CARE HOMES FOR OLDER PEOPLE
Aden Lodge Nursing Home Long Lane Clayton West Huddersfield West Yorkshire HD8 9PR Lead Inspector
Sally McSharry Key Unannounced Inspection 21st February 2007 10:00 X10015.doc Version 1.40 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 Aden Lodge Nursing Home DS0000001106.V325969.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 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. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Aden Lodge Nursing Home Address Long Lane Clayton West Huddersfield West Yorkshire HD8 9PR 01484 866602 01484 863749 kazsmith@gmail.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) Aden House Ltd Position Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd October 2006 Brief Description of the Service: Aden Lodge provides nursing care and accommodation for up to forty elderly people. It is a purpose built brick home adjacent to its larger sister home, Aden House. The home provides single room accommodation with en-suite facilities. It is situated on the corner of the main Wakefield Road in Clayton West. Aden Lodge is owned by Aden House Limited, a local company. The home is centrally located for Barnsley, Huddersfield and Wakefield with the villages of Clayton West and Scissett providing all local amenities within a few minutes’ walk. There is a bus stop outside the home. There is a garden area for service users’ use. The provider informed the Commission for Social Care Inspection on 22 January 2007 that fees range from £354.72 to £471.00 per week. Additional charges include hairdressing, personal newspapers, private chiropody and a charge of £5.35 per hour made to escort service users to out patient and nonemergency hospital appointments. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out to the home by an inspector on 21 February 2007. The inspector arrived at the home at 10:00 am and left the home at 5:00 pm. The last key inspection, which was carried out in August 2006, identified some areas of concern and, since August, the Commission has carried out a further additional random visit. This visit took place on 3 October 2007 and was carried out to monitor the improvements made at the home following the poor inspection in August. Both the random visit carried out in October and this key inspection show the home has made good progress in addressing the issues identified. Since August last year a new acting manager, Ms Joanne Clegg, has been appointed to the home. Service users were generally very complimentary about the proposed manager, one service user commented, “We are happy to have Joanne as a friend.” During this visit, the inspector spoke to some of the service users, a visiting relative, some of the staff and the home’s management. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, carried out a brief tour of the building and observed lunch being served. Prior to the inspection, eleven service user questionnaires were sent to Aden Lodge to obtain service users’ views about living at the home. Two completed questionnaires were returned. Some service users in the home are very frail and may have difficulty completing a questionnaire. There were thirty seven service users resident in the home on the day of this visit. Relative surveys were sent out to ten of the service users’ relatives or friends. Two GP practices attend the home and questionnaires were sent to them. When the inspector wrote this report, five of the relatives had responded and one response had been received from GPs. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, minutes of residents’ meetings and a pre inspection questionnaire completed by the provider and manager. The inspector would like to take this opportunity to thank everyone who participated in the inspection process.
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
Generally, information in care plans has improved and care plans now provide better detail about the service users’ needs and how staff are to meet those needs in Aden Lodge. Risk assessments are in place and assessments and care plans are reviewed at least monthly. Service users and relatives felt their needs were being met in Aden Lodge. One relative said of Aden Lodge in the questionnaire they returned, “Meets my Mum’s needs in care for her and her medical needs”. The level of social activities has improved in the home. Some service users thought they were very good, with varied ideas and visits from a “pat a dog” service, a pantomime at Christmas and a visit from some donkeys from a local donkey sanctuary, to name a few. However not all service users felt their
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 7 needs were being met and a further recommendation has been made in this report. Comments about the food and the meals provided varied. Some service users felt they were very good, other were less impressed. Training for staff in the home has improved. The acting manager is encouraging staff to take part in National Vocational Qualification (NVQ) training. She is also ensuring staff receive mandatory training sessions. Regular staff supervision and appraisals are now beginning to take place. The new acting manager seems to be settling into her new role well. Quality assurance has been introduced at the home and is helping the company to identify good and poor practice and standards, and taking action where necessary. What they could do better:
Although care records have improved, the home uses a dressings’ record sheet that asks staff to estimate the size of any wound. This is not good practice and it is recommended that staff accurately measure and record the size of any wound every time it is dressed. Generally, the management of medications is good, however staff must ensure the medications dispensed by the pharmacist each week are correct to avoid confusion and possible drug errors. Although activities have improved, it is recommended these be reviewed with service users to ensure each service users’ social needs and preferences are being met. Meals and menus should also be reviewed with input from all service users to ensure their likes, dislikes and preferences are catered for. Comments about staffing levels from service users and relatives should be taken into account. These included, “The home is under staffed. The staff who are there do the best they can”, and “Staff are generally caring and friendly, they are under pressure due to a lack of staff”. The registered provider and acting manager should monitor staffing levels to ensure there are always sufficient staff on duty to meet service users’ many and varied needs. Work should continue with NVQ training to ensure 50 of the care staff have NVQ level 2 training or above. This is to help maintain and improve standards of care. Care should be taken to ensure the fire alarm system is checked and tested weekly at least every seven days.
