Care Home: St Michaels Lodge

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What the care home does well Overall, the inspector was satisfied that this is a well run home. Service users spoken to expressed satisfaction with the care and support they receive. One commented that "It`s very nice here, very good." While another said "I was able to look around before moving in." There was evidence that service users have a large degree of control over their daily lives, and that they are able to access local community facilities on a routine basis. The home was generally well maintained both internally and externally. Staff were able to demonstrate a good understanding of their roles and responsibilities. Care planning was of a good standard, as was record keeping generally. What has improved since the last inspection? At the previous inspection a total of two requirements were made, and both have been met. All service users are now issued with a written contract/statement of terms and conditions, and the carpet on the upstairs landing has been cleaned. What the care home could do better: There are still some issues that must be addressed, and a total of seven requirements have been made as a result of this inspection. The home must ensure that CRB`s are in place for all staff, and that all staff undertake appropriate adult protection training. Other areas that need to be addressed include ensuring that comprehensive risk assessments are in place for all service users, and that clear records are maintained of all medical appointments. CARE HOME ADULTS 18-65 St Michaels Lodge 68 Bulwer Road Leytonstone London E11 1BX Lead Inspector Rob Cole Unannounced Inspection 20th December 2007 09:00 St Michaels Lodge DS0000007242.V356473.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 St Michaels Lodge DS0000007242.V356473.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. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michaels Lodge Address 68 Bulwer Road Leytonstone London E11 1BX 0208 556 9555 0208 554 6662 stmichaelslodge@btinternet.com 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) Mr Bhoojesswur Gopaul Mr Bhoojesswur Gopaul Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places St Michaels Lodge DS0000007242.V356473.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. Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 11 3rd January 2007 Date of last inspection Brief Description of the Service: St. Michaels Lodge is a privately run care home offering twenty-four hour care to eleven adults with enduring mental health problems. The stated aims of the home are for staff, in conjunction with health professionals, to support service users to maintain lives of their choice within the community. The home is situated in a quiet residential area of Leytonstone, in the London Borough of Waltham Forest. Accommodation is offered in nine single and one double bedroom. Service users have shared use of a lounge, kitchen and dining room on the ground floor of the home, with toilet/bathroom facilities throughout the building, which is on three floors. There is also a garden and outhouse containing laundry facilities to the rear of the home. The current range of fees charged by the home is between £500 and £800 per week. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 20/12/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff, and the homes manager/proprietor was present throughout the course of the inspection. The inspection also included an examination of records and other documents, along with a tour of the premisis. The inspector was able to observe staff interaction with service users. Prior to the inspection, the home completed an Annual Quality Assurance Assessment at the request of the CSCI, and this was also used to form part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: There are still some issues that must be addressed, and a total of seven requirements have been made as a result of this inspection. The home must ensure that CRB’s are in place for all staff, and that all staff undertake appropriate adult protection training. Other areas that need to be addressed include ensuring that comprehensive risk assessments are in place for all service users, and that clear records are maintained of all medical appointments. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Michaels Lodge DS0000007242.V356473.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 St Michaels Lodge DS0000007242.V356473.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): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that prospective service users are provided with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has Statement of Purpose in place. The Statement says “St Michaels Lodge aims to provide its service users with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance.” The Statement also includes details of the organisational structure and of the staff team and their qualifications, and is in line with National Minimum Standards (NMS). The Statement is subject to regular review. The home also has a Service User Guide (or Residents Handbook) in place. This is written in plain English, and all service users are provided with their own copy of the Guide. The Guide includes the home’s complaints procedure and information about fees payable. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 9 Since the previous inspection all service users now have a written contract/statement of terms and conditions in place. These have been signed by the homes proprietor and the service user, and both parties have a copy of the contract. Contracts include details of fees payable, what the fees cover and what is extra. The home has an admissions procedure in place. This makes clear that service users will be given the opportunity of visiting the home before making a decision as to move in or not. One service user has moved into the home since the last inspection, and they were able to confirm that they had been able to visit the home before moving in. The policy also states that service users will initially move in on a trial basis, after which a placement review meeting will be held. Again, there was evidence that this meeting had taken place for the most recent admission to the home, this was attended by the service user, their next of kin, social worker and the homes manager. Pre admission assessments are carried out for all prospective service users prior to them moving into the home. These contain information on service users mental and physical health, but very little information on any other needs service users may have, for example around equality and diversity issues, or social and leisure issues. It is required that comprehensive pre admission assessments are carried out on all prospective service users, prior to them moving into the home, covering all areas of potential need. This will help establish if the home is indeed a suitable placement, and that it is able to meet all the needs of service users. St Michaels Lodge DS0000007242.V356473.