Inspection on 30/11/06 for Russell Lodge

This inspection was carried out on 30th November 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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell Lodge 24/10/07

Russell Lodge 12/10/05

Russell Lodge 21/07/05

Russell Lodge 16/12/04

Russell Lodge 06/05/04

Russell Lodge 30/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Russell Lodge 18 Russell Gardens, Ley Street Ilford Essex IG2 7BY Lead Inspector Diane Roberts Unannounced Inspection 30th November 2006 09:30 Russell Lodge DS0000025924.V321571.R02.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 Russell Lodge DS0000025924.V321571.R02.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. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell Lodge Address 18 Russell Gardens, Ley Street Ilford Essex IG2 7BY 020 8554 4858 020 8518 4545 ragini@careone.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) Care One Ltd Mrs Ragini Sivakumar Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1) of places Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. People with mild to moderate learning disabilities and associated mild to moderate physical disabilities. One named person beyond the age of 65 to be accommodated. Date of last inspection 12th October 2005 Brief Description of the Service: Russell Lodge is a care home providing accommodation and support for residents with a moderate learning disability. The home is registered to accommodate up to five residents. The home is a semi-detached property situated in the Ilford area of the London Borough of Redbridge. The area is well served by public transport and there are many easily accessible facilities within the local area. There are three single rooms on the first floor and two on the ground floor, one with en-suite facility. The home aims to support residents in order for them to access and participate in mainstream as well as specialist resources in the community in which they live, within their individual capabilities. A Service User Guide is available at the time of assessment. The current fees are £800.00 to £950.00 per week, depending on service users needs. Additional charges are made for personal items such as hairdressing and toiletries and service user also pay for all outside leisure activities such as bowling, cinema etc. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours and was carried out as part of the annual inspection programme for this home. The registered manager was available throughout the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. One resident and two staff were spoken to during the inspection and two relatives completed feedback sheets. All residents were helped by staff to also complete feedback sheets. All these comments were taken into account when writing the report. The Community Learning Disability Team were contacted but felt unable to comment at the current time, as they had limited contact with home over the past year. What the service does well: What has improved since the last inspection? What they could do better: The team at the home need to review and update a lot of their recording systems in order to evidence their assessments, planning and services provided to residents. This includes the provision of some key policies and procedures and training records. The care provision to service users could be better thought out, through an up to date care planning system. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 6 Use of a more appropriate assessment and care planning system may help them to identify resident’s individual needs and preferences more and care plan objectively, with future goals in mind. Access to social activities in the community needs to improve for individuals. The handling of residents’ personal monies must improve and records be more accountable. Systems for fire safety in the home need to improve. 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. Russell Lodge DS0000025924.V321571.R02.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 Russell Lodge DS0000025924.V321571.R02.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents are assessed prior to admission, to ensure that their needs will be met. EVIDENCE: There have been no admissions to the home since the last inspection. The last admission to the home was in May 2005. The home currently has one vacancy. At the previous inspection the pre-admission assessment of the last admission was inspected and found to be in good order and the standard was met. The home completed a full assessment and also obtained care plans /information from other appropriate agencies. Since that time, the home’s admission policy has not changed and the same assessment documentation is in place. The manager and the proprietor, who is a nurse, would go out and complete the pre-admission assessments. As appropriate, residents would be able to Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 9 visit the home and have short stays to ensure the placement was appropriate. Russell Lodge DS0000025924.V321571.R02.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): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a care planning system in place, which needs to be brought up to date to ensure that all residents’ needs are met. Residents could be assisted more to make decisions about their lives, as they are able. Evidence of this needs to improve. Staff understanding of a residents right to take risks is limited and needs to be addressed so they can be managed appropriately. EVIDENCE: The home has a care planning system in place. These were seen to be reviewed every two months or more if required. It was noted that the Community Learning Disability Team had been to the home to visit residents and undertake reviews. The system was seen to be basic overall and not Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 11 person centred. The home needs to work on bringing the system up to date. No life histories, future objectives/personal goals or identification of strengths for development were noted. Whilst it is accepted that some of the residents in the home are over 