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 8 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. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 9 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 Outcomes Statutory Requirements Identified During the Inspection Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. No service user moves into the home without having had their needs assessed and been assured their needs can be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and a relative confirmed when spoken to, and in questionnaires, that they had information about the home before they came to live there and that their needs had been assessed before admission to the home. The sample of case records audited showed that service users admitted to the home recently had been assessed prior to admission. One relative confirmed that the acting manager had visited her and her husband before admission to Aden Lodge and that the admission process and introduction to the home had been a good one. The relative felt they had been made to feel welcome at the home and had settled in well.
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 11 The home has admitted service users with a diverse range of needs and from a variety of cultural backgrounds. Aden Lodge does not currently provide intermediate care. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Service users’ health, personal and social care needs are set out in an individual plan of care. Suitable risk assessments are carried out and monitored. Not all records contain specific information and detail. Service users are able to make decisions about their lives with the support of staff. Medications are generally managed safely, however further steps are needed to ensure discontinued medications are removed from the system promptly. Service users are treated with respect, their privacy and dignity is maintained by the staff in the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each service user has an individual plan of care. Staff at the home have carried out work to improve care plans and there are plans to introduce new care plan documents. A sample of three care plans was checked during this visit. Care plans identified the service users’ needs and advised staff how these were to be met whilst at the home. Risk assessments are in place and care plans and risk assessments have been reviewed at least monthly. Service users and their relatives/representatives are encouraged to take part in the development of care plans, however not all choose to do so and there is a document which service users and relatives have signed about this. Daily records and care plans are now quite detailed, however the home uses a dressings’ form to monitor and record the management of wounds or pressure ulcers. This form is not specific and asks staff to assess the wound as small medium or large. This system is not accurate and should be changed. Staff should measure and record the actual size of the wound each time it is dressed. This is a good practice recommendation of this report. Appropriate pressure relieving equipment is available for service users who have ulcers or are at risk of developing ulcers. There is written evidence that other health care professionals visit the home and service users confirmed that the chiropodist, optician and dentist visit when required. The one survey returned by a GP indicated that staff at the home provide appropriate care and support to service users. Service users who spoke with the inspector confirmed that they are able to make choices about their care and their lives in Aden Lodge. One service user spoke about their wish to have a local dentist and optician. Although this took time to arrange, staff at the home were able to access these services locally to meet the individual’s wishes. The management of medications has generally improved in the home. The home uses the Nomad monitored dose system for administering medications. In this system, the pharmacist dispenses a week’s medications into a cassette with seven chambers, one for each day of the week. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 14 The medications of three service users were audited. Two were found to be correct. The third highlighted a problem. Aspirin had been discontinued by the GP, however the pharmacist had continued to dispense the aspirin into the cassette. On two of the three mornings prior to the visit, the aspirin had not been given and remained in the cassette, however it had been removed from the cassette on one day. It was not clear if it had been administered or removed and destroyed. Staff at the home contacted the pharmacist immediately and arranged for the aspirin to be removed from the cassette. Care must be taken to check the cassettes when they come into the home. If the pharmacist has dispensed medications that have been discontinued, staff must contact the pharmacist to have the medications removed from the cassette immediately. This is to avoid any drug error occurring. Staff should sign to say they have checked the cassettes as they come in and that they are correct. All the service users who spoke with the inspector felt the staff in the home were kind and caring, treated them with respect and maintained their dignity. One service user stated in the returned questionnaire about staff, “Caring staff, excellent - kind and gentle”. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users’ social, cultural, religious and recreational needs are generally being met, however further improvement should be made; service users are helped to maintain contact with their families and the local community. Service users are able to exercise some choice and control over their lives. Meals provided should be more varied and reflect service users’ preferences. Meals are served in a pleasant environment and service users who need support receive the assistance they require. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and relatives said at the visit, and commented in questionnaires, that activities in the home have improved. One service user commented about activities, saying “At Christmas they did us proud”. Other service users spoke of crafts, games and a charity auction that had been held at the home.
