Inspection on 15/01/07 for Lonsdale House

This inspection was carried out on 15th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lonsdale House 28/01/09

Lonsdale House 15/12/05

Lonsdale House 11/07/05

Lonsdale House 17/11/04

Lonsdale House 10/06/04

Lonsdale House 14/10/03

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

CARE HOME ADULTS 18-65 Lonsdale House 8 Lichfield Road Walsall West Midlands WS4 2DH Lead Inspector Ms Maggie Bennett Key Unannounced Inspection 15th January 2007 09:40 Lonsdale House DS0000020830.V324324.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 Lonsdale House DS0000020830.V324324.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. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lonsdale House Address 8 Lichfield Road Walsall West Midlands WS4 2DH 01922 721566 01992 722767 Angie.crisp@caldmorehousing.co.uk 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) Caldmore Area Housing Association Limited Angela Crisp Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users may be accommodated at the home in the category MD(E). This will remain until such time that the identified service users’ placement is terminated. 15th December 2005 Date of last inspection Brief Description of the Service: Lonsdale House is registered to provide residential care for 15 adults aged between 18 and 65 who are experiencing mental ill health. The home aims to provide a rehabilitation service to enable service users to develop skills required for independent living. They are closely supported by the Walsall Community Rehabilitation Team. The property is a large detached house, which is situated close to Walsall Town Centre and local amenities including shops, a market, pubs, Arboretum park and has good access to local public transport. There are ample car parking facilities for visitors, a ramp for easy access at the front of the property, whilst at the rear are landscaped gardens. Accommodation is provided over three floors with a summerhouse and 2 selfcontained houses situated separately at the rear. There are 10 single bedrooms and 3 self-contained bed-sits within the main building. Additionally there is a large kitchen, smaller training kitchen, dining room, 2 lounges, office and separate staff sleeping in room and toilet. Fees charged at the home are £391.69 per week. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday over a period of 9 hours. Prior to the visit a Pre-Inspection Questionnaire was completed by the Manager and returned to the Commission. In addition 4 service users completed an anonymous survey on their views of the home. All the Key Standards of the National Minimum Standards were assessed. At the last inspection a total of 5 statutory requirements were made. It was found that 4 of those requirements had been met and 1 was in the process of being met. 1 new statutory requirement was made following this visit. During the course of the day 5 service users were spoken to and informal interviews were held with 2 members of staff. Discussion took place throughout the inspection with the Registered Manager and Team Leader. The Head of Support Services for Caldmore Housing Association was also present during part of the inspection. The Support Plans (care plans) of 5 service users were seen in order to inspect assessment and care planning processes. The medication and administration records were seen. Staff files were inspected in order to assess recruitment processes and staff training. A tour took place of the building, during which a sample of the service users’ bedrooms were seen. Various other documents were seen in order to check health and safety procedures and policies. What the service does well: Lonsdale House provides a very good service for people recovering from mental health problems. The home provides its service users with a range of opportunities to develop their independent living skills. They are supported in this by the multi disciplinary Mental Health Team. The home has good assessment procedures and staff work hard to ensure that admission to the home is personal and well managed. A comprehensive needs assessment is carried out before any new service user is admitted. Service users are fully involved in the development of their Support Plans, which follow the principles of person centred planning. A variety of educational and employment opportunities are explored with the service users to help them to develop their social, emotional, communication and independent living skills. Service users have access to a range of health services, including advice from the multi disciplinary team, and are assisted to work towards managing their own healthcare. There is a robust medication policy and procedure in place. Service users spoken to feel confident that any concerns or complaints they have will be listened to and acted upon. There is a robust Adult Protection Procedure and Policy in place. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 6 Lonsdale House is comfortable and well maintained and meets the needs of the service users. There is an experienced staff team in place who are well trained, friendly and approachable. Robust recruitment procedures protect the service users. The home is well managed and administered. There are good systems in place to protect the health and safety of service users and staff. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lonsdale House DS0000020830.V324324.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 Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. There are very good assessment procedures in place at Lonsdale House. Service users are fully involved in this assessment, which ensures as far as possible, that the home is able to meet their individual needs and aspirations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All new referrals for Lonsdale House come through Walsall’s Community Rehabilitation Support Team, who continue to be involved through the service user’s stay and subsequent move to independent living. The files of the 3 most recently admitted service users were seen at the inspection in order to inspect assessment procedures and practice. It was found that the home itself has very good systems in place for ensuring that service users’ needs are fully assessed before any decision is taken about the service user moving to the home. The home have not always received prompt and up to date information from the referring social worker, although there is evidence that this situation is now improving. