Inspection on 13/02/07 for Stewart Lodge

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stewart Lodge 09/09/08

Stewart Lodge 24/09/07

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Stewart Lodge 24 Rosecourt Road Croydon Surrey CR0 3BS Lead Inspector David Halliwell Key Unannounced Inspection 13th February 2007 09:30 Stewart Lodge DS0000068073.V329274.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 Stewart Lodge DS0000068073.V329274.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. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stewart Lodge Address 24 Rosecourt Road Croydon Surrey CR0 3BS 020 8684 7333 020 8684 7333 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) Harvey Stewart & Smith Ltd Angela Doreen Gordon Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Mental disorder, excluding LD or dementia (MD). Maximum no of 3 people. Date of last inspection This is the first inspection since the registration of the home in September 2006. Brief Description of the Service: Stewart Lodge is a residential care home for adults 18 – 65 years of age who have experienced long-term mental health problems. The home is a 3 bed roomed terraced house situated in a quiet residential road in Croydon. Local transport facilities are good which means this home is easily accessible. The Proprietor told the Inspector that the average price for a placement would be £990 per week. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this inspection no residents were living in the home and no residents have lived in this home since it was registered with the Commission for Social Care Inspection in September 2006. It is a 3-bedded unit for people with mental health problems excluding learning disability or dementia. The Proprietor Miss Sharon Smith and the Registered Manager Mrs Angela Gordon were present on the day of the inspection and are to be thanked for their support over the course of this inspection. As a result of the home not yet having any residents in placement some of the Key Standards could not be inspected or inspected fully and only limited evaluation was possible of the outcomes because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. What the service does well: What has improved since the last inspection? What they could do better: Some developments to the home’s policies and procedures are outlined in the body of this report as being necessary. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 6 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. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 4 & 5. Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Prospective service users should receive sufficient and appropriate information, which they need to make an informed choice about living at Stewart Lodge. The proposed assessment framework and process described by the Proprietor should ensure that prospective service users needs are assessed. The proposed process and documentation in place now should ensure that prospective service users get the opportunity to test drive the home. They will be provided with a contract for the services they are to receive. EVIDENCE: Standard 1 – The process of marketing and recruitment is underway and the Proprietor and the Manager are working towards filling the vacancies. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 9 The need to ensure that prospective service users have the information they need to make an informed choice about living at Stewart Lodge is therefore very relevant now to these processes. The Inspector asked to see the Statement of Purpose and was provided with a copy that the Proprietor is using as a part of the marketing process. The Statement of Purpose includes all the information required under this Standard. It includes the relevant details about the qualifications and experience of the Manager and the Proprietor; it also contains details of the range of needs the home is intending to meet; the arrangements for meeting social care needs and needs to do with cultural and religious needs; it also includes details of the complaints process. The Inspector believes that together with other elements of the service such as the proposed familiarisation visits and trial periods of stay it should provide prospective service users and their referring professionals with sufficient information from which they can decide if Stewart Lodge may meet their needs. Standard 2 – This Standard refers to the assessment of service users needs. Since there are no service users living at Stewart Lodge the usual inspection of residents files was not possible. However the Manager was able to show the Inspector a blank assessment form that the staff at Stewart Lodge intends to use to assess their prospective service users needs. The format proposed covers the range of needs likely to be relevant to a prospective service user and from that point of view is “fit for purpose”. In addition to this the Proprietor said that staff would ensure that they get the referring professionals assessment of the individuals needs, which will be used as a part of the assessment process. A familiarisation visit will be offered prospective residents that should inform staff as well as the individual about their needs, what they are and whether they may be met. The Proprietor informed the Inspector that the prospective service user would be asked what their needs are and what their views, wishes and preferences are. Standard 4 – As indicated above the Proprietor informed the Inspector that any prospective service user will be offered an opportunity to visit and to “test drive” the home. The Proprietor said that this may be done over a day or a day and a night and that this is aimed at informing the prospective resident about the home, a chance to meet other residents, to see their room, the food and what it would be like to live in the home. It also provides the staff with another opportunity to ensure that the prospective resident’s needs may be met. The Manager informed the Inspector that the home would not admit any emergency admissions and this was supported in the Statement of Purpose. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 10 Standard 5 – The Proprietor showed the Inspector a “licence agreement” which she said will be given to each resident and which they will need to sign in agreement to the terms and conditions set out in the agreement. The Inspector reviewed the agreement and all the elements that need to be specified under this Standard have been included. The only additional detail that is needed is for the licence agreement to identify for each resident which room they will be living in, in the house. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 11 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): Standard 9. Only limited evaluation was possible of the outcomes for the standard outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Quality in this outcome area has not been rated as there was only evidence available relating to how the system could be used, no actual examples of risk assessments have yet been undertaken. Outcomes for the key standards 6 & 7 were not assessed on this occasion. EVIDENCE: Standard 9 – Given that there are no residents in place at the home it is not possible to fully inspect the home’s provision in meeting the requirements of this Standard. However the Proprietor showed the Inspector the proposed risk assessment framework which they said will be used for each resident where there is a need to do so. The proposed document should be useful and should Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 12 assist residents to be supported to take appropriate risks as a part of developing a more independent lifestyle. The Inspector advised the Proprietor and the Manager that risk assessments should be included in the admission procedure and should be reviewed together with the service user’s care plan every 6 months or sooner if circumstances dictate. Stewart Lodge DS0000068073.V329274.R01.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): Standard 12 & 17. Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. From the evidence seen by the Inspector at this inspection prospective service users should be enabled to take part in appropriate activities. Proposed plans for menus and diet also indicate that prospective service users should enjoy a healthy, varied and well balanced diet. EVIDENCE: Standard 12 - Given that there are no residents in place at the home it is not possible to fully inspect the home’s provision in meeting the requirements of this Standard. However the Inspector did ask both the Proprietor and the Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 14 Manager how they planned to ensure that prospective residents would be able to take part in age, peer and culturally appropriate activities. The Inspector was informed that the unit’s needs assessment of the individual would include looking at that person’s dietary and cultural needs as well as their social care needs and the activities which they had been engaged in prior to coming to live in the home. Any cultural and specific needs for instance with regards to diet or religion would then be able to be planned for. The Proprietor said that this should help residents to get involved with culturally appropriate activities. The Manager said that she is planning to make available information about local activities available for the residents when they are in place. The Proprietor explained that residents will be encouraged to take an active part in the local community and that an active lifestyle is recognised to be important in promoting good mental health. To this end the garage has been converted into a fully equipped gymnasium that will assist future residents to keep healthy if they wish. Standard 17 – This Standard relates to the provision of a healthy diet and whether residents enjoy their meals. The Manager showed the Inspector the planned menu that works over a rolling programme. The menu plan seen by the Inspector would provide a varied, healthy and well balanced diet for residents. The Manager explained that there will be menu planning meetings which will involve the residents and enable them to state their preferences. A choice will always be offered to residents which includes a vegetarian option and the Proprietor said that as a part of the needs assessment process any cultural dietary needs will be provided for in the menu planning. The Proprietor told the Inspector that there will always be a bowl of fresh fruit available and where necessary a dietician’s advice will be sought if any resident requires it. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 20. Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. From the evidence seen by the Inspector at this inspection prospective service users physical and healthcare needs should be able to be met by the home and that they should be protected by the home’s policies and procedures with regards to medication. EVIDENCE: Standard 19 – The Proprietor told the Inspector that residents healthcare needs will be a part of the needs assessment and care planning process. She said that she recognised how important healthcare is and that all residents will be supported and enabled to have access to a dentist, optician, chiropodist and community nurse and any other healthcare professional as and when they Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 16 need it. The Proprietor told the Inspector that annual health checks for residents would be arranged with their GPs. Standard 20 – The Proprietor showed the Inspector the home’s policy on medication. This policy covers all the main areas required and provides appropriate guidance for support staff to carry out their duties in this area of work to a satisfactory standard. The Proprietor showed the Inspector medication records / files which have been set up for residents and they will include all the necessary details including photographs of each individual resident so that there is no confusion when administering medication. The policy and procedures states that the home will ensure that they obtain information and clear written guidelines from GPs for “as required” medications, this is seen as good practice. The Inspector was impressed by the preparations both the Proprietor and the Manager have made to do with medication and it seems as if service users will be encouraged to retain control of their medications where appropriate with satisfactory storage facilities being available and that they should be protected by the home’s policies and procedures that have already been put into place. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. Quality in this outcome area is poor. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. From the evidence seen by the Inspector at this inspection prospective service users should be able to feel that their views are being listened to. However policies and procedures for the protection of vulnerable adults need some development work in order to ensure that all residents will be protected from abuse appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 22 – The Proprietor showed the Inspector the home’s complaints procedure. It contains the appropriate stages of the complaint process and the associated timescales. It also says who will deal with the complaint and has the appropriate contact details for contacting the CSCI if this becomes necessary. Details of the complaint process have been included in the service users guide that the Proprietor told the Inspector that all residents would receive a copy of. The complaints process is also included in the statement of purpose that all referring agencies will receive a copy of. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 18 No complaints have been made as there have been no residents yet in placement at this home however the Inspector recommended to the Proprietor and to the Manager that a record or log book should be kept in order to track and record any and every complaint made about the home’s services in the future. Standard 23 – The Proprietor showed the Inspector the homes adult protection policy. On inspection of these documents together with the Proprietor the Inspector found there was a lack of sufficient detail and therefore requires that for ease of use and clarity, the practical steps anyone would have to take in order to make an allegation of abuse be described in the documentation. It is also required that a copy of the local authorities protection of vulnerable adults policy is made available for staff within the home and that it is made clear in the homes policy that the local authorities protection of vulnerable adults policy and procedures are those that will be followed at all times by staff. LA training for all the homes staff will also become necessary when staff have been recruited and residents are in place. With regards to the Whistle blowing Policy shown to the Inspector by the Proprietor the Inspector found there was a lack of sufficient detail and therefore requires that for ease of use and clarity, the practical steps anyone would have to take in order to “blow the whistle” be described in the documentation. With regards to the handling of resident’s money the Proprietor informed the Inspector that this would depend on the ability of the resident to do this for themselves. Where ever possible service users will be encouraged and supported to be independent with this. However the Proprietor told the Inspector that there is not in place at present a policy or procedure for the safe handling by staff of residents monies and this will be required to be put into place. It is also required that the Proprietor ensures an inventory of residents valuable belongings is made at the point of a resident’s admission to the home that this is signed by the resident or their representative and dated. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30. Quality in this outcome area is adequate. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Prospective service users at Stewart Lodge should feel that they are able to live in a homely, comfortable and safe environment. The home was seen to be clean and hygienic and well looked after by staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 24 – A tour of the home together with the Proprietor and the Manager was undertaken as a part of the inspection and the home was seen to Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 20 be clean and tidy in all areas. Not all areas of the home however are accessible to wheelchair users. The general condition of the home and the facilities available for prospective service users is good; communal areas and bedrooms are furnished to a high standard and were seen to be clean and odour-free. There is a ‘homely’ feel to the home with supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. The Proprietor showed the Inspector the fire records for the home. The LFEPA last visited Stewart Lodge in August 2006. 3 requirements were made which the LFEPA subsequently confirmed by letter that the required works had been completed home and the requirements met in October 2006. The Inspector viewed each requirement and can also report that they have been met. Records were also shown to the Inspector by the Proprietor for other safety checks that have been carried out over the last year and that are part of a regular process of checks carried out to help ensure the safety of the residents. Environmental Health have not made a visit yet to the home’s kitchen and it is recommended that the Manager request L.B.Croydon’s environmental health officer to do so once some residents have been admitted. This will ensure that the relevant standards are being met within this home, however no problems are anticipated due to the high standards being maintained. Standard 30 – The Proprietor showed the Inspector the home’s infection control procedure, which seems comprehensive and should be effective when in practice. At the time of this inspection the home was clean and hygienic. The laundry facilities in the home are appropriate for the 3 residents who may live within the home. The Inspector was informed that laundry would not be taken through any areas where food is being prepared. 2 requirements were made: 1. The floor in the laundry room needs to be sealed in order to ensure it is impervious to possible leaks and to water penetration that might lead to infection and poor hygiene control if not prevented now. 2. The open window space between the kitchen and the laundry room also needs to be filled with a window frame in order to prevent contamination of laundry with food and food preparation. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 34, 35 & 36. Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Service users should benefit from the clarity of staffing roles and responsibilities given the proposed recruitment processes. They may also be assured that Stewart Lodge’s recruitment policy and procedures will help protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 31 – The Proprietor told the Inspector that there are job descriptions (JDs) for all posts in the files in the main office. These JDs were inspected and are clear and cover the full range of duties that are expected of the staff they apply to. Copies of the JDs should also be attached in the staff handbook to ensure that all staff has copies of their JDs. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 22 The Inspector asked the Proprietor about Stewart Lodge’s policies and procedures and what the opportunities staff will have to discuss them and sign to say they have read and understood them. The Proprietor said that this will form a part of the staff induction process and that staff will receive copies of the home’s key policies and procedures and that they will be asked to sign to say that they have read them. The acting Manager told the Inspector that each member of staff will be provided with a copy of the General Social Care Council’s standards Code of Conduct. This should assist staff to recognise the standards of care that they are working within. Stewart Lodge will not have volunteers working in the home. Standard 34 - The Proprietor told the Inspector that the home does have a recruitment policy and procedure and that all staffing posts will be filled by application and interview. Evidence of these processes will need to be seen at the next inspection visit when staff have been recruited. The Proprietor said that herself and the Manager will constitute the interview panel. The Proprietor acknowledged the need for staffing files to evidence that suitable application forms have been