Inspection on 18/04/06 for Russell Hill Lodge

This inspection was carried out on 18th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell Hill Lodge 15/04/08

Russell Hill Lodge 20/09/07

Russell Hill Lodge 23/12/05

Russell Hill Lodge 15/08/05

Russell Hill Lodge 13/01/05

Russell Hill Lodge 12/08/04

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

CARE HOME ADULTS 18-65 Russell Hill Lodge 39 Russell Hill Road Purley Surrey CR8 2LD Lead Inspector David Halliwell Key Unannounced Inspection 18th April 2006 9:30 Russell Hill Lodge DS0000025833.V288109.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 Russell Hill Lodge DS0000025833.V288109.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. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Russell Hill Lodge Address 39 Russell Hill Road Purley Surrey CR8 2LD 020 8668 3212 020 8668 3212 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) Laurel Residential Homes Limited Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd December 2005 Brief Description of the Service: Russell Hill Lodge is registered to provide care to up to 18 adults who have past or present mental health problems. The home is situated close to Purley town centre and therefore well placed for access to the towns amenities and transport. The house is a large detached traditional brick built building. It has 18 single rooms, a lounge, dining area and conservatory. The latter area is the designated smoking room. One of the single bedrooms has en - suite facilities, including bathing and catering facilities. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection to Russell Hill. A new Registered Manager has been appointed to the unit and has been working there for several months. Progress is being made and 4 of the 6 previous requirements from the last inspection visit have now been met. As a result of this most recent Inspection there are 3 new requirements and 5 recommendations. The Inspector was impressed by the commitment and enthusiasm of the new Manager and of the staff group. What the service does well: What has improved since the last inspection? Work on developing the Unit’s policy and practice to do with the administration of medication for residents has been successful and the previous requirement has now been met. Similar improvements have been made on the recruitment and induction process that now reflects a comprehensive approach and contributes to the overall safety and well being of the residents. It is a positive improvement that the monthly reports of the Proprietors required under Section 26 of the Regulations are now underway. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 6 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. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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 Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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): 2 Russell Hill staff assess prospective service users needs and their wishes are taken account of in the process. However service users needs would be understood at an earlier stage with more consistent provision of comprehensive information by referring agencies EVIDENCE: The Inspector reviewed 7 of the 17 residents files and found that assessments of needs had been undertaken by the staff at Russell Hill for each person admitted. The review of files included the last service users to have been admitted to the home. Assessment and care planning information supplied by the referring agencies was not always as comprehensive as would have been expected and the Inspector has recommended that the Manager should always request full documentation from referring agencies at the time of their requesting a new placement. This would ensure that staff at Russell Hill have all the available information about a prospective resident at an early stage of the process and would enable a fully informed decision to be made about whether and how best a service users needs could be met. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Service users are not able at present to be fully assured that all their assessed and changing needs are reflected in their individual care plans. However they are able to make decisions about their lives with appropriate levels of assistance. Service users are also supported to take risks as a part of developing an independent life style. EVIDENCE: As indicated above the Inspector reviewed 7 residents files and found evidence of individual plans having been drawn up and reviewed for each of these residents. The plans were however not as comprehensive in their detail to do with social care as would be expected. Whilst key areas of need are being addressed in the plans other areas of need, which would assist in attaining the unit’s objective of rehabilitation wherever possible for the resident are not evidenced in the care plans. The development of care planning was discussed in full with the registered Manager and one of the Proprietors who have agreed to develop this detail in the care plans for each of the residents. All of the information required in schedule 3 of the Regulations was seen by the Inspector to be documented on the files and of the 5 residents interviewed Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 10 by the Inspector all said that they had been involved in the drawing up of their individual care plans. All residents interviewed felt that they had been properly consulted as to their own views and wishes and that what they had said had been properly considered in their care plans. Individual care plans are regularly reviewed both within the home by the key workers and the co-workers with the residents and every 6 months with the referring agencies and other key people involved with the service users plan. Regular residents meetings are held within the home and there is an opportunity for residents to make their views known about relevant topical issues. Service users are enabled to make decisions about their lives with assistance as needed. Risk assessments were seen on each of the files reviewed as a part of the initial assessment and care planning undertaken by Russell Hill. This helps in making the appropriate decision about a suitable placement and then in taking risks as a part of developing an independent lifestyle. However the Inspector felt that this area could be further developed to better assist residents in achieving independent living wherever possible. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Opportunities for the personal development of service users could be expanded if care plans included more detailed programmes for developing independent living skills, for instance shopping, budgeting, cooking, dealing with stress and conflict and social skills for improving communication and social interaction. Service users are able to take part in appropriate leisure and other external activities this enables them to feel part of the local community. Service users are also encouraged to maintain appropriate relationships. There is strong emphasis in the home on respecting resident’s rights in all aspects of daily living. The menu is varied, offers choice and provides a healthy enjoyable diet which contributes to the well being of the residents. EVIDENCE: The Inspector did not find any evidence that indicated whether or not residents were involved in activities which they did before they entered the home. However significant relationship links were recorded in those care plans seen Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 12 by the Inspector and there was evidence that Russell Hill staff appropriately encourage the maintenance of these relationships if residents also wish to do so. Visitors to the home are encouraged and use the visitor’s book to sign in. Interviews with residents and staff identified that some residents are involved in local activities such as swimming, going to the cinema, local car boot fairs and in using the local gym, all of which assists service users in developing their social skills and their integration with the community. The Manager informed the Inspector that all residents are registered to vote in elections and are supported by staff to do so if they wish. However staff interviewed by the Inspector also reflected the difficulty in encouraging and motivating some residents to take an active part in this and other activities. The Inspector saw information made available within the home about local activities for residents to take up if they wish. Service users can and often do make full use of local public transport facilities in order to get out and about and to see friends and family. Residents interviewed felt that transport facilities were good. Opportunities for the personal development of service users could be expanded and it is a requirement that care plans include more detailed objectives for developing independent living skills, for instance shopping, budgeting, cooking, dealing with stress and conflict and social skills for improving communication and social interaction. Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to the front door and to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. Interviews both with staff and residents confirmed that residents participate in household chores as a part of the rehabilitative process and this participation was seen to be supported in residents care plans. There is a specific area for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they thoroughly enjoyed. The Inspector saw suitably planned menus for 3 weeks ahead. Specific needs are catered for and alternative choices are provided. However it was reported that not enough fresh fruit is available for residents and the Inspector found this was supported Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 13 by a lack of a fruit bowl or fruit available during the day. It is recommended that a selection of seasonally fresh fruit is made available for residents during the day. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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 Service users do retain responsibility for their own medication where appropriate and are protected by the unit’s policies and procedures for medication. The physical, health and emotional needs of residents are being met but there would be improvements in this area with the further development of care planning. EVIDENCE: As a part of the Inspector’s review of residents case files, those care plans that were seen did not seem as comprehensive and holistic in their detail of social care. Further development in this area would be helpful in achieving the rehabilitation objective. The care plans seen on file do not always reflect the actual support that staff do offer residents on a daily basis. While residents interviewed confirmed to the Inspector that they felt supported by staff in a way they prefer and require, the further development of care planning would also provide an appropriate expansion of their support. Residents confirmed that they have a choice when they are allocated their key worker. The Manager informed the Inspector that the healthcare needs of residents are assessed and reviewed regularly as a part of the care planning process. This Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 15 was supported by evidence on resident’s files. All service users do have access to the full range of healthcare professionals thereby ensuring that their needs are being met. Resident’s health checks are usually undertaken by the GP at their surgeries. Previous requirements to do with the recording of medication have now been met and when the Inspector reviewed the medication records no errors were evidenced. Appropriate medication records were seen and reviewed by the Inspector. The Manager has drawn up a new system which identifies staffs daily responsibility for supervising medication for those residents who are unable to self administer their own medication. The Manager informed the Inspector that staff have all been involved in discussions about the importance of following the policy on the administration of medication within the home and that this has resulted in an improved situation. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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 Service users views are both listened to and acted upon at Russell Hill. Service users are protected from abuse, neglect and self harm by the policies and procedures of the home. Staff however should receive regular training in the protection of adults from abuse. EVIDENCE: All those service users interviewed by the Inspector confirmed that they feel their views are listened to and acted upon. They also all said that if they had a complaint they know the procedure to be followed and would do so if they needed to. Staff interviewed confirmed to the Inspector that the residents were all aware of the complaints process and that the whole staff group took any issues raised by residents seriously. The complaints record was reviewed by the Inspector, 1 complaint had been made since the last inspection visit and this was satisfactorily resolved within the timescale and guidelines, to the satisfaction of the resident. The home has an adult protection policy and the Manager informed the Inspector after consultation with the training manager that the whole staff group had received training last year in 2005. Unfortunately there was no evidence of the fact that this training had taken place and it is therefore a requirement that the staff group receive VAP training this year 2006 from an acknowledged specialist trainer. Certificates of staff attendance will be required. The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The Manager confirmed this to the Inspector. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 17 The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process and staff are asked to sign to say that they have read and understood the policies and procedures. A review of staffing records held on staff files by the Inspector confirmed that all staff had signed such an agreement. The Manager informed the Inspector that training in this area is offered to staff. The home does look after resident’s money and the Inspector reviewed the financial records for these transactions that were in order. All transactions are dated and signed for by both staff and residents to confirm satisfaction by all parties. The Inspector found no anomalies. An inventory is maintained and kept up to date by key workers for all residents’ belongings that kept in their bedrooms. The Inspector checked these records. One resident was evidenced as not having an inventory of their belongings and it is recommended that this is carried out as soon as possible. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Service users do live in a clean, hygienic, homely and comfortable environment at Russell Hill. When the new flooring on the first floor has been completed the trip hazards that are there now will ensure it also a safe environment. A programme of redecoration and refurbishment for the communal areas is required. EVIDENCE: The Inspector reviewed all areas of the home to assess the quality of the environment and décor. The home was found to be generally clean and hygienic however some areas are rather tired from considerable use and it is recommended that the annual development plan for Russell Hill include refurbishment of the kitchen, shared bathrooms and toilets which should all be made a priority. A new floor has been laid upstairs which remains to be completed; this is a requirement as there are trip hazards in the doorways. Resident’s bedrooms were inspected with the permission of the residents. They told the Inspector that they are happy with their rooms. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 19 The fire safety officer from the LFEPA visited last September 2005 and a requirement was made by the previous Inspector that appropriate action is taken to meet all of the requirements of the LFEPA. During the course of this inspection the Manager was unable to locate the LFEPA letter and so it was impossible to assess whether the LFEPA requirements have all been met or not. It is therefore still a requirement that appropriate action is taken to meet all of the requirements of the LFEPA. The last environmental health officers’ report was completed in May 2005 and any action points identified have been met. The Manager informed the Inspector that the next environmental health officers visit is due in October 2006. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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): 31, 32, 34 & 35 Service users do benefit from clarity of staff roles and responsibilities and service users are supported by a competent and qualified staff team. An appropriate recruitment policy and induction process helps protects residents and ensure that they are supported appropriately. EVIDENCE: The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. Evidence of this was seen by the Inspector on staff files and from discussions with staff interviewed. Staff have copies of the General Social Care Standards / Code of Conduct. Volunteers are not used within the home. The Manager told the Inspector that there is a training programme underway to ensure that all staff are NVQ qualified by the required date. 6 staff are just completing their NVQ level 2 training and 6 staff are identified for the next training course. Staff interviewed confirmed with the Inspector that they were just completing their NVQ training. There is in place a recruitment policy and at the time of this unannounced inspection interviews were underway for the deputy managers post. Staff files evidenced that suitable application forms are completed, that 2 references are Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 21 obtained including one from the last employer. All staff files reviewed by the Inspector evidenced that proper CRB checks have been carried out for staff employed within this unit. Equally that all other documentary evidence required to be gathered for staff was seen to be held on the staff files reviewed. Staff interviewed confirmed that all have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home. The Manager informed the Inspector that residents do play a part in the recruitment of new staff. A part of the recruitment process for new candidates is to meet residents and there is a chance for residents to provide feedback to the recruitment panel. The Manager informed the Inspector that there is an overall training and development plan and budget for the 3 units that make up the Laurel Group of Homes. Disaggregating the information specifically for Russell Hill was not possible. There is a person responsible for the training and development of staff. It would be beneficial for Russell Hill if there was identified a specific training and development plan and budget for the unit as a part of the overall plan and it recommended that this be drawn up. This would enable the Manager some flexibility to meet identified training needs of his staff group and to arrange timely and appropriate training for example adult protection training and training on rehabilitation