Care Home: Russell Lodge

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What the care home does well The registered persons continue to maintain a homely environment, one that enables service users to enjoy a cosy atmosphere, and engage with all levels of staff including management. The levels of engagement by all staff run throughout the aspects of care and support and so the team is well aware of the service users` needs and aspirations. Relatives have continued to express high levels of satisfaction with the services provided to the people living at Russell Lodge. The registered persons have worked cooperatively with the Commission to bring about improvements to the service. What has improved since the last inspection? Service users` funds and the management of it is more appropriately recorded, making it more transparent and auditable. Lessons have also been learnt regarding recording and reporting incidents. These improvements are key to providing better safeguards for all service users living at Russell Lodge. Annual appraisals have been carried with staff. An annual development plan is in place for the service and an internal audit of the service has been carried out. What the care home could do better: Explore ways of including service users in the staff recruitment process. Keep updated with developments in the field of learning disability, particularly as it relates to the age- range and make up of the service user group. CARE HOME ADULTS 18-65 Russell Lodge 18 Russell Gardens, Ley Street Ilford Essex IG2 7BY Lead Inspector Stanley Phipps Unannounced Inspection 12 to 15th August 2008 15:39 th Russell Lodge DS0000025924.V368258.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 Russell Lodge DS0000025924.V368258.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. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell Lodge Address 18 Russell Gardens, Ley Street Ilford Essex IG2 7BY 020 8554 4858 020 8518 4545 ragini@careone.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care One Ltd Mrs Ragini Sivakumar Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 24th October 2007 Date of last inspection Brief Description of the Service: Russell Lodge is a registered care home providing accommodation and support for five (5) residents with a moderate learning disability. The home aims to support residents in order for them to access and participate in mainstream as well as specialist resources in the community in which they live, within their individual capabilities. Russell Lodge is a semi-detached property situated in the Ilford area of the London Borough of Redbridge. The area is well served by public transport and there are many easily accessible facilities within the local area. There are three single rooms on the first floor and two on the ground floor, one with en-suite facility. Residents also have access to a communal lounge, dining area, kitchen, a laundry facility and a rear garden. A Service User Guide is available at the time of assessment. The current fees are £800.00 to £1150.00 per week, depending on service users’ needs. Additional charges are made for personal items such as hairdressing and toiletries and service users also pay for all outside leisure activities such as bowling, cinema etc. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was carried out on the 15/08/08. It was unannounced and a key inspection of the service, which meant that all the key minimum standards for ‘Younger Adults’ were assessed. The assessment considered information provided in the Annual Quality Assurance Assessment (AQAA) by the registered persons as well as feedback from service users, relatives, staff and external professionals. An assessment was also made of: medication practice, menus, policies and procedures, records required by regulation, residents’ care plans and the environment was undertaken. Discussions were held with the registered manager and several members of staff. The inspection found that service users were in receipt of an improved service and this was evidenced from the various pieces of evidence that was assessed, but also and importantly the registered persons compliance with the national minimum standards for younger adults and the Care Homes Regulations 2001. What the service does well: What has improved since the last inspection? Service users’ funds and the management of it is more appropriately recorded, making it more transparent and auditable. Lessons have also been learnt regarding recording and reporting incidents. These improvements are key to providing better safeguards for all service users living at Russell Lodge. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 6 Annual appraisals have been carried with staff. An annual development plan is in place for the service and an internal audit of the service has been carried out. 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. Russell Lodge DS0000025924.V368258.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 Russell Lodge DS0000025924.V368258.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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Their needs are assessed in detail prior to admission to determine the suitability of the home in meeting them. EVIDENCE: There were no admissions to the home since the last inspection and as such the home continues to maintain one vacancy. The pre-admission documents were found in order at the previous inspection, and service user plans have been developed from those assessments, which were carried out by the management of the home. The home’s current admissions’ process ensure that service users participate in choosing whether to live at Russell Lodge, part of which involves them having a trial stay at the home. Service users have some assurances that their needs would be met, once they decide to live there. Russell Lodge DS0000025924.V368258.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. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,9) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Good systems are in place to ensure that the changing needs of service users are reflected in their individual plans. There was evidence that they take decisions with support, and are also supported to maintain their independence and safety, within a risk management framework. EVIDENCE: From the care plans viewed, it was clear that service users are involved in planning their care, which ensures that they are not only aware, but accept responsibility for their direction. As part of this arrangement, they have the benefit of a key worker who works closely with them in setting up and reviewing their individual plan. Most of the care plans viewed were updated and generally individualised, detailing the specific needs of service users. They were borne out of the assessments carried out initially with them. Most of the service users knew their key workers by name and up to three of them spoke of what they did for the week with their key workers during the course of that week, which is positive. The needs of the service user group are complex and though they are fairly settled in the home, most needed a high level of support to influence and Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 10 communicate their needs. Staff play a major role in enabling residents to make decisions about their goals and objectives. This includes; decisions about their activities, meals and personal development. On the day of the visit, staffing engagement with service users indicated that the service was structured around the needs and wishes of the service user group. This is positive. Service users’ meetings are held regularly and they are enabled to participate and contribute to the home’s operations. Information for e.g. complaints and activities are available to them in suitable formats. A system for risk assessment and risk management is in place at Russell Lodge. In all cases they were linked to each of the service user’s plan. Staff spoken to understood the importance of risk assessments in ensuring that both the independence and safety of service users are promoted. Linking the risk assessments to their care plans ensures that staff are knowledgeable about the needs, risks and safe management of each individual service user. Both the service user plans and risk assessments were updated at the time of the inspection, which is positive. A missing persons procedure is in place at the home. Russell Lodge DS0000025924.V368258.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. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users continue to participate in their community, enjoy a range of activities and are able to maintain and develop social and personal networks of their choosing. They are supported to exercise their rights, which are respected and promoted by staff in the home. Service users also enjoy a variety of meals that meet their cultural and nutritional needs. EVIDENCE: There was evidence that service users were supported to develop and maintain their living skills however restricted they might be. This is true despite having varied and complex levels of needs, and motivation. This presents a challenge for the staff team and from observation they were aware of the challenges in providing care and support to the service user group. Service users have an individual programme of activity, which is specific to their choice and interests and all staff were expected to work in accordance with this. Two service users were playing game of bowling on a Nintendo Wii, which they were enjoying. From speaking with service users they were satisfied with how the staff supported them with regard to the range and level of activities that is are on offer at Russell Lodge. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 12 Service users provided evidence of literacy, numeracy and craftwork, which is done with the support of staff. Each had their individual exercise books with the work that they have been doing over the last year. They proudly showed off their progress to date, which is extremely positive. Evidently they were at different levels, however their achievements meant the world to them individually and the management and staff made them feel proud of it. Some service users were also involved in gardening and again provided evidence of the vegetables that they had grown. This is a strong area of the homes operations. Service users continue to make use of the community facilities such as the restaurants, parks, the library, shopping areas, and bowling, which they really enjoy. Most of them were familiar with the community facilities and so make good use of them and again the staff are very instrumental in enabling this. Service users receive support in a flexible manner to enable them to enjoy accessing and using the community resources. It was clear that they were engaging with their community in an effective manner. This conclusion is supported from views of external professionals, relatives and the records viewed. This is positive. From assessing service users’ records, talking to the staff, relatives and community professionals, it was noted that they (service users) are encouraged to develop and maintain relationships with their friends and families. Relatives are also invited to and in some cases attend social events in the home such as birthday events. Service users in some cases go out to visit their relations and it was clear that every opportunity is given to ensure that service users are able to maintain their personal and social networks, which is positive. During the course of the inspection staffing interactions with service users were appropriate and more importantly respectful. Service users were addressed by their preferred names and staff were observed checking with them their preferences around food and personal support. Advocacy information is being accessed for residents should they need such a service and the key worker system is used as a means of ensuring that the rights and needs of service users are respected and provided for. Views taken from external professionals confirmed that service users are treated in a dignified and respectful manner. Service users continue to have the benefit of a key for access to their bedrooms. Their responsibilities for housekeeping remain documented in their service user plans through their choice. From observation they were both proud and positive about, making a contribution to the maintenance of their home. Service users were engaged with staff as a matter of choice, throughout the inspection, notwithstanding the fact that individuals wanting to spend time Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 13 alone were encouraged to so do. Clear guidance remains in place for handling service users’ mail. Menus were assessed and service users were quite positive about the quality, content and variety of the meals provided at Russell Lodge. The menus were presented in more of a user-friendly format to enable service users to make a more informed choice. There was also a good supply of food and drink available to service users, which could be accessed as when they needed it. Service users continue to have access to healthy snack options, which were noticeable over the course of the inspection. Meals also took into consideration the health requirements of individuals and a system of monitoring service users’ weight was in place to in relation to the meals arrangements at Russell Lodge. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy personal support in a manner that is generally suited to them. Arrangements are in place to provide for their physical and emotional health needs, as staff continued to maintain effective links with external professionals in achieving this outcome. This is enhanced by the good practices by staff in the handling of medication. EVIDENCE: Feedback received from relatives was positive with regard to how service users received personal support, which is coordinated through the key-worker system used in the home. Most individuals are supported to independently manage their personal care. Staff were observed throughout the course of the inspection providing personal support to residents and this was carried out in a safe and dignified manner. It was also clear that the staff had a system for determining individuals’ preferences and dislikes, which made the relationship between them – a positive one. Service users have their individual style of dress, which was consistent with their choice, culture and personality, and this was promoted in the home Service users are given good support to ensure that their health needs are provided for. They were all registered with a GP and records assessed indicated that arrangements are in place for them to see other health professionals such Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 15 as the dentist, chiropodist and the opticians. They also have the benefit of getting support to attend their outpatients’ appointment should they require this. Feedback received from external professionals was positive about the staffing awareness of residents’ needs. Records bore evidence that all community appointments were documented as they occurred. Good support is provided in relation to the healthcare needs of residents at Russell Lodge. At the time of the visit, service users were receiving support with medication, as they were unable to independently manage this task. A medication policy was in place to guide staff in the safe handling of medication in the home. The safety is enhanced by: ensuring that staff receive training in drug administration prior to supporting service users. This practice acts as a safeguard in ensuring that mistakes/errors are kept minimal. Medication storage in the home is was good. There was evidence from the recording systems in the home to confirm that drugs stocks are appropriately recorded and monitored at Russell Lodge. A pharmacist also visits monthly and at the last occasion (July 2008), the home received a good report, which is positive. Service users are therefore assured that their health care support needs are well provided for. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A satisfactory complaints procedure is in place and widely available to all service users and staff. Improvements in handling service users’ finances, as well as in the recording of accidents, now assure service users that they are safer living at Russell Lodge. EVIDENCE: One hundred percent of the feedback received from service users indicated that they knew how and who to complain to. The procedure is widely available to them as it is to their relatives. From discussions held with staff and external professionals, they generally felt able to raise issues of concern, should they feel the need to. The complaints record was analysed and in the main, complaints were logged and dealt with in line with the home’s complaints’ procedure. There was an improvement in this standard as the registered persons ensured that policies were adhered to in relation to handling service users’ finances. A rigorous assessment of the finances held for service users was undertaken and found to be; satisfactorily maintained. Another key area of improvement was the way in which incidents were reported and recorded, which now provides better protection for service users living at Russell Lodge. Information on abuse is now widely advertised in the home for the benefit of service users and staff. A safeguarding adults’ procedure is also in place and available to staff. The staff have also had the benefit of safeguarding training and there were no safeguarding issues in the home since the last inspection. Russell Lodge now provides a safer environment for its service users and staff. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users continue to live in a safe, comfortable environment with adequate and well-maintained facilities. A high standard of cleanliness ensures that the home remains a safe place for all. EVIDENCE: On the day of the inspection the home was clean, tidy and in good decorative order. Service users benefit from a range of facilities including: toilets, bathrooms, bedrooms, lounges for dining, relaxation and recreating, and a rear garden. The environment is homely and service users were observed enjoying various parts of it during the course of the inspection. As stated earlier service users do make use of the garden for leisure and therapeutic purposes. They were pleased to be involved particularly where their involvement meant that they could reap the rewards of their labour e.g. the vegetables grown. Feedback from external professionals indicated that the home is always well maintained. The fittings and furnishings were in good order and a programme of maintenance and renewal is in place. One hundred per cent of the feedback received from service users and their relatives indicated that they were happy with the standard and quality of the accommodation provided at Russell Lodge. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 18 A laundry facility remains in place, which is used by staff in supporting service users to launder their washing. Its location does not lend itself to promoting service user independence and the registered persons informed that they would like to have it relocated to the rear of the building. This proposal has been reportedly raised objections from a neighbour and so had to be aborted. It would be useful for this option to be re-explored with the planning authorities. An infection control policy remains in place and service users and staff are encouraged to work in line with this e.g. hand-washing. There was good evidence of signs being strategically posted throughout the toilets and baths reminding service users and staff of the importance and techniques of hand hygiene. This would help to minimise the risk of infection and is positive. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The home was free of offensive odours and the registered manager confirmed that it complies with the Water Supply Regulations 1999. Russell Lodge DS0000025924.V368258.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. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35,36) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users receive care and support from a staff team that is motivated to work with them. Their welfare and best interests are promoted by ensuring that generally staffing levels do reflect their needs. Sound recruitment practices and improvements in the frequency of staffing appraisals ensure that service users remain in safe hands, while living at Russell Lodge. EVIDENCE: In observing practice staff demonstrated their ability to positively engage and interact with service users. It is fair to say that even at times when a service user became anxious, staffing interventions were generally appropriate. From the records viewed, staff were able to make appropriate referrals to external professionals e.g. the GP and generally able to act when emergencies occur. There is a stable staff team in place, as staff retention is quite good. This ensures that there is consistency in the delivery of care and support to the service users. A minimum of two staff are on duty on day shifts with one person on night duty and an on call person is available to provide support in emergencies and as required. There have been no further additions to the staff team and as such the recruitment of staff could not be fully tested. The quality that was identified at the last inspection would therefore remain unchanged. Recruitment practices Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 20 continue to act as safeguard for service users. The robust practices prevent staff that may be undesirable to work with vulnerable service users – away from them. A detailed induction programme remains in place and staff have a copy of the General Social Care Council’s code of conduct, which is positive. It is still not evident how service users were involved in the recruitment processes and the registered persons. may wish to explore some of the options discussed at the last inspection. A training and development plan is in place along with a training needs analysis for the benefit of staff. Dates were provided for training in; Dementia, Medication, Disability Awareness and Safeguarding Adults (refresher) training, Basic First Aid and Food Hygiene, Managing Aggression and the Management of Diabetes. Feedback from staff indicated they were pleased with the level and quality of training that was given to them. External professionals expressed the view that staff were knowledgeable about the needs of service users and so, remain in a good position to meet them. There was evidence to confirm that staff continue to receive regular recorded supervision, which were in line with the national minimum standards for younger adults. This ensures that they not only meet their personal objectives, but also the aims and objectives of the service. There was an improvement in the frequency of annual appraisals for staff. Plans are now in place to support the further development of staff, which would be of benefit to people using the services at Russell Lodge. Russell Lodge DS0000025924.V368258.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. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,42) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Good management systems remain in place to provide a quality service at Russell Lodge. This includes systems for record keeping, reviewing policies and procedures, and the promotion of health and safety in the home. Improvements in ‘quality monitoring’ have enhanced the overall quality of services provided at Russell Lodge. EVIDENCE: The registered manager has completed her Registered Managers Award (RMA), which is in line with the national minimum standard. She continues to receive good support from the responsible individual and continues to attract the support of service users and their relatives and members of the staff team. She has also undertaken relevant training to update her skills and knowledge. All service users relate well to her and they also think highly of the works she does. As such they enjoy living at Russell Lodge. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 22 There has been an improvement in the quality monitoring of the service, as an internal audit was carried out following the requirements of the last inspection. An annual development plan is also available and service user surveys have been carried out. Surveys for relatives have also been undertaken. Monthly provider monitoring visits continue on a regular basis and so service users are assured that systems are in place to monitor and develop the service for their benefit. The health and safety policies and procedures and practices continue to ensure that the home remains safe for all that use it. Risk assessments for all safe working practice topics were in place and service users were also involved in maintaining a safe environment. A monthly health and safety audit is undertaken to identify any deficiencies, which are acted upon. Safety records for fire, gas and electricity were found in order. Records of accidents were maintained and the home was compliant with all the building, fire and environmental health regulations. As a matter of fact a fire safety inspection was carried out in May 2008 and the home was deemed safe. It was noted that COSHH risk assessments were also carried out and so Russell Lodge offers a safe environment to all that use it. Russell Lodge DS0000025924.V368258.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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 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 4 13 4 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 YA34 Good Practice Recommendations The registered persons should explore ways of involving service users in the staff recruitment process of the home. Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Russell Lodge DS0000025924.V368258.R01.S.doc Version 5.2 Page 26 - 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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