Inspection on 22/06/05 for Minster Lodge Residential Care Home

This inspection was carried out on 22nd June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Minster Lodge Residential Care... 22/05/07

Minster Lodge Residential Care... 15/11/06

Minster Lodge Residential Care... 25/04/06

Minster Lodge Residential Care... 08/03/06

Minster Lodge Residential Care... 21/09/04

Minster Lodge Residential Care... 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Minster Lodge 6 Westminster Road Earlsdon Coventry CV1 3GA Lead Inspector Suzette Farrelly Unannounced 22 June 2005 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 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 Older People. 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. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Minster Lodge Address 6 Westminster Road Earlsdon Coventry CV1 3GA 02476 552585 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) R M Health Ltd CRH 27 Category(ies) of PC- Care Home only registration, with number of places Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Minster Lodge is situated close to Coventry City Centre and can be reached aeasily using public transport. Parking is prohibited on the road and the home does not have its own parking facilities. There is a Pay & Display care park close to the home. The home is situated over two floors and can care for 27 older people who are frail. There is one shared rooms and the remained are single occupancy. There are two bedrooms with en-suite toilets, one was occupied at the time of the inspection by a respite resident. The remaining rooms have no en-suit facilities and the residents use the communal toilets and bathrooms. There is a back garden which is secure. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived at the home at 8:00 am, three care staff were on duty with the cook. It was found that there was one member of care staff absent this shift was not covered. The acting manager was not available until later that day, and the deputy manager did not arrive until 11:30am. Also the domestic staff were absent. It was observed that the three care staff assisted the residents to meet their needs, did some basic cleaning of the lounge, dining areas and the communal toilets. The care staff were also responsible for laundering the residents clothes and linen. From discussion it was found that the home rarely use agency staff when carers are absent. The role of the manager is to ensure that there are sufficient staff on duty at all times to meet the needs of the residents and ensure that the environment is maintained. The inspector spoke to five residents, two staff and one relative, their comments have been taken into account within this report. There are various areas of the home where floor coverings require replacement. It was found that some bedroom furniture has been replaced and this is an ongoing programme. On the day of the inspection it was very warm outside and the radiators in the main lounge and one resident’s bedroom were found to be broken and the heat could not be turned off, this increased the heat in these rooms and felt quite uncomfortable. The inspector was informed that an engineer was visiting later to fix this. The manager’s office is situated on the first floor, there is no natural ventilation and the area is very small. Sitting is this room became very uncomfortable after only a short time. The garden is spacious but very untidy and there was a lack of suitable garden furniture for the residents to use. A letter of serious concern was sent to the home regarding the poor state of the Kitchen, poor care planning and environmental issues related to the sluice area and flooring in the bathrooms and residents bathrooms. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home did not perform well during this inspection and there are a number of areas that require attention, below is a summary. • • • • • • • Specialist training for staff to ensure that they can meet the complex needs of all the residents. The home must ensure that all residents have care plans that address their needs and these must be evaluated monthly and changes in needs clearly stated. Risk assessments are available, however, these are not being completed properly giving a false reading and resulting in possible oversight of care and harm to the residents. The home does not have a system that adequately monitors the residents’ physical and/or mental health. The home has no activity organiser, activity programmes and there no books, magazines, games or other items of interest visible in the home. There are no risk assessments related to residents leaving the home alone, this could cause increased risk to the residents. The kitchen is not following the policies and procedures, it was found to be disorganised, not very clean and records were not up to date. E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 7 Minster Lodge • • • • • • • • • • • • Food in the fridge is to be labelled with the date to ensure that it is not used when out of date. The cleanliness of the home requires attention. There must be sufficient care staff, domestic staff and laundry staff available at all times to ensure that the care and needs of the residents is met. The environment requires attention, areas need decorating, some carpets need replacement; some furniture requires repair or replacement and the bathroom window must be covered to maintain the residents’ privacy. Some bedrooms smell unpleasant and the home must deal with this. There are a large number of flies in the home bedrooms and this needs to be addressed. The radiators must be covered to prevent scalding. The home must ensure that there are adequate staff on duty at all times and that there is a policy to ensure that absence and sickness of staff is covered appropriately. The home must fine a way to involve the residents, their representatives and the staff in changes that occur in the home. The home must develop a quality assurance and monitoring system. All care staff must receive supervision six times a year and other staff must receive supervision and appraisals at least yearly. The manager must ensure that all safety checks related to fire, health and safety and maintenance. 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. