Inspection on 27/04/06 for White Lodge (126)

This inspection was carried out on 27th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

White Lodge (126) 24/11/05

White Lodge (126) 04/07/05

White Lodge (126) 06/01/05

White Lodge (126) 02/06/04

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 White Lodge (126) 126 Foxley Lane Purley Surrey CR8 3NE Lead Inspector Claire Taylor Key Unannounced Inspection 27 April & 5 May 2006 10:45 White Lodge (126) DS0000025867.V298542.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 White Lodge (126) DS0000025867.V298542.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. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Lodge (126) Address 126 Foxley Lane Purley Surrey CR8 3NE 020 8763 2586 020 8763 2586 whitelodge@sussexhealthcare.org 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) Sussex Health Care Miss Kelly Anne Bennett Care Home 8 Category(ies) of Learning disability (8) registration, with number of places White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24 November 2005 Brief Description of the Service: White Lodge is registered to accommodate eight people with learning disabilities, aged between 18 and 65 yrs. The home provides a service that caters for the needs of eight young adults who display behaviours that may challenge the care services that they require. Situated in Purley, on a main road, it is well positioned to access local transport links and amenities. There is large kitchen and communal lounge/dining room and all service users have the benefit of a single room. A conservatory at the back of the house leads out to a large well-maintained garden with lawn and wooden decking area. The home has its own transport to enable service users to access community activities. Fees charged range from £780.00 to £1220.00 and were accurate at the time of this inspection. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based upon findings from two unannounced inspections that took place on two separate occasions. During the first visit most of the service users were out at their various day care placements. An afternoon / early evening visit was therefore carried out on the second occasion so that they could meet the inspector and give their views. The total time spent in the home was eight hours. There have been no new service users admitted to the home since the last inspection although there have been some significant staff changes following outcomes from an adult protection investigation. This has been discussed later on in the report. Inspection time was spent talking to service users, staff, examining records, and touring the premises. The acting home manager, Ann Bicknell, facilitated both visits. During the second inspection, two relatives were in the home and shared their views about the service. The service users and staff of White Lodge are thanked for their welcome and cooperation during this inspection. Having assessed all the available evidence prior to and during the inspection, the home is judged to have substantially more strengths than weaknesses and has been assessed overall as a good service. What the service does well: The same eight people continue to live at the home and their needs continue to be met. Service users have a range of needs and records indicate that staff have clearly developed a working knowledge of their behaviours, moods, signals and temperaments. The plans are well created and closely reflect the needs of the specific person so that staff have clear information on how to support them. Planning and review of care is regular and helps the service users build upon and develop their independence as far as possible as well as address any changing needs. Recruitment practices are well managed to ensure that service users are protected from staff who should not be working with vulnerable people. Likewise, the home has robust policies and procedures in place concerning adult protection. Service users spoken to gave positive comments and appeared relaxed and comfortable in their home. Some service users said they particularly like the spacious rear garden and going out for drives. The home is well furnished and the premises continue to be maintained to a good standard. The home shows consistency in its compliance with the National Minimum Standards and Regulations. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. White Lodge (126) DS0000025867.V298542.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 White Lodge (126) DS0000025867.V298542.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Arrangements are in place for assessing service users needs so that staff are aware of how to support them. EVIDENCE: There have been no new service users admitted to the home. A needs assessment plan is available that is detailed and covers all areas to ensure that any new service user’s needs are fully assessed prior to their admission. This provides staff with comprehensive information about the individual and how they should be supported. Suitable admissions policies are in place which ensures that the home would only admit service users whose needs can be met. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Service users’ plans of care clearly identify their needs and how they are supported to achieve their planned goals. Individuals are provided with the necessary support to take risks so that independence is maximised as far as possible. Wherever possible, staff provide service users with information, assistance and support to enable them to make decisions about their own lives. EVIDENCE: Good standards of care planning are in place for each service user. Five of the service users files were sampled. The care plan, written in a person centred format, covers all aspects of personal, social support and health care needs of the individual service user. Reviews are held at least six monthly and involve the service user, their relatives/ representatives and Care Manager. The outcome of reviews is recorded and maintained on file. Specific programmes and support plans are in place to guide staff to meet service users’ needs. Daily records indicated that staff have clearly developed a working knowledge of the behaviours, moods, signals and temperaments of the service users. In White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 10 response to a recommendation made at the last inspection, the home has taken steps