CARE HOMES FOR OLDER PEOPLE
Aisling Lodge Church Street St Neots Cambridgeshire PE19 2BU Lead Inspector
Don Traylen Key Unannounced Inspection 10:00 22 September & 3rd October 2006
nd 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 Aisling Lodge DS0000064767.V313757.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. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Aisling Lodge Address Church Street St Neots Cambridgeshire PE19 2BU 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) 01480 476789 01480 214410 Orchid Care Homes Ltd Mrs Morag Morgans Care Home 22 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19) of places Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. OP (19) for the duration of condition number 2. DE(E) for 3 named females for the duration of their residency only. DE(E) 3 places for unnamed individuals over 65 years of age with dementia. When 3 unnamed individuals over 65 years of age with dementia are in the home then the number of other service users may not exceed 19. 18th April 2006 Date of last inspection Brief Description of the Service: Aisling Lodge is a privately owned registered care home that provides accommodation and care for up to twenty-two people over 65 years of age. The home is situated close to the centre of the busy market town of St. Neots, opposite the church, with shops and local facilities only a few minutes walk from the home. Originally a Victorian rectory, the old part of the house retains many original features. It has been extended to provide accommodation in single and double rooms. The walled garden is well maintained. As at April 2006 the fees ranged between £345 and £500. Additional costs include those for private chiropody, hairdressing and some toiletries. A copy of the inspection report is available at the home on request and via the CSCI website. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted as key inspection requiring all key National Minimum Standards to be assessed. Two visits were made to the home on the 22nd September & 3rd October 2006 by two Regulation Inspectors, Don Traylen and Janie Buchanan. National Minimum Standard 9 was not assessed on this occasion but will be assessed by a specialist pharmacist inspector who is intending to follow up a previous pharmacist inspection carried out on 18th April 2006. The inspection methods that were applied included a review of information received by the Commission since 18th April 2006, such as Regulation 37 and 26 reports; Protection of Vulnerable Adult Strategy Meeting minutes; a tour of the premises; discussions with the Registered Manager and with the Responsible Individual; an assessment of the home’s policies; staff records; training records; other records the home are required to maintain relating to health and safety; service user’s care plans and their assessments and interviews with three care assistants. A considerable amount of time was given to making observations of the interaction between service users and care staff, observing service users’ needs and routines and talking to service users and to care staff to determine their level of knowledge and understanding of service users’ needs. Two visiting relatives were spoken to. During the two days of inspection there were visits to the home by a GP and District Nurses and on one day a McMillan nurse visited. Both inspectors relayed their findings to the Registered Manager on the 22nd September and to the Registered Manager and the Responsible Individual, on the 3rd October 2006. What the service does well:
Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 6 A pleasant and comfortable environment is provided for service users. Service users confirmed they were satisfied with the care they received and considered they live in a comfortable and friendly home. Staff were observed to be pleasant and appeared enthusiastic about their roles as care workers. Care staff were generally found to be respectful, polite and good communicators and in some instances had an informed and appropriate knowledge of service users’ routines of care. Care staff who have gained NVQ level 2 awards in care is more than the adequate percentage (over 50 ) expected by National Minimum Standards. The manager considers that she is supported by the registered providers. She has been trained by Cambridgeshire County Council as a key practitioner in the Protection of Vulnerable Adults. The home has developed questionnaires for service users/relatives and staff to comment on the quality of the service. What has improved since the last inspection?