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 4, 5 The residents have not been issued with a contract of terms and conditions resulting in the residents’ not being aware of extra costs and the responsibility of the provider and the resident. This can reduced the residents’ right to choice. The home could not demonstrate that it is capable of meeting the complex needs of some of the residents this could result in an oversight of care and poor outcomes for the resident. All prospective residents are offered the opportunity to visit prior to admission increasing their right to choose. EVIDENCE: The new contracts were discussed, the home has had these since December 2004 and they have still not been issued. This was discussed and the manager said that they were now ready to be given to all residents or their representatives. The home has a number of residents with complex mental health needs, from discussion, records and observation it was found that the staff are not trained Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 10 to manage some of the needs of the residents and it was observed that they did not react appropriately to one resident who was very anxious and at times distressed. The care plans did not include the care necessary to deal effectively with the residents’ mental health issues, and challenging behaviour. There was no evidence that specialised services are offered to residents with mental health problems and there was little evidence that the residents are stimulated through activities. The home states that all residents are offered the opportunity to visit prior to admission, one resident spoken to said that her relatives found the placement and she trusted their judgement. She also said that she had time to make up her mind about remaining at the home, the resident revealed that the staff were nice to her however, they kept giving her sprouts for dinner event though she had informed them that she did not like them. The relative stated that she had no concerns about the care received. There was an absence of books, newspapers and other items of interest for the residents to use. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The residents’ health, personal and social care needs are not all set out in an individual care plan resulting in a possible oversight of care resulting in harm. Residents are not always protected by the homes’ policy and procedures for dealing with medicines and therefore there is a risk to the residents. The residents’ right to privacy is upheld and they feel that staff treat them with respect increasing the residents self-worth and positive experience of care. EVIDENCE: Three service users care profiles were seen. One profile had a new format for care planning which addresses all the care needs of the resident. The other two profiles still had the older format and these did not cover the assessed needs of the resident. Discussion demonstrated that the home is in the process of changing all the care plans and that these will all be in place at the next inspection. It was noted that there are no care plans for residents with mental health issues or challenging behaviour. This was also discussed and the manager informed that she would look into this. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 12 There was no indication that the care prescribed is evaluated monthly, this could result in an oversight of care and eventual harm to the resident. There is evidence of resident and family involvement in the development of care plans where possible. The home has a risk assessment to determine if residents are at risk of pressure damage to their skin. These were seen in two of the profiles and had been scored wrongly, giving a lower score. This could result in the home not taking appropriate action with the outcome of pressure damage. Pressure relieving equipment was seen; no corresponding preventative care plans were seen, which may result in an oversight of care needs being met. Nutritional screening started six weeks ago and these are to be completed on a monthly basis to establish if there are changes. Residents are not weighed regularly and this may result in continual minor weight loss not being recognised and complications of malnutrition occurring. A high number of residents have mental health issues and the home does not monitor their mental well being. This could result in changes not being recognised and the risk of further deterioration in mental health occurring. The residents were seen walking around the garden and the home, there was no evidence of structured physical activity for those residents who were less mobile. The storage, administration and disposal of medicines are correctly carried out and the records seen were up to date. The prescriptions written by the home are not signed, it is good practice to sign and date all prescription and include the quantity of medication available. In one profile it indicated that the resident gave their own medicines, when examining the medicine records this was not so. This could cause confusion and errors may be made. It was confirmed that staff who administer medication have received training either from North Warwickshire College or the local pharmacist. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Social, cultural and recreational interests and needs are not completely met by the home and the residents’ life style experience may be reduced. Residents can maintain contact with family, friends and the local community if they wish ensuring their right to choose and maintaining their sense of belonging. The residents do not always receive a wholesome appealing balanced diet in pleasant surroundings, which may result in reduced dietary intake and complications of malnutrition. EVIDENCE: During the inspection no activities were seen, there were no leaflets or information about forthcoming activities available. One resident spoken to stated that she is often bored of sitting with nothing to do, and from where she was sitting she could not see the television. Daily routines are to some degree flexible, however meals are served at a stated times, however residents may choose to eat later. Their meal is chilled and re-heated. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 14 The home does not have an activity organiser and the care staff are instructed to carry out two hours of activities in the afternoon. This was not seen and as there were insufficient staff on duty this would be difficult to achieve. The lack of stimulation and activities may result in an increase of challenging behaviour or lethargy. A number of residents go out into the community alone, no risk assessments were available and one resident is at risk due to his alcohol intake. The home encourages residents to make contact with the local church and some are involved and go to services and other events. Some residents are taken to the local shopping area and the city centre, which is close by. A high proportion of residents do not have relatives or friends visiting and only a few have advocates. Three male residents were seen in their bedrooms and it was confirmed that they rarely leave their rooms. There was no evidence that the home attempt to encourage these residents to participate in one to one interactions or smaller groups. The home manages small amounts of the residents’ personal monies for items such as toiletries, newspapers and personal items. The home also uses advocates from Age Concern for some residents who do not have relatives or representatives. Some of the residents can manager their own money with assistance if required. Records are maintained by the home and these were examined. The tour of the home showed that some residents have personalised their rooms others have not, the manager stated that this was in part to do with the relatives. After breakfast the residents are asked what they would like for lunch. The menus state that there are two main choices, however if the resident does not want either of these there are further choices of omelettes, salads and backed potatoes. These options were not offered. The meal is served in the dining room, the carpet is stained and there is an underlying smell of stale food. The meal was average, belly pork was served which had a large amount of fat, the potatoes were slightly hard and the vegetables were over cooked. The residents were offered assistance where required. Drinks are served at regular times during the day, it was noticed that residents in their bedrooms did not have a jug of water or any other drinks, this may result in dehydration especially when the weather is hot. The kitchen area was examined and it was found to be untidy, disorganised and some food items were out of date. Areas such as the work surfaces, the Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 15 microwave and cooker were not clean and a dirty jug and two cups were found with the clean items. A bin without a lid and other movable items blocked the back door, which is the main exit. The records required for cleaning the kitchen could not be found and the kitchen staff were not available to give information. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17, 18 The residents’ legal rights are protected reducing the risk of financial or legal harm. The homes policies, procedures and practices protect the residents from abuse and harm. EVIDENCE: Through discussion it was found that all residents are registered on the electoral role and have the opportunity to vote if they wish. Some residents choose to use the local polling station and other use postal voting. Age Concern advocate for some residents and there have been no concerns raised related to the financial handling of residents’ monies. Accounts of incoming and outgoing monies for the residents are up to date and correct. The home has a number of policies and procedures related to the protection of residents from abuse. These are kept in different folder and initially they were difficult to find. This was discussed with the manager who agreed that the policies would be better kept together. The home has had one allegation of abuse from a resident concerning the practices of a member of care staff. The home suspended the staff member and proceeded to follow the local and national guidance. The incident was unfounded and the member of staff returned to work. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 The residents do not live in a safe, well maintained, comfortable and homely indoor and outdoor environment reducing their quality of life. The residents’ personal space is poorly maintained and in some cases lacks comfort and personalisation reducing the residents’ quality of life. The home is unclean and dreary and a number of areas have an unpleasant smell reducing the quality of the service users life. EVIDENCE: The inspector toured the home and garden and found that these were poorly maintained. The rear garden is laid out with pathways and a selection of ground level and raised flowerbeds. The path had weeds growing between the slabs and the flowerbeds had a few mature shrubs and many weeds. A resident had attempted to weed part of this area. There was a poor selection of dirty plastic furniture and the area needed sweeping and rubbish removing. The domestic Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 18 waste bin was overflowing and the area around these bins was untidy and disorganised. The manager stated that there was more garden furniture in storage. A number of residents were seen using the garden and this is the main area where the men smoke. The dining area was untidy and smelt of stale food, the carpet was stained and the décor looked tired. One resident spent most of the day in this area watching a small portable television and smoking. The manager said that residents are allowed to smoke in this area except during meal times. The lounge is in the front of the home and it was noticed that the main radiator could not be switched off; this made the area very warm and uncomfortable. The manager stated that an engineer was due to visit the home and deal with the problem. The carpet in this area was in need of hoovering, and the overall area was dusty. Some corridors are in need of redecoration and look tired and scuffed in places. The bedrooms vary, some have been redecorated, however a larger number are in need of attention. In many rooms the furnishings are old and broken and most residents do not have a locked facility for their own use. Some bedroom carpets are old and in need of replacement and there are a number of rooms that