completed, that 2 references are obtained including one from the last employer. All staff files will need to be reviewed by the Inspector and evidence seen that proper CRB checks have been carried out for staff employed within Stewart Lodge. Equally that all other documentary evidence required (under Standard 34) to be gathered for staff will need to be seen to be held on the staff files. Staff will be interviewed to confirm 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. Standard 35 – The Proprietor said that there is an overall training and development plan and budget for the home of approximately £5000 per annum. She informed the Inspector that a structured induction programme will be offered to new staff and documentary evidence of this will need to be seen (at the next inspection when staff have been recruited) by the Inspector and supported in interview with staff. It should include: • Safe working practices • The workers role • Meeting the needs of service users • The home’s policies and procedures. Standard 36 – The Proprietor told the Inspector that there is a properly structured staff supervision policy and procedure and that staff will receive supervision at least once every 4 – 6 weeks. Records were inspected and both Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 23 the policy and the supervision tools comprehensively cover the areas that are required in order to implement an effective supervision process. When fully implemented this will ensure that residents do benefit from well-supported and supervised staff. The Proprietor also informed the Inspector that annual appraisals will be implemented when staff have been in place for a year. The processes used for both supervision and appraisals should be closely linked as together as they form a useful tool in the effective management of staff and in the proper delivery of care for residents. Stewart Lodge DS0000068073.V329274.R01.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): Standards 39 & 42. Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Prospective service users may be confident that they will benefit from a well run home. The quality assurance system will help ensure that their views underpin monitoring and review of the homes developments. Service users may also be confident that their rights and best interests are safeguarded by the home’s record keeping policies and procedures. This judgement has been made using available evidence including a visit to this service. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 25 EVIDENCE: Standard 39 – The Proprietor informed the Inspector that Stewart Lodge will have a quality assurance procedure in place once there are residents living in the home. She went on to describe the planned process that will include feedback questionnaires for residents covering all aspects of care being provided. It will include issues raised at the monthly residents meetings, a review of actual performance against the home’s performance indicators and a review of how well the care service has met each residents care plan objectives. The Inspector advised the Proprietor and the Manager that this quality assurance process should also include feedback via a questionnaire from referring and visiting professionals to the home. Standard 42 – The Inspector was shown information to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, moving and handling and fire. A risk assessment policy is currently being developed to ensure that the health and safety of the residents and staff will be promoted and protected. The Proprietor showed the Inspector risk assessments that have been completed for areas of the building including: • Kitchen area • Office • Lounge and communal areas • Bedrooms and bathrooms • Medication • COSSH materials. Clear thought has obviously therefore been given to potential hazards by the Proprietor and the Manager and actions as to how they may be avoided or minimised. The Proprietor informed the Inspector that all staff will receive training in moving and handling, fire safety, first aid, food hygiene, and infection control. Up to date certificates were seen by the Inspector for: Boiler – February 2007 Gas – February 2007 Fire alarms – August 2006 Fire extinguishers – August 2006 The Manager explained how food will be stored and that it will be properly labelled with dates of opening and expiry. An accident record book is to be used at the home to record any incidents or accidents. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 26 Records were seen by the Inspector that confirmed regular tests had been carried out for the: Fire alarm Fire extinguishers Emergency lighting Fridge and freezer temperatures all within the acceptable ranges Hot water temperatures all within the acceptable range. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. Cleaning materials and other hazardous substances are being stored securely and clearly signed. Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X X X 3 X X 3 X Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 28 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 AP23 Regulation 13 Requirement That the practical steps in order to make an allegation of abuse be described in the documentation. That a copy of the local authorities protection of vulnerable adults policy is made available for staff within the home and that it is made clear in the homes policy that the local authorities protection of vulnerable adults policy and procedures are those that will be followed at all times by staff. That the practical steps anyone would have to take in order to “blow the whistle” be described in the procedure. That a policy or procedure for the safe handling by staff of residents monies be implemented. The floor in the laundry room needs to be sealed in order to ensure it is impervious to possible leaks and to water penetration that might lead to infection and poor hygiene control if not prevented now. DS0000068073.V329274.R01.S.doc Timescale for action 01/03/07 2. AP23 13 01/03/07 3. AP23 13 01/03/07 4. AP23 13 01/03/07 5. AP30 13 01/03/07 Stewart Lodge Version 5.2 Page 29 6. AP30 13 The open window space between 01/03/07 the kitchen and the laundry room also needs to be filled with a window frame in order to prevent contamination of laundry with food and food preparation. 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 AP22 Good Practice Recommendations That a record or log book should be kept in order to track and record any and every complaint made about the home’s services in the future. That the Manager request L.B.Croydon’s environmental health officer to visit the home’s kitchen for an inspection after residents have been admitted to the home. 2. AP24 Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Stewart Lodge DS0000068073.V329274.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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