Inspection on 07/06/06 for Amber Lodge

This inspection was carried out on 7th June 2006.

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

Amber Lodge 15/04/08

Amber Lodge 19/04/07

Amber Lodge 08/11/05

Amber Lodge 19/07/05

Amber Lodge 22/10/04

Amber Lodge 12/05/04

Similar services:

Abbey The

Snydale Care Home

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Amber Lodge 21 Thornhill Road Armley Leeds West Yorkshire LS12 4LL Lead Inspector Susan Knox Key Unannounced Inspection 09:30 7th June 2006 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 Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 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. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Amber Lodge Address 21 Thornhill Road Armley Leeds West Yorkshire LS12 4LL 0113 2633231 0113 2038556 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) Meridian Healthcare Ltd Mrs Lynne Dawson Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (40) Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for MD (E) are specifically for named service users Date of last inspection 8th November 2005 Brief Description of the Service: Amber Lodge is a two-storey purpose built home situated in Wortley, near Armley. It has a large private garden to the rear of the building. A large car parking area is located at the front of the building therefore access is easy for those with mobility problems. Local shops and bus routes are also within easy access. The home is registered to provide personal care for up to 40 older people. Accommodation is provided on two floors. There are 38 single bedrooms and one double bedroom. All bedrooms have en-suite facilities. Lounge and dining areas are located on both floors. There are three bathrooms, two of which have hoisting facilities, and two shower rooms. All laundering is undertaken on the premises. The gardens are enclosed; a large lawn and patio area is at the rear of the building. Service users can access the garden from the dining room. The current scale of fees is £390 weekly. Additional charges are for chiropody, hairdressing, newspapers and personal items. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. One inspector carried out this unannounced inspection between 09.00am and 4.30pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. A pre inspection questionnaire was sent to the manager to be completed with up to date information in time for the inspection and returned to the local CSCI office. This was available at the inspection. During the inspection the inspector spoke to six residents, two visitors, five staff and the registered manager. The inspector looked around some parts of the home. Records were inspected including care plans, assessments, staff recruitment and training records, accident reports, financial records and health and safety records. Comment cards were sent to visiting professionals and also left with the home to be given to service users and sent to relatives. Five from relatives and one from a resident were returned in time for the report. The majority of the comments were positive and some have been incorporated into the report. The written and verbal feedback from residents, relatives and professionals involved in the home showed that all thought that the residents were well cared for. Feedback was given to the registered manager at the end of the inspection. What the service does well: Residents were pleased with the care provided in the home. The home is clean and well maintained. National Vocational Training (NVQ) has ensured that more than 50 of care staff has achieved this qualification. Quality assurance audits are regularly carried out and involve residents. Palliative care was said to be good. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 6 Choice is provided for residents such as having bedroom door keys and remaining in their bedrooms if they wish. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 7 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 Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 8 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. The Statement of Purpose and Service User Guide provides sufficient information so that existing and prospective residents are kept fully informed of the service. The home does provide a written statement of terms and conditions/contract to inform residents of what is included in the fees and the overall care. The home does ensure that residents are assessed prior to admission. EVIDENCE: The Statement of Purpose and Service User Guide was available and provides information to prospective and existing residents regarding the services and care on offer by the home. These documents were available in the hallway. A relative and a resident confirmed that they had been given information about the running of the home. The residents that were case tracked as part of the inspection had been provided with a Contract or Statement of Terms and Conditions. Therefore, Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 9 details of residency were made known. Copies of contracts for those residents who were either self-funding or local authority supported were on file. In the care documentation for the four-service user’s case tracked there was evidence that all had been assessed before admission. The manager, deputy or senior care staff undertake these visits. The manager confirmed that no residents would be admitted with mental health needs other than dementia and the Mental Disorder (MD) category is being phased out as occupancy changes. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 7, 8, 9, 10. Care planning addresses the majority of residents needs but a plan of care about tissue viability needs is required. In addition, any risks identified must be followed by care plans in order to fully protect residents. Residents and their representatives are not always given the opportunity to have their say. The residents are protected by the procedures for administering medication but one issue not robustly dealt with has put a resident at risk of unnecessary pain. Resident’s are happy with the way staff respect their privacy. Dignity and privacy is compromised at times by the way some staff speak to residents about personal care. EVIDENCE: Up to date care planning was in place for the four-service users case tracked. Planning addressed individual needs and risk assessments were in place these were evaluated monthly as required. However, what was not included in some care documentation was evidence that service users or their representatives had been involved in care plans and their views listened to. One relative who visits regularly was unaware of care planning. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 11 Risk assessments followed clinical guidelines and this was good practice. In two cases the low score arrived at by using the nutritional risk assessment tool showed that there was ‘cause for concern’. This had not been followed through in a care plan. The manager said that with her knowledge of individual residents she disputed these particular results but said the tool had been completed correctly. She is to discuss this with the operations manager. In addition, care staff must establish care plans when risk assessment tools identify there is a concern. One resident’s weight record showed a significant weight loss with no evidence in the care records that this had been followed up by referral to a GP. The manager thought she knew the reason for the weight change. This needs to be recorded and if loss continues then a referral made. The group Meridian Care owns Amber Lodge and they are constantly updating the records in the homes and this has happened with care plans. It is suggested that they review the current care documentation, as much of it is repetition causing unnecessary additional work for care staff. A visiting professional on the day of the inspection confirmed that a team of community nurses visit some residents regularly. She said that although staff did not always carry out their instructions in the day-to-day routine the care given to those with palliative needs was praised. Any concerns would and have been referred to the registered manager. Community nurses were monitoring a resident with skin care needs and they had established their own plan of care for treatment. The manager was advised that a care plan was required to be established by the home. This would not include the treatment by the nurses but should set out the details of the input required by staff. Such as the nurses instructions and details of pressure relief and equipment. The medication records and storage were checked. A monitored dosage system (MDS) is in place and storage was secure and satisfactory. The recording of the administration of medication was also satisfactory. The manager said that no secondary potting up of medication took place. Residents said they were happy with the way medication was given to them. Some residents self-administered part of their medication. Staff confirmed that they had had medication training and this was verified in the training records and training certificates. One comment card referred to an issue about a repeat prescription. The quantity of medication was not sufficient and therefore did not last until the next prescription was issued. Although relatives and the home had liaised with the health centre the problem was on going. This was dealt with by the operation manager but should have been dealt with more robustly and speedily by the registered manager. Residents and a relative spoke positively about the care provided by staff. Residents confirmed that staff knocked on doors before entering and privacy and respect was given, for example during bath times. However, staff were Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 12 overheard referring to personal care quite loudly. It may be that some residents are hard of hearing but they are not fully respecting resident’s dignity to refer to personal care loudly and in front of others. This should be discussed during staff meetings and positive changes made in this area of care. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 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. There are organised activities taking place in the home but not everyone is aware of them. In consultation with residents outings would further extend their interests. Visitors are welcomed into the home. Residents said they had plenty of choice and enjoy the meals but choice at bedtime is limited. EVIDENCE: An activity coordinator is now employed in the home three days weekly. In addition, other activities are arranged such as motivation every month and arts and crafts every fortnight. The residents spoken to preferred to stay in their bedrooms. This was reflected in the care plans. From the records and in discussions with residents it was confirmed that residents could follow their own religion if they wish. Religious representatives do visit the home regularly. During discussions it was felt that the choice of activities could be further improved if outings were arranged and one comment was there was no activities. The manager said that annual trips are made to a local garden centre and to local pubs in the summertime. During the residents meeting to Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 14 discuss the quality monitoring survey recently carried out, activities will be discussed. During the visit many visitors called at the home and staff were observed making them welcome. Good interaction was noted between visitors and staff. Residents confirmed that they were offered a key to their bedrooms if they wished. This is also recorded in care plans. This is good practice. The residents spoken to confirmed that they in particular preferred to start the day early. It was apparent from discussions with residents and staff that residents were given little choice about bed times and were eating their breakfast by 8 am. The manager said this did not happen. She was advised to discuss this with all staff and emphasise that a definite choice is to be encouraged. Care plans should reflect discussions with residents who may not want to be awakened and given a cup of tea. The majority of the residents said they enjoyed their meals and that there was plenty of choice. One said the meals were enjoyed sometimes. In the recent quality monitoring survey a small percentage had some issues about meals and this will be discussed with them in a meeting. The midday meal was not observed but residents said they had enjoyed it. The dining room is a pleasant area adjacent to the kitchen. Tables were set appropriately with place settings and condiments. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 16, 18. Residents are confident to approach the manager with concerns. An appropriate complaint’s procedure is in place. Service users are safeguarded from abuse but staff need to periodically up date their knowledge and have the opportunity to discuss any issues. EVIDENCE: The homes complaint procedure was displayed in the hallway near to the main door. It is also in the Service User guide. A record is available to record complaints but the manager said that none had been received. In the pre inspection questionnaire the manager said that two had been received and gone to head office. The residents spoken to had no complaints and one said he would go to the manager if he had any concerns. In a telephone conversation with the organisation’s operation manager she confirmed that she had investigated two complaints, both had been concluded and one was awaiting a response from the complainant. She was advised that records of complaints and subsequent investigation and action are required to be kept on the premises. The manager has attended Adult Protection training and she said that a training package was available for any of the staff to see. Leaflets are also displayed. She was advised that as these issues occur rarely it is important to ensure that they are periodically discussed with staff. During discussions it was positive to note that staff would respond robustly to allegations that incidents had occurred but their first actions may be incorrect. A periodic time should be Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 16 set aside for staff to view the training package and Adult Protection and Abuse should be a topic discussed regularly during staff meetings. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 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 the following standard(s): 19, 26. The home is well maintained and provides the residents with a comfortable safe environment that is well maintained. The home is clean with good malodour control. Good systems are in place for laundering resident’s clothes. EVIDENCE: There is ease of access into and throughout the building for those with mobility needs. A passenger lift provides access to the first floor. Communal rooms were well maintained with comfortable furniture for residents. Digital locks are fitted to the first floor doors in order to protect vulnerable residents. In a later discussion with the operations manager it was agreed she would check if the digital locks have been agreed with the fire authority and are linked into the fire system. In addition, easy access to the lift and then to the outside was pointed out as a possible hazard for those who may leave the home and be at risk. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 18 There are level gardens to the rear of the building and the residents were making good use of the patio. The garden is not completely secure but the manager said that staff would monitor those residents at risk if they left the premises. A smoking room is located on the first floor. Due to a health and safety issue a notice was displayed on the door banning residents from using the room unless accompanied by staff. The manager did this in order to protect the home and occupants. However, this blanket decision was inappropriate and could limit some resident’s personal choice. Instead, the individual risk assessments of those who smoke should be reviewed. This and a review of the furnishings and fire protection in the smoking room would identify the residents who need to be observed and ensure the safety of the home and occupants. A random inspection of the bedrooms was carried out. Residents said they were comfortable in their bedrooms and many were personalised with own possessions. Some of the en-suite toilets were bare looking and some also had no light shades. Otherwise decoration and furnishings were good. Care plans provided evidence that residents had been offered a key to their bedroom door and some had refused. This was also confirmed in discussions with residents and the manager. Cleaning was in progress during the visit and the building was clean with good malodour control. Residents praised the cleanliness of the home. The laundry was clean and tidy and procedures were well managed. A number of health and safety procedures were displayed in the laundry. It was said that missing laundry and spoilt clothes does occur at times but these issues are dealt with. Laundry is usually missing because it is unmarked, this happened during the inspection and the manager was able to identify the owner. Sometimes staff other than the laundry staff return clothing to wrong rooms or drawers. When this occurs drawers are searched until clothing is located. If staff continually spoil clothing by inappropriate laundering they have to pay compensation. Otherwise the company reimburses the resident. None of the residents spoken to had any concerns about laundry. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 19 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 staffing rota ensures that all the needs of residents are met. The recruitment procedures adopted by the home do protect the residents apart from one instance. The staff group has undertaken more specialist and mandatory training to ensure they are appropriately trained to provide care to residents. EVIDENCE: A rota for the week of the inspection was provided. No concerns were raised in discussions with residents, visitors or staff about staffing levels. The staff structure comprises of manager, deputy, seniors and support staff. Two working staff cover night shifts, one a senior. National Vocational Qualification (NVQ) training for two members of staff was taking place during the visit. The home has achieved more than 50 care staff with a NVQ level 2. During discussions with staff this training was confirmed and certificates were seen in staff files. Four staff files were checked for those employed since the last inspection. Recruitment practices have improved with