Inspection on 29/08/07 for Wellington Lodge

This inspection was carried out on 29th August 2007.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wellington Lodge 15/06/06

Wellington Lodge 24/01/06

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Wellington Lodge 47 Wellington Road Hatch End Middlesex HA5 4NF Lead Inspector Julie Schofield Key Unannounced Inspection 29th August 2007 9:00 Wellington Lodge DS0000065106.V347781.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 Wellington Lodge DS0000065106.V347781.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. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellington Lodge Address 47 Wellington Road Hatch End Middlesex HA5 4NF 020 8421 2266 F/P 020 8421 2266 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) Forini Limited Manager post vacant Care Home 15 Category(ies) of Past or present alcohol dependence (14), Past or registration, with number present alcohol dependence over 65 years of of places age (1), Past or present drug dependence (15) Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation to include one female service user over the age of 67 years for the duration of their stay. 19th January 2007 Date of last inspection Brief Description of the Service: Wellington Lodge is a registered care home that offers residential second-stage treatment to 15 adults aged 18 to 65 years who are recovering from drug/alcohol addiction. It can also offer a medicated withdrawal from alcohol service. Structured therapeutic programmes are offered to residents for between 6 and 24-week periods. The aim of these programmes is to assist residents in their recovery from drug/alcohol abuse, maintain their long term abstinence and reintegration back into the community. There was no Registered Manager at the time of the inspection. The Registered Provider is Forino Limited and the Responsible Individual is Mrs Ciara Aylett. The care home is located on a quiet road in Hatch End. It is close to community recreational, shopping, leisure and transport facilities. The care home is a large detached property that offers 11 single and 2 double bedrooms to residents. Bedrooms, lounges, bathing and toilet facilities are situated on both floors of the house. There are patio doors leading from the lounge on the ground floor to the garden area. On the day of the inspection 7 residents were accommodated in the home. Information about the fees charged may be obtained from the home, on request. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Wednesday in August. The visit started at 9.00 am and finished at 7.15 pm. During the inspection discussions took place with the responsible individual, Ms Ciara Aylett, members of the staff team and with each of the residents. A site visit was carried out. Records and policies and procedures were examined. Case files and staff files were checked and case tracking took place. The Inspector would like to thank everyone that took part in the inspection for their comments. What the service does well: What has improved since the last inspection? During the random inspection in January 2007 three statutory requirements were identified. When staff files were examined it was noted that each file now contained proof of ID e.g. the person’s passport details, with a photograph. The staff files that did not contain an enhanced CRB disclosure at the time of the random inspection in January 2007 now have evidence of this document being obtained. The requirement that was made in respect of the manager that was in post at the time of the random inspection in January 2007 has been withdrawn, as this person is no longer applying for registration with the Commission for Social Care Inspection. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wellington Lodge DS0000065106.V347781.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 Wellington Lodge DS0000065106.V347781.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): 2, 4 People who use this service experience good outcomes in this area. A comprehensive assessment of the needs of the prospective resident, and pre-admission visit where possible, enables the home and the resident to decide whether the programme can meet the needs of the resident and whether the resident is prepared to give their commitment to the treatment programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. The policy of the home is to obtain as much information as possible from the referral agency to ensure that the needs of the prospective resident can be met. This is in addition to the assessment form that is completed by the home, when talking with the resident. It was noted that although 2 case files contained information sent to the home there was a note on the third case file that the home had chased up a copy of a report on 3 occasions. Each file contained an initial assessment form that the home completed and 1 resident said that this form had been completed when they visited the home. Most of the current residents are privately funded and it was noted that the pre-admission information includes areas such as education/employment, family/social contact, cultural and faith needs, physical Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 9 and mental health, communication and treatment/rehabilitation program. On admission the resident has signed a number of agreements in respect of any restrictions on choice, freedom and services or facilities. These were present on each of the 3 case files and included a therapeutic contract, a reasons for instant discharge document, a confidentiality document and an agreement to voluntary testing form. They had all been signed and dated by the residents. There was evidence that rehabilitation needs are assessed by health care professionals using recognised assessments methods and tools. When the initial assessment form is completed by the prospective resident, at Wellington Lodge, it provides the person with the opportunity to meet the staff team, including support workers and counsellors and to view the home and its facilities. The person can also meet the current residents and hear about what the home is able to offer and what is expected of the resident during the programme. A resident confirmed that they had visited the home, prior to admission. Due to each individual resident’s circumstances and reasons for admission it may not be possible for a pre-admission visit to be made to the home. Wellington Lodge DS0000065106.V347781.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 People who use this service experience good outcomes in this area. Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The treatment programme gives residents the confidence and skills to make choices about their lifestyle both for the present and in the future. Responsible risk taking contributes towards the resident leading an independent lifestyle and reviewing these ensures that the changing needs of residents are identified and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. One of the residents was on a 13-week programme and the other 2 residents were on 6-week programmes. Each file contained a client care and support plan. This identified support issues, what Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 11 action was needed, establishing goals, assignment ideas and desired outcomes. Support issues included abstinence, aspirations, communication, cultural needs and emotional needs. There was space to review the care plan at key stages during the programme. Residents were involved in the formulation of the care plans. Each file contained a number of documents, signed by the resident, which related to restrictions or agreements that form part of the programme. There was a therapeutic contract, circumstances that would warrant an instant discharge from the home, duties regarding confidentiality, an agreement to voluntary testing for drugs/alcohol and It is agreed by the resident that giving a commitment to their treatment programme entails some necessary restrictions on their choices and freedoms. However there are some elements of choice e.g. local fellowship meetings where attendance is recommended but not compulsory, although there are a minimum number of fellowship meetings that residents are expected to attend. Residents agree to community living when they enter the home so some decisions taken have to be agreed by the majority of residents. The home is not directly involved in residents’ finances although they will try to assist residents in sorting out entitlement to benefits on leaving Wellington Lodge. Risk assessments have been drawn up to meet the individual needs of the residents and these were included on the case files examined. They included areas such as personal safety, harm to others and physical and mental health. They included risk management strategies. There was evidence that these are kept under review. Wellington Lodge DS0000065106.V347781.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, 17 People who use this service experience good outcomes in this area. The treatment programme provides residents with the opportunity to make changes in their lifestyles and to prepare them for living independently in the community again. Residents are able to maintain contact with friends and family members who are supportive of the resident’s desire to change. Residents are offered a balanced diet to promote their physical health and well-being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of the weekly programmes were available. Most of the residents were accommodated on a 6-week alcohol rehabilitation programme. The programme provided residents with a structured framework for their daily lives and included therapeutic duties, group meetings, 1:1 sessions, assignments, specialised sessions, therapy sessions and meditation. Residents are expected Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 13 to attend a minimum of 3 fellowship meetings per week and this involves taking part in meetings held in the community. During the inspection the art therapist was holding an art class in the home and residents said that they enjoyed the sessions because they gave the resident another way of expressing themselves. Residents said that they were pleased to have this framework and that although they were busy they were given time to think and to reflect. One of the residents who was undertaking a 13-week programme had started to work on a voluntary basis for 2 days per week at a charity shop. She said that she enjoyed the responsibility and the opportunity to meet new people. Another resident said that they were looking forward to their first 1:1 session with their counsellor and that they had completed the preparation work. There were opportunities for exercise and one resident said that after the first 2 weeks, when residents were expected to remain in the home, he had taken part in a walk with a member of staff and with other residents. During the inspection some of the residents were doing some shopping locally and it was noted that they offered to shop for newer residents that had only just finished their medicated withdrawal from alcohol and were expected to stay in the house for the initial part of the programme. Residents may go into the community on their own, but only towards the end of their programme. Being absent from the home without permission could result in the placement being terminated. Residents do have time to relax in during the evenings and one resident said that she liked to have a soak in the bath and to read in her room although she was encouraged to spend time with other residents and not to isolate herself. At the weekend there is time to watch some television or to receive visits or to contact family and friends by telephone. There are rules attached to visits and contact to prevent distractions or relapses. As residents may have children the responsible individual said that the home has arranged child protection training for the staff team and is developing a child protection procedure. There are opportunities for residents to have contact with family and friends that will support the resident in their aim to come to terms with and to control their addiction. This is generally after the initial 2 week settling in period. Contact with people that might discourage the resident is prohibited. Sometimes residents go out with their relatives. Residents have to apply to have a visit or go out on an outing and full details of the persons involved and where they will be going have to be given before a decision is made. Acceptance of restrictions is part of the early stages of the treatment programme although the promotion of independence, choice and freedom of movement is included in the latter stages as preparation for leaving the home. Residents were aware of the rules and the responsible individual provided a copy of the newly revised and amended residents’ handbook. Members of staff and residents are subject to random drug or alcohol tests. The counsellor Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 14 requesting a resident to provide a breath or urine sample is the same gender as the resident to respect the dignity of the resident. A discussion took place with a support worker regarding the importance of good nutrition as part of a treatment programme. One of the residents said that the food is tempting and that they had a “beautiful fish pie” for their evening meal. She said that they had gained 8 lbs in weight and that this was an improvement in her overall well-being. Another resident was pleased that he was eating now. A third resident said that the food was very good and that there was variety and fresh ingredients were used. Wellington Lodge DS0000065106.V347781.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): 18, 19, 20 People who use this service experience good outcomes in this area. Residents are encouraged to develop the skills to take control of their lives through the support of a team of staff. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well-being is promoted by staff that assist the residents to take prescribed medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are self-caring although members of staff need to encourage residents to regain their self-esteem and to take pride in their appearance. Residents are encouraged to keep regular hours as the 12-step programme provides a structure and timetable for their day. Counsellors and therapists provide specialist support, as part of the programme. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 16 Two of the residents that took part in the inspection had recently completed the detox part of their programme. They confirmed that they were closely checked and supported through the detox stage and were already beginning to feel in a better physical condition. The medicated withdrawal phase is closely supervised and monitored by the prescribing nurse and with an on call doctor. There is evidence that support is given if residents have any health care problems that require medical intervention. During the inspection a resident that was complaining of pain in her shoulder was taken to the local accident and emergency department. Two residents that are self-medicating take the medication in the presence of a member of staff. One resident that has started a medicated withdrawal course had records for this, which were satisfactory. Medication is kept in a secure and safe facility. Medication training was provided for members of staff on the 30th January 2007 by an accredited trainer. Wellington Lodge DS0000065106.V347781.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): 22, 23 People who use this service experience adequate outcomes in this area. Residents are aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. Staff working without a pova first check, prior to receipt of a CRB disclosure, compromises the welfare and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place in the home. The procedure forms part of the resident’s handbook, a copy of which is given to each new resident. One was also made available during the inspection. The procedure includes each stage of the process and the timescale for responding under each stage is noted. It is stated that all complaints are responded to within 28 days. The procedure also refers to other agencies that the complainant may wish to refer to i.e. the Commission for Social Care Inspection (CSCI) and gives contact details for the local office. It is recommended that the telephone number is also included. One complaint has been recorded since the last inspection. This complaint initially was made to the CSCI. After an investigation the complaint was not upheld. There are several ways in which residents can raise concerns before these develop into complaints. There are house meetings, there are Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 18 community meetings and there are individual sessions with counsellors. Residents confirmed that all staff are approachable. Members of staff received training in respect of adult protection procedures by an accredited trainer in March 2007. The responsible individual also said that child protection training is being given to all staff towards the end of September as it is recognised that children may visit their parents, if they are residents, at the home. She confirmed that no incidents or allegations of abuse have been received since the last inspection. A copy of the local authority’s interagency guidelines are available in the home. The home has a dress code in respect of communal areas in the home, which can be linked to the protection of vulnerable adults, and the complainant above was unhappy when they were reminded of this. It was noted that the investigation report referred to above also dealt with how events were managed, taking into account adult protection issues. When staff files were examined it was noted that there was a new member of staff working in the home without a pova first check being obtained pending receipt of a satisfactory enhanced CRB disclosure. Wellington Lodge DS0000065106.V347781.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): 24, 30 People who use this service experience good outcomes in this area. Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax and enjoy although some minor redecoration and refurbishment is needed. Residents live in a home where overall standards of cleanliness are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a site visit took place. A loft conversion is almost complete and this was viewed. The additional space is to be used for the benefit of existing residents and not to increase the number of residents for which the home is registered. One of the 2 rooms is to be used as a group meeting room and the other room is to be used as an IT suite. These additional facilities will enhance and extend the communal areas in the home. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 20 The paintwork and walls on the first wall landing and corridors has been redecorated since the last inspection. It was noted that there were “water stains” on the ceiling of one of the first floor bedrooms and that the carpet on the stairs and landing and in the hallway is stained and in need of cleaning or replacement. All other areas of the home that were inspected were satisfactory. Residents were pleased with their accommodation. One resident described Wellington Lodge as a “nice place – cosy” and another resident said that it had a homely feel. It was noted during the site visit that all areas of the home inspected were clean and tidy and free from offensive odours. Laundry facilities are sited on the ground floor and do not involve carrying laundry through any areas where food is stored, prepared or consumed. Members of staff received training from an accredited trainer in respect of infection control procedures in January 2007. Wellington Lodge DS0000065106.V347781.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): 32, 33, 34, 35 People who use this service experience good outcomes in this area. Support staff need DANOS accredited training to assure residents that their care practices are based on an understanding of the residents needs. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices lacked obtaining a pova first check before staff start to work in the home and this compromises the safety and welfare of the residents. Residents benefit from support given by carers that are skilled and trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents described staff as “kind and positive” and “supportive”. Another resident said that it was like a family in the home and not an institution. Therapists and counsellors are appropriately trained and qualified. Training for support workers includes familiarisation with the “12 Step Approach”. The home is still working towards Danos accreditation for the home and for individual support workers. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 22 On the day of the inspection the responsible individual, a support worker, 2 therapists and a counsellor were on duty. A copy of the weekly rota was available. There are sufficient staff, at each level, to support the residents accommodated in the home. A prescribing nurse closely monitors the detox programmes and a doctor is on call to support residents, if necessary. A resident said that the staff team was always there to support them and that they made time to respond to residents whenever there was a need. During the random inspection in January 2007 two statutory requirements were identified. The first requirement was that all staff files contain proof of ID e.g. passport details. The second requirement was that all staff working with residents, including therapists and counsellors, have an enhanced CRB disclosure. Two staff files were examined and these belonged to 1 member of staff that had recently started to work in the home and 1 member of staff that would be starting work in the home when all the checks were complete. Both files contained proof of identity i.e. passport details but although applications had been made for an enhanced CRB disclosure neither file contained a pova first check. Enhanced CRB disclosures had been obtained in respect of files examined previously although the disclosure letter had not been kept on file for one member of staff. This person’s file did contain a record of the disclosure number and date of issue. Each staff file also had a training file attached. The individual training files contained a training profile for the member of staff. The Commission for Social Care Inspection was provided with a copy of the training plan for the home in January 2007. There was evidence that new members of staff complete a 4 part in house induction program. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use this service experience adequate outcomes in this area. Residents and staff benefit from a registered manager’s ability to develop and maintain good standards of care in the home and so recruitment to this post is vital. Information gained through quality assurance systems is used to shape the future development of the service and ensure that the needs of residents continue to be met. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of all equipment and systems used in the home is needed to ensure that items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 24 A statutory requirement was repeated during the random inspection in January 2007 that a manager must be appointed to work in the care home and that this person must submit an application for registration to the Commission for Social Care Inspection (CSCI). The requirement had been outstanding from June 2006. A manager had been appointed prior to January and after January began their application for registration by the CSCI but has subsequently withdrawn. Another manager is due to start working in the home in September. Although the requirement related to the previous manager in post and is now withdrawn, it is of concern that the home has been without a manager and/or registered manager since shortly after the home was registered. A requirement is therefore made in respect of the new manager that they successfully complete the registration process with the CSCI. A discussion took place with the responsible individual regarding quality assurance and quality monitoring systems. Ms Aylett said that they ask for feedback from the referral agency after the placement has ended and from any after care teams that the resident may have contact with. She said that the home is developing a feedback questionnaire for residents to complete immediately prior to their discharge, at the end of the placement. During the inspection residents also gave their opinions on the quality of the service offered by the home. This was not the first experience of support in a residential setting for all of the residents and Wellington Lodge was the preferred option. The treatment programme includes house council meetings and residents’ meetings and residents confirmed that these were an opportunity to give feedback. There was a valid certificate for the servicing/checking/inspection of the electrical installation for the loft conversion, the emergency lighting and fire alarm system, the fire extinguishers and the portable electrical appliances. The Landlord’s Gas Safety Record was dated June 2006 and had expired. The testing of the fire alarms on a weekly basis and holding fire drills had been suspended while key stages in the building works on the loft took place. There was evidence that staff had received training in safe working practice topics. There was a fire risk assessment in place. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 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 3 X 1 X 3 X X 2 X Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 16(2) Requirement The registered person must ensure that the carpet in the hallway and on the stairs and landing is cleaned or replaced and that the ceiling of the first floor bedroom is redecorated to assure residents of a well maintained environment. The registered person must ensure that support staff have the opportunity to achieve DANOS accreditation to assure residents that support staff are competent and qualified. The registered person must ensure that all staff working with residents, including therapists and counsellors have a pova first check, pending the return of a satisfactory enhanced CRB disclosure, so that unsuitable people do not work in the home. The registered person must ensure that the home retains the CRB letter until the next inspection to demonstrate that recruitment processes are thorough and that decisions taken are in residents’ best interests. DS0000065106.V347781.R01.S.doc Timescale for action 01/03/08 2 YA32 18(1) 01/04/08 3 YA34 19(1) 01/10/07 4 YA34 19(1) 01/10/07 Wellington Lodge Version 5.2 Page 27 5 YA37 8(1) 6 YA39 13(4) 7 YA39 23(4) The registered person must ensure that the newly appointed manager successfully completes their application for registration with the Commission for Social Care Inspection (CSCI) so that statutory obligations are met. The registered person must ensure that a copy of a valid Landlord’s Gas Safety Record certificate is faxed to the CSCI to demonstrate that the safety and welfare of residents, staff and visitors to the home is protected. The registered person must ensure that the fire alarms are tested on a weekly basis and that fire drills are carried out on a regular basis so that in the event of the fire alarms sounding members of staff assist residents and visitors to safely evacuate the building. 01/01/08 01/10/07 01/10/07 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 2 Refer to Standard YA2 YA22 Good Practice Recommendations That letters requesting copies of reports etc are kept on file. That the telephone number of the Commission for Social Care Inspection is included in the complaints procedure that forms part of the Client’s Handbook. Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Wellington Lodge DS0000065106.V347781.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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