Inspection on 17/08/06 for Angel Lodge

This inspection was carried out on 17th August 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

Angel Lodge 27/07/07

Angel Lodge 11/11/05

Angel Lodge 12/04/05

Angel Lodge 13/01/05

Angel Lodge 12/07/04

Angel Lodge 02/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Angel Lodge 15-17 Eastwood Road Goodmayes Ilford Essex IG3 8UW Lead Inspector Ms Gwen Lording Unannounced Inspection 10:00 17 August 2006 th 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 Angel Lodge DS0000025883.V301215.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. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Angel Lodge Address 15-17 Eastwood Road Goodmayes Ilford Essex IG3 8UW 020 8597 4399 020 8597 4399 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) Chana Bros Limited Mr. Amrik Singh Chana, Mr. Bhupinder Singh Chana Pauline Ann Baker Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th November 2005 Brief Description of the Service: Angel Lodge is registered to provide personal care and accommodation for up to 20 service users over the age of 65 years who have related illnesses/ conditions. Five of the beds are contracted by the London Borough of Barking and Dagenham to provide admission for respite care. The home is owned and operated by a family business. The premises are situated in a residential area of Goodmayes, close to the busy Ilford High Road with access to shops and other community facilities. The home provides accommodation on two floors, which is mainly in single bedrooms with one double bedroom and there is a passenger lift. On the day of the inspection the range of fees for the home was between £360.00 and £420.00 per week. A copy of the Statement of Purpose and Service User Guide to the home is made available to both the residents and the family. A copy of the most recent inspection report is available on request. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced was unannounced, started at 10am and took place over five hours. The registered manager was available at the start of the inspection and later on in the afternoon to aid the inspection process. She left the home for a period of time during the visit to undertake planned pre-admission assessments in the community. This was a key inspection visit in the inspection programme for 2006/ 2007. At the previous inspection on 11/11/05 there was no evidence that regular visits under Regulation 26 had taken place. This was despite the two previous reports making requirements for the registered persons to do so. On 20/12/05 a Statutory Requirement Notice was issued to the registered providers for failure to comply with Regulation 26 of the Care Homes Regulations 2001. The inspector is able to evidence that this Statutory Requirement Notice has been complied with in full. Discussion took place with the registered manager, care staff, the cook and domestic. Care staff were asked about the care residents receive, and were also observed carrying out their duties. Currently one bedroom is out of commission whilst the ongoing re-decoration of bedrooms takes place. The inspector spoke to a number of residents and visitors. Where possible residents were asked to give their views on the service and their experience of living in the home. In addition the inspector was able to speak to a visiting Community Care Worker. She was very positive about the quality of care being provided to residents living in the home and those on respite placements. All parts of the home were visited and a number of staff, care and home records were looked at. The Inspector would like to thank the staff, residents and visitors for their input and assistance during the inspection. What the service does well: There is a relaxed atmosphere in the home and residents appeared unhurried and are given sufficient time and support in their everyday lives. Staff were seen to be working effectively as a team throughout the inspection, with staff interacting well, both with each other and the residents. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 6 Those residents spoken to, who were able to express a view, said that they were happy in the home, staff were friendly and they were well looked after. 85 of care staff are qualified to NVQ level 2 or above and this demonstrates a very positive commitment to training by the registered persons and the staff. 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. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are being undertaken for all residents prior to them moving into the home. Care plans are drawn up from the information in this assessment, ensuring that the needs of the residents are identified, understood and met. EVIDENCE: The home’s Statement of Purpose and service user guide have now been amended to include more information about how to make a complaint, and in line with the home’s complaints policy and procedure. Prospective residents and their relatives/ representatives are encouraged to visit the home prior to making any decision to move in. Pre-admission assessments are undertaken for all residents prior to them moving into the home. Care plans are drawn up from the information in these assessments. Where appropriate, information provided by the placing authority Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 10 was also on file. The records also showed that residents, where capable and their relatives are also involved in the assessment process. The Care Homes Regulations 2001 have been amended with effect from the 1st September 2006 for new residents, and for existing residents with effect from the 1st October 2006, so that more comprehensive information is to be included in the service users’ guide. Details of information to be included are contained within the amended regulations. Therefore, the service users guide must be reviewed and amended by the stated timescales. The home does not offer intermediate care. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care and social care needs are set out in individual care plans and provide staff with the information they need to satisfactorily identify and meet residents’ needs. However, care plans must reflect any changes identified at reviews so as to accurately record changing and current needs. There are clear medication policies and procedures for staff to follow. However, there are some inconsistencies in the recording of medication, which may result in unsafe practices. EVIDENCE: A total of five residents were case tracked and their care plans and related documentation examined. All residents had care plans, which were generally detailed and covered health and personal care needs. Whilst it was evident that care plans were being reviewed/ evaluated on a monthly basis, some of Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 12 the care plans examined did not reflect changes, which had been identified at the reviews. All care plans must be updated to reflect changing and current needs. As part of case tracking the documentation/ health records relating to wound management; the management of a resident with diabetes; the most recently admitted resident and a resident admitted for a period of respite care, were examined. These were found to be generally detailed and being adequately maintained. The District Nursing Service visits the resident with a leg wound and her notes are incorporated into the individual’s care plan. Risk assessments are routinely undertaken on admission for all residents, but not all risk assessments were being regularly reviewed. The manager stated that residents’ are weighed monthly. Records were being maintained and included weight loss or gain, but not all residents were being weighed monthly. Regular monitoring of weight is important so that appropriate action can be taken where necessary and in a timely manner. Records indicated that residents are seen by other health professionals such as optician, dentist, optician, district nurse and GP. On the day of the visit the inspector was able to speak to a visiting Community Care Worker. She was very positive about the quality of care being provided in the home and commented: “Staff are very caring and reliable, and it is a comfortable and friendly home. Residents that she places here for respite admissions always ask to come back” There was no evidence in the files of “End of Life” care plans and the importance of developing these was discussed with the manager. However, from conversations with staff and the inspector’s knowledge of the home it was apparent that staff dealt with a person’s dying and death in a sensitive manner, both for the individual and relatives. During the recent spell of hot weather the registered providers had purchased three large air conditioning units for use in the two lounges and the dining room. Staff were observed to treat residents with respect and the arrangements for their personal care ensure that their right to privacy is upheld. There are policies and procedures for the handling and recording of medicines. An audit was undertaken of the management of medicines and a random sample of Medication Administration Record (MAR) charts were examined. The following issues were discussed with the registered manager: • Hand written entries on MAR charts must be signed and dated by the person making the entry. The entry must also include the source of the information. e.g. GP, registered nurse. DS0000025883.V301215.R01.S.doc Version 5.2 Page 13 Angel Lodge • • • When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. The temperature of the medicine refrigerator must be recorded daily. It was noted that sundry items of equipment/ personal possessions were being stored in the medicine cupboard e.g. cigarettes, digital camera. The manager must ensure that alternative storage is identified for such items. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to this service. There is a varied programme of activities available which suit individual needs preferences and capacities. Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends as they wish. EVIDENCE: The home does not employ an activity organiser and care staff take responsibility for organising activities with residents. There is a programme of general activities for all residents and regular visits by professional entertainers, which seem popular with most of the residents. Some of the activities are individual and others are small group activities such as exercise sessions, quizzes and bingo. Residents can choose whether to participate or not. One resident chooses to stay in his room for most of the day watching television or reading, another resident likes knitting. There is a limited programme of activities outside the home. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 15 Relatives are encouraged to visit the home and there are no restrictions on when relatives and friends can visit. Visiting can be undertaken in one of the lounges or in the privacy of the resident’s room. One relative said: “Staff are very friendly and I am always offered a cup of tea/ coffee when I visit. There is lots of entertainment and plenty to keep residents occupied”. From observation and talking with several residents it was evident that the routines of daily living are flexible and varied to suit the differing needs and preferences of residents. All residents have an individual ‘night care plan’ which details preferences such as duvet or blankets and quilt, and times for getting up/ going to bed. The serving of the lunchtime meal was observed and provided residents with a varied, appealing and nutritious meal. Residents can choose to eat in the dining room, one of the lounges or in their own rooms. However, the décor and furniture in the main dining room looks “tired”, despite having been redecorated quite recently. There is a large unattractive metal storage system that appears to dominate the room and is only utilised to store a small amount of crockery. The general appearance of the dining room was discussed with the manager who will in turn, raise this with the registered providers and review as part of the ongoing re-furbishment programme for the home. Pureed meals were presented in an attractive and appealing manner and residents who required assistance were not hurried. Staff were seen to offer assistance where necessary and this was done discreetly and individually. A visit was made to the kitchen and the storeroom situated outside the kitchen. The inspector discussed the storage and preparation of food with the cook in charge. She was aware of those residents requiring special diets, for example diabetic diet. There was fresh fruit/ vegetables in evidence; all food stored in the fridge was appropriately labelled and stock items were in date. The area outside the kitchen needs to be cleared and this is detailed in another part of this report. (See Environment) Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make very effort to sort out problems or concerns and makes sure that residents and their relatives feel confident that their complaints and concerns are listened to and will be acted upon. Staff working in the home have received training in Adult Protection/ Abuse Awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy/ procedure and the records indicate the number of complaints received and includes details of the investigation, any action taken and the outcome for the complainant. At the last inspection a requirement was made for the complaints policy/ procedure to be amended to include information for referring a complaint to the Commission at any stage, should the complainant wish to do so. The inspector was able to evidence that this requirement has been met. Those residents spoken to were aware of how to complain and to whom. One resident spoken to said: “If I have any problems I speak to Pauline (the manager) or one of the carers and they sort it out for me”. All staff working in the home have received training in adult protection and this includes ancillary staff. Those staff spoken to during the inspection were aware Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 17 of the action to be taken if they had concerns about the safety and welfare of residents. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The concerns around the maintenance and safety of the premises impacts upon the assessed judgement on this group of standards. The overall atmosphere in the home is welcoming and improvements have been made to the décor, some of the internal furnishings and refurbishment/ relocation of facilities. However, in general the environment does not always meet the residents’ needs and does not provide people living in the home with safe, comfortable or well-maintained premises. EVIDENCE: The building was toured by the inspector, unaccompanied, at the start of the visit, and all areas were visited again during the day. Some bedrooms were seen either by invitation of the residents, or with permission, whilst others were seen because the doors were open or being cleaned. There were no offensive odours in the home and generally the home was clean and tidy. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 19 It is acknowledged that the registered providers have made some significant improvements, including refurbishment of the kitchen; re-location and decoration of the manager’s office and laundry area; and decoration of communal areas and some bedrooms. There is an ongoing programme of refurbishment and re-decoration for the home and this must be progressed, as it will greatly improve the environment for all current residents and any prospective residents. However, whilst building/ refurbishment is being carried out the registered providers must ensure that rubbish, broken furniture and building materials are removed from the rear garden and not allowed to accumulate over a period of time. This potentially poses a health and safety risk to both residents and staff, and does not provide appropriate, accessible or pleasant external surroundings for people living in the home. In addition directly outside the kitchen leading to the existing laundry/ storeroom there was an assortment of sundry items including cardboard boxes, empty plastic juice containers and discarded mops. The registered providers must ensure that all rubbish, broken furniture and building materials from the rear garden and perimeters are removed and these external areas kept clear. A requirement has been made in this report with a timescale for compliance. The laundry is currently sited in the rear grounds and is in the process of being moved to a more suitable place inside the home. The laundry area was visited and though found to be clean, was untidy with items of equipment not related to the functions of the laundry being stored there. This area must also be cleared of items not required for laundry purposes. Soiled articles, clothing and foul linen were being stored appropriately, pending washing. During a tour of the internal premises the following issues were noted: • One of the large glass panels in the freestanding unit in the main lounge is missing and the unit appears to be used for storing a number of miscellaneous items. The manager stated that this is being replaced by two smaller units. Upstairs toilet (31) – the wall behind the toilet outlet pipe is rusted with exposed/ cracked plaster. This requires repair. Consideration needs to be given to replacing the large metal storage unit in the dining room with a smaller more suitable alternative. The existing unit could be better utilised in another part of the home for bulk storage. • • In conclusion, despite the improvements made to the internal areas of the home quality in this outcome area can only be judged as poor. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: In addition to care staff the home employs a cook, laundry person and domestic. The home has a relatively stable staff team and effective team working was observed and evidenced throughout the inspection. Staff interacted well, both with each other and residents. The staff team are very committed and staff understand and fully support the main aims and values of the home. Where possible residents were asked to give their views on the service and the care they were receiving. One resident commented: “I am very happy here, staff are kind to me”. Other comments included: “The carers know how I like things to be done”; and “Everyone is friendly”. Staff had received training in essential areas such as moving and handling, first aid, fire safety and medication awareness and administration. One senior Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 21 carer is scheduled to complete an accredited training course on ‘Training Skills in Dementia Care’, she will then undertake a programme of training for all staff in dementia awareness. 85 of care staff are qualified to NVQ level 2 or above and this demonstrates a very positive commitment to this training by both the registered providers and care staff. A random sample of personnel files of the most recently recruited staff were inspected. These were found to be in good order with necessary references; criminal records bureau disclosures and application forms duly completed. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): Standards 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to this service. The registered manager is qualified and has the necessary experience to manage the home. Monitoring visits are now being undertaken regularly by the responsible individual to report on the quality of the service being provided. However, both the registered manager and the registered providers must ensure that the residents’ health, safety and welfare are promoted and safeguarded through the provision of well-maintained and safe premises. EVIDENCE: At the last inspection a repeated requirement was made for the registered persons to undertake Regulation 26 visits to the home. On the 20/12/05 a Statutory Requirement Notice was issued for failure to comply with Regulation 26 of the Care Homes Regulations 2001. This Statutory Requirement Notice has now been complied with and monitoring visits are being undertaken by the Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 23 responsible individual and a copy of the report is sent to the Commission. However, such monitoring visits must include health and safety issues and maintenance of both internal and external areas of the home with action required to address areas of concern. Currently the manager does not act as an appointed agent for any resident. Most of the residents’ financial affairs are managed by their relatives/ representatives. The home has responsibility for the personal allowances for a small number of residents’. Secure facilities are provided for the safe keeping of money and any valuables held on residents’ behalf and written records are maintained. A wide range of records were looked at including fire safety, water temperature checks, accident/ incident reports and Portable Appliance Testing (PAT). These records were found to be up to date and accurate. Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 1 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 25 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 All care plans must be updated to reflect changing and current needs identified at care plan reviews. All handwritten entries on Medication Administration Records (MAR) charts must be signed and dated by the person making the entry; and include the source of the information e.g. GP, registered nurse. When directions for administering medicines are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart The medicine cupboard must only be used for the appropriate storage of medicines. ‘End of Life’ care plans must be developed for all residents. The premises must be kept in a good state of repair and maintenance, externally and internally. The registered providers must ensure that that all rubbish, Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 26 Timescale for action 31/10/06 2 OP9 13 17/08/06 3 4 5 OP9 OP11 OP19 OP20 13 15 23(2) (b)(o) 17/08/06 31/10/06 30/09/06 6. OP31 OP33 OP38 10 & 23 broken furniture and building materials from the rear garden and perimeters are removed and these external areas kept clear. The registered persons must ensure that the health, safety and welfare of residents and staff are promoted and protected through safe working practices and in compliance with all relevant legislation. 17/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 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 Angel Lodge DS0000025883.V301215.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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