Inspection on 09/02/07 for Sherringham Lodge

This inspection was carried out on 9th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sherringham Lodge 14/02/06

Sherringham Lodge 21/07/05

Sherringham Lodge 14/09/04

Sherringham Lodge 27/04/04

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 Sherringham Lodge 70 Sherringham Avenue London N17 9RP Lead Inspector Susan Shamash Key Unannounced Inspection 9th – 15th February 2007 3:00pm Sherringham Lodge DS0000010809.V323242.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 Sherringham Lodge DS0000010809.V323242.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. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherringham Lodge Address 70 Sherringham Avenue London N17 9RP 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) 020 8376 0860 Mrs Seela Khadun Mrs Seela Khadun Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Sherringham Lodge is registered as a care home providing care and accommodation for up to 4 people with a learning disability. It is a single private home with the registered provider also registered as the homes manager. The home is located in a quiet residential road and is close to a range of amenities including local and High Street shops as well as an effective public transport network. The home was opened in 1998 and is a converted domestic property that comprises two storeys. Two resident bedrooms and staff facilities are on the first floor with two further resident bedrooms, one with en-suite, and communal facilities are situated on the ground floor. The home has a well-kept accessible garden at the rear. The aim of the home is to provide a homely, domestic environment for residents with learning disabilities and to encourage them to live as independently as possible. Weekly fees for the home range between £750-£1000 depending on need, correct as of February 2007. The most recent CSCI inspection report can be obtained from the home’s office or the CSCI website at www.csci.org.uk Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis and lasted approximately five and a half hours over two days. On the first day of the inspection, the inspector was assisted by a staff member on duty at the home and had the opportunity to meet and speak to all four residents including a resident staying at the home on a prolonged respite basis. The registered provider who is also the registered manager was unavailable on the first day of the inspection, and therefore the inspector fixed a second day to meet the manager at the home and complete the inspection of care plans, staff files and health and safety certificates. Feedback forms were received from one health and social care professional, three care managers and four residents (although the latter were completed with assistance from staff at the home). All provided positive feedback about the support provided within the home. The inspector was shown around the building, records were examined and practice issues discussed with the staff member and the registered manager. What the service does well: The registered provider and her staff continue to provide a homely environment for residents which values and supports independence and choice. Detailed care plans are in place for all residents and appropriate support is provided to meet their physical and emotional needs. A range of appropriate educational, vocational and leisure activities are available to residents, and they are supported to go on holidays of their choice. A varied and nutritious diet is available to residents with special diets catered for appropriately. The home is furnished and decorated to a high standard and residents are encouraged to be involved in the home routines. Staff are supervised and supported appropriately and the home places a strong emphasis on training, supporting staff to take appropriate qualifications. Staff act upon the advice of external health and social care professionals to provide appropriate support to residents. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 6 Rigorous health and safety procedures are in place at the home to ensure the safety of residents. Feedback from the families of residents who stay at the home on a respite basis is very positive. One noted that it is ‘like a home from home. I don’t have to worry.’ What has improved since the last inspection? What they could do better: Residents’ contracts with the home should be improved to include the room in which the resident lives. It is recommended that staff sign and date care plans and risk assessments at least six-monthly to show that they have been reviewed. The use of Person Centred Planning is also recommended. Confidentiality procedures within the home must be reviewed. It is recommended that more trips out of the home be provided for residents at weekends and in the evenings. It is recommended that residents’ GPs be asked to agree a list of homely remedies that they may be given. Any medicines stored in the home’s refrigerator must be kept secure. It is recommended that records be maintained of concerns raised by residents and how these are addressed in each instance, rather than only recording formal complaints raised. More training in fire safety and manual handling should be provided for staff members. Arrangements should be made for staff to access care plans when the manager is away. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 7 Staff meetings and residents’ meetings must be held regularly and a more formal quality assurance audit system should be put in place. Records of fire drills should specify the residents and staff involved and there must be a drill in the evening at least once a year. 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. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that their individual aspirations and needs will be properly assessed. They benefit from opportunities to visit the home and stay overnight so that they have the information they need to decide if they wish to live in the home. Residents are protected by a statement of terms and conditions with the home, although they would benefit from it being further updated. EVIDENCE: The inspector looked at all four residents’ files, and these contained assessments of needs undertaken by the local authority funding the placements in addition to the registered manager’s own assessments, which she undertakes personally. The inspector had the opportunity to speak to the resident most recently admitted to the home and they confirmed that they had had the opportunity to visit the home, prior to admission, so as to be able to make an informed decision as to whether they wish to live in the home. These visits were recorded in this resident’s file as appropriate. Each resident had a contract with the local authority and a statement of terms and conditions with the home as appropriate. However these must be updated to specify the room to be occupied in each case, to further protect residents. