Inspection on 04/12/06 for Lynton Terrace, 1-3

This inspection was carried out on 4th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lynton Terrace, 1-3 09/05/07

Lynton Terrace, 1-3 23/05/06

Lynton Terrace, 1-3 13/10/05

Lynton Terrace, 1-3 29/04/05

Lynton Terrace, 1-3 20/09/04

Lynton Terrace, 1-3 01/06/04

Lynton Terrace, 1-3 23/06/03

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

CARE HOME ADULTS 18-65 Lynton Terrace, 1-3 Lynton Road Acton London W3 9DU Lead Inspector Ms Jane Collisson Key Unannounced Inspection 4th December 2006 11:20a Lynton Terrace, 1-3 DS0000027756.V313869.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 Lynton Terrace, 1-3 DS0000027756.V313869.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. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lynton Terrace, 1-3 Address Lynton Road Acton London W3 9DU 0208 992 3343 0208 992 3353 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) Hestia Housing & Support Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2006 Brief Description of the Service: 1/3 Lynton Terrace is a detached property, situated in a residential area of Acton and close to Acton Main Line Station and bus routes. Acton town centre is about a mile away and there are local shops nearby. The home is a mental health facility for ten service users, providing medium to long-term accommodation. Hestia Housing and Support manage the home. The communal areas on the ground floor comprise of two lounges, one of which can be used by service users who smoke, a dining room and kitchen, and a games room. A small kitchenette is located on the first floor. There are ten single bedrooms, four of which are on the ground floor. Three bathrooms, one with a separate shower, are available for the ten service users. All of the bathrooms have toilets and there is one separate toilet close to the communal facilities. The staff sleeping-in room, which has its own bathing facilities, is on the first floor. This is also used as the manager’s office. There is a small garden to the rear, with a separate building which houses the laundry room. There is off road and street parking. The staff team consists of a Project Manager, two Deputy Managers, and a team of five Project Workers. They support the service users with personal care, practical tasks and leisure activities. There are no waking night staff and one member of staff sleeps in at night. A new post of housekeeper has been introduced to oversee all of the domestic duties and support service users with practical tasks. The current charges are £742 a week. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 4th December 2006 from 11.20am. The Acting Manager was present, together with two project workers and the housekeeper. Two more project workers were met during the later shift. The inspection process took a total of seven hours. Since the last inspection, in May 2006, a new service user was admitted to fill the vacancy, but died in November 2006 following a hospital admission. At the time of this inspection, the vacancy remained. Two service users have had prolonged stays in local mental health units. One returned to the home recently but the other service user was still in hospital. Four of the service users were met during this inspection, although three others remained in their rooms. One service user was out of the home all day. One family member made a very short visit to the home but was not met. The Registered Manager had not been working in the home since November 2005 and ceased to be employed by Hestia in October 2006. The manager of another Hestia registered home has been the Acting Manager during this period. A new Manager Designate has now been appointed and was due to commence as soon as all of the necessary documentation had been obtained. The Acting Manager will be returning to his former post. One of the Deputy Managers had been seconded to another home, and the staff team consisted of the second Deputy Manager, and five project workers. There were no staff vacancies. Since the last inspection, a full-time housekeeper has been employed. The home has service users and staff from various ethnic backgrounds and the staff team reflects this diversity. There is also an appropriate gender mix of service users and staff. For a full assessment of all of the key standards, this report should be read in conjunction with the inspection report of the 23rd May 2006. At that inspection, twenty requirements were made of which sixteen have been met. Four have been repeated and a further four have been made at this inspection. Progress has been made with fulfilling the requirements although the disruptions to the service, caused by staff suspensions in the past year, has impacted on the development of the service and staff morale. The Registered Providers need to address this issue to ensure that the staff team can improve the resource for the benefit of the service users. What the service does well: The service provides a quiet environment with sufficient communal areas for the service users to enjoy their own pursuits. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lynton Terrace, 1-3 DS0000027756.V313869.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 Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information on the home’s facilities and services still requires updating. The aims and objectives of the home need to be clarified to ensure that they are clearly defined for new service users. The admission procedures were seen to be satisfactory for the last service user admitted. EVIDENCE: It was a requirement that the Statement of Purpose and Service Users Guide were reviewed, updated and made available to the service users and the Commission for Social Care Inspection. Because of the uncertainly about the management of the home, this work had not been carried out and the documentation was last reviewed in October 2004. A Service Users Guide has been available to the service users but will need to be updated, together with the Statement of Purpose, when the new Manager Designate is in post. The aims and objectives of the home were discussed with the Acting Manager, as the current service users have a variety of needs. These range from service users requiring support to move on to different, or less supported, housing to the provision of long-term accommodation for those who are less able. Because the home has limited staff on duty, and minimal staffing at night, the needs of the service users have to be accommodated within this level, unless staffing should be increased. If the home continues Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 9 to admit service users needing the variety of support currently offered, the