to further develop the service users’ plans of care. An occupational therapist has begun working with the service users and staff team. Although not yet completed, the acting manager explained that plans would be more personalised with pictures and photos to make them more accessible and meaningful to individuals. The acting manager has only recently taken up post in the home and added that she intends to undertake a thorough review of the service users’ care plans. Staff on duty were observed taking their time to deal with service users’ queries and appeared to actively encourage them to participate in the daily running of the home. Service users are supported to take ‘responsible’ risks as appropriate whilst promoting independence. Risk plans form part of the individual service user’s person centred plan. Detailed behaviour management strategies and interventions are in place for service users who may behave in a way that puts themselves or others at risk of being physically harmed. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Improvements have been made so that service users are provided with further opportunities for recreational and social activity based upon their assessed needs and individual preferences. Service users’ rights are more fully respected although some minor improvements are still needed. Relationships with family and friends are well supported. Food provision allows for a healthy and varied diet based upon choice and preference; meals are enjoyed at times to suit individual service users. EVIDENCE: Most of the daily activities offered are through various day centres and community resources. The home is well placed for local transport links and has the added benefit of its own vehicle. One service user travels by bus independently in the local community and risk plans are in place to reflect this. Findings from the last inspection indicated that service users were being provided with limited social and recreational activities - both at the home and in the wider community. Records showed that improvements have been made White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 12 in this area. Following staff changes, the home now has three drivers to facilitate more links for service users with the local community. Individual activity timetables were sampled and clearly show what activities service users take part in. Personal goal plans refer to individual choices made by service users. Two individuals had expressed an interest in dogs and the staff have organised for them to go dog walking once or twice a week. One service user said that they looked forward to this activity. Some service users attend social clubs such as the “Monday” club organised by Mencap. Recreational activities are organised within the home like beauty treatments including manicure, pedicure, make up and facials. An aromatherapist continues to visit weekly and service users said that they enjoy these sessions. Other indoor entertainment includes television, music centre, videos, DVDs, board games, puzzles and art and craft activities. Based upon service users preferred requests, there are plans for future activities such as late night shopping and summer trips to the coast. One service user wishes to go to the Isle of Wight and has support from their keyworker to achieve this. There is a conservatory where sensory stimulation activities can take place with soft music and coloured lights. Service users have the benefit of using this area for relaxation and quieter activities. There is a spacious well-maintained garden where, weather permitting, some service users like to spend their time. Records showed that suitable arrangements are in place to enable service users to maintain good links with their families and friends. Staff were observed to be respectful of service users wishes and choices. Daily routines and house rules appear to promote independence and individual choice. Meals, for example, can be taken where and when service users want depending on their own activities planned for the day, and service users go to bed and get up when they want. This is done within the context of enabling service users to attend appointments and other commitments. Service users have all been offered keys to their bedrooms and their respective choices have been documented in the care plans. Key workers encourage and support the service users to participate in the up-keep of their bedrooms and contribute to the domestic tasks in the communal parts of the home. Meetings for service users are still not being held at the desired frequency and this must be addressed. This will ensure that service users are regularly consulted about the home’s operation and show that their choices are respected. During both visits, service users were able to freely access the kitchen and supported to choose a drink or snack of their choice. Service users who wish to are supported to plan the menu and go weekly food shopping for the home. Daily records are kept of all meals with any alternatives offered. Cultural preferences and dietary requirements are catered for as needed. Service users spoken to say that they liked the meals served at the home. Appropriate dietary guidelines were in place for some service users. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Service users welfare is closely monitored and suitable arrangements are in place to ensure that their physical health and emotional needs are met. The home’s systems regarding medication are well organised to ensure the safety and consistent treatment and support for each service user. EVIDENCE: At the last inspection, personal toiletries were being stored collectively in the home which did not reflect choice or individuality for the service users. Positively, this had been addressed and each service user has been provided with their own facility for keeping toiletries. The service users require varying degrees of assistance with their personal care. Where support is required with personal physical care, this is identified and guidance is available on how specific tasks should be undertaken. Records concerning healthcare needs were in very good order and involvement with specialist services highlighted where necessary. They showed that potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. E.g. regular physiotherapy for one service user following a fractured hip injury. Service users are registered with a local GP practice and have access to other NHS facilities as necessary such as a dentist, optician, White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 14 chiropodist, and “well woman” clinic. Medication records are appropriately maintained by staff and no errors were noted on the sampled administration sheets. An appropriate healthcare professional reviews medication regularly and each service user has a written profile to specify what medication is required. In addition, guidelines for the use of ‘as required’ (PRN) medication were in place to ensure that staff are clear about when and how to administer this type of medication. Certificates showed that adequate staff are trained to administer medication. The local pharmacist provides an audit service and no concerns were identified following their most recent visit in February of this year. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to the service. An appropriate complaints procedure is in place to ensure that the views of service users, their families and friends are listened to and acted upon although records of all complaints must be kept in the home. There are good procedures and systems in place regarding adult protection and prevention of abuse. EVIDENCE: The complaints policy has a clear process, includes each stage and timescales and is available in a “Widgit” symbol format for the benefit of those service users who have limited communication abilities. There were no complaints recorded at the home since the previous inspection although a relative commented that they had made a complaint directly to the registered provider. Details of all complaints made about the home or services provided must be logged in the record book and kept in the home. This will ensure that service users, their relatives and staff are made aware of any findings and actions taken. The home has policies and procedures in place to safeguard service users from abuse including whistle blowing, management of service users money and financial affairs, dealing with physical aggression and the use of restraint as a last resort. A copy of the London Borough of Croydon’s Adult Protection procedure and West Sussex multi agency guidelines were both available. The home maintains accurate records of any incidents or accidents. Since the last inspection, an allegation of abuse was reported to the local office of the Commission for Social Care Inspection. Following an investigation under the auspices of adult protection, two members of care staff were dismissed and the White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 16 registered manager suspended. Sufficient evidence was sent to the Commission local office that the investigation was dealt with appropriately and in accordance with both the home’s policy and local authority procedures on protecting vulnerable adults. In addition, the two staff dismissed were referred for inclusion on the Protection of Vulnerable Adults register. Records showed that the majority of staff had recently completed in house training on abuse awareness through video and questionnaire resources. It is suggested that staff should also attend formal training on adult protection that is organised by the local Croydon authority. White Lodge (126) DS0000025867.V298542.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home is maintained, decorated and furnished to a good standard enabling service users to live in comfortable surroundings. Improvements have made areas more homely for the service users. Facilities are clean and safe although the upstairs bathroom would benefit from refurbishment. EVIDENCE: As previously required, the dining table and chairs had been replaced and as suggested, areas of the environment improved upon. I.e. Organisational and administrative documents removed from the kitchen cupboards and walls. The kitchen had also been repainted. Bathroom cabinets that were previously padlocked had been replaced. Such changes have created a more homely impression for the service users. The home has addressed an enforcement notice set following a fire safety inspection by the London fire and emergency planning authority in February of this year. Requirements included provision of a fire risk assessment for the premises as well as replacement of some fire doors. The home was very clean, tidy with good hygiene practices well observed. Relatives spoken to during the inspection complimented the acting manager and staff on how much cleaner the home appeared. The first floor White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 18 bathroom is now in need of some attention however due to an unpleasant odour surrounding the toilet area and the sealant around the bath was discoloured and in need of replacing. It would be good practice if the bathroom suite were upgraded to a more modern type. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Despite significant staff changes, service users remain supported by a welltrained and competent staff team. Although progress has been made with staff training on specific needs, some further development of care staff’s expertise is still needed. Robust recruitment practices are securely managed to maximise protection for the service users. EVIDENCE: There have been significant changes to the staff team since the previous November 2005 inspection. This has occurred due to a recent adult protection investigation that involved two senior staff and the registered manager. As mentioned earlier, these three staff no longer work in the home. As a consequence, the registered providers Sussex Health Care appropriately arranged for a home manager from another home to transfer to White Lodge. In addition a senior staff from the same home has also since joined the staff team. Although this has naturally been an unsettling period, records showed that the service users have not been unduly affected by such changes and continue to receive good support from the staff. Three service users said they liked the new staff. Staff spoke respectfully with service users and Rotas were sampled and staff allocation allows for three carers to be on morning duty, White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 20 three in the afternoon with one waking staff and one sleep in at night. The manager is included within this allocation and reported that she had appointed to the home’s one vacancy subject to CRB clearance. All staff