have an unpleasant smell. The en-suite toilet in the respite room requires new flooring, the floor tiles are lifting making it difficult to maintain cleanliness and increasing the risk of tripping, and this is also the case in the bathroom in the same area. One bathroom has a selection of un-named toiletries, which implies that communal toiletries are being used for the residents. The personalisation of the rooms varied, in part this is due to the residents not having relatives, however the home has made little effort to make these rooms comfortable. They appear sparse and dreary. A resident stated while in his room that he was very warm, on investigation his radiator had been left on and no one had shown him how to adjust the thermostat. The laundry area also contains the sluice. The sluice area was untidy, the floor was very wet and it was difficult to determine if there was a leak or the water had come from the commode pans stacked on the floor. There is no hot water in the sluice area and the spray gun used to clean the commode pans is ineffectual. The sluice sits between the washing area for clothes and the clean area where the clothes are ironed and stored. There is no door to the sluice area. This was discussed with the manager and there are no plans to alter this Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 19 situation. There is a risk of contamination and cross infection due to the poor management of cleaning commode pans. The laundry area is untidy and appears disorganised. The residents’ clothes seen varied in condition one resident was seen with buttons missing from her dress and a male resident had buttons missing from the cuffs of his shirt. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 There are insufficient staff on duty resulting in possible oversight of care and risk of harm to the residents. The level of training and the employment process ensure that the residents are in safe hands at all times. EVIDENCE: On arrival to the home there were only three care staff on duty. The manager was not available until later and the deputy manager arrived after 11:00 am. There was no domestic or laundry staff available in this day. Care staff were seen offering care to the residents cleaning the communal areas and carrying out laundry duties. These extra duties meant that the care staff could spend only limited time with the residents meeting their individual needs. This strain on staff could result in an oversight in care and an increased risk of harm to the residents. The home does not have a policy on replacement of staff that are sick or absent from work and often manage with reduced numbers. Half the staff are trained to National Vocational Qualification II in care, which suggests that they have achieved the basic levels in care. Staff did not always demonstrate this and it is suggested that this is due to the reduced numbers of staff and the dual roles. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 21 Four staff files were examined and it was confirmed that the procedure for employment are followed and all checks are made to ensure that the prospective employee is suitable to work with vulnerable adults. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 36, 38 The residents do not benefit from the ethos, leadership and management approach of the home and it is not run to their best interest resulting in increased risk of harm and reduced quality of life. Staff are not supervised increasing the risk of job dissatisfaction and inconsistency of care for the residents. The health, welfare and safety of the residents and staff are not fully promoted and protected increasing the risk of harm. EVIDENCE: The present manager has been in post since March 2005, during this time some areas have been addressed and the manager informed that there was resistance to new ideas. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 23 The lack of staff numbers on duty and lack of actual support for the staff was evident throughout the inspection. It was also evident that the manager does not audit the home and systems used to ensure that the areas such as the kitchen and laundry are maintained to an acceptable level. It was difficult to determine the impact of the change in management and through discussion it is apparent that there is resistance to changes that the manager wishes to implement. The auditing of the home and surveying of the residents and others involved in the home is insufficient and incomplete. The manager could not show what changes would be made from the results of the limited survey and auditing that has been conducted. The residents’ personal monies were checked and it was found that all records of incoming and outgoing money with receipts were available and up to date. Formal supervision of staff has not started, the manager stated that the contracts for supervision are now available and she will start supervision in the near future. Supervision assist staff to carry out their role more effectively and it also ensures that all staff work toward the philosophy and ethos of the home. The records related to health and safety of the home were examined, these records were disorganised and time was taken to find all the necessary test certificates and records. There were no records related to fire safety, the alarms are not regularly tested and the door closures are also not checked. There was also no evidence that the system had been serviced for more than a year. There were no records for the hot water outlets to ensure that the thermostatic mixing valves are working. The home does not have suitable risk assessments and there is further work required to ensure that the staff receive appropriate training in the control of substance hazardous for health. It was also found that there are new formats for induction of new staff these have not yet been implemented. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 2 COMPLAINTS AND PROTECTION 1 1 3 3 2 2 2 1 STAFFING Standard No Score 27 2 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x 2 2 x 3 2 x 2 Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 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 OP3 Regulation 14(1)(d) Requirement The manager must ensure that the staff have received suitable training in specialist areas sush as challenging behaviour to assist them in meeting the needs of the resident. The manager must ensure that there are suitable facilities available for residents who have sensory or physical deficits. The manager must ensure that all care plans are evaluated monthly and that the outcomes are recorded and signed. The manager must ensure that changes in residents physical and mental health are clearly recorded. The manager must ensure that the risk assessment tools are used correctly and that staff do not omit scores. The manager must ensure that there is a suitable monitoring format to assess residents mental and physical health. The manager must ensure that there is an activity programme available each week and the residents and/or their families are aware. Timescale for action 30.09.05 2. OP3 31.06.05 3. OP7 31.07.05 4. OP7 31.08.05 5. OP8 31.08.05 6. OP8 30.09.05 7. OP12 31.08.05 Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 26 8. OP13 9. OP13 10. 11. OP15 OP15 12. OP19 13. 14. OP20 OP21 23 15. OP21 16. OP24 17. OP24 The manager must ensure that those residents who go out alone are risked assess to ensure that the risk of harm s minamised. Any restraint of leaving the home or restrictions to freedom must be clearly documented. The manager must ensure that those residents without relatives are given the opportunity to go on outings and have fun. The manager must ensure that all food in the fridge is labelled once opened. The manager must confim that the carpet in the dining room is now clean and/or replaced and that the walls are suitably recevoratd. The manager must furnish the Commission with an acton plan on how the issues related to the garden and iterior of the home are to be addressed including the time this will take. The lighting is poor in the main lounge the manager must assess this and make suitable changes. The regiatered provider must ensure that the bathrooms have adequate lighting, are suitable decorated and where need the floor covering is changed. The registered provider must ensure that the plain glass window in the bathroom is either covered appropriately or fitted with suitable covering to ensure privacy. The registered provider and manager must ensure that all broken furniture in the bedrooms is replaced, an action plan with time scales must be forwarded to the Commission The registered provider and manager must ensure that unpleasent smells in bedrooms E53 S50158 Minster Lodge V234524 220605 Stage 4.doc 31.08.05 31.07.05 31.06.05 31.09.05 31.08.05 31.08.05 31.08.05 31.07.05 31.08.05 31.08.05 Minster Lodge Version 1.30 Page 27 are dealt with. 18. OP24 The registered provider and manager must assess why there are a large number of flies in some rooms in the home and find a suitable way of minimising this in line with infection control and health and safety. The regiatered provider and manager must ensure that all radiators are covered in areas used by the residents. AN action plan with time scale must be sent to the Commission. The manager must ensure that where there are no readiator covers a full risk assessment is carried out to minimise the risk of harm to the resident. The manager must ensure that the lighting is bright and safe in the residents areas. The manager must ensure that all staff are fully aware of infection control issues particularly related to laundering and managing the sluice area. The registered provider and manager must ensure that there are sufficient staff on duty to carry out all the necessary tasks such as cleaning, laundering and caring for the residents. A clear policy must be available to ensure that unplanned absence or sickness of staff is dealt with appropriately and suitable cover is made available. The manager must ensure that the residents, their families and the staff are involved and consulted in changes that are occuring in the home. Records must be maintained. The registered provider and manager must ensure that a complete quality assurance and 31.07.05 19. OP25 13(4) 23(2)(p) 31.08.05 20. OP25 13(4) 23(2)(P) 31.07.05 21. 22. OP25 OP26 13(4) 23(2)(p) 13 16 23 31.07.05 31.07.05 23. OP27 31.07.05 24. OP27 31.08.05 25. OP32 31.08.05 26. OP33 30.09.05 Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 28 27. OP36 28. OP37 29. OP38 30. 31. OP38 OP38 32. OP38 33. OP38 34. OP38 monitoring system is in place and that results from audits and surveys inform changes in practice and provision. The manager must ensure that all care staff receive supervision six times a year and these records are available for inspection. The manager must ensure that all records related to the home and residents are up to date, organised and easily available for inspection. The manager must ensure that the fire safety checks are made as required, to include fire alarms, automatic door closures, and emergency lighting. The manager must ensure that staff attend fire training and participate in regular fire drills. The manager must ensure that all portable electrical equipment is checked, records must be available for inspection. The manager must ensure that all hot water outlets are tested monthly and remedial action taken if above the recommended temperature. The manager must ensure that pathing and steps are maintained and kept free from weeds, obstructions and trip factors. The manager must ensure that any water outlt not used for seven days is flushed and a record is maintained in line with legionellea safety. 31.08.05 31.07.05 31.07.05 31.08.05 31.07.05 31.08.05 31.07.05 Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP19 OP19 Good Practice Recommendations It is recommended that the home implement a suitable homely medication policy and procedure. It is recommended that an assessment of the suitablity of the managers office in line with health and safety at work is carried out and if required a more suitable space found. It is recommended that an assessment of garden furniture is conducted and where required new furniture is pirchased. Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection 5th Floor Coventry Point Market Way Coventry CV1 1EB 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 Minster Lodge E53 S50158 Minster Lodge V234524 220605 Stage 4.doc Version 1.30 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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