Inspection on 30/11/06 for Lodge Hill (145)

This inspection was carried out on 30th November 2006.

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

Other inspections for this house

Lodge Hill (145) 14/11/07

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 30th November 2006 11:00 Lodge Hill (145) DS0000006764.V308579.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.V308579.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.V308579.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 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mrs Saraspady Dullip Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 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 which 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 single bedrooms. Lodge Hill (145) DS0000006764.V308579.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 five hours on 30/11/06. Two members of staff and the manager assisted the Inspector. All but one of the eight residents were seen in the home by the Inspector, one service user was in bed unwell. 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 and 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. 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: 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. Attention was given to meeting residents’ individual needs and to provide residents with leisure and social activities. Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 6 Residents were well cared for and no complaints were made about the service to the home or the Commission since the last inspection. 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. Lodge Hill (145) DS0000006764.V308579.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.V308579.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided adequate information about the service. Introductory visits were part of the admission process. Admission procedures were in place to comply with these standards. EVIDENCE: Standard 1 The Statement of Purpose ands Service User Guide had been updated and the document complied with Regulation. Standards 2,3,4 & 5 No new residents had been admitted to the home since the introduction of the National Minimum Standards, therefore these Standards were not assessed. Lodge Hill (145) DS0000006764.V308579.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 at least once during a 12 month period. 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. Care plans and risk assessments viewed were up to date and comprehensive and reviewed on a regular basis. Annual Life Plans were also up to date and showed that residents were involved and family or representatives and professionals involved had been invited. Residents were involved in decisions about them and enabled to be as independent as possible. EVIDENCE: Standard 6 Two care files and individual plans were examined in respect of two service users. Individual plans were comprehensive and involved service users 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 following a previous recommendation are conducted on a six monthly basis. Records seen were comprehensive and up to date and Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 10 included monthly summaries completed by key-workers that contribute to the review process on individual service users; 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 their lives. Where risks were identified procedures and care plans reflected how these were being managed. Standard 7 Interaction between staff and service use, observed by the Inspector, demonstrated choice being encouraged by staff members in relation to 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 service users in participating in the running of the home and contribute to policies and procedures. On a daily basis staff do make attempts to involve service users and this was evidenced in the daily diaries, the activities file and within tasks for staff listed in the shift planners. Enabling service users 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. Standard 9 Risk assessments are available in all service users’ care files and are readily available for all bank or agency staff who may be less familiar with service users’ needs. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. Evidence was available from the service users’ records examined that they are enabled to express choice in what they do and staff record these occasions. Lodge Hill (145) DS0000006764.V308579.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 at least once during a 12 month period. 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 Evidence was available from the care files of service users that opportunities are being made available for the personal development of residents, although, owing to the level of learning and physical disability and associated communication difficulties, none of the service users have been identified as Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 12 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. Standard 13 Service users are provided with a satisfactory level of community outings and activities but regrettably the home is not assisted in this provision by having a member of staff designated as coordinator of activities as was anticipated at the previous inspection. See Recommendation 1 Standard 14 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, although in view of the position regarding the lack of availability for day centre placements for four residents this does put pressure on staff to compensate for this lack of provision. It is also difficult to maintain the balance of staff engaged in activities and those remaining in the home to supervise residents. In view of the level of needs presented the current staffing level should be reviewed to ensure that residents are being fully met, see Standard 33. See Requirement 4 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. Continued efforts should be made to recruit permanent staff to the home able to drive the vehicle provided for service users. See Recommendation 2 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. 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.V308579.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 report that there are no relationships 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 did not have family had been referred to the Greenwich Advocacy Service. Five residents are on a waiting list for the provision of advocates and two for “befrienders”. 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. Lodge Hill (145) DS0000006764.V308579.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 at least once during a 12 month period. 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 all residents to comment on whether this suited them or not. 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. 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. Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 15 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 and recorded appropriately and tallied with the blister packs that were retained in a lockable cabinet. External medication was stored separately. Lodge Hill (145) DS0000006764.V308579.