Statement of Purpose must reflect how these diverse needs can met. It also needs to be clarified so that any new service users being referred to the home are fully aware of the home’s aims and objectives. This should be presented in a manner that would assist them, and their representatives, to make an informed judgement about moving into the home. Since the last inspection, a new service user had been admitted to the home. Following a hospital admission, the service user sadly died. There remains one vacancy and two prospective service users had been referred to the service. Their initial referrals were being considered at the time of the inspection. The file of the last service user admitted was examined and showed that the service user had been able to visit the home prior to admission. Information of the visits was recorded, including information on the service user’s preferences, and a Licence Agreement had been issued. The service has a written “induction” for new service users, to introduce them to the procedures of the home, and a copy of this was seen in the service user’s file. Lynton Terrace, 1-3 DS0000027756.V313869.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 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 adequate. This judgement has been made using available evidence including a visit to this service. While improvements, regarding individual needs and choices, have been noted for some of the service users, the progress with others has been very limited. This is for a variety of reasons, and more professional medical input may need to be sought where the efforts of the staff team are not effective. EVIDENCE: Finding ways of offering service users further opportunities to participate in the day-to-day running of the home, and to maintain and develop social and independent living skills, has been the subject of previous requirements. It has been recognised that not all of the service users are receptive to becoming involved although some progress has been made with a small number of the service users. For one service user, it has been recognised that a different environment, with younger service users, may provide an incentive to participate. For another service user, a less supported environment is being considered and a review was due to be held to discuss this possibility. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 11 The group of service users who are older are generally more settled in the home’s environment and the staff support they receive appears to be appropriate to meet their needs. There are some service users who have very little to do with daily life in the home and refuse staff support. In some cases, this has been a long term issue and needs to be discussed with the relevant professionals to see if further support can be accessed. There has been an improvement in the recording of the service users’ involvement in domestic chores to help them to work on improving their skills. A small financial reward is provided where service users undertake these tasks. Not all of the service users wish to participate in the service users’ meetings, for instance, but it was noted that around half of the service users attend them regularly. Progress has been made in involving one service user, who previously declined to participate at all. It was noted, in the three service users’ files that were examined, risk management strategies had been put in place, and reviewed recently. Lynton Terrace, 1-3 DS0000027756.V313869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is evidence that the staff team have made efforts to involve the service users in both individual and group activities and there has been some success. However, there are a number of service users who have no little or no involvement with the staff team and ways need to be found of engaging with them to enhance their wellbeing. EVIDENCE: None of the current service users have taken advantage of attending any additional leisure or educational opportunities which could be made available. Only one attends any services on a regular basis. The staff were seen to be working on promoting individual activities, including outings, and are recording and evaluating them. An outing was arranged for three service users to go on a day trip to the coast earlier in the summer and other individual outings were seen to have been arranged. Efforts are made to advertise any events to encourage service users to attend including, currently, the Christmas party. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 13 Staff have found that some of the service users have responded to a more spontaneous approach to activities and have made a number of barbecue meals in the garden which have been popular. The last had been held during a spell of good weather in October and five of the service users attended. A small number of the service users maintain contact with their families. One relative visits the home on a regular basis, while a small number of other service users visit their families and share occasional holidays. There are local shops nearby which most service users access. Within a short walking distance, there are buses and trains available. With the new housekeeper in post there has been a more orderly approach to shopping. She is also involved in helping service users with any household purchases, such as bed linen. Staff said that new ideas for menus were being tried and, although service users were not always receptive to new dishes, they would be trying to encourage new choices. To reflect the diverse backgrounds of the service users, occasional cultural days, including a Jamaican Day, have been held. A weekly takeaway meal is popular. As a way of trying to improve the take up of food at lunchtime, sandwiches and fruit are now being prepared and left in the dining room, so that service users can choose when to eat them. The Acting Manager said that this had worked well. A professional nutritional plan had been provided for a service user to assist with health needs. