Inspection on 16/11/06 for Lodge Hill (169)

This inspection was carried out on 16th 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lodge Hill (169) 09/01/06

Lodge Hill (169) 19/07/05

Lodge Hill (169) 09/03/05

Lodge Hill (169) 21/09/04

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 (169) 169 Lodge Hill Abbey Wood London SE2 OAS Lead Inspector Keith Izzard Unannounced Inspection 16th November 2006 10:00 Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lodge Hill (169) Address 169 Lodge Hill Abbey Wood London SE2 OAS 0208 854 8888 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) feizalglo@yahoo.co.uk Greenwich Council Post Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: 169 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 providing accommodation for service users with moderate to severe learning difficulties and physical disability. There are two vacancies as one undersized room is being reviewed for a possible building extension in order to meet current Standards and one room available upstairs following the move of a resident requiring ground floor accommodation. Four rooms are located on the ground floor two of which are suited for two service users who use wheelchairs and have access to the downstairs bathroom and separate walk in shower. The lounge and kitchen diner area are also located on the ground floor. There is level access to the small garden and patio area from the kitchen diner. Upstairs are a further two service user bedrooms a combined bathroom and toilet and the staff sleep in room / office. The home is one of a number, managed by the London Borough of Greenwich within the Greenwich Living Options Scheme. A staff team of eight provide 24 hours cover, supported by a manager and deputy manager. Service users attend local day centres during weekdays and are provided with personal care and support to live as independently as possible and to take part in activities both within the home and the community. Residents are encouraged to personalise their own room; meals, laundry and care support are provided by staff. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 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 six hours on 16/11/06. Three members of staff and the manager assisted the Inspector. All but one of the residents was seen in the home; the other was attending his day centre placement. The service was last inspected in February 2006. One requirement was made at the last inspection and was complied with, however, the manager still needs to submit an application to become the Registered Manager. 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. Residents were well cared for and no complaints were made about the service to the home or the Commission since the last inspection. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 6 Relatives were satisfied with the quality of care provided. The home had a stable staff team. What has improved since the last inspection? What they could do better: 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. Some liaison with the pharmacist for the home is needed to clarify how medication will be supplied to the home. Attention must be paid to ensuring day centre responsibilities are adhered to. The surrounding paving must be levelled for safety and trees on one side of the house removed to allow natural light into two residents’ rooms. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 7 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 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): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are comprehensively assessed Admission procedures were in place to comply with these standards. EVIDENCE: Standard 2 The Inspector viewed two pre-admission assessments in service users’ care plans, and these were very detailed, and showed that sufficient information was recorded before a decision was made to offer a placement to the service user. The assessments indicated that information was taken in regards to different aspects of daily living, communication needs, and social preferences, and included health needs and evidence of assessing compatibility with other service users. Standard 3 The admission procedures in place complied with Standard 3; evidence of this was seen during an examination of the records relating to the last service user admitted to the home, in November 2005. The records showed that there had been very good preparation in terms of the specialist equipment and advice Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 10 needed to support his assessed needs and that a phased admission had been organised. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 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 and risk assessments viewed were up to date, 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, supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality. EVIDENCE: Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 12 Standard 6 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. Records seen were comprehensive and up to date. 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. Additionally, clinical meetings with CLDT are also taking place when specialist individual support with complex health problems are dealt with. Standard 7 Interaction between staff and service users, 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. Two staff members interviewed said they endeavoured to involve residents in decision making based on their individual communication and comprehension. This is inevitably restricted by the severe communication difficulties of the residents and depends heavily on staff interpretation and historical knowledge of residents likes and dislikes. Staff members were observed communicating with residents and involving them in whatever was going on in a professional and caring manner. Standard 9 Risk assessments for service users had been updated in accordance with a previous requirement and the Inspector found evidence that this had taken place in the two service user care files that were examined. The risk assessments are readily available for all bank or agency staff members 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 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 EVIDENCE: Standards 11 & 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 being able to participate in employment or further education. Four residents currently attend day centre places varying from two times to four times per week. The attendance of the new resident has been reduced from five days to Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 14 four to facilitate quality time spending a day with his key worker. The resident assessed as inappropriate for a day centre placement has a daily activity plan to compensate for the lack of day centre provision and went on a bowling trip on the day of inspection with her key worker. Standard 13 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, games, sightseeing and annual holidays were recorded. Standard 15 Staff members actively support and encourage family contact for three of the residents who have family. One resident has an advocate from “Mencap” and the other resident is on the waiting list for the provision of an advocate. Through the various activities and outings residents are provided with some opportunity for meeting with other people; however, staff report that there are no relationships of significance for any of the residents. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping trips. 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. Clear instructions are readily available on an individual basis for any special diets for residents. One resident sometimes refuses food and a risk assessment was in place advising staff members of alternatives such as ensure. Weight is regularly monitored at the day centre and communication is maintained with the day centre regarding monitoring of intake whilst he is there over the lunch time period. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 but complications arising from the service provided by the Pharmacist must be resolved, and also a local policy / procedure put in place. 