Eight of the ten requirements made at the last inspection were met. The two requirements made about medication were not assessed and therefore remain until a pharmacist inspection is carried out. Four of the five recommendations made are considered as met and the remaining one has been amended to suggest that continuous external training arrangements are sought. Additional care staff have been employed and over the two days of inspection the home demonstrated they have increased the number of staff working and have a planned approach to providing extra staff at busier times of the day. The services of a handyman have also been organised. Further staff training had been arranged and some of this had been provided. Infection control and POVA training was being given to care staff on the first day (22nd September) of the inspection and further dates for this training for the remaining staff had been arranged. Appropriate recruitment procedures had been followed in the case of the one recently recruited member of care staff. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 7 A Health and Safety Officer’s revisit report dated 25/09/2006 indicated the home have attended satisfactorily to concerns previously identified. The service has improved by making improvements in staffing levels and in training and through preparation to introduce new care plans, a sample of which was shown to the inspectors and considered to be a good model. What they could do better:
The Service User’s Guide must include the range of fees asked by the home. Care plans and care planning should embrace the philosophy of inclusion and consultation. For instance, service users or their representatives should be aware of and included in the preparation and writing their own care plan and sign it whenever possible. Care plans must include sufficient detail about service users’ changed needs and the current and accurate information about the specific assistance that is needed. Health Service intervention that is provided by visiting community nurses or other Health Service professionals must be recorded and instruction offered by community nurse or GPs about a service users care needs must be recorded in their care plan. Reviews of care plans must be carried out and agreed whenever appropriate It is anticipated that the home will improve their care planning and recording after the open and full discussions between the manager and the inspectors. During the inspection the manager showed the inspectors a pro-forma care plan and declared her intentions for these to be utilised in a person-centred manner. Whilst it is acknowledged that the manager is an NVQ assessor and a Moving and Handling trainer it was discussed with her that there are some aspects of these topics that should be improved. For instance, the manager must monitor and ensure that care staff do not undertake any non-recommended or unsafe manoeuvring practices. Additionally, the home should seek to establish, with the professional advice of an Occupational Therapist, that the specific needs of service users are confirmed and the equipment used by the home to aid moving and handling is appropriate to individual service user’s needs. Service users who need to use wheelchairs or hoists must be provided with the correct type of equipment for their individual needs. The correct equipment must be made available and the accuracy of needs associated with manual handling must be comprehensively and accurately recorded in individual care plans. As a result of the above processes being arranged, the manager should initiate any re-training of care staff and new instructions about moving and handling. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 8 The manager must be able to assure that the moving and handling training and skills that she has instructed care workers with, is accredited training. A regular monitoring system must be devised to quality assure that care staff are carrying out appropriate moving and handling skills. Staff training arrangements in dementia care and POVA should be continuously updated. Refresher training and more advanced training in both of these subjects should be provided so that staff are enabled to improve their knowledge and care skills and are more confident of their responsibilities to report a potential allegation of abuse. The manager, who is a Cambridgeshire Local Authority trained “Key Practitioner” in adult abuse is expected to proactively promote the prevention of abuse, as part of her responsibilities and agreement as a key practitioner. A system should be introduced to monitoring the timeliness of service users baths and to ensure that the slow flow of hot water does not delay or prevent service users from having a bath. Any outcomes must be in the service users best interests. The activities that are stated in the Service User’s Guide should be promoted or alternative social and physical stimulation should be provided. Offensive odours that were identified in the home are expected to be eradicated. 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. Aisling Lodge DS0000064767.V313757.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 Aisling Lodge DS0000064767.V313757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, Quality in this outcome area is good. Service users are guaranteed an appropriate admissions procedure to the home and their needs are satisfactorily known by the home prior to admission. EVIDENCE: The home has written a Statement of Purpose and an admissions policy that explains the admission process. Service users’ files indicated pre-admission assessments were completed and in some cases visits were made to the home by prospective service users and their relatives. One service user who was admitted for emergency respite care had a PCT Care Manager’s assessment that was “basic”. There was some evidence to suggest the home should be prepared to request a more comprehensive assessment from the commissioning care managers and should also be prepared to undertake their own full assessment in the absence of a satisfactory assessment. All service users are offered the opportunity to visit the home before deciding whether they should live there. Intermediate care is not provided.