care planning. The Manager informed the Inspector that a structured induction programme is offered to new staff and documentary evidence of this was seen by the Inspector and supported in interview of new staff. The previous requirement on this item was reviewed at this Inspection and the Inspector can confirm that this requirement is now met. At present staff receive ongoing support in the work they undertake but they do not receive 1:1 supervision which includes the: • Translation of the homes philosophy and aims into working with individuals, • Structured monitoring of work with individual service users and the analysis of care plan outcomes, • Support and professional guidance, and the • Identification of training and development needs, • Annual appraisals. The Manager has informed the Inspector that this form of supervision is being planned now for implementation in the near future. This is welcomed as this structured supervision will greatly assist the unit in meeting some of the needs identified in this inspection report. The Inspector is advised that all staff will receive supervision at least once every 2 months. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 22 Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Service developments currently underway at Russell Hill will maximise the potential for Service users to benefit from a well run home. Their views are taken into account as a part of the Quality Assurance process. The Inspector felt assured that the health, safety and welfare of Service Users are promoted and protected. EVIDENCE: The Registered Manager was appointed at Russell Hill in December 2005. He has had 2 years or more experience in a senior management capacity and is currently just completing his NVQ level 4 training. During the course of this inspection the registered manager’s competence, enthusiasm and commitment to improve the services provided for residents at Russell Hill impressed the Inspector. A number of the previous requirements set out in the last inspection report have now been met and if current initiatives deliver the expected and hoped for results, then it seems likely that other required improvements will be met over the course of the coming year. The development of an annual development plan is recommended and was discussed and it’s usefulness Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 24 in carrying forward many of the issues discussed in this report was agreed with both the Manager and Proprietor. The Inspector spoke to the Manager and Proprietor about the development of the quality assurance system referred to in the last inspection report. The current QA system gathers information from residents about different aspects of the unit for instance with regards to food, the environment, and to do with staff. Whilst this information is useful and is being used by the unit to develop its services now, it requires further expansion to seek feedback from the families and carers of residents, from referring professionals and other key stakeholders who all have a valuable contribution to make to this process and whose views will assist in the further development of effective service provision at Russell Hill. Survey questions need to be developed in order to provide feedback, which covers aspects of the service such as key working, care, plans, rehabilitation programmes and activities. This remains a requirement. Both the Manager and the Proprietor gave assurances that the QA system is currently being developed to cover these areas within the next 3 months. A requirement at the previous inspection was that proprietors must ensure that they visit the home on a monthly basis and write a report of that visit. A copy of which must be sent to the CSCI local office. The Inspector had a full discussion about this requirement with one of the Proprietors who agreed that they will now undertake this action as required. The Inspector was shown a report template which when completed would meet the needs of the Regulations. It was also agreed with the Inspector that these monthly reports would be sent to the local CSCI office regularly with the first report being submitted within the next 2 weeks. The Inspector upon receipt of this will be satisfied that this requirement has now been met. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 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 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 3 X Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 26 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 YA39 Regulation 24 Requirement An appropriate quality assurance system must be implemented in the home, which seeks service users views and measures the success of the home in meeting the aims and objectives laid out in the Statement of Purpose. The previously set timescale has not been fully met. Completion of the new flooring to remove trip hazards. The development of care planning to ensure all residents needs are planned for, monitored and reviewed including social care and rehabilitative needs All staff in the unit should receive adult protection training from a specialist trainer and certificates of attendance provided The registered person must ensure that action is taken to meet all of the requirements of the LFEPA. The previous timescale has not been met as of the date of this inspection. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 27 Timescale for action 28/07/06 2. 3. YA24 YA6 23 14 03/05/06 03/10/06 4. YA23 14 31/03/07 5. YA42 23 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA2 YA17 YA23 YA27 YA32 Good Practice Recommendations The Manager should always request full assessment documentation from referring agencies at the time of their requesting a new placement. A selection of seasonally fresh fruit is made available for residents during the day. One resident’s inventory of their belongings should be carried out as soon as possible. The annual development plan for Russell Hill includes refurbishment of the kitchen, shared bathrooms and toilets which should all be made a priority. A specific training budget and training plan identified for the unit as a part of an overall annual development plan. Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Russell Hill Lodge DS0000025833.V288109.R01.S.doc Version 5.1 Page 29 - 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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