Inspection on 26/09/06 for Lodge Hill (167)

This inspection was carried out on 26th September 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lodge Hill (167) 17/02/06

Lodge Hill (167) 15/12/05

Lodge Hill (167) 22/11/04

Lodge Hill (167) 05/04/04

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 (167) 167 Lodge Hill Abbeywood London SE2 0AS Lead Inspector Keith Izzard Unannounced Inspection 26th September 2006 10:00 Lodge Hill (167) DS0000036908.V308530.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 (167) DS0000036908.V308530.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 (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lodge Hill (167) Address 167 Lodge Hill Abbeywood London SE2 0AS 02088548888 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) Greenwich Council Michelle Capar Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lodge Hill (167) DS0000036908.V308530.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: 167 Lodge Hill is a modern chalet style building situated in the grounds of the former Goldie Leigh Hospital, close to the facilities of Welling and Bexleyheath. There are six single bedrooms for service users with physical and severe learning disabilities. The accommodation is arranged on one floor with a large sitting room/ diner, a large kitchen and level access to a small garden at the rear of the house. The home has its own mini bus to facilitate outings and other appointments for service users. The home is run by Greenwich Living Options part of the London Borough of Greenwich Social Services provision. Twenty- four hour care is provided by care staff and this is supplemented by regular daily visiting by District Nurses to provide peg feeding to two service users requiring this intervention. Service users are provided with a good level of activities and all attend local day centres on a four or five day basis. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visits for this unannounced inspection was completed over six hours on two separate days 26/09/06 and 5/10/06 in order for the Inspector to meet the new manager and to see all service users. Two members of staff assisted the inspection on the first day and the manager on the second day. All the residents were in the home as the day centres were closed for the week. The service was last inspected on the 21st February 2006. No requirements and recommendations were made at the last inspection. 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 days 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. Residents were well cared for and no complaints were made about the service to the home or the Commission since the last inspection. Relatives were satisfied with the quality of care provided. The home had a fairly stable staff team. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care reviews must take place on a six monthly basis and some risk assessments require updating and signing. The assessments records should be indexed and any duplication of old assessments removed in order to avoid potential confusion for staff members. Training had been provided for staff members but individual profiles should be developed and an overview of the staff team requirements, a matrix produced to assist with identifying future training needs. The results of surveys of the opinions of relatives and involved professionals should be retained in the home to afford access and a copy sent to the CSCI. Meeting for residents should be set up on a regular basis and efforts made to increase their involvement in the running of the home and encourage their views as best they can given their communication difficulties. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 7 Requirements were made to improve the separate toilet and the kitchen work to review and consider increased provision for storage now that the sixth bedroom is back in use following another admission of a resident to the home. 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 (167) DS0000036908.V308530.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 Lodge Hill (167) DS0000036908.V308530.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information was provided about the service in the Statement of Purpose and Service User Guide to enable prospective residents to make a decision to the suitability of the service. Admission procedures were in place to comply with these standards. EVIDENCE: Standard 1 The home has produced a comprehensive Statement of Purpose and Service User Guide that clearly sets out the information required in Schedule 1 Regulation 4 (1) c Care Standards Act 2000. Similarly, the home has produced a clear and comprehensive brochure intended to provide information for all those who might be interested in using the service provided at the home. Standard 2 The admission procedures in place complied with Standard 2, evidence of this was seen during an examination of the records relating to the last service user Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 10 admitted to the home in the weeks just prior to the inspection. The records showed that there had been good preparation in terms of the transfer arrangements from the previous home and that comprehensive documentation in respect of care plans and risk assessments were in place to support his assessed needs and that a phased admission had been organised. Standard 4 In respect of this new service user the pre assessment information was examined and noted to be comprehensive and well recorded. The service user had a phased move that was planned and evidence was available that the move was communicated to the service user and that it was made as smoothly as possible in order to minimise the trauma of moving home. Lodge Hill (167) DS0000036908.V308530.