files were sampled on this occasion. Records confirmed that the home’s recruitment practices are robust to ensure that service users are protected from people who should not be working there. Staff have provided the necessary documentation and undergone the appropriate checks before commencing work. This included the completion of a police CRB and POVA check. The newest staff, appointed in November 2005, spoke positively about the home and the support given during their induction period. The induction process for staff is based on the ‘Skills for Care’ format. Record keeping regarding staff training is well organised and clearly shows what courses staff have attended. An organisational training programme is available that provides a variety of courses for staff to update their skills and knowledge along with recognition of mandatory training that they must attend. Certificates seen included training in epilepsy, food hygiene, first aid, moving and handling and a recent update on fire safety (February 2006). As previously recommended, some specialist training for staff has commenced e.g. on the management of challenging behaviour. To further ensure that specific needs are fully understood, staff should be provided with training on autism and communication methods. A requirement has been set for this as some service users have limited verbal skills. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The new acting manager has good experience and professional qualifications relevant to managing the home. Effective systems are in place to monitor the quality of care and enable service users to have some influence over the running of the home. Good health and safety practices ensure that service users live in a safe environment and the welfare of service users and staff is protected. EVIDENCE: White Lodge had recently undergone changes to the management structure at the time of this inspection. The acting manager now in post, Ann Bicknell, has attained the required NVQ level 4 management qualification as well as the Registered Manager’s Award. She has worked for Sussex Health Care for nearly ten years and has acquired valuable experience in the care of people with learning disabilities. She also demonstrated a good knowledge of her managerial responsibilities due to her experience in one of the organisation’s White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 22 other registered homes. Staff and some service users available during this inspection expressed a liking for her leadership qualities and confidence in her ability to run the home. Improvements have been noted in the home’s administration procedures and the standard of care for the service users since the manager joined in February of this year. Effective systems are in place for quality monitoring which include general daily checks; regular audits of service users’ care plans, the environment and monthly visits by the registered providers in accordance with regulation 26 of the Care Standards Act. White Lodge has also achieved accreditation with Investors in People and is audited three yearly by an independent quality assurance company (HQS). The organisation sends out satisfaction questionnaires to service users and their families on a rotational basis. In view of recent events and staff changes in the home, it would now be good practice if the registered provider carried out a general survey to seek the views of all service users, their families and other relevant stakeholders. Findings from these surveys should be published. This is made a recommendation. Health and safety practices are well managed in this home. All staff members undergo training in safe working practices and comprehensive health and safety procedures are in place. Risk assessments covering safe working practices have been completed for the home to safeguard the welfare of the service users, staff and visitors. The assessments are comprehensive and had recently been reviewed by the acting manager. Accurate records are kept for accident and incidents and the home keeps the Commission promptly informed of any reportable events. All services, equipment and facilities are regularly checked and maintained in a safe state to maximise protection for all those living and working in the home. Maintenance and servicing records were sampled and up to date. Fire drills are organised at regular intervals and fire alarms and equipment had been checked. White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 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 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes- 1 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 YA16 Regulation 12(2 & 3) Requirement Meetings for service users need to be held more frequently to ensure that they are regularly consulted about the home’s operation and that show that their choices are respected. (Outstanding from November 2005 inspection- it is acknowledged however that the home has undergone recent management change) Timescale for action 31/07/06 2. YA22 17(2) Sch.4 (11) 3. YA27 13(3) 23(2)(a,c & d) 18(1a)(c) 19(5 b) Records and outcomes of all 31/07/06 complaints need to be made available in the home to ensure that residents, their relatives and staff are made aware of any findings and actions taken. The bathroom needs 30/09/06 redecoration as outlined in this report. All staff need training on autism and alternative communication methods to ensure that service users specific needs are more fully understood. 30/09/06 4. YA35 White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 25 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 Some service users cannot use verbal communication and the home should therefore consider ways to develop their plans into a format that is more meaningful to them. (Repeated from November 2005 inspection) All staff should attend Croydon Councils training on adult protection. The first floor bathroom suite should be upgraded. In view of recent events in the home and staff changes, the registered provider should carry out a general survey to seek the views of all service users, their families and other relevant stakeholders. 2. 3. 4. YA23 YA27 YA39 White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI White Lodge (126) DS0000025867.V298542.R01.S.doc Version 5.2 Page 27 - 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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