily basis and ensures outings into the community on a daily basis. One resident also has a one to one worker provided on a daily basis. Referrals have been made for three service users to be provided with day centre placements and remain on a waiting list. Standards 13 &14 Service users are provided with a satisfactory level of community outings and activities and following a previous recommendation the home is now assisted in this provision by having a member of staff designated as coordinator of activities. This is especially beneficial given that five residents rely on this input to compensate for their lack of day care provision The manager is required to submit regular monthly returns to Millbury recording the level of community and in house activities and the Inspector, having seen these, was satisfied that a reasonable level is provided. Records showed that residents were supported to access leisure activities of their choice and to integrate with the community. A range of outings, for example, visits to pubs, cinemas, shops, parks, football games, sightseeing and an annual holiday were recorded including residents’ comments on how they enjoyed these events. The home has now been provided with a small people carrier able to take a wheelchair, this is a more versatile vehicle and has also resolved the problem, previously experienced, of not enough staff being able or willing to drive the mini bus. However, the home still has access to the larger minibus for occasional group outings, such as the forthcoming Christmas shopping trip. Standard 15 Staff members actively support and encourage family contact and two residents go home to their parents for weekend visits every two months and have good contact otherwise, one is also visited at the home weekly. Two other residents have less regular contact and three no contact. The manager has attempted to provide advocates for the residents but thus far their names remain on the waiting list for this provision. Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 13 Through the various activities and outings provided residents are provided with some opportunity for meeting with other people outside of the home. However, staff members reported that there are no relationships, outside of families, of significance for any of the residents apart from one who is regularly taken to see a friend in another home in Kent. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise in activities of their own choosing. Residents were supported to maintain positive relationships with their family. Residents who do not have regular family contact had been referred to the Greenwich Advocacy Service, but with no success because of an acute shortfall in this provision locally. It is recommended that the home continue to investigate whether this provision might be obtained in some other way. See Recommendation 1 Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks; a good supply of both fresh and frozen food was seen stored in the home. One service user receives a peg feed and another a low fat diet; evidence was available in care records that both were monitored carefully and regularly weighed. One resident had been referred for a Speech and Language Therapy assessment owing to the development of swallowing difficulties and was currently receiving a special pureed diet. Lodge Hill (145) DS0000006764.V350847.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 good. This judgement has been made using available evidence including a visit to this service. Residents’ needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Care plans seen showed how personal care needs were to be met. It was not possible for residents to comment on whether this suited them or not, given the level of communication difficulties. Most of the residents in the home were unable to give feedback about any aspect of the service. Daily records were kept to show the care provided and activities the residents were involved with. Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 15 All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Links were maintained with the community learning disability team to support staff with meeting resident needs. Standard 19 Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about residents’ individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example OT’s, Physiotherapists, Speech and Language Therapists, Psychiatrist and Dietician. One service user receives a peg feed and staff members have been trained and are annually updated to provide this service. Any nursing care needs would be commissioned via the GP from the local District Nursing service or Community Psychiatric Nurse. All service users require considerable assistance with their personal care needs and the home operates a same gender care policy, where possible, in relation to male service users, and strictly in relation to female service users. On the day of inspection service users appeared adequately and tidily dressed in age appropriate clothing. Personal appearance had been attended to and staff were observed to be sensitive and respectful to service users. Standard 20 The system for medication was examined and was well managed. None of the service users are able to deal with their own medication and all staff members who deal with it are trained to do so and their training is recorded. MAR sheets were examined for two residents and were recorded appropriately and tallied with the blister packs that were retained in lockable cabinets, one for each floor of the home. External medication was stored separately. The organisation has a system for monitoring and the reporting of any mistakes with medication these would be dealt with via temporary suspension from giving medication and retraining if appropriate. Since the previous inspection two such incidents had occurred and were satisfactorily dealt with in this way and appropriately reported to CSCI as regulation 37 notifications, as appropriate. Lodge Hill (145) DS0000006764.V350847.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. Adequate systems were in place to ensure residents were protected from abuse and to manage complaints about the service. The system for dealing with the finances of residents was robust and accountable. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. The complaints, suggestions and representations procedure was examined. The procedure included information about the process, the timescales for responding to complaints and details of whom they could contact if they were not satisfied with the response. Information about the local CSCI office were also provided. A pictorial complaints leaflet had been developed to assist residents understand the facility. No complaints had been made either to the provider, or the CSCI since the previous inspection. Standard 23 Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 17 Staff members had received training on adult protection and those interviewed, displayed a good understanding and an awareness of whistle blowing procedures. Any suspicions or allegations of abuse, or unexplained injuries to residents would be referred to the Greenwich Community learning disability team for investigation and to CSCI on regulation 37 notifications. Accidents records were seen and were well maintained and appropriately recorded. Robust systems were in place to safely manage residents’ personal finances and none of the staff acted as appointee for a resident as this person is based in the head office of the company. The ledger and amounts held in individual wallets for residents was examined in respect of two residents and found to be accurate and accountable. The home is subject to a financial audit every week by a cashier from head office and additionally, spot checks can be undertaken at any time without notice. Lodge Hill (145) DS0000006764.V350847.