65, person centred care planning can still apply and may concentrate on sustaining current abilities. Person centred care planning was discussed with the manager. It is clear from observation and other records that residents are getting involved in various skill developing activities. However, the care plans do not reflect this at all or show a thought out and constructive approach. Care at the home tends to be reactive/intuitive rather than proactive or knowledge based and the care records reflect this. Care plans were seen to be in place for personal care, behaviour management, weight control and social life etc. On the whole these did not reflect residents personal preferences and likes and dislikes. Other care records evidenced a poor approach to the management of resident’s behaviour, which was not age appropriate. There was not evidence of a full up to date assessment of the resident on file, other than specific items noted in care plans. Daily notes are maintained and they generally reflected how the resident had spent their day, but did not reflect the care plan as a whole. These could improve further to give a fuller picture of the resident and the services provided. Records, some time previously, showed that residents had signed documents in relation to care management. No up to date input was evident from either residents or their relatives. Residents seen and spoken to were relaxed and interacted well with the staff. More information on personal preferences and future goals in the care plans etc. would help the home to evidence that they are helping residents make all the decisions they can about their lives as they are able. At the current time there is no advocacy input into the home. The team have completed risk assessments as part of the care planning process. These were seen to cover a wide range of subjects but did not include a community risk assessment, for when residents leave the home. This should be considered. It was noted that home needs to deal with residents taking risks in a more age appropriate way. They need to acknowledge that residents will take risks and that they need to do all they can to reduce this without adversely affecting the resident’s rights. This was discussed at length with the manager. It is felt, from discussion, that the team feel that they are acting in the residents best interests but do have a limited knowledge base on how to manage these basic risks. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 12 Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in age, peer and culturally appropriate activities, but individual preferences are limited at times. Residents do take part in the local community but this can be limited at times. Residents have appropriate personal relationships. Residents are respected by staff. Residents receive a varied diet and mealtimes. EVIDENCE: Records show that residents spend time during the week at local day centres or clubs where a wide range of activities are provided. At the current time none of the residents are attending any adult education classes or work Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 14 experience. Staff at the home take the residents out into the community to go shopping, occasionally bowling or out for a meals and walking etc. Minutes of residents meetings show that residents do express what they want to do. Records show that these choices can be limited as activities tend to be provided in a group way and linked to what all the residents would like to do. Choice can be affected by the staffing levels, in this small home. In house the residents watch television, play music, do exercises and help with household tasks. The staff team need to work more on trying to fulfil resident’s individual preferences and needs, especially in relation to outside activities. Person centred care planning may help to facilitate this. The activity records kept by the staff at the home do evidence some choice, as do the minutes of residents’ meetings, but both are limited by the style of recording. This was discussed with the manager in relation to providing better evidence. Family and friends are invited to attend functions at the home and comment positively about the home and the level of communication with the staff. A Christmas party was being planned at the time of the inspection. Some residents, where possible, do go and visit family members. Whilst family members do visit, evidence of their input was limited in the records provided. All of the residents went on holiday recently to Bognor Regis, with two members of staff. Residents spoken to commented positively on this. Residents paid for the holiday themselves. Residents meetings are held regularly and minutes were available for inspection. Residents discuss a range of subject including menu related preferences and that they would like to go out and eat more. The minutes were well balanced and reflected a range of views. Minutes recorded that residents are happy with the outings offered. Appropriately the recent passing of one resident was discussed in a supportive way as the residents missed him. Residents also talk about each other behaviours and what they find acceptable and not acceptable. Meals were seen to be prepared in line with the current menu. No specialist or cultural diets are currently required. From discussion and some records, the staff are very aware of residents preferences and residents are happy with the meal provided in the home. The manager does the food shopping and states that she often takes a resident with her, but records do not evidence this input. Records in the kitchen outline a rota for residents input into household activities. Whilst this is positive, it was not seen to be linked to a care plan objective. One care plan showed that residents’ weights are monitored where appropriate and that a referral to a dietician had been made in the past. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 15 Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 16 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): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal care and support in a respectful way but personal preferences could be better identified. Resident’ physical health needs are met but the assessment and management of emotional care needs required more work. The home has satisfactory systems in place for the safe handling of medicines. EVIDENCE: Care plans show the level of personal support required by residents from care staff in the home. Whilst interaction between staff and residents was seen to be respectful and staff know residents well, personal preferences were limited in the care plans. Records show that residents visit the GP surgery at the appropriate times. Staff accompany residents going to the surgery. Records also show that residents are seeing other healthcare professionals such as dentists, chiropodists and opticians as required. The residents attend appointments, in the past, with the local learning disability consultant and nurses as required. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 17 Evidence of emotional support is limited in individual care plans but the minutes of the residents meetings do show some level of emotional support in relation to bereavement. This area of care planning needs to be developed. The medication systems at the home were inspected. A blister pack system is used. The administration of residents’ medication was appropriate and records were kept in good order. A returns system was in place and records show that returns are minimal, although it was noted that old medication was still kept at the home, because of a recent change of pharmacist. This should be addressed. No controlled drugs are kept at the home. Records submitted show that staff have been trained in the safe administration of medication but no dates are given. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints system in place, which ensures that views are listened to and acted upon. The home needs to improve the arrangements for adult protection in order to ensure that residents are fully safeguarded from harm. EVIDENCE: The home has a complaints procedure in place, which is available in the main hallway. A basic logging system was in place although the home has not had any complaints since the last inspection. The manager reports that she has a good level of contact with residents’ relatives and deals with any queries straight away. Relatives who commented said that they knew how to raise any concerns. At the current time the home does not have any information on advocacy service in the local area. This was discussed with the manager. There was no evidence provided to the inspector on the home’s adult protection policy or local guidance. Adult protection policies were discussed with the manager. Training records submitted show that all staff have received training in the protection of vulnerable adults but dates were not given. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 19 At the time the draft report was submitted, the provider challenged the evidence regarding the existance of an adult protection policy. Although the inspector did not see the home’s adult protection policy and procedure on this visit, the report of the last inspection stated that the home did have a policy and procedure for dealing with allegations of abuse, and that the member of staff spoken to on that occasion did have an understanding of the procedure and knew what to do. Because of some ambiguity in this area, the subject of safeguarding procedures will be followed up in more detail at the next inspection of the home. A whistle blowing policy is in place. The home does not have procedures in place regarding the safe handling of residents’ monies. The manager is currently acting as appointee for two residents. Residents’ monies were checked at random. Records were in place but more effort should be made to obtain receipts for money spent in order to provide full records. It was a concern to note that the cash balances recorded were not available in the home on the day of the inspection. The systems maintained need to improve and the safe keeping of residents money be less haphazard and better organised. This was discussed with the manager. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment but the need to improve upon fire safety systems is a concern in relation to people safety. The home is clean. EVIDENCE: A partial tour of the home was undertaken. The home was seen to be well maintained and safe. Where residents were happy for the inspector to see, bedrooms had been personalised and were comfortable. At the time of the inspection, the hallways were being redecorated. The home was seen to be clean and no odours were noted. Access around the home for the current residents was good. The home has a good-sized hard standing to the rear of the property with two small flowerbeds. Garden furniture is available and the manager stated that in the summer beddings plants are used to brighten the area. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 21 At the time of the inspection the manager had not completed a fire safety risk assessment. Records showed that the fire alarms are checked but this is on an inconsistent basis. Evidence that a recognised engineer had maintained the fire alarm and emergency lighting system was not available. The above issues were discussed with the manager and the information was provided to the inspector on the day after the inspection. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are competent to meet the general needs of residents, although staff induction needs to improve and the skills attained via NVQ training and other training need to be utilised. Recruitment practices at the home are sound. Staff are appropriately supervised. EVIDENCE: The home has a small staff team who cover the rota, six in all including the registered manager. The registered manager takes an active part in cover shifts in this small home. Records submitted show that 2 of the care staff have NVQ level 2 and two further staff are qualified nurses although not acting in this role. The manager is currently undertaking her NVQ 4 and hopes to finish in spring 2007. Interaction between staff and residents was seen and heard to be caring and appropriate. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 23 Training records submitted to the CSCI as supporting information show that staff have completed both statutory and additional training. However, dates are not noted on the record so it is not possible to assess how up to date staff training is in the home. In the past staff have received training on infection control, adult protection, fore safety, administering medication, first aid, the principles of care, food hygiene and health and safety. Consideration should be given to providing staff with up to date training in person centred care planning. The staff team at the home is stable, with the newest member of staff commencing work at the home in February 2006. A basic home linked induction was provided although the manager has the information/documents on the Skills for Care Induction. Progression of this approach was discussed with the manager. It was later noted that the Skills for Care induction had been started but not completed. Staff files were checked and found to be in good order with the required documentation and checks in place. It is recommended that interview records should be maintain in order to evidence equal opportunities and that any gaps in employment have been explored with the applicant. Staff supervision at the home is on a day-to-day basis as the manager works closely with all of the staff. Records are not maintained for any formal supervision and consideration should be given to this. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is stable. The quality assurance systems in the home need to be developed further. Whilst the health and safety or residents and staff is promoted, shortfalls were noted which need addressing. EVIDENCE: The manager has worked at the home since 2000. The proprietor visits regularly and also covers shifts. Regulations 26 reports are regularly submitted to the CSCI. The manager has a background in care both in the NHS and the private sector. Records submitted show that the manager has been attending training, although dates of training were not available. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 25 The manager has a basic quality assurance programme in place. A quality monitoring form is used for obtaining feedback from relatives and visiting professionals. The manager was able to provide copies of three forms that had been returned in May 2006, which all had positive results. Residents meetings are held and this is used as a time to obtain residents views. Minutes evidence the subject areas covered and the individual residents input. The system could do with a more systematic approach a streamlining of the forms used as these differed. Relatives who commented were very positive regarding the standards of care and the staff at the home. The manager has a health and safety policy in place and staff have attended health and safety training in the past. Safety certification was checked at random and found to be in order apart from items mention under Standard 24. Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 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 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X X 3 Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12,14 and 15. Requirement The registered person must develop and update the assessment and care-planning system in the home to include residents, with a person centred approach. The registered person must, through good care planning, evidence that residents are assisted to make decisions about their lives, as they are able. The registered person must ensure that an up to date, person centred approach is used applied to residents individual risk assessments, including a community access risk assessment. The registered person must ensure that resident’s personal social preferences/choices are facilitated as far as possible, and the recording of such must improve. The registered person must develop further resident’s access to the local community as their preferences indicate. The registered person must ensure that residents’ personal DS0000025924.V321571.R02.S.doc Timescale for action 14/03/07 2. YA7 15 14/03/07 3. YA8 13 28/02/07 4. YA12 14 and 16 14/03/07 5. YA13 16 14/03/07 6. YA18 15 14/03/07 Russell Lodge Version 5.2 Page 28 7. YA19 12 8. YA23 13 9. YA23 13 10. YA24 23 11. YA32 18 12 YA39 24 preferences regarding the provision of personal care are recorded and taken into account. The registered person, through good care planning, must ensure that resident’s emotional needs are assessed and met. The registered person must ensure that residents are protected from abuse and provide a policy in the home for staff guidance. The registered person must ensure that residents’ monies are handled appropriately in the home and that full accountable records are maintained. The registered person must take adequate precautions against the risk of fire, including regular checks of systems, maintenance of systems and the completion of a fire safety risk assessment. The registered person must ensure that the staff have the competencies to fully care for residents, in relation to person centred assessment and care planning. The registered manager must develop the homes quality assurance programme further to include, for example, an internal audit. 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 14/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The registered person should ensure that information on local advocacy services is available in the home and positive links are made with those services. DS0000025924.V321571.R02.S.doc Version 5.2 Page 29 Russell Lodge 2. 3. 4. YA32 YA34 YA35 The registered person should records, including evidencing The registered person should The registered person should supervision. maintain full staff training dates of training undertaken. maintain interview records. maintain records of staff Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Russell Lodge DS0000025924.V321571.R02.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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