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from individual care plans that reflect their needs and goals. They are supported to make decisions about their lives and to take appropriate risks in developing independence skills. However their confidentiality could be further protected within the home. EVIDENCE: The residents’ files seen during this inspection contained a care plan, which included all the matters as set out in national minimum standard 2.3. There was evidence on file that care plans had been reviewed recently in addition to monthly summaries regarding residents’ progress on goals identified in their care plans. Residents told the inspector that they are consulted about the care and support provided to them as appropriate. One service user told the inspector that they continue to receive support from staff to go out on shopping trips and social activities in the local community. The inspector observed a staff member assisting a resident to learn the values of different coins so that they had a better understanding of money. Another Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 11 resident told the inspector that staff assisted them to keep their room clean and tidy. Risk assessments were in place for all residents including guidelines for a resident who uses a computer on a regular basis, to avoid eye strain and repetitive strain injury. As required at the previous inspection, a risk assessment was undertaken for the resident who had the water to the sink in their room cut off, for safety reasons, and an agreement form signed by all relevant parties, was completed as appropriate. It is recommended that staff should sign and date care plans and risk assessments (making any necessary amendments) at least six-monthly to evidence that they have been reviewed, in addition to the current system of producing monthly progress reports. It is also recommended that the use of Person Centred Planning methodology be considered for residents at the home, so that they can be further involved in the formulation of their care plans. In the absence of the manager, it was not possible to see residents’ care plans as these are kept locked in the staff office. It is recommended (under Standard 37) that this system be reviewed, so that staff can access important resident information in the event of an emergency and consult and update care plans at any time. Whilst storage of confidential documents within the home was generally satisfactory, the inspector was concerned to see a notice posted within the residents’ lounge detailing some residents’ individual care needs. Use of the home’s telephone by staff or residents in the lounge (where it is connected) may also have implications in terms of privacy. It is therefore required that these issues be addressed as part of a review of confidentiality procedures within the home. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to develop and maintain relationships, and to enjoy appropriate activities of their choosing both within the home and in the community. They are treated respectfully and encouraged to make their own lifestyle choices and take appropriate responsibilities. The food served in the home provides residents with individual choices, and supports them to enjoy a healthy diet. EVIDENCE: One resident attends a local day centres and one attends various courses at a local college. They have structured programmes including visits to a farm project and cinema trips. Two residents are not currently undertaking structured activities away from the home, one because they are remaining at the home on a respite basis and the other from their own personal choice. Staff advised that they support these residents to undertake some activities within the home and local area, and this was confirmed by residents spoken to. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 13 Records seen in the home show that residents have the opportunity to enjoy a number of activities inside and outside the home. The inspector was impressed to note that the three permanently placed residents had been on holidays within the last year, each to different destinations, with support from staff. Two of the residents do not have regular contact with their relatives. The registered manager advised that the home continues to place great importance on encouraging them to develop and maintain friendships that they make. The other residents are supported to maintain contacts with their family members on a regular basis. One resident told the inspector that they were due to go out with a relative that evening, and spoke to them on the phone during the inspection. Within the home, residents are supported with numeracy sessions, cooking and developing their daily living skills, in addition to dancing, reading magazines, listening to the radio and watching television. Residents are encouraged to make use of facilities in the local area including a disco club attended once weekly, visits to local shops, the library and walks in the park. However discussion with residents indicated that there are few opportunities to go out at weekends and on evenings (other than the disco club night). It is recommended that more trips out of the home be offered to residents at weekends and in the evenings. Care plans evidenced that staff support residents to undertake individual activities of their choice, for example one resident subscribes to the ‘New Scientist’ magazine, another was supported to have music therapy, although they chose not to take this up. All residents told the inspector that they enjoyed the choice of meals served within the home. One resident told the inspector that the home provides them with a vegetarian diet. There was evidence in residents’ care plans that healthy eating is encouraged, and that the advice of specialists such as dieticians has been sought where appropriate. The home was well stocked with fresh fruit and vegetables alongside a range of meat, fish, poultry and vegetarian foods. Sherringham Lodge DS0000010809.V323242.