either evidence of the Protection of Vulnerable Adults (POVA) first or Criminal Record Bureau (CRB) checks carried out. Two references were taken up for all four members of staff. In one case the references were not relevant to the post and were more about good character. The manager had sent for a reference three times to a care agency Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 20 with no reply. She was advised to request a reference from a previous care employer. Other good recruitment practices were also evident such as interview questionnaires, completed application forms and evidence about identity checks. The staff have undertaken a number of training courses in the last 12 months. This has been NVQ level 2, Basic Food Hygiene, Dementia, Moving and handling, Fire and Pressure care. Planned for the future are Nutrition and Healthy Eating, NVQ 2 and 3, Dementia and Medication. This ongoing training was confirmed during discussions with staff and in training records. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. The registered manager is competent to manage the home. The residents are given the opportunity to have a say in the running of the home. Further discussions are needed about resident’s financial records in order to ascertain if they are protected by the procedures for safeguarding finance. The health and safety of people in the home is promoted but maintenance records must be on the premises and available for inspection. EVIDENCE: The manager has been in post since 2001 therefore she has the relevant experience in care of the client group. She has completed NVQ level 4 in care and confirmed a recent successful completion of the Registered Manager’s Award. She is awaiting her certificate. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 22 Meridian Care organise annual surveys and a copy of the most recent was submitted to the CSCI. This was displayed in the home and is followed by a residents and relatives meeting. The manager discussed the difficulties in organising meaningful meetings with relevant interested parties. Due to a lack of response meetings are infrequent. The manager was advised to continue arranging periodic meetings. Residents financial records held by the home were checked. Personal allowances are held on behalf of some residents. Each has a book providing details of incomings, expenditure and balance. The record of fees paid by or on behalf of residents is held and dealt with by the organisations head office. In addition, for the convenience of residents some monies are held in one account so that the manager can access money on their behalf. These last two issues do not meet the requirement. This was discussed with the operations manager and the CSCI’s Provider Relationship Manager (PRM) who will reach an agreement with the organisation about how this can be resolved. Health and safety is well maintained throughout the home. No hazards were observed during the visit although bedrooms doors were wedged open early in the day for cleaning purposes. Wedges were removed later in the day. Maintenance records and certificates were seen and were all up to date. Staff have attended a range of health and safety training courses and a number of safety notices were displayed. Evidence was submitted after the inspection about up to date 5-year electrical hard wiring certificate and the Portable Appliance Testing. Fire records were up to date apart from the regular testing of emergency lights. These were regularly inspected but not tested routinely by staff. The manager agreed to check this with the local fire authority. The manager also agreed to submit copies to the CSCI of the fire risk assessment to the building Accident reporting was checked and cross-referenced with daily reports. These were satisfactory. The manager confirmed that she audits accident reports in order to identify recurring incidents. In order to be effective this should be recorded. Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 24 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 OP7 Regulation 15 Requirement The manager must ensure that a care plan follows on if a risk has been identified. Also if tissue viability is a concern. Residents and/or relatives must be involved in care plans. Review risk assessments for those who smoke and identify those who may need staff supervision. The manager must ensure that care staff carry out the community nurses instructions The manager must respond more robustly to issues with health centres about prescribed medication. The manager must ensure that staff carry out residents personal care in accordance with respect, dignity and confidentiality. The manager must discuss bedtime routines with staff and re-emphasise that a choice has to be given. The providers must ensure that complaint records including any investigation and action required must be available for inspection. DS0000001412.V294219.R01.S.doc Timescale for action 31/08/06 2 2 OP8 OP9 13 12, 13. 31/08/06 31/07/06 3 OP10 12 31/08/06 4 OP14 12 31/08/06 5 OP16 17 31/08/06 Amber Lodge Version 5.1 Page 25 6 OP19 23 7 OP29 19 8 OP35 17, 20 9 OP38 16, 23 The providers must ensure that light shades are fitted in en-suite facilities and these areas are made more homely. The manager must ensure that relevant references are obtained where previous work has been in a care setting. The providers must review the present procedures for recording fees and the pooling of residents savings. The providers must submit evidence that there is a fire risk assessment of the building. Check with the local fire officer about the timing of the testing of emergency lights. 31/08/06 31/08/06 31/08/06 31/08/06 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 Review care documentation in order to stop repetition of records. Review the current nutritional tool in use to ensure that it is effective. Consult with residents about arranging more outings. Ensure that adult protection and abuse are regularly discussed with staff. Ensure that the auditing of accidents in the home is recorded. 2 3 4 OP12 OP18 OP38 Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Amber Lodge DS0000001412.V294219.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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