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 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 viewed were up to date and comprehensive and reviewed on a regular basis and showed that residents were involved and any family or representatives and professionals involved had been invited. However care plans must be reviewed on a six monthly basis and all risk assessments kept up to date and eliminate any duplication of records. Residents were involved in decisions about them and supported to be as independent as possible. EVIDENCE: Standard 6 Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 12 Two service user care files were examined and found to be comprehensive in content, and evidence was available that developing or changing needs are acted upon and outcomes recorded. The Inspector also cross referenced entries in the daily diary for service users with their care plans and risk assessment folders and noted that entries and actions taken were in accordance with the requirements of individual care plans and that care plans were regularly updated. Reviews are being conducted on an annual basis but must be reviewed at least six monthly as required in this Standard. Requirement 1 Standard 7 Care records of service users and the service user daily diaries provided evidence of service users making decisions for themselves. However, because of the communication difficulties of the service users living at this home, it must be acknowledged that service users are heavily dependant on staff members’ interpretive skills. Recorded information was available describing the subtle variations in both verbal and non-verbal communication specific to individual service users. The Inspector is aware that staff members have developed expertise in communicating in various ways such as signs gestures and pointing to objects or pictures to facilitate communication and have also built up an historical knowledge of service users’ likes and dislikes which further aids communication. This information is recorded in order to assist any staff that may be new or temporary in the home. Standard 9 Two service users’ care files were examined which showed that risks in relation to individuals are assessed at the point of admission and thereafter reviewed on a regular basis, or immediately, in response to significant changes in behaviour. Risk assessments have been drawn up in respect of each of the service users and are recorded both within care plans and a specific file that is readily available to new or temporary staff to quickly identify what to be aware of in respect of individuals’ needs. This has led to some duplication, compounded by retention of out of date assessments that could cause confusion to staff. It was noted that a moving and handling assessment needed updating in relation to one service user, not now requiring a grab rail in the bathroom and that dietary information also needed updating to reflect a move away from pureed food for another service user. Requirement 2 and Recommendation 1 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, or handling hot drinks without supervision. Evidence was available from the service users’ Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 13 records examined that they are enabled to express choice in what they do and staff record these occasions. The home has an unexplained absence procedure that should ensure a swift response to such circumstances with descriptive information including photographs of service users, readily available to facilitate this. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 14 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): 11-17 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, enabling community participation and developing educational and occupational abilities. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Standards 11-14 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 being able to participate in employment or further education. All six residents currently attend day centre places on either a four or five day basis. Service Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 15 users have access to the local Speech and Language Therapy, Occupational and Physiotherapy services and these facilities assist with the development of social, emotional, and living skills in addition to the care and support provided by the home care staff. The Inspector examined a list of activities for service users that is updated weekly and notes are recorded in the daily diary and staff communication book of those activities that are planned for service users. Valued and fulfilling activities are provided both within the home and via outings provided. A range of activities is provided for service users including shopping, either individually with their key workers or together on a group outing. Occasionally, trips are organised with service users from a neighbouring home in order to increase contact for service users with other people. The home has a number of musical instruments, audio equipment and television. One service user likes to watch TV in his own room and another is particularly keen on “soaps”. A variety of art materials, puzzles and board and ball games are available that staff members assist service users to participate in when required, or requested to. The records clarify whether staff assistance is needed and those staff allocated to provide this support. Staff members continue to implement “Active support”, a programme designed to provide a coordinated response from both home and day centre staff in encouraging service users involvement in learning new tasks. Input has been received from a number of people from the Community Learning disability team such as Psychologist and Occupational Therapist. The manager has identified this as an area requiring further encouragement from staff members and this is recommended by the Inspector in order that service users are assisted to maximise their abilities. See Recommendation 2 This group of service users are heavily dependant on staff assistance to go out from the home because of their disabilities and the manager reported that the home does now have a number of staff who are able to drive the mini bus; this has facilitated additional outings for service users. It has been noted in the past that the two service users on peg feeds administered via District Nurses have been compromised in terms of access for outings and holidays. The manager reported that developments are underway to train care staff to administer these feeds and that the opportunities for them to go out more will be greatly enhanced as there will less restrictions imposed by their feeding regime previously dictated by the availability and schedule of the nurses. Two staff members interviewed and the manager confirmed their approval at this development. The Inspector commends the efforts made by the organisation to bring about this change that will be of great benefit to the residents. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 16 Standard 15 Service users are provided with a good level of contact with people outside of the home and good efforts are made to maintain family links; one resident goes to church regularly. 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. 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 and a good supply of both fresh and frozen food was seen stored in the home. Two of the service users require a special peg feed diet administered by District Nurses attending twice daily. The other service users do not require special or culturally appropriate diets, but some require their food to be cut up, soft or liquidised. Two require specific assistance from staff to enable them to eat safely and ensure adequate intake. Relevant risk assessments addressed these issues and had been completed by a member of the speech and language therapy service to advise staff members. One risk assessment needed updating as mentioned in Standard 9. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 17 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): 18-21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Standard 18 All six of the service users receive assistance with personal care owing to the extent of their physical disability. Staff members provide sensitive and flexible personal support and are sensitive to the privacy and dignity of service users. The home is not registered to provide nursing care, but that required is provided by the District Nursing service staff; they provide professional supervision for two service users who use peg feeds on a daily basis. As stated in a previous Standard this is about to change, as care staff will be trained to take on this role. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 18 Standard 19 All service users are registered with a local GP and are supported by staff to attend any surgery visits, or alternatively are seen within the privacy of service user’s own rooms. Three service users have individual needs around the management and monitoring of Epilepsy. Since the previous inspection there has been two admissions to hospital and this was in relation seizures suffered by one service user. Evidence was available from service user care files and daily diaries that regular and prompt attention is given to the ongoing health needs of service users. Standard 20 Due to the level of disability, service users are not able to self medicate and would not be able to do so without a high degree of risk. Medication is stored in a locked cupboard in the hallway. The medication for the two service users on peg feeds is entirely administered by the visiting District Nurses via this intervention. Medication is the responsibility of the designated person in charge on all shifts and only permanent staff that have received training are authorised to administer medication. Two MAR sheets were examined and checked against stored medication and found to be accurate. It was noted that liquid medication had not been dated on the bottle as to when opened and the fridge for storing relevant medications must be checked for correct temperature regularly. See Requirement 3 Otherwise, the administration, receipt recording, handling and disposal of medicines met the Standard. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 19 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. EVIDENCE: Standards 22 & 23 The home had policies and procedures to deal with complaints and allegations of abuse and whistle blowing. Staff members have all received training on adult protection, however for some this was not recent and it is recommended that those individuals be provided with updated training. See Recommendation 3 Any suspicions or allegations of abuse would be referred to the CLDT for investigation under adult protection procedures, as would any unexplained injuries. There have been no complaints received either by the home or the CSCI since the previous inspection of the home. There have not been any incidents in respect of adult protection issues. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 20 Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 21 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. However, more attention needs to be given to the lack of adequate storage facilities. The premises were homely in appearance and decorated to a satisfactory standard although some minor repairs are required in the kitchen and separate toilet. Individual and communal accommodation suited residents’ needs and service users are provided with specialist equipment as required. EVIDENCE: Standard 24 Two service users have been provided with special beds and equipment for administering peg feeds. The home does not currently use a hoist for moving and handling although an ARJO bath is used in the bathroom. It was noted that in the separate toilet, the seat needs repair or replacement and the washLodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 22 basin stand replaced and the mirror removed. Also, in the kitchen the sealing between the worktop and the wall needs replacement, as it is