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported appropriately with their physical and emotional health needs taking account of their preferences. They have access to appropriate medical professionals to meet their health needs, and are protected by systems in place, which govern the administration and handling of medication. Further precautions needed in the storage of medication had been addressed by the last day of the inspection thus ensuring that residents are fully protected. EVIDENCE: Residents spoken to indicated that they received the appropriate emotional and physical support from staff. Observation of the relationships between staff and residents during the inspection confirmed supportive interactions. All residents are registered with a local GP and evidence of appointments were seen in the home’s diary and within each resident’s case file evidencing that they had regular dental and optician appointments as appropriate. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 15 Where residents had hospital appointments to follow up health concerns, these were clearly recorded indicating action needing to be taken following each visit. Medication was appropriately stored in a lockable wall cabinet located in the staff sleeping-in room. Records demonstrated that the staff team have received training in the safe handling and administration of medication. The records of receipt, administration and disposal of medication were completed appropriately and the medication administration policy and procedure for the home had been updated. As recommended, the administration of homely remedies and dietary supplements such as cod liver oil, were being recorded on the medication administration records for clarity. It is recommended that residents’ general practitioners be asked to agree a list of homely remedies that may be given at the home. A district nurse visits one resident twice daily to administer insulin injections and this was recorded appropriately. However the inspector was concerned to note that the insulin device (which included a needle) was being stored in the refrigerator in the residents’ kitchen. A requirement was made accordingly that the insulin must be stored securely. By the second visit to the home (to see staff files) this requirement had been met, with a locked safety deposit box being used to store the insulin in the refrigerator. The inspector’s recommendation that a thermometer be placed in the medication cabinet and the temperature noted daily to ensure that it does not exceed 25°C, was also met by the time of the second visit to the home. Sherringham Lodge DS0000010809.V323242.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to complain and are protected by the homes adult protection policies. EVIDENCE: The home has a complaints procedure that meets the requirements of this Standard. There have been no complaints made to the home, or to the CSCI in respect of this home since the last inspection. Three compliments had been recorded by a district nurse and two relatives visiting the home. It is however recommended that records be maintained of concerns raised by residents indicating how these are addressed in each instance, rather than only recording formal complaints raised, in order to evidence that the home is receptive to residents’ concerns. The registered provider has undertaken a one-day “training the trainer” course run by the London Borough of Barnet, which focussed on adult protection procedures. All members of staff have been trained in this area of practice. In the last year, there was one issue regarding the protection of a resident, unconnected to the home, and evidence was available that this had been addressed appropriately by all concerned within the home. Residents spoken to during the inspection indicated that they felt able to speak to staff or the manager if they were unhappy about anything in the home, and that they felt safe living in the home. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, homely and comfortable environment in which their safety is promoted. EVIDENCE: The home is a converted domestic property that blends in well with the immediate neighbourhood, and is conveniently located for shops and public transport. A tour of the building showed that the home was, comfortable, well decorated and maintained, and cleaned to a high standard. Appropriate laundry facilities are available and there is a shower accessible to people with restricted mobility on the ground floor. Residents spoken to indicated that they were satisfied with their private rooms and the communal areas within the home. The inspector visited all rooms and noted that each had been personalised and was furnished appropriately. Residents told the inspector that they kept their rooms clean and tidy with support and assistance from staff when needed. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 18 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, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Safe recruitment procedures are in place to protect residents in the home. The commitment shown by the home and individual staff to training and professional development ensures that residents are supported by appropriately trained and experienced staff. However further training is needed in some areas to ensure that residents are protected as far as possible within the home. Staff are supervised appropriately to ensure that they support residents as effectively as possible. EVIDENCE: The home has a small staff team, which has remained consistent over the last few years. Inspection of three staff files indicated that appropriate Criminal Records Bureau (CRB) disclosures, two references, application forms and identity documents had been obtained for each staff member. There were also records of each staff member’s induction programmed, regular supervision sessions and training and development certificates, indicating that safe recruitment practices are in place at the home. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 19 Two staff have completed the NVQ level 2 in Care, and one of these staff had recently completed her level 3 award. The registered manager is a qualified NVQ assessor, and also holds the registered manager’s award at NVQ level 4. Training courses undertaken by staff include Communication Skills for Working with People who have Learning Disabilities and Challenging Behaviour, Basic First Aid, Principles of Fire Safety, Safe Handling of Medication, Infection Control, Care Planning, Adult Protection, Manual Handling and Empowering Personal Care. Discussion with the staff member working in the home indicated that she was appropriately experienced and knowledgeable about the needs of residents within the home. However although all staff had covered basic training in fire safety and manual handling as part of a one day health and safety course, it is required that the staff members identified should undertake further training in these areas. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 20 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, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, but whilst there is evidence that residents’ individual views are taken into account, there is room for improvement in demonstrating consultation with residents as a group. Residents are assisted to manage their monies safely with appropriate support from staff at the home, and records maintained up to date. Rigorous health and safety systems are in place to ensure the promotion of residents welfare. EVIDENCE: The home’s manager has owned and managed the home since it opened in 1998. She is appropriately qualified and knowledgeable about the needs of the residents at the home. She continues to undertake relevant training for her Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 21 role and advised that she is working towards becoming a ‘communication champion’ sharing ideas with others about how best to run such a service. Observation of the running of the home and inspection of records indicated that the home is well run and that the residents’ wellbeing is central to all policies at the home. It is recommended that arrangements for staff to access care plans in the absence of the manager should be reviewed, as these may be needed in an emergency or simply to allow staff to consult with and work on care plans at any time of the day. The inspector saw a number of completed resident satisfaction questionnaires within their files, indicating that they are consulted regularly. Records indicated that staff meetings are held approximately annually, although the manager advised that more frequent meetings are held but these are not necessarily minuted. The manager advised that resident meetings are not currently being held. It is required that staff and resident meetings should be held on a regular basis and that residents’ views be recorded. A more formal quality assurance system should be put in place, with the results of each audit sent to the local CSCI area office at least annually. Resident monies looked after by the home were inspected, and these corresponded with the records of transactions maintained for each resident and their bank account records as appropriate. Residents confirmed that they were able to access their monies whenever needed, and that they signed for monies taken out on each occasion. There had been no accidents recorded since the previous inspection, and staff and residents confirmed that this was the case. Safe practices are in place within the home including a range of current health and safety certificates and appropriate safety measures in place. Systems are also in place to ensure that fire equipment is regularly tested and serviced, and fire drills are undertaken. To ensure that all staff and residents are involved on a regular basis, the names of all staff and residents involved in each fire drill should be recorded. An evening fire drill should also be conducted at least annually although this may be silent if this is felt necessary to avoid distress to residents. Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 22 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 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 3 2 X Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 YA5 Regulation 5(1c) Requirement The registered person must ensure that service users’ statements of terms and conditions with the home are amended to specify the room to be occupied in each case. The registered person must ensure that confidentiality procedures within the home are reviewed with reference to recording of service users’ individual care needs and use of the home’s telephone in the lounge. The registered person must ensure that any medicines stored in the home’s refrigerator are kept in a secure locked container and the storage temperature of the home’s medicines is monitored on a daily basis. This requirement was met by the last day of the inspection. The registered person must ensure that more detailed training in fire safety and manual handling is provided for the identified staff members. The registered person must ensure that staff meetings and DS0000010809.V323242.R01.S.doc Timescale for action 04/05/07 2. YA10 12(4a) 16/03/07 3. YA20 13(2) 09/03/07 4. YA35 13(5) 18(1ci) 23(4d) 24 01/06/07 5. YA39 04/05/07 Sherringham Lodge Version 5.2 Page 24 6. YA42 23(4e) service user meetings are held on a regular basis and that service users’ views are recorded. A more formal quality assurance audit system should be put in place with results sent to the local CSCI area office at least annually. The registered person must ensure that records of fire drills specify the residents and staff involved and that a drill is undertaken in the evening at least annually (this may be silent if necessary). 30/03/07 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 YA6 Good Practice Recommendations It is recommended that staff sign and date care plans and risk assessments (making any necessary amendments) at least six-monthly to evidence that they have been reviewed, in addition to the current system of producing monthly progress reports. The use of Person Centred Planning methodology is also recommended. It is recommended that more trips out of the home be provided for service users at weekends and evenings. It is recommended that service users’ general practitioners be asked to agree a list of homely remedies that may be given at the home. It is recommended that records be maintained of concerns raised by service users and how these are addressed in each instance, rather than only recording formal complaints raised. It is recommended that arrangements for staff to access care plans in the absence of the manager should be reviewed. 2. 3. 4. YA12 YA20 YA22 5. YA37 Sherringham Lodge DS0000010809.V323242.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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