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 16 The inspector had a very lively and animated conversation with a small group of service users who advised that they would like more exercise classes in the home. This was discussed with the acting manager. It is recommended in this report that the activities provided in the home be reviewed with input from service users to ensure the activities being offered meet all the service users’ needs and preferences. Relatives and friend said at the visit, and in returned questionnaires, that they are always welcomed into the home. Those service users who are able, leave the home and go out with their relatives. Members of the local community visit the home and a monthly church service is held at Aden Lodge. Service users confirmed that they do have choice over their lives in the home. They are generally able to choose when they get up in a morning and go to bed at night, what they wear and where they spend the day. Activities are offered but service users are able to choose whether to join in or not. Comments received about the meals provided were varied. Some service users felt the meals were good and that there was always a choice available. Others said it was difficult to please everyone all the time. However, some service users were not happy with the meals provided, saying they had chips too many times, that food was sometimes cold when served and that they would like more variety at tea time. Service users did say that the acting manager had found a supplier of “tripe” as some service users had asked if they could have some. A delivery of tripe was expected within the week. These comments were discussed with the acting manager and it was recommended that meals and menus be reviewed with input from service users to ensure individual service users’ likes, dislikes, preferences and suggestions be taken into account and menus reviewed accordingly. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Service users and their relatives and friends are confident to make complaints and that these will be listened to and taken seriously. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection three complaints have been made at the home. These have been investigated and a response has been provided to the persons raising the concerns. One related to care and was partially upheld. One was about the laundry service; this has been addressed and, since, the person raising the concern has written again to the home complimenting them. The third complaint has not yet been resolved, however the acting manager has responded appropriately in writing to the person raising the concern. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 18 All service users and relatives who spoke to the inspector and returned questionnaires confirmed that they knew the complaints procedure and how to make a complaint. Service users and a visiting relative who spoke with the inspector felt that if they need to they would be confident to raise any concerns they might have. Service users are protected from abuse in the home. All members of staff have had adult protection training. During the visit, when asked, service users said they felt safe in the home. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and the standard of accommodation fixtures and fittings are good. Service users and staff advised that seventeen bedrooms have been redecorated and new carpets have been provided in some bedrooms and the lounge. Service users also said the home was always clean. During this visit, the home looked clean and tidy and no unpleasant odours were noticed. The two service user questionnaires returned also commented on the high standard of cleanliness in the home.