defective. See Requirement 4 Since the admission of a sixth resident the home has reverted to using all designated bedrooms leaving one room used as an office instead of two, this has substantially reduced the amount of storage space available. The lack of storage space generally within the home should be reviewed, particularly wheel chair storage. It is recommended that storage facilities be increased and that consideration is given to providing separate office accommodation for the manager. See Recommendations 4 & 5 Standard 30 On the day of inspection the home was clean, bright and airy and free from offensive odours throughout. Systems are in place to prevent the spread of infection. Overall, it was noted that the laundry area was satisfactory, although very cramped, with adequate equipment for dealing with soiled articles. Domestic cleaning materials are now stored in this area in a locked cupboard and COSH procedures are readily available for domestic staff. Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 23 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): 32-35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users 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 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 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. The home has the required 50 level of care workers trained to NVQ Level 2. Standard 34 Three personnel records were seen in relation to newer staff members and it was noted that all the requirements of Regulation 19 and Schedule 2 of the Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 24 National Minimum Standards had been complied with. Staff personal files need to be improved, this was recognised by the manager and was recorded on her developmental plan of changes to needing implementation. 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, as required and additionally, sensory awareness, autism, valuing people and epilepsy. However each member of staff should have a training and development assessment and profile and there should be a training matrix for the team as a whole. See Requirement 5 Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 25 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. The health and welfare of service users are promoted and protected. EVIDENCE: Standard 37 The recently appointed 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 held 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. The manager does need to apply to become the Registered Manager, as soon as Lodge Hill (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 26 practicable and confirmed that this would occur as soon as CRB clearance had been completed. See Requirement 6 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. The manager acknowledged that service user meetings need to be set up and showed the Inspector a development plan recently drawn up by her that included this as an area for implementation. See Requirement 7 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 8 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 and however the Inspector could not establish that night care staff had taken part in at least two fire drills over the past year, this must occur and be recorded. See Requirement 9 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 the electric, gas and water systems. 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 (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 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 X 34 3 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 3 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 (167) DS0000036908.V308530.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 c Requirement Care plans must be reviewed six monthly with the service user, family, friend, advocates and significant professionals. Risk assessments must be reviewed regularly and updated in writing. Liquid medication should record when container opened and the fridge containing medication regularly temperature checked. The washbasin stand in the separate toilet must be replaced, the toilet seat repaired and the mirror removed. The sealing between the worktop and wall in the kitchen replaced. Each member of staff must have a training and development assessment profile. A training matrix for the staff team must be developed. The Registered Person must ensure the manager submits a completed application to register with the Commission as soon as she receives her CRB check. Meetings to consult service users about the care they receive must be set up on a regular basis. DS0000036908.V308530.R01.S.doc Timescale for action 01/01/07 2 3 YA9 YA20 15 (2) & 17 (3) 13 (2) 01/12/06 01/12/06 4 YA24 16 & 23 01/01/07 5 YA35 18 01/01/07 6 YA37 9 01/01/07 7 YA39 24 (3) 01/01/07 Lodge Hill (167) Version 5.2 Page 29 8 YA39 24 9 YA42 23 (4) e Surveys of the views of; relatives, friends, advocates and involved professionals in respect of the home, must be conducted and a copy retained in the home and sent to CSCI. All night care staff must be involved in a minimum of two fire drills per year and this must be recorded. 01/01/07 01/01/07 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 3 4 5 Refer to Standard YA9 YA11 YA23 YA24 YA24 Good Practice Recommendations The filing and organisation of risk assessments should be reviewed to avoid duplication and ensure regular review. “Active support” should be further encouraged by staff members to maximise the abilities of residents. Staff members not recently updated in Adult Protection training should be provided with this training. The amount of storage space should be reviewed and improved in the home Separate office accommodation should be considered for the manager. Lodge Hill (167) DS0000036908.V308530.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: 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 (167) DS0000036908.V308530.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!