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 because of the extent of their communication difficulties and likewise they were unable to give feedback about any aspect of the service. Daily records Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 16 were kept to show the care provided and activities the residents were involved with. Standard 19 Care plans and daily records showed how personal care was provided. Three staff members 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. Evidence was available within the care notes of two residents who were case tracked that hospital appointments were followed up and good preparation made to avoid any possible challenging behaviour and secondly that great care and attention had been paid to clarifying the types of Eplileptic fitting experienced by one resident and how staff members should deal with this. One shortfall was noted in respect of follow up with a day centre regarding food intake; it was also noted that the home had been using a temporary communication book for this new resident that had contributed to this oversight. See Requirement 1 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 generally well managed. However it was noted that the home does not have a local policy/ procedure but the manager was in the process of compiling this. This must be implemented as a priority. Also there has been some recent confusion caused by the pharmacist not clarifying the identity of certain tablets and a shortfall in the quantity provided for one resident. The manager was aware of these problems and readily agreed to sort the matter out with the Pharmacist supplying the home. None of the service users are able to deal with their own medication and is, therefore, only dealt with by staff members who have been trained and assessed to do so. MAR sheets were examined and recorded appropriately and tallied with the monitored dosage packs that were retained Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 17 in a lockable cabinet. External medication was stored separately but two medicinal creams, to be externally applied, were not dated as to when they were first opened; this must be done. See Requirement 2 Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 18 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 procedures were in place to ensure complaints were appropriately managed and to ensure protection for residents. EVIDENCE: Standards 22 & 23 The home had policies and procedures to deal with complaints and allegations of abuse. Staff members have received training on adult protection. Any suspicions or allegations of abuse would be referred to the CLDT for investigation under the London Borough of Greenwich adult protection procedures, as would any unexplained injuries. 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. All the residents have their money managed by an appointee from the Greenwich Living Options office, part of the London Borough of Greenwich social services department. The Inspector examined the system for dealing with the personal monies of two service users within the home, chosen at Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 19 random, and found it to be accountable and with a clear audit trail. Additionally, the home is regularly audited by Greenwich Living Options within the programme of monthly visits undertaken under Regulation 26. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 20 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, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users generally live in a homely comfortable and safe environment but paving outside must be attended to and also the lack of natural light in two bedrooms as well as inadequate storage space. Specialist moving and handling equipment has been provided for two residents that met their assessed needs. The home was clean and hygienic throughout. EVIDENCE: Standard 24 All areas of the home seen were clean, tidy and free of unpleasant odours. Bedrooms were nicely personalised and the home suitable to meeting the needs of the residents. However, a previous requirement that the paving Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 21 around the building must be made level in order to prevent accidents was not complied with and must be attended to. See Requirement 3 The lack of storage space generally within the home should be urgently reviewed, particularly wheel chair storage, this is a restated recommendation. It is recommended that storage facilities be increased and that consideration is given to providing separate office accommodation for the manager. See Restated Recommendation 1 It was noted that two residents’ bedrooms are very dark and gloomy resulting in insufficient natural light caused by the proximity of conifers very close to one side of the house. See Requirement 4 Standard 29 Two service users have been provided with special beds and ceiling track hoists in order to facilitate safe moving and handling. The extension to the home, built to accommodate the most recent resident’s needs has been well finished and complements the building and has met the Standard in relation to newly built accommodation. 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 stored in this area in a locked cupboard and COSH procedures are readily available for domestic staff. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 22 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. 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 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 and foundation training following this. The home has already achieved the required minimum of 50 trained 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 members were observed to be respectful and caring in the way they were Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 23 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 Staffing levels have been increased to meet the needs of the new resident recently admitted. It is recommended that that the two vacant posts are filled by permanent appointments. See Recommendation 2 Standard 34 Three personnel files were examined for more recent staff recruited 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 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 Two members of staff interviewed and stated that they had received a thorough induction programme and subsequent training had been provided and was being planned for. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 24 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 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 Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 25 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 practicable and confirmed that this would occur as soon as CRB clearance had been completed. See Requirement 5 Standard 39 None of the service users would be able to comment 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 6 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 7 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 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 1 25 X 26 X 27 X 28 X 29 3 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 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 27 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 YA19 Regulation 16 2 (i) Requirement Failure by day centre staff to provide nutritional information, as requested, must be followed up promptly and communication books between the home and day centre checked daily on placement days. The Registered Person must: Implement a local medication policy/procedure. Clarify the description and quantities of tablets supplied for residents. Ensure medicinal creams are dated, when opened. 3 YA24 23 (2) o The paving around the home must be made level in order to prevent accidents for residents. 01/03/07 Timescale for action 01/01/07 2 YA20 13 01/01/07 4 YA24 23 (2) p 5. YA37 8 The trees blocking daylight to 01/03/07 two residents rooms must be removed to facilitate good natural light for them. The Registered Person must 01/02/07 ensure that the manager submits an application to become the DS0000036906.V290371.R01.S.doc Version 5.1 Page 28 Lodge Hill (169) Registered Manager as soon as CRB clearance has been received. 6 7 YA39 YA39 24 (2) 24 (3) Residents meetings must be set up, as planned, as soon as practicable. The surveys of relatives and professionals views regarding the service provided by the homer must be made public and a copy retained in the home and accessible to view. 01/03/07 01/03/07 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 Refer to Standard YA33 Good Practice Recommendations It is recommended that the two permanent staff vacancies are filled with permanent staff as soon as practicable. Lodge Hill (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 29 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 (169) DS0000036906.V290371.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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