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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 the following standard(s): 7, 8, 10, Whilst the quality outcomes for service users for this group of Standards is generally good, there are significant areas that can be improved upon. More attention to detailed care planning for service users’ individual and specific care needs is still to be achieved. EVIDENCE: Each service user has a care plan, three of which were viewed in detail. The information they contained was variable and there was no evidence that service users had been actively involved in, or consulted about, the review of their plans. Service users confirmed this. Information in the plans was often not detailed enough to ensure staff deliver care in a comprehensive and consistent way. For example, in one plan all that was stated for the service user’s needs under personal care was ‘needs assistance of one carer’. One plan stated that the resident suffered with Parkinson’s disease but there was very little information in the plan for staff about how this affected the person on a day-to-day basis. Some information contained in the plans was not signed or dated and was uncertain to know how current it was. Conversations with staff did show that they knew service users’ needs and idiosyncrasies well. However, this information was not always recorded in care plans.
Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 12 Risk assessments for moving and handling were sometimes not detailed enough to ensure service users’ or staff safety. For example, one assessment stated, ‘assistance with one, assess daily until pattern established’. There was no evidence that this action was being managed or even if a review had been carried out, or a daily assessment completed. A risk assessment had not been completed for one service user who had recently fallen down the stairs and had been admitted to hospital as a result. Reviews of service users’ care plans had not been recorded by the timescales indicated in the plans. One plan included “resident unable to sign”, although she was able to do this. Reviews of some service users who had fallen, or who were at risk of falling and who had moving and handling needs, had not been undertaken or recorded. It is a requirement that the detail about the level and type of intervention, the frequency of the intervention and a descriptive detail of the intervention must be recorded clearly in each service user’s care plan, so that staff are clearly informed of the amount of assistance any one service user should receive. Regular reviews of care plans including the aspects of care that have been reviewed must be arranged and must be recorded. Service users reported that they saw health care professionals regularly. One service user felt that staff understood the fluctuating nature of her Parkinson’s disease well and that staff ‘were rigorous’ about giving her medication at the right times throughout the day. One visiting daughter stated that the manager was always quick to get her mother to the doctor when needed. The inspector spoke to a visiting District Nurse and McMillan Nurse. Both reported the quality of care provided by staff was good. Some poor care practices around moving and handling were observed: • The inspector witnessed two members of staff using the ‘drag lift’ to help one service user stand up from her chair. This move is not a recommended practice and all lifting is considered a potential risk to both staff and to service users. There was a lack of conversation between the care workers and the service user about what they were attempting to do. As Moving & Handling training had been provided for most staff in July 2006 this issue must be addressed as soon as possible. • Three service users were observed being transferred from the lounge to the dining room in wheelchairs without footplates on. This puts service users at unnecessary risk of injury. Interactions observed between staff and service users were generally very positive, encouraging of independence and respectful. Staff were described by one service user as, ‘all friendly, not toffee nosed at all’. Staff were seen knocking on service user’s bedroom doors before entering, offering them choices of what to eat and drink and responding quickly to calls for assistance. The quick responsiveness of care staff was evident on different occasions during the two days and during the lunchtime meal that was observed. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15, The quality outcome for service users relating to this group of Standards is good, although more service user control over their care planning and decision making could be achieved. EVIDENCE: Lunchtime was observed to be relaxed, unhurried and a sociable event. The tables were pleasantly laid and residents were offered genuine choice over what, and where they ate. Food was served to meet the needs of all service users, including those with eating difficulties. Staff gave discrete and sensitive assistance to those that needed help and service users were given the time they needed to finish their meal comfortably. Many positive comments were received about the quality of the food at the home. However, one relative interviewed stated there was never any fresh fruit available for residents. When the inspector requested some from the kitchen, none was available. The cook stated that only bananas were ever ordered for service users. On the second day of the visit one inspector ate lunch with service users in the dining room and the other inspector ate lunch with service users in the lounge. Assistance with eating was given to service users in a sensitive and considerate manner that allowed service users to remain independent whilst ensuring they were not being left alone struggling to eat a meal.