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 9 The home’s own assessment form ensures that all those areas listed in Standard 2.3 are covered. The needs assessment includes a personal history, daily living skills, risk assessments, physical and mental health, early warning signs and relapse prevention plans. The assessment information seen had been signed by the service user. The Registered Manager states that she intends to improve on the assessment format further by making it more “personalised” to the individual. The Manager is consulting with the service users at their next meeting (16th January 2006) about the new assessment format. The home also obtains a copy of the Care Programme Approach prior to the service user being admitted. In one case a 2003 assessment had been forwarded. The Registered Manager stated that this situation had now improved and one social worker is now taking responsibility for submitting assessment information to the home and ensuring that up to date information is received prior to admission. Once service users move in the assessment information is used to develop a comprehensive support plan (see also Standard 6) in which the service user is fully involved. Although Standards 3 and 4 were not assessed on this occasion, service users spoken to during the inspection confirmed that they had been able to visit Lonsdale and spend some time there before making any decisions about moving in. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. There are comprehensive Support Plans in place, which ensure that action is taken to meet individual needs and develop independence skills. Service users are fully involved in decisions affecting their lives. Any risks are assessed and steps taken to minimise these risks in discussion with the service user. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Support Plans of 3 service users were seen in order to assess the home’s care planning processes and practice. The Needs Summary obtained from the assessment information is used as a basis for the development of the Support Plan. This Plan is discussed with the service user, who signs their agreement to the Plan. The plans are comprehensive and include a Summary of Needs, Agreed Objectives, Agreed Support Tasks and Key Worker Tasks. They are further broken down into daily planners, to include specific areas such as medication, budgeting, cooking and cleaning skills. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 11 From discussion with the service users it was confirmed that they are fully involved in the development and review of their Support Plans. A key-worker system is in place and staff spoken to during the inspection were fully aware of their responsibilities as key-worker. Service users spoken to all knew who their key-worker was and spoke very positively of the assistance they received. Daily records were also seen and these could be cross-referenced to Support Plans. The Support Plans contained evidence of regular reviews between the service user and key-worker. Formal reviews are held with the multi disciplinary team, either on an annual basis (Standard review) or 6 monthly basis (Enhanced review). There was evidence of staff at the home being flexible with regard to reviews, in order to meet the needs of the service user. One service user feels much more able to contribute to consultation and planning during the evening, so evening reviews are arranged. The home aims to promote independence and choice. During the inspection service users spoken to confirmed that they were able to make decisions about their everyday lives. An Advocacy service is available locally if needed. There is evidence of service users being regularly consulted about the running of the home. One service user was enabled to take responsibility to choose decorating materials, purchase them and redecorate the “smoking” lounge. The home aims to assist service users to ultimately manage their own finances. Advice is given with regard to budgeting. The home does have a policy that no alcohol is allowed on the premises. This was brought in following consultation with the service users and followed concerns about the effects that alcohol was having on some service users. All service users are subject to a risk assessment at the point of referral as part of the Care Programme Approach. This risk assessment is developed in consultation with the service user and action is taken to minimise identified risks. It was found that the risks to one service user had changed since their original assessment had been produced and the risk assessment did not reflect the current situation. The home must ensure that all risk assessments are regularly reviewed and updated. The home has a Missing Person Procedure in place. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. There are very good opportunities at Lonsdale for service users to develop their independent living skills. A variety of educational and employment opportunities are explored, with service users being enabled to take part in those that are appropriate to their needs. Individual rights and choices are promoted. The food provided at the home is of good quality and is enjoyed by the service users. There are good opportunities for service users to progress to preparing their own meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users receive assistance from the staff at the home, plus members of the multi disciplinary team (which includes an Occupational Therapist) to find suitable training and educational opportunities. One service user is currently on a full-time College course, which may lead to employment. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 13 Other service users are being assisted in a variety of ways to develop their independent living skills. Some attend various day centres and a healthy eating group. There are also examples of service users going out on a “one to one” basis with either their key-worker or the occupational therapist to their own homes or future accommodation. One service user has been introduced to dog walking. A number of local facilities are used by the service users, including the local Pub and the library. Several service users are participating in a trip to the Theatre in Wolverhampton in January 2007. Staff are aware of the service users’ rights of access to public facilities under the Disability Discrimination Act. Information about local activities is displayed on the notice board. All service users are on the electoral register and some have opted for a postal vote. All staff time with service users outside the home is recognised as part of their duties. In consultation with the service users a number of trips and activities are planned throughout the year. In the summer of 2006 4 service users enjoyed a holiday to Butlins at Skegness. Friends and family are welcome to visit the home between 10.00 a.m. and 10.00 p.m. and some visitors were present during the inspection. Several service users also visit their families, some spending nights and weekends away. Service users are free to develop friendships (including intimate friendships) of their choice and advice with regard to contraception is given if needed. All service users have their own daily and weekly planner within their Support Plans. This schedule is agreed with them and includes information on cleaning rooms and responsibility for tidying the training kitchen. Everyone has a key to their room and a front door fob. Service users are requested to be home by 11.30 p.m. at night, or to let the staff know if they intend to be out later. During the inspection staff were observed to engage with the service users, seeking involvement in the daily routines of the home. Rules on smoking, alcohol and drugs are clearly stated in the contract. Several service users are being assisted to budget for, shop and prepare their own meals. This is done in a staged way with assistance from their keyworker. For those service users at the initial stage, the home provides 3 meals a day, plus supper in the evening. Three choices are provided for the main meal, which is served at night, apart from Sundays. The choice includes a Healthy Eating option. A cooked breakfast is available each morning. Times for the meals are flexible, although service users are aware that the main meal cannot be kept any longer than 5.30 p.m., because of food hygiene requirements. The cook is intending to meet with the service users in the near future to discuss the menus. Two members of staff have successfully completed accredited training in Healthy Eating. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 14 Service users living in the Coach House mostly prepare all their own meals, although meals can be provided for them if they wish. Service users in the main building have a locked cupboard in which to keep their dried foods, cutlery, crockery and cooking utensils. They also have access to shared fridges and freezers. A catering assessment is carried out of all service users. Both the main kitchen and training kitchen were seen at the inspection and were found to be clean and in good order. Fridge and freezer temperatures are taken daily and recorded. The temperature of cooked meat is taken and recorded. Ample supplies of food were seen. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. Service users take charge of their own personal care and receive assistance and advice from care staff if needed. Healthcare needs are clearly documented and the service users have access to a range of health services. They are assisted to work towards managing their own healthcare. There is a robust medication policy in place, which is supported by procedures and practice guidance, which protects the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the service users at Lonsdale House take charge of their own personal care and all have their own single rooms. Times for getting up and going to bed are flexible and this was confirmed by the service users at the time of the inspection. On occasions service users are reminded to get up so that their medication is taken at the correct time. The staff group contains people from different ethnic backgrounds. As stated above, the staff team at Lonsdale House are supported by the community mental health team and advice and assistance is provided from a number of disciplines. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 16 Service users are supported to take charge of their own healthcare, where this is possible. They are all registered with a local G.P. and visit healthcare professionals such as chiropodist, dentist and optician in the community. Some service users are able to manage their own appointments, whilst others are entered into the home’s diary, with outcomes recorded on a separate log sheet. All mental health needs are discussed at the monthly multi disciplinary meetings. Where a concern arises, a Case Conference can be called with the multi disciplinary team and at the time of the inspection one had been arranged. The home have good systems in place for the receipt, storage, administration and recording of medication. There has been a further improvement in this area since the last inspection and this Standard is now fully met. Each service user has an individual medication file, which contains details and descriptions of the medication the person is prescribed, the medication administration record sheet and a copy of the prescription. An audit is carried out each evening by the senior member of staff on duty. A monthly audit is carried out by the Team Leader. The home have in place comprehensive policies and procedures with regard to medication. Service users are assisted towards