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While there has been a response from the medical professionals when service users’ mental health needs are acute, the service users with longer term problems do not appear to have made much progress. Efforts need to be made to engage the service users with the relevant professionals to try and improve the quality of their lives. EVIDENCE: Staff support the service users where personal care is required, but sometimes this is refused. Staff have tried to find strategies to deal with these situations but this has still proved to be difficult. It was noted that this has been discussed at reviews. Service users are often able to make their own arrangements for meeting medical appointments, but staff support is available. There has been a history of non-compliance of medication with some service users. At the time of the inspection, the general practitioner and other mental health professionals had been alerted to the non-cooperation of one service user. Others may have to be reminded, on several occasions during the day, to visit the office to take medication. A blister packed 28-day medication system is used and Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 15 medication stock is checked regularly. However, the medication checked on this inspection identified an error made that day, when a medication has been signed for but had not been given. This was reported to a senior staff member who confirmed that this was an error. This may have been as a result of the irregularity of administration and staff need to be extra vigilant where service users do not have their medication at the prescribed time. There is a Home Treatment Team based within the mental health services who are able to intervene and visit the home twice daily to try and prevent hospital admissions. However, two service users had recently been admitted for long stays where it had not been possible to continue treatment within the home. Where service users have had acute episodes, appropriate action has been taken to arrange medical services. However, there seems to be less involvement with the service users who have longer term problems, particularly those who prefer to say in their rooms and take no part in any activities or have little interest in what the home offers. Some service users refuse to work with staff, even at the monthly key working sessions. This has been an ongoing problem and it needs to be shown that every effort has been made to try and engage mental health and medical professionals to improve the service users’ situation. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although only one complaint was seen to have been recorded in the last six months, the procedures are in place for the service users to be able raise their concerns and they have, in the past, done so. EVIDENCE: The service users have the opportunity, through attendance at service users’ meetings and key working sessions, to express any concerns and complaints that they may have. Some of the service users who choose not to attend meetings have families who could advocate on their behalf, should this be necessary. Service users have shown in the past that they are confident about making complaints. However, there has been only one made since the last inspection in May regarding an incident between two service users. The action taken was detailed in the record. Hestia also has a Tenants’ and Residents’ Forum, in which the service users can participate if they wish to do so. A small number of the service users who have been in the home for some years have, on occasions, chosen to attend the meetings and social events run by Hestia. Since the last inspection, two separate issues, which involved possible financial abuse, have been resolved. These were dealt with under the London Borough of Ealing Safeguard Adults procedures and involved the mental health team and the Commission for Social Care Inspection. The police were involved initially but did not proceed with the investigations. The procedure took almost a year to complete and resulted in the dismissal of one staff Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 17 member and reinstatement of two others. The time taken for the process has had a detrimental effect on the staff team and the procedures for dealing with any financial irregularities, or other adult protection matters, need to be concluded within the earliest possible timescale. Since the problems with the financial irregularities, the policies and procedures of the organisation have been changed. The money held for service users must not exceed the set limit. Where it has not been possible for one of the service users to visit the bank regularly, a relative is involved in holding the excess money on the service user’s behalf. A valuables book is in place with items such as passports and cheque books being recorded as held. The staff confirmed that no PIN information is held. There is now a separate book for each service user whose money is held to maintain confidentiality. The majority of service users manage their own financial affairs. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the communal accommodation and the cleanliness of the home has been improved. The long outstanding work on the ground floor bathroom was being carried out. Work still needs to be undertaken to ensure that service users’ bedrooms have sufficient storage and other items they may require to suit their individual needs. EVIDENCE: Some improvements have been made to the environment since the last inspection and there was a better standard of cleanliness. Work has been carried out on the garden, some planting and tidying had taken place and more is planned. The lounge has been a more pleasant area since the laminate flooring replaced the damaged carpets. It is planned that the next budget will include provision for new lounge furniture. None of the service users were seen to be using the communal areas during the visit. The damaged worktops in the kitchen have been replaced by new ones. Refurbishment on the ground bathroom was finally underway at this inspection. This has been a long outstanding requirement as the bathroom was Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 19 in poor condition. The games room was not in use as this inspection as it was being used for storage while the work on the bathroom was being undertaken. It has been a requirement at the previous inspection that adequate furniture, particularly for storage, was provided for the service users’ bedrooms to support them to keep their rooms in better order. The Acting Manager said that some had been provided but that an audit was being carried out, for next year’s budget, to see what was required. He was in the process of completing this. Changes have been made since the last inspection to accommodate the needs of two service users who have a close relationship. There has been a beneficial arrangement to make better use of the accommodation that they share. There have been plans to have the windows replaced, throughout the home, for some time. Quotes have now been obtained and the work will be funded by the Primary Care Trust. The frames and sills are in poor condition in some areas of the home and this work is needed to be carried out before they deteriorate further. An Action Plan is required to show when the work is planned to commence. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The training for National Vocational Qualifications and basic training courses is satisfactory. Two staff have undertaken some mental health training with an external body. However, not all of the team have received the advanced mental health training which might support them to better understand and motivate the service users and this should be provided. EVIDENCE: The current staffing levels, of two Project Workers on each of the early and late shifts, and one member of staff sleeping in at night, continues. There were no vacancies in the staff team, at the time of this inspection, as a new manager had been recruited. However, only one of the Deputy Managers was working in the home as the other had been seconded to another home temporarily. With the recruitment of the new manager, the Acting Manager will return to his previous post and the new manager will need to apply for registration with the Commission for Social Care Inspection in due course. Most of the staff team have been in post for some time, which has provided some continuity for the service users during the difficult period of the last year. Only one staff member, the full-time housekeeper, has commenced work in the past twelve months. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 21 Two of the senior staff team have National Vocational Qualification Level 4 and one staff member has Level 3. The remaining staff team are registered, or have completed their induction, to undertake the qualification. Having 50 of the staff team qualified to National Vocational Qualifications Level 2 or above, to meet the National Minimum Standards, should be reached within a reasonable timeframe. There has been little additional training in mental health issues, other than that provided for two staff by an external organisation. The Registered Providers should consider a regular programme of advanced mental health training to ensure that staff knowledge is developed and updated. Suitable courses, particularly to assist and motivate the service users who do not respond the support offered at present, need to be available regularly. This has been a previous requirement for the organisation. The provision of a training matrix, or spreadsheet, to demonstrate the training that the staff have undertaken would be useful for planning training and for evidencing that it is all up-to-date. This is recommended. Regular one-to-one supervision of the staff was seen to have been carried out and regular staff meetings, which are fully documented, take place. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While efforts have been made to improve team work, the difficulties of the past year, particularly with regard to staff morale, needs to be addressed further by the Registered Providers. A more speedy investigation of the allegations may have alleviated some of the anxieties within the team and lessons need to be learned from this experience. EVIDENCE: There have been difficulties for the staff team in the past year which has impacted on the running of the home. Staff were positive about the way in which the Acting Manager has been able to manage the home and provided support for the team and the service users during a difficult period. The suspension of four of the staff throughout the year has impacted on the staff team and an “away day” was held to try and improve the relationships between the staff team. While this was deemed to be helpful, it has not solved all of the concerns and there will need to be an emphasis on team building Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 23 when the new manager is in post. The Registered Providers must provide the support to ensure that the relationships between the team members are satisfactory. No review of the quality of care has been carried out. This is an outstanding requirement and needs to be completed. A new fire alarm board was installed in October 2006. The records showed that weekly fire tests have been carried out, with the exception of two weeks. A fire risk assessment, dated 23rd October, had been prepared. Five fire drills have been held since July in which all of the staff team have been involved. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 2 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X X 2 2 X X 3 X Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA1 Regulation 6 (a)(b) Requirement The Statement of Purpose and Service Users Guide must be reviewed, updated and made available to the service users and the Commission for Social Care Inspection. (Previous timescale of 31/08/06 not met) The service users must continue to be offered opportunities to participate in the day-to-day running of the home and to maintain and to develop social and independent living skills. It must be ensured that all of the service users have their health needs fully assessed and that professional support is sought to improve their quality of life. An Action Plan is required to be provided to show when the window replacement programme will commence. Adequate and suitable furniture and fittings must be provided in bedrooms to meet the needs of the service users. (Previous timescale 31/08/06 not fully met) It must be demonstrated that staff have training appropriate to the duties they perform, DS0000027756.V313869.R01.S.doc Timescale for action 31/03/07 2 YA7 12(1) b 16(2) m, n 30/04/07 3 YA19 12 (1)(a) 30/04/07 4 YA24 23 (2)(b) 28/02/07 5 YA25 16 (2)(c) 31/03/07 6 YA32 18 (1) c (i) 31/03/07 Lynton Terrace, 1-3 Version 5.2 Page 26 7 YA38 12 (5)(a) 8 YA39 24 (1)(2) (3) including advanced mental health training, to support their staff development. (Previous timescale of 31/08/06 not fully met) The Registered Providers must 28/02/07 work to improve the relationships within the staff team to ensure that they are working together to support the service users, and to develop and improve the home. A review of the quality of care 30/04/07 must be carried out at regular intervals and the report provided to service users and the Commission for Social Care Inspection. (Previous timescale of 31/08/06 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. 1 Refer to Standard YA35 Good Practice Recommendations That the provision of a training matrix, or spreadsheet, to demonstrate the training that the staff have undertaken would be useful for planning training and for evidencing that it is all up-to-date. Lynton Terrace, 1-3 DS0000027756.V313869.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Lynton Terrace, 1-3 DS0000027756.V313869.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. 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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