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 20 Service users’ rooms were pleasant and some had been personalised with photographs, pictures and small items of furniture. The home has a maintenance person who sees to day-to-day repairs. There is also a system of planned maintenance and service checks carried out. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 21 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Care should be taken to ensure that suitable numbers of skilled staff are employed. The staff receive induction and foundation training and are competent to work in the home. Staff recruitment policies and records protect service users. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the visit, there were thirty seven service users resident in the home. The acting manager reported that recently the home has had some staff members off sick with the flu. Records show that vacant shifts have, wherever possible, been covered by agency staff. A present, the home has a manager who is supernumerary to staffing levels. There is one nurse, five care staff and one care cadet on duty during the morning. During the evening, there is one nurse and four care staff on duty. At night, there is one nurse and two carers on duty. Two questionnaires returned stated that there were staff shortages in the home and that staff were very good and caring, however there weren’t enough staff. One service user also spoke of staff shortages. They said that the regular
Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 22 staff were “top class”, however they were sometimes “overwhelmed” and “under pressure” particularly during the evenings, at teatimes and at bedtime. These comments were discussed with the acting manager. In a service where people’s needs frequently change, the manager and registered provider should ensure staffing levels are kept under review. At all times, staffing levels must be sufficient to meet the needs of service users in the home. National Vocational Qualification (NVQ) training is progressing in the home and 29 of the care staff in the home have a NVQ level 2 in care practice. A further seven staff are undertaking this training. It remains a recommendation of this report that 50 of the care staff in the home are trained to this level. Training has progressed in the home. Staff records show that all staff are receiving regular mandatory training in movement and handling, fire safety, infection control, adult protection and abuse. Other training provided includes dementia care, palliative care and complaints awareness. New staff receive a detailed induction and staff supervision and appraisals are now being implemented. The recruitment and training records of three members of staff were audited. Recruitment records were complete and included all the required references and checks. This helps to protect service users from staff who might be unsuitable to work with vulnerable adults. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 23 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Service users live in a home with an experienced and competent acting manager. The home is now being run in the best interest of service users. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are generally promoted and protected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 24 EVIDENCE: Since the last inspection, a new manager has been proposed to run the home. Ms Clegg has worked in the home before and has settled into her new role well. Members of staff, service users and relatives reported Ms Clegg to be approachable and the home has an open friendly atmosphere. Ms Clegg advised that she has submitted an application to the Commission for Social Care Inspection to become the registered manager and she has commenced the Registered Managers Award. Since the last key inspection, a quality assurance manager has been appointed by Aden House Ltd. Quality assurance questionnaires have been sent out to service users and relatives. The results of these questionnaires are currently being summarised. This information is to be printed out and made available in the home. The quality assurance manager has also spent a week in the home auditing systems and practice. A report has been produced highlighting the areas to be addressed by the acting manager. A service user and relative meeting has been held and the minutes of the meeting were available. These showed that service users are being asked for their opinions about the service and ways to improve the service provided. On a monthly basis, Aden House Ltd produces a management report monitoring the service and identifying any issues to be addressed. No one at the home acts as an appointee for any of the service users. Some service users have small amounts of spending money held by the home. A sample of these records and monies was audited during this visit. Records are clear and show how money has been spent on the service users’ behalf. All money checked was correct and corresponded to the records held. There is a planned maintenance programme in place in the home, with records to show maintenance checks and tests have been carried out. Records seen during this visit noted that routine weekly tests and checks of the fire alarm system had not been carried out weekly. On some occasions, checks had not been carried out for ten days. Care should be taken to ensure the fire alarm and emergency lighting is tested every seven days. This is a recommendation of this report. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 Requirement Care must be taken to check the Nomad medications cassettes when they come into the home. If the pharmacist has dispensed medications that have been discontinued, staff must contact the pharmacist to have the medications removed from the cassette immediately. This is to avoid any drug error occurring. Staff should sign to say they have checked the cassettes as they come in and that they are correct. Timescale for action 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Staff should measure and record the exact size of any wound every time they redress the area so that everyone can clearly see if the lesion is getting bigger or smaller.
DS0000001106.V325969.R01.S.doc Version 5.2 Page 27 Aden Lodge Nursing Home 2. OP12 3. OP15 4. 5. OP28 OP38 The activities provided in the home should be reviewed, with input from service users, to ensure the activities being offered meet all the service users’ needs and preferences. The meals and menus should be reviewed with input from service users to ensure individual service users’ likes, dislikes, preferences and suggestions be taken into account and menus reviewed accordingly. Work must continue to ensure 50 of care staff have NVQ level 2 or equivalent. Care should be taken to ensure the fire alarm and emergency lighting system is tested every seven days. Aden Lodge Nursing Home DS0000001106.V325969.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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
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