managing their own medication and all have a lockable facility in their rooms in which to keep their medication. At the time of the inspection some people were taking charge of their medication, with some starting to do so on a gradual basis, with staff assistance and supervision. The home does not use a monitored dosage system, but administers from original containers. There is a policy and procedure in place for the administration of homely remedies and service users’ G.P.s have been requested to confirm in writing their agreement to the taking of specific homely remedies. There are no service users who are prescribed controlled drugs at present. A random sample of the medication was checked against the administration record sheet and there were no discrepancies. The home keeps a list of sample staff signatures. All staff who administer medication have successfully completed accredited medication training. The Registered Manager supervises all staff following their training and when she is satisfied of their competence gives written authorisation for them to administer medication. Information is available in the home on all the medications prescribed. Any unused medication is returned to the Pharmacist and records were seen to verify this. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. There is a good Complaints Policy and Procedure in place and service users feel confident that if they have concerns they will be listened to and their concerns acted upon. There is a robust Adult Protection Procedure in place, which protects service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Caldmore Housing Association produced a new Operational Manual in October 2006, which contains a comprehensive Complaints Procedure. This is in line with Standard 22 of the National Minimum Standards. A copy of this policy and procedure is given to all the service users and a summary is displayed on the notice board. The procedure follows a clear and effective process with specified timescales for dealing with complaints. No complaints have been received by the home, or by the Commission, since the last inspection. Records are also kept of Compliments made about the home and a number were seen at the inspection. Service users spoken to said that they would know who to speak to if they were unhappy about anything at the home. They also felt confident that any concerns they had would be listened to and acted upon. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 18 As with the Complaints Procedure, there is an up to date (November 2006) Adult Protection Procedure in place, which is in line with the Walsall Social Services Procedures. A recent allegation of abuse was made at the home and this is currently being investigated. The home followed all procedures correctly and acted speedily and effectively to protect the service users. Staff receive regular training in Adult Protection issues and those spoken to during the inspection were fully aware of their responsibilities with regard to the Protection of Vulnerable Adults. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. Lonsdale House is well maintained and meets the needs of the service users. It is a pleasant and safe place to live. The home is comfortable, warm and clean and free of any offensive odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of all the communal living areas, bathrooms, toilets, summerhouse, kitchen and training kitchen took place. One single room, one bed-sit and one of the coach houses were also seen. The home have a maintenance plan in place, the next area for re-decoration being the hall, stairs and landings. Service users have been consulted and have chosen the carpets and colours for the walls. Some radiator covers are to be replaced with more up to date models. The next areas to be re-decorated will be the non smoking lounge and the dining room, where it is hoped that new tables will be provided. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 20 An intercom system is linked from the office and staff sleeping-in room to all the individual rooms. All service users are issued with an electronic key for the front doors and a key to their rooms. Bathrooms, toilets and showers also have appropriate locks fitted. Staff will only use override devices in an emergency or if action is needed to ensure health and safety procedures are being followed. Monthly checks are made of the building as well as audits of individual rooms. There are very pleasant gardens to the rear of the property. The home was found to be in generally good decorative order, clean and free of any offensive odours. There are policies and procedures in place for the control of infection and several staff have taken part in infection control training. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35. Quality in this outcome area is good. There is a good rapport between service users and staff and service users have confidence in the staff that care for them. There is a stable staff team in place who are experienced, friendly and approachable. Lonsdale House is staffed according to the needs of the service users and there are satisfactory systems in place with regard to staff “lone working”. The home has robust recruitment procedures, which protect the service users. Staff receive appropriate training and this results in a skilled and competent workforce. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were observed to be approachable and attentive to the service users’ needs. Key-workers spoken to during the inspection had a good understanding of the needs of the service users that they were working with. The home has a very good relationship with the multi disciplinary team, who are consulted at regular intervals. 50 of the staff are trained to NVQ3 or equivalent and 3 members of staff are undergoing this training at present. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 22 Staff rotas were seen during the inspection and these showed that there are sufficient staff on duty during the day-time to meet the needs of the service users. During the evening, overnight and on some shifts at weekends there is a lone worker at the home. At the time of the inspection the Registered Persons were devising a new risk assessment on lone working. Staff have been consulted about the new risk assessment. A copy of this document will be forwarded to the Commission when it is completed. There is an emergency call system in place, plus an “On Call” manager. All staff receive “lone worker” training, plus training on how to handle any violence or aggression. The Registered Manager’s hours are supernumerary. There is a cleaner on duty on 7 days a week. After some staff changes and a period of instability, the staff group now appears settled and staff spoken to during the inspection said that they felt that there was a stable staff group in place, who worked well together and were well supported by senior staff and the Registered Manager. There are regular staff meetings and the notes of these meetings were seen at the inspection. The files of 2 recently appointed members of staff were seen in order to check recruitment practice. The files contained evidence of robust recruitment procedures and all the documentation required by legislation. Two written references were seen as well as application forms, which contained a full employment history. Files also contained evidence of satisfactory Criminal Records Bureau and POVA checks. All staff receive statements of their terms and conditions. Records seen showed that staff receive appropriate training and that there is a sound training and development plan in place. The files of the most recently appointed members of staff included a copy of the six week induction training, which meets Skills for Care specifications. All staff have an individual training and development assessment. In addition to regular training in the mandatory health and safety issues (see Standard 42) staff receive training in a number of areas including: The Safe Handling of Medicines, Violence and Aggression, Adult Protection, Lone Working, Supporting Victims, Disability Awareness and Equality and Diversity. Service users spoken to during the inspection felt that they received very good support from the staff. They felt they could speak with their key-workers and one person said that if the key-worker was not on duty “there is always someone to talk to”. In their returned surveys, service users said the following about the staff: “My carers and key-worker are very good and reliable.” “They know what to do whatever that problem might be.” Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good. There is an experienced and competent Manager in place who leads a strong staff team. There has been progress on the development of a quality assurance system. Service users’ views are sought and acted upon. There are good systems in place to protect the health and safety of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager was appointed in June 2005 and successfully completed an interview to become registered with the Commission later that year. She holds the NVQ level 4 in Care, the Registered Managers’ Award and the City and Guilds Level 3 in Community Health Care. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 24 Prior to her appointment at Lonsdale House she worked as a Team Leader at Oak House. The manager is well respected by the staff group and service users. She undertakes periodic training to update her skills and knowledge. The home uses various strategies to seek the views of the service users. This includes service users’ meetings and regular discussion between service users and their key-workers. Service users also take part in regular review meetings of their care. The Registered Persons are currently developing a Quality Assurance System. They intend to produce this in partnership with the service users. An implementation team has been formed and there will be a service user representative on this group. Questionnaires are to be sent out to all stakeholders. Information received from the quality assurance monitoring system needs to be used to produce an annual development plan for the home, with an action plan implemented for improvements. Staff receive regular training in moving and handling, fire safety, first aid, food hygiene and infection control. Certificates to verify this training were seen in staff files. All hazardous substances are stored securely and the home keep an analysis of all products used. Evidence was seen at the inspection of the regular maintenance of systems and equipment, including the gas system and boiler, the electrical system and electrical appliances. Water temperatures at outlets accessible to service users are regularly checked and recorded. The water system is tested each year for evidence of legionella. There is a Fire Risk Assessment in place and a senior member of staff carries out routine fire checks. Fire alarms tests, emergency lighting tests and fire drills are carried out at the required intervals. All fire fighting equipment is regularly checked. The home is currently updating its key areas of risk assessment on the buildings and all activities which effect service users, staff and visitors to the home. Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 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 Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13(4) Requirement Timescale for action 31/01/07 4. YA39 24 Risk assessments must be regularly reviewed and updated to reflect any changing situations. 31/03/07 The quality assurance system must be formalised and based on a systematic cycle of planning, action and review covering all aspects of Standard 39 of the National Minimum Standards. (Although not yet met, progress is being made towards meeting this Standard). (Previous timescale of 01/11/05 not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lonsdale House DS0000020830.V324324.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lonsdale House DS0000020830.V324324.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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