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): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users have control over their daily lives, and that they are given the opportunity of been involved in their care planning, as well as the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users. These have been drawn up with the involvement of the service user and the homes manager. The manager informed the inspector that they were planning on introducing a key worker system within the home so that all service users will have a designated keyworker, who will also be involved in their care planning. Care plans have been signed by the service users, and are subject to regular review. Plans are of a satisfactory standard, and cover needs around mental health, social and leisure needs and needs around equality and diversity issues such as religion and ethnicity. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 11 Risk assessments are in place for all service users. These are generally of a good standard. As well as identifying risks, assessments also include strategies to manage and reduce the risks. Assessments cover risks associated with violence and aggression, smoking and self neglect. However, one service user has a history of attempted suicide, and has attempted suicide on several occasions in the past but there was no risk assessment in place around this. It is required that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. Service users are able to get up and go to bed as they choose, and are able to choose their own clothes to wear and mealtimes etc. Service users are able to leave the home independently as they choose. Service users are involved in the day to day running of the home, for example with menu planning. Regular service user meetings are held, and there was evidence that service users have been able to choose the décor for their bedrooms. The home has a policy in place on confidentiality, this makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Confidential records are stored securely, staff and service users can access their records as appropriate. St Michaels Lodge DS0000007242.V356473.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): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are supported to live valued and fulfilling lives. Service users have routine access to the local community, and food is of a good standard. EVIDENCE: One service user attends a gardening course, and is in the process of seeking part time employment around gardening. Service users are involved in various educational opportunities, for example studying maths, English and craft at a local adult education centre. The home is able to meet service users needs around equalities and diversities through access to various community facilities. For example, service users attend mental health day services where they are involved in poetry writing and drama, and provides the opportunity of developing relationships. One St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 13 service user attends a Jewish centre, which arranges activities including cooking and discussion groups, they also regularly attend synagogue. Another service user attends an African-Caribbean centre. Two service users attend a weekly disco organised by “Eastsiders.” Service users have routine access to community facilities, including shops, banks, cafes, markets, post offices and the library. Service users are able to access public transport, including buses and trains. Service users are involved in the daily routine around the home, such as helping to keep their bedrooms tidy and preparing meals. In house service users have access to a variety of social and leisure activities, for instance TV, DVD, music, BBQ’s and puzzles. Occasionally professional entertainers visit the home, for example a show was booked for the weekend following this inspection entitled “A Magical Musical Show.” Service users also visit local pubs and restaurants, and go to the theatre. All service users are offered an annual holiday away from the home as part of their basic contract price. This year service users went to Butlins, which they helped to choose. The home also organises various day trips, recent trips have included Southend. Visitors are welcome at the home at any reasonable time, and service users are able to see visitors in private if they so wish. Service users are also able to visit family and friends, and to stay with them overnight. Service users are given their own mail to open, and have access to the use of a telephone in private. The home maintains records of menus, these indicated that service users are provided with a balanced, varied and nutritious diet. Service users are able to help themselves to drinks and snacks throughout the day, and are involved in the food preparation. Fresh fruit was available on the day of inspection, and there was evidence that fresh produce is routinely used in cooking. The kitchen was clean and tidy, and food was stored appropriately. Mealtimes were observed to be relaxed and unhurried. The home checks fridge and freezer temperatures on a daily basis. St Michaels Lodge DS0000007242.V356473.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 and 21. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is generally meeting the health and personal care needs of service users, although it must ensure that clear records are maintained of any medical appointments. EVIDENCE: Service users are supported to manage their own personal care as much as possible, in line with their care plans. However, staff will offer encouragement to service users to attend to their personal care as appropriate. The home has sought and recorded the views of service users on their wishes in the event of their death. The manager informed the inspector that service users could remain in the home with a terminal illness, as long as the home was able to meet their medical needs. All service users are registered with a GP and a dentist. The home makes a note of forthcoming medical appointments in the daily diary, these are then St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 15 written up afterwards in the service users daily notes. However, this system makes it difficult to monitor what appointments service users have had, for example the home was unable to evidence that last time a service user had any access to dental care. In order to ensure that service users have routine access to relevant health care professionals, and to help monitor and record appointments, the home must set up a clear system for the recording of medical appointments, which includes the date of any appointment, who it is with, the reason for the appointment, and details of any follow up action necessary. The home has a comprehensive medication policy in place, and all staff undertake training before they are expected to administer medications. Medications are stored in a locked cabinet inside the office. No service users self administer medication at present, and none are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record charts are maintained, those examined by the inspector were accurate and up to date. However, two service users have been prescribed DIAZEPAM on an as required basis, yet there are no protocols or guidelines in place around when this is to be administered, and this must be addressed. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home has taken reasonable steps to help ensure that service users are safeguarded from the risk of abuse, although the home must ensure that all staff undertake appropriate adult protection training. EVIDENCE: The home maintains a complaints log. This evidenced that any complaints received have been appropriately recorded and investigated, although only one complaint has been received in the past year. The home also has a complaints procedure. This includes timescales for responding to any complaints received, and contact details of the CSCI. All service users have been provided with their own copy of the procedure, and those spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. This appeared to be in line with current legislation. However, not all of the staff employed at the home have undertaken training in adult protection issues, and this must be addressed. The home holds money on behalf of service users in a locked cabinet within the office. Records and receipts are maintained of all financial transactions involving service users monies. Where service users are given their own money St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 17 to spend, they are expected to sign to verify that they have received this money. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 18 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): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was well maintained, and service users are provided with adequate communal and private space. EVIDENCE: The home is situated in a quiet residential area of Leytonstone in the London Borough of Waltham Forest. It is close to shops, transport links and other local amenities. The home is built over three floors. The home is generally well maintained, both internally and externally. Décor, furniture and fittings were homely and domestic in character. Communal areas consist of a dining room, sitting room, kitchen and a well maintained garden, with appropriate garden furniture. Service users were St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 19 observed to move freely around communal areas. The home is no smoking apart from the rear garden area. The home has nine single bedrooms and one double bedroom. Appropriate screening is provided in the double bedroom to promote service users privacy. All bedrooms have a hand basin fitted, and meet NMS on size requirements. Service users have been able to personalise their rooms to their individual tastes, for examples with pictures and televisions. Bedrooms contained adequate furniture, including table, chair, wardrobe and a chest of draws. Curtains, carpets and bedding were well maintained and domestic in character. Rooms are all centrally heated, and radiators are fitted with protective coverings. Bedrooms had adequate natural light and ventilation. The home has adequate numbers of bathrooms and toilets to meet the needs of service users. Service users have the choice of a bath or shower. One of the baths on the ground floor has been specially adapted to help make it more accessible to one service user with mobility issues, thus helping to meet their needs around equalities and diversity. Bathrooms were clean and tidy, and free from offensive odour. However, the ground floor bathroom and one of the ground floor toilets did not have working locks fitted, and it is required that all bathrooms and toilets have working locks, which include an emergency override device. The home was generally clean and tidy throughout. To help prevent the spread of infection staff are provided with protective clothing such as gloves and aprons. Hand washing facilities are situated around the home. The home has a separate laundry facility at the far end of the garden, which was suitable in scale for the home. COSHH products were stored securely. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 20 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): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is staffed in sufficient numbers to meet the needs of service users, and that staff are sufficiently experienced and qualified to carry out their duties. EVIDENCE: The home provides 24-hour support including a waking night staff and an emergency on-call procedure. The home had a staffing rota on display, this accurately reflected the actual staffing situation on the day of inspection. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and that they have built up good relations with service users. Staff were seen to interact with service users in a friendly and respectful manner. At times service users made it clear that they wished to be alone, and staff were seen to respect this. Service users spoken to expressed satisfaction with the staff, one commented that “They are very friendly here.” All staff have been provided with a copy of their job description. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 21 The home has various employment related policies in place, including on equal opportunities and recruitment and selection. The manager informed the inspector that they intend to give service users the opportunity of been involved in any further recruitment of staff to the home. There was evidence that the home carries out pre employment checks on staff, including references and proof of ID. However, for one member of the staff team it was found that the home had not carried out a CRB check for them. There was a CRB check in place, but this was from a previous employer, but CRB’s are not transferable, and it is required that the home carries out its own CRB check on all prospective staff prior to them commencing work in the home. Ten of the thirteen care staff employed at the home have achieved an NVQ Level 2 in Care or equivalent qualification, well above the 50 minimum set by the NMS. The homes manager informed the inspector that it was the intention of the home that in time all staff should possess such a qualification. Staff undertake induction training on commencing work at the home, this includes health and safety and service user issues. Recent staff training provided by the home has included food hygiene, medication and diabetes awareness. All staff receive regular formal supervision. Records are maintained of this supervision, and staff have access to their own supervision records. Supervisions includes discussions on training, performance and service user issues. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 22 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): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that this is a generally well managed home. There are appropriate quality assurance systems in place, and health and safety within the home is managed appropriately. EVIDENCE: The homes proprietor also operates as its registered manager. They are a Registered Mental Health Nurse, and have many years experience or working in a care setting, including in a managerial capacity. Service users and staff informed the inspector that they found the manager to be supportive and accessible, and staff were observed to interact with the manager in a relaxed manner on the day of inspection. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 23 The home had appropriate policies and procedures in place. Those checked by the inspector, including medication, equal opportunities and adult protection were of a satisfactory standard and in line with NMS. Record keeping in the home was of a generally good standard. Confidential records are stored securely, staff and service users can access their records as appropriate. Care plan reviews, staff supervisions and service user meetings all contribute to the quality assurance process within the home. Copies of previous inspection reports were available to view in the home. The home issues questionnaires to service users and their relatives to gain their feedback on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback. One relative commented that “The home as a whole seems very well run and managed, with good communication between staff and residents.” Fire extinguishers were situated around the home, these were last serviced in June 2007. Fire exits were free from obstruction on the day of inspection. Fire alarms are tested weekly, and were last serviced on the 31/10/07. The home holds regular fire drills. The home has in date safety certificates for gas safety, electrical installation and PAT testing. Hot water and fridge/freezer temperatures are routinely checked. The home has in date employer’s liability insurance cover in place. St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 3 4 3 5 3 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 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 3 3 3 3 3 St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14 Requirement The registered person must ensure that comprehensive pre admission assessments are carried out for all service users prior to them moving into the home. The registered person must ensure that comprehensive risk assessments are carried out for all service users, covering all areas of potential risk to themselves and others, and that these assessments are subject to regular review. The registered person must ensure that clear and comprehensive records are maintained of all medical appointments, including the date of the appointment, who it is with, the reason for the appointment and details of any follow up action necessary. The registered person must ensure that clear guidelines are in place for the administration of any medications prescribed on an as required basis. The registered person must ensure that all staff who work at DS0000007242.V356473.R01.S.doc Timescale for action 31/01/08 2. YA9 13 29/02/08 3. YA19 13 31/01/08 4. YA20 13 31/01/08 5. YA23 13 31/03/08 St Michaels Lodge Version 5.2 Page 26 6. YA27 23 7. YA34 19 the home receive appropriate training in adult protection issues. The registered person must ensure that all bathroom and toilet doors are fitted with a working lock, which includes an emergency override device. The registered person must ensure that the home carries out a CRB check for all staff prior to them commencing working at the home. 29/02/08 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 St Michaels Lodge DS0000007242.V356473.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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