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely and comfortable environment that is safe clean and hygienic. The premises were generally homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs and they have the specialist equipment they need to maximise their independence. EVIDENCE: Standard 24 An inspection of the building was undertaken and included service user bedrooms and all communal areas. Residents’ bedrooms reflected their own Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 19 preferences in respect of furnishings and contents and several had been redecorated in colours chosen by the individual. An ongoing programme was in place to redecorate all residents’ rooms. Residents were encouraged to have personal items in their rooms to reflect their interests and hobbies. Two requirements made arising from the previous inspection; to replace carpets in the upstairs living room, and in the downstairs lounge had been complied with as well as the kitchen floors with new vinyl and one kitchen window was double-glazed. However, three residents’ bedrooms require re carpeting and the stairway. See Requirement 1 It was noted that the garden area provided for residents had undergone extensive renovation and the handyman for the home is commended for the effort he has made to significantly improve this area for the benefit of all the residents. Standard 30 A laundry is situated on the ground floor, which is purpose designed and has a washing machine and incorporates a sluicing facility and a tumble dryer. Overall, the home was clean and hygienic on the day of inspection and appropriate infection control and COSH procedures were in place. Lodge Hill (145) DS0000006764.V350847.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): 32-35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and cared for by competent and qualified staff members who act as a team to meet their needs. Recruitment practice was satisfactory. EVIDENCE: Standard 32 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff, followed by foundation training. The home has already achieved the required minimum level of 50 staff members qualified to NVQ Level 2. From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 21 members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions, such as assistance with eating or engagement in activities. Standard 33 Following a requirement arising from the previous inspection the home has appointed an activities coordinator as stated in Standard 13 this has resulted in an improvement in the level of outings and activities for residents and freed up some time for other care staff. It is also recommended, that the current permanent staff vacancies be filled by permanent appointments, in order to reduce the dependence on bank staff members and be more reflective of the cultural mix of residents. See Recommendation 2 Standard 34 A personnel file was examined for one new member of staff, recruited since the previous inspection and recruitment practice was found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. However, it is recommended that all references be verified by phone if no company stamp or signed compliments slip is provided with the reference. See Recommendation 3 Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for new staff and foundation training following this. Overall, a comprehensive spread of training had been provided for staff members and included annual updates in fire training and moving and handling. A training matrix showed training scheduled and assists the manager to identify any gaps existing for the staff team as a whole. Lodge Hill (145) DS0000006764.V350847.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 good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Regular meetings need to be introduced to enable residents to contribute their views on the running of the home. The health and welfare of service users are promoted and protected EVIDENCE: Standard 37 The Registered Manager is very experienced and has the necessary NVQ4 qualification. Staff members interviewed stated that she is approachable and supportive and would not hesitate to discuss any concerns about the home or Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 23 the welfare of service users with her. Communication within the home was of a good standard with team meetings planned regularly and the manager, overall, complies with the requirements of Standard 37. The manager has undertaken training in order to update her own skills and knowledge. Standard 39 None of the service users would be able to comment easily on the quality of the service provided owing to their communication difficulties. A survey of the views of service users and a recent survey of the views of relatives and involved professionals had been sent directly to CSCI and a copy retained in the home. The manager and staff members are currently developing plans to introduce regular meetings for residents and it is recommended that these are introduced as soon as practicable in order to facilitate residents’ involvement in the running of their home as much as is possible. See Recommendation 4 Monthly monitoring visits were conducted and subsequent reports were completed, as required under Regulation 26 and copies sent to the CSCI. Standard 42 A number of records to do with safety and maintenance were seen by the Inspector and were found to be up to date and well recorded. The manager confirmed that all staff had annually updated fire training and moving and handling training and also training records showed this. In respect of other checks the implementation of fire drills, alarm tests and checking of fire prevention equipment was recorded and up to date. Evidence was available that routine servicing and testing had taken place on specialist equipment such as ceiling track hoists. The manager had also provided a comprehensive checklist within the pre-inspection questionnaire. Overall, health and safety requirements had been well attended to. Lodge Hill (145) DS0000006764.V350847.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Lodge Hill (145) DS0000006764.V350847.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 YA24 Regulation 24 Requirement The Registered Person must ensure the renewal of three carpets in residents’ bedrooms and the staircase. Timescale for action 01/04/08 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. 2. Refer to Standard YA16 YA33 Good Practice Recommendations Continued efforts should be made to obtain independent advocates for those residents without support and contact from relatives. The current permanent staff vacancies should be filled by permanent appointments, in order to reduce the dependence on bank staff members and should also be more reflective of the cultural mix of residents. It is recommended that all references be verified by phone if no company stamp or signed compliments slip is provided with the reference. Regular meetings for residents should be set up As soon as possible to encourage their views on the running of the home. 3. 4 YA34 YA39 Lodge Hill (145) DS0000006764.V350847.R01.S.doc Version 5.2 Page 26 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. 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