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 at least once during a 12 month period. 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: The home had local policies and procedures to deal with complaints and allegations of abuse. Staff members had received updated training on adult protection in November 2006 and those interviewed, displayed a good understanding and an awareness of whistle blowing procedures. Any suspicions or allegations of abuse would be referred to the Greenwich Community learning disability team for investigation Accidents records were well maintained and any unexplained injuries would be referred to CDLT for investigation. 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 and found to be accurate and accountable. The home is subject to a financial audit every three months and additionally spot checks can be undertaken at any time without notice. Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 17 There were no allegations of abuse made about the service to the home or the Commission since the last inspection. No complaints had been received by the home or the CSCI. Lodge Hill (145) DS0000006764.V308579.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 at least once during a 12 month period. 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, but attention must be paid to adherence to the annual maintenance schedule, as two carpets need replacement and redecoration is required on an ongoing basis. Several windows were identified as in need of repair. The premises were generally homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs and service users have the specialist equipment they need to maximise their independence. EVIDENCE: Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 19 Standard 24 An inspection of the building was undertaken and included service user bedrooms and all communal areas. Residents’ bedrooms reflected their own preferences in respect of furnishings and contents and two 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 carpets need replacement, in the upstairs dining room, and in the downstairs lounge, as these pose a tripping hazard. Kitchen floors also require new vinyl and one kitchen window needs to be double-glazed. Windows on thee ground floor service users rooms also require some renovation. See Requirements 1 & 2 An immediate requirement was made on the day to repair the front door locking mechanism for the safety of service users and the inspector can confirm that this was attended to as a matter of priority. 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.V308579.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Owing to increasing dependency needs of residents and difficulty compensating for lack of day centre placements for five residents, the staffing level should be reviewed to ensure that recreational and social needs can be fully met by the staff team. Staff recruitment procedures were found to be satisfactory. Service users were supported by staff who were appropriately trained and competent. 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 member 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 Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 21 skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff 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 In view of the evident increasing dependency needs of this group of residents and the difficulties referred to in Standard 13 in relation to the provision and management of staff time in relation to outings and activities a requirement has been made to review whether the home can adequately meet all the needs of the residents in respect of activities and outings. Requirement 3 It is also recommended, that the current 70 hours permanent staff vacancies be filled by permanent appointments, as soon as possible, in order to reduce the dependence on agency or bank staff members. See Recommendation 3 Standard 34 A personnel file was examined for a 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. Standard 35 The Inspector examined the training both provided and being planned for and was satisfied that this was appropriate to the needs of both staff and the needs of service users. Lodge Hill (145) DS0000006764.V308579.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 at least once during a 12 month period. 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. Surveys of relatives and professionals views on the running of the home must be publicly available and residents meetings introduced as soon as practicable. 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 the welfare of service users with her. Communication within the home was of a good standard with team meetings now planned regularly and the manager, Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 23 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 on the quality of the service provided owing to their communication difficulties. Attempts must be made to survey the views of service users and a recent survey of the views of relatives and involved professionals had been sent directly to head office, a copy of this should be retained in the home and also sent to the CSCI. See Requirement 4 Monthly monitoring visits and subsequent reports were conducted, 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. 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.V308579.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 X 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 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 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Lodge Hill (145) DS0000006764.V308579.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 YA24 Regulation 24 Requirement The Registered Person must ensure the renewal of two carpets, in the upstairs dining room, and in the downstairs lounge, as these pose a tripping hazard. Kitchen floors also require new vinyl. One kitchen window requires double-glazing. Windows on the ground floor service users rooms also require some renovation. The number of staff must be reviewed to assess whether an adequate level of activities and outings are provided. The Registered Person must ensure that surveys of the views of residents, relatives, advocates and involved professionals regarding the service provided are conducted annually. A copy must be sent to CSCI and retained in the home. Timescale for action 01/04/07 2. YA24 24 01/04/07 3. YA33 18 01/04/07 4. YA39 24 01/04/07 Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA13 YA14 Good Practice Recommendations Consideration should be given to the appointment of an activities coordinator. Continued efforts should be made to recruit permanent staff to the home able to drive the vehicle provided for service users. The existing permanent staff vacancy of 70 hours should be filled with permanent staff members if possible. 3 YA33 Lodge Hill (145) DS0000006764.V308579.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 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 Lodge Hill (145) DS0000006764.V308579.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. 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