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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 the following standard(s): 16, 18, Quality outcome in this area is good. Service users benefit from wellintentioned arrangements to protect them from abuse. EVIDENCE: A copy of the complaints procedure was on display in the entrance hallway to the home. However, it was not in a format or position easily accessible to service users. It was noted that on the second visit to the home, new and clearer larger print posters, of how to complain, had been put up throughout the home. Although most service users and staff spoken to were unaware of the home’s complaints procedure most stated they would feel confident raising any concerns they had with the manager. One resident stated ‘ I usually have a word with Morag (the manager) and she sorts it quickly’. The manager is a ‘key practitioner’, trained by the adult protection trainers for Cambridgeshire County Council and as such has agreed responsibilities to ensure effective promotion within the home of the best practice to protect vulnerable adults from abuse. Service users are protected from abuse by staff being trained in Protecting Vulnerable Adults from Abuse. It was discussed with the manager that because the Local Authority has the lead responsibility to protect vulnerable adults from abuse and has made training arrangements available to care service providers, it would be good practice to arrange for all care staff to receive training provided by the Local Authority. The manager has arranged and already provided some of this training to some care workers through an external training agency and has also made additional arrangements with Cambridgeshire County Council for future training.
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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 the following standard(s): 19, 21, 22, 23, 24, 25, 26, The quality outcome for this group of Standards is adequate, but can be improved in a number of ways. EVIDENCE: The home was generally clean and comfortable. On the days of inspection one or two cleaners worked the mornings shifts. Service users’ rooms were mostly furnished with their belongings. There were noticeable variations in the decorative quality in some rooms. One service user commented she was very pleased with her room and with the home, whilst another room smelled of stale urine. The home is in need of regular maintenance and repair because of the age of the building and the fittings. There were some areas of the home where wheelchairs had damaged paintwork to hallways and doorways and service users’ rooms. Attention to a non-operative shower and faulty electric lighting in one bathroom was needed. There were some areas of the home that had unpleasant aromas and these were pointed out to the manager during a tour of the home.
Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 16 The manager informed the inspectors that a maintenance worker has recently been employed by the home but has not yet commenced work. The flow of hot water to bathrooms is slow. Although it was not evident that there was any delay or inconvenience to service users who wished to have a bath, it is recommended the slow flow is increased to a more satisfactory level. Additional mechanical equipment for moving and handling are required, such as a standing hoist. The manager informed the inspector that the home is prepared to provide a standing hoist. The hoist used by the home is used for any service user who requires a moving and handling mechanised aid. The needs of service users requiring a hoist to facilitate their manoeuvring should be assessed by an Occupational Therapist for compatibility with the hoist that may be used. Similarly, the use of appropriate wheelchairs should be pursued by the manager and these wheelchairs should be identified with service users names. Some wheelchairs were stored near doorways and in hallways were potential hazards and the manager agreed to reconsider where they would be stored. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, The quality outcome for service users in this group of Standards is good. Staff training, recruitment procedures and numbers of staffing help to assure the safety of service users. EVIDENCE: The levels of staffing employed by the home have increased recently. The shift patterns are now arranged for four staff to work a morning shift plus an additional care worker to administer medication, an afternoon staff of two care workers plus a care assistant who works part of the afternoon and evening shift of 4 hours, one cook and breakfast assistant and two cleaners. A handyman has recently been employed and the effects of this are yet to be assessed. Also a bathing assistant works an, ‘as and when’ required basis. The manager works 5-6 days each week. The home is better staffed than it previously was and the outcomes for service users have been improved by this arrangement. Recruitment procedures were assessed and found to be satisfactory. The majority of staff have achieved an NVQ level 2 award. Training in adult protection, food hygiene and infection control are recent training arrangements that had been made. Some revisiting of moving and handling skills may be necessary and falls prevention training should be provided as a skill to all staff. It is recommended the manager introduces an effective monitoring system for the above mobility issues.
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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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37, 38, The quality outcome for this group of Standards is adequate, although it is anticipated improvements should be rapidly achieved by improved record keeping. EVIDENCE: The manager has an NVQ level 4 award and is an accredited NVQ assessor. It was discussed with the manager during the feedback given by both inspectors on the 22/09/2006 and recommended that the home makes their Statement of Purpose, Service User Guide and their Complaints process more easily available to any visitor to the home. One the second day of the inspection these documents had been made more easily available by the main entrance.
Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 19 The home has developed an annual quality assurance questionnaire for service user/relatives and staff to make their comments. The responsible individual visits the home each week and has sent Regulation 26 reports to the Commission. There are issues concerning care plans and their accuracy of instructions for providing care and in particular the record of health service professionals’ interventions. It was reported by staff that they do not always have sufficient time to complete handover notes between shifts and that some staff are not included in the handover reporting process. Decisions and action plans written in two recent POVA Strategy meeting minutes indicated similar concerns and that assistance from Cambridgeshire County Council’s Service Contracts personnel was offered to support this action plan. Progress regarding these actions will be assessed again at the next inspection. Policies that were read during the inspection, supported the efforts being made by the home included, a Complaints policy, Infection Control policy, Abuse policy, Code of Conduct, Staff Supervision and a Confidentiality policy. Fire training and fire testing has been provided and carried out. Portable electrical appliances had been tested. Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 20 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 Key 3 4 5 Key 6 ENVIRONMENT Standard No Score Key 19 20 21 22 23 24 25 Key 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score Key 7 2 Key 8 3 Key 9 X Key 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score Key 12 3 Key 13 3 Key 14 3 Key 15 3 COMPLAINTS AND PROTECTION Standard No Score Key 16 3 17 X Key 18 3 3 X 3 2 3 3 3 2 STAFFING Standard No Score Key 27 3 Key 28 3 Key 29 3 Key 30 3 MANAGEMENT AND ADMINISTRATION Standard No Key 31 32 Key 33 34 Key 35 36 37 Key 38 Score 3 X 3 X X X 3 2 Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation Requirement Timescale for action 01/11/06 2 OP7 3 OP9 5(1)(b)(b The Service Users’ Guide must b)(bc)(bd) contain the relevant details about fees as cited in the Care Homes Regulations 2001, amended on 01/09/2006. 15(2)(b) Care Plans must be reviewed 17(1)(a) regularly and must include a full & description of assistance that is Schedule needed to assure service users 3, of good quality care and must Para 3, take account of their current (m)(n)(o) needs and of any changes in needs and must include details of any community health nurses interventions and treatment provided to service users. 13(2) & The Registered Person must 17(1)(a) ensure that records of & medication administered to Schedule residents are accurate and 3(3)(i) complete. This requirement has been carried forward as timescale for action of 28/02/06 has not been met. This requirement was given a timescale for action of 03/05/06 but was not assessed on the 22/09/06. 01/01/07 22/09/06 Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 22 4 OP9 13 (2) The Registered Person must ensure that medication no longer prescribed for residents is disposed of promptly and not retained for future use. This requirement has been carried forward as timescale for action of 28/02/06 has not been met. This requirement was given a timescale for action of 03/05/06 but was not assessed on the 22/09/06. An Occupational Therapist must be consulted to re-assess or confirm that the correct equipment is used for service users who need moving and handling equipment. The home must be kept free of offensive odours as directed by the Care Homes Regulations 2001. The manager must ensure that staff are trained by an accredited trainer when they receive training in safe moving and handling. The manager must ensure that correct moving and handling procedures are used within the home. 22/09/06 5 OP22 14(1)(a) 01/01/07 6 OP26 16(2)(k) 01/11/06 7 OP38 18(1)(c)(i ) 01/01/07 8 OP38 13(5) 01/11/06 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 Care planning undertaken by the home should always embrace the philosophy and intention to include and consult with service users whenever possible.
DS0000064767.V313757.R01.S.doc Version 5.2 Page 23 Aisling Lodge 2 OP9 3 4 OP12 OP25 The Registered Person should ensure that records of the receipt and disposal of medicines controlled under the Misuse of drugs Act 1971 are recorded in accordance with the Act and associated Regulations. Activities written in the Service Users’ Guide should be promoted, or alternative activities should be initiated. A system to monitor the effects upon service users having baths because of the slow flow of hot water to bath taps should be considered. The Registered Person should continue to consider ways for staff to attend external training and should consider that service users would benefit from staff having further training in dementia care and in the protection of vulnerable adults. 5 OP30 Aisling Lodge DS0000064767.V313757.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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