Inspection on 14/06/05 for Arbour Lodge

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Arbour Lodge 23/05/08

Arbour Lodge 31/05/07

Arbour Lodge 06/08/06

Arbour Lodge 12/01/06

Arbour Lodge 01/11/04

Arbour Lodge 29/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Arbour Lodge 92 Richmond Road Compton Wolverhampton WV3 9JJ Lead Inspector Bhag Jassal Announced 14 June 2005 09.00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Arbour Lodge Address 92 Richmond Road, Compton, Wolverhampton, WV3 9JJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 771139 01902 565522 Arbour Lodge Limited Anne Younger Care Home 29 Category(ies) of Old Age (29) registration, with number of places Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 01.11.2004 Brief Description of the Service: Arbour Lodge is a large, semi – detached Victorian building which has been adapted to accommodate 29 older people in 27 single bedrooms and 1 double room. All the bedrooms have en-suites and will meet the National Minimum Standards. The home has a large garden at the front and side of the building and ample road parking. The home is situated in a residential area of Compton, approximately a quarter of a mile from the Compton shops. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 9.00 am, and lasted 7 hours and 35 minutes. All 29 places were occupied. The inspection included discussions with service users, staff, relatives/friends and other professionals. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities was also undertaken. What the service does well: Arbour Lodge care home is registered for 29 older people. The home makes every effort to provide individuals with good standard of care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with families/friends and representatives. The visitors’ book indicated a lot of activities. The service users spoken with said that they are content, happy and enjoy living in a homely and caring home. Service users were in three lounges/sitting areas engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. Several service users sat outside in the patio areas/garden as it was a warm and sunny day. Several service users remained in their bedrooms and watching television. The atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was also observed between service users and staff. Meals are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. The home provides good standard of accommodation and facilities, which are being maintained safe, secure and comfortable for the use of service users and staff. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The home must continue to improve and enhance the quality of care, and care recordings. The Care Manager must ensure that there is an activities programme in the home, which actually reflects the service users’ choices, preferences and capacities and also offers a range of activities. Those members of staff who as yet not received safe working practice topics training and training in safe handling of medication must do so as a matter of priority, which would enable staff to improve further their care practices and professionalism. There are only four small issues relating to the home’s environment, which must be addressed in order to have safe and comfortable environment for service users. The Registered Provider must take swift action to ensure that the home is adequately staffed at all times and the two vacant posts of a senior carer and a domestic assistant cover for weekends must be filled as a matter of priority. The Registered Provider and the Care Manager must take appropriate action to progress the implementation of the home’s Quality Assurance development plan and outcomes for service users. Overall, the home has made a good progress in complying with the requirements arising from the previous inspection report. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 7 The Inspector would like to acknowledge the improvements made by the Registered Provider and the Care Manger since the last inspection. 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. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 The home has a comprehensive admission procedure providing effective needs assessment and suitability evaluation for both privately funded service users and those placed by the Local Authorities. EVIDENCE: A sample of four service users’ care plans and files were seen at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The care manager also carryout assessments and these details are documented on care plans, which are drawn up by the senior staff with the assistance from the service users and their relatives and where appropriate other professionals. There was evidence to show that all the service users have been provided with contracts. The home has a very good admission procedure, which is made available to all prospective service users and their relatives/representatives. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, and 10 The staff within home is aware and sensitive to the needs of each service user and all service users and meet their needs in a professional manner. There is a clear and consistent care planning system in place, which provides the information they require to meet the service users’ health and personal care needs. Lack of accredited training in safe handling of medication by care staff potentially could place service users at risk. EVIDENCE: There was evidence to show all the service users undergo a comprehensive assessment of their needs prior to admission to the home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans are implemented. Four service users’ care plans were examined and these were kept up to date and reviewed on a monthly basis. The daily care recording formats were also examined and the quality and details of recording has improved since the last inspection. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 11 It was evidenced that the home maintains detailed records of all health checks carried out by the doctors, opticians, dentists, district nurses and chiropodists. The home also ensures that nutritional screening is undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultations with health and social care professionals are carried out within the service users’ bedrooms. The Inspector spoke at some length with 18 service users and all them commented positively about their care and they felt that they have everything that they need. Eleven service users stated that “the carers are very good caring people and they look after us very well and they always show kindness”. Other several service users said “the carers are always there to help”. The Care Manager stated that only the three senior carers medicate and they have received training in safe handling of medication. Six carers are currently undergoing this mode of training and five others also have been enrolled to undertake this training shortly. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Arbour Lodge provides a good quality of care and promotes individual lifestyles for the service users in residence. The service users maintain contacts where they wish with the family, friends, and the local community. The service users are positively helped to exercise choice and control over their lives and daily living. Meals at Arbour Lodge are of a good homely type offering both choice and variety and catering for special needs. EVIDENCE: There was evidence to show that the home provides a basic activities programme, which need to be developed further to offer a range of social and leisure activities in accordance with the service users’ choices, preferences, and capacities. The staff must be more pro-active in organising social and leisure activities and cultural interests. Records of activities enjoyed by the service users are maintained appropriately and incorporated into the individual service users’ care plans. All the service users spoken to stated that they are in touch regularly with their friends and family members and spoke about their visitors’ involvement and interest in their daily care matters. The visitors’ book showed a considerable activity. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 13 Relatives of two service users’ stated that they visit at various times of the day as the wish. All the relatives and friends who spoke to the Inspector said they are given a warm and friendly welcome by the staff whenever they visit. The service users also keep contacts with the local community facilities – church services, local shops and park. The service users are positively encouraged and helped to exercise their choice and control over their lives and daily living, subject to risk assessments in terms of safety and security and capacity to make decisions. There was evidence to show that the home provided a varied, wholesome, and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. The Care Manager stated that the menu is changed on a regular basis and in consultation with the service users. Over fifteen service users told the Inspector “the food was very nice and tasty”. Several service users also stated that the food was very good offering a good variety. The kitchen staff is well trained in food safety and hygiene matters and the kitchen is well equipped and kept clean and tidy. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Concerns or complaints are dealt with promptly and professionally. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a good Complaints Procedure, which is referred to for information in the Service Users’ Guide. There is a satisfactory system of recording complaints. It was noted that there was only one complaint directed to the Commission for Social Care Inspection within the previous 12 months. All the issues arising from this complaint were addressed immediately and appropriately by the Registered Provider and the Registered Manager. The service users spoken to by the Inspector stated that their views are always listened to by the staff and the Manager. The home has a good policy and procedure in place with regard to the protection of service users from abuse. The Care Manager stated that the staff has been made aware of the adult abuse and protection issues. The staff also has received induction training on these issues. The Care Manager stated that several members of staff have received in-house adult protection video training in August and November 2004. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24, 25 and 26 The general standard of the environment is very good providing service users with a homely place to live. The high standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample communal space - three lounges and dining room. The home is safe and is suitable for its stated purpose. The home has an ongoing rolling programme of redecoration to maintain good standard. The garden/patio and grounds are also being well maintained for the use of service users. All the bedrooms have en-site facilities. There are adequate communal toilets, bathrooms and washing facilities. The home has undertaken an assessment of the premises and facilities by an occupational therapist. The home has also provided suitable aids and adaptations in the home to meet the general and specific needs of all service users. There is good standard of furniture and fittings provided in the service users’ bedrooms. It was also Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 16 noted that the bedrooms have been personalised by the service users. However a suitable lockable facility in bedroom 18 must be provided; electric heaters must be removed from bedrooms 19 and 21; and prints/pictures are provided in consultation with the service users and their families in several bedrooms. The level of lighting throughout the home was adequate and central heating system is working well. The hot water outlets in the service users’ bedrooms and communal facilities are fitted with thermostatically controlled mixer valves. However, it was noted that the hot water pressure in bathroom/shower on the first floor was in urgent need of repair/replacement. The hot water temperature in all hot water outlets is now being tested on a weekly basis and appropriate records maintained. All radiators throughout the premises are suitably covered/installed to ensure safety of the service users. During the inspection the home was found to be clean and tidy and free from any unpleasant odour. The home has good policies and procedures regarding infection control, and all staff has received in-house induction training in infection control and they are made aware of the dangers of cross-infection. Several members of staff have also attended the formal infection control training. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 29 and 30 The home is not adequately staffed at all times, which could impact upon the quality of care provided, and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures. EVIDENCE: On the basis of information provided by the Care Manager and the available staff rotas indicated that the home does not meet the National Minimum Standard OP 27 and Regulation 18 of the Care Homes Regulations 2001. The comments cards received from two service users’ relatives/visitors also indicated that in their opinion there are not always sufficient numbers of staff on duty. During the inspector’s meetings with staff on duty, they also stated that they are “pushed” at peak times and during the afternoon when the numbers of carers on duty reduces to three and with a senior carer/Care Manager on duty. The carers are also expected to cover laundry duties at the weekends. The home accommodates 29 the service users on three floors with a varying degrees of dependency levels. In addition, several service users on all floors prefers to remain in their own bedrooms and thus the carers are required to supervise them and attend to their care needs. The implications of this situation have lead to the carers being severely stretched in having to provide care to service users on three floors. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 18 The Registered Provider must ensure that there are minimum of four carers and a senior carer on duty throughout the day (i.e. morning and afternoon shifts), and sufficient numbers of ancillary staff to adequately cover laundry, domestic and catering duties throughout the week. The Care Manager’s hours are in addition to the above staff hours and should be considered supernumerary to allow her to manage the home effectively and efficiently. The Registered Provider must ensure that the vacant posts of a senior carer (28 hours per week) and a laundry assistant (to provide cover at the weekends – i.e. 8 hours per week) are filled as a matter of priority. It was noted from the staff training records that only four members of staff have completed their NVQ Level 2 qualification. The Care Manager stated that currently four carers are undergoing this mode of qualification, and the remaining ten carers will be enrolled to undertake their NVQ Level training shortly. The Registered Provider also should consider providing specialist training – e.g. caring for service users with dementia, adult protection from abuse and disability awareness. The Care Manager stated that the TOPSS Induction and Foundation training for all new staff has been introduced and they are undertaking this training. The home has a good staff training programme in place. However, the Registered Provider must ensure that those member of staff who as yet have not received safe working practice topics (i.e. moving and handling, food hygiene, first-aid and infection control etc.) training must do so as a matter of priority. Discussion with the Care Manager and examination of the most recently recruited staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and enhanced CRB and POVA checks are being undertaken before new staff actually commences their duty. The Registered Provider and the Care Manager are aware that any member of staff with criminal records would not be employed in accordance with the Department of Health Guidance issued in July 2004. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, and 38 The home is managed by an experienced Care Manager, who lead the group of staff with a great deal of confidence. The staff is clear of their roles and responsibilities. Good systems of communication are in place to seek views of the service users and their families/friends. The service users’ monies are appropriately handled by the Care Manager. The staff is regularly supervised to enable them to carryout their work professionally. Health, safety and welfare of service users and staff are promoted by safe working systems put in place by the Registered Provider and the Care Manager. EVIDENCE: The Care Manager has completed her NVQ Level 4 qualification in care and management and RMA. On her arrival at Arbour Lodge in April 2005, Tania Mason has introduced a number of changes in order to improve further the Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 20 care practices and recording formats in order to further enhance high quality of care for the service users and development a resourceful staff team. The home has a quality assurance system in place. The Care Manager stated that she need to undertake some more detailed work on this Standard – i.e. obtaining feedback through questionnaires from service users and their relatives/friends and other stakeholders (e.g. professionals who visit the home). The home needs to move swiftly in ensuring the implementation of this Standard shortly. The home has good financial procedures in place. The home assists a number of service users with their money. There is a safe in the home for storage of money and valuable. A sample of three service users’ money was checked and found to be satisfactory. The records of all financial transactions are appropriately maintained. There was evidence to show that now all staff is appropriately being supervised on a regular basis. Records of supervision meetings were examined during the inspection. The Care Manager has also held a meeting with the staff in order to move swiftly to build a cohesive and resourceful team, who would deliver a good quality of care to service users. Accidents and fire prevention records were examined, which found to be appropriately maintained. Matters pertaining to fire safety and environmental health were found to be satisfactory and all the issues were appropriately addressed. The Fire Safety Officer has not visited the home in recent times. The Care Manager stated that all those members of staff who as yet not received the safe working practice topics training would do so as a matter of priority and all newly appointed members of staff would also complete their Induction and Foundation training in accordance with the TOPSS specifications and standards. (See NMS OP30 above). Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 2 3 x 2 3 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x 3 3 x 3 Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 9 Regulation 13 Requirement The Registered Provider must ensure that care staff who as yet have not received completed accredited training in safe handling of medication must do so as a matter of priority. The Registered Provider must ensure that the staff are proactive in organising a range of social and leisure activities in accordance with the service users choices, preferences and capacities, and records of these activities enjoyed by the service users are appropriately maintained at all times, and incorporated into the individual service users care plans. The Registered Provider must ensure that the water pressure and hot water temperature in the bathroom/shower outlets are checked/repaired by a suitably qualified heating engineer/plumber as a matter of priority. The Registered Provider must ensure that a suitable lockable facility is provided in bedroom 18; and portable electric heaters must be removed from Timescale for action 31/12/05 2. OP 12 16 The home states this has been completed. 3. OP 21 23 The home states this has been completed. 4. OP 24 23 & 23 The home states this has been completed. Page 23 Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 5. OP 27 18 6. OP 27 18 7. OP 28 18 8. OP 30 12, 13, & 18 9. OP 33 24 bedrooms 19 and 21; and suitable prints/pictures are provided in several bedrooms with bare walls, after due consultation with the relevant service users and their relatives/friends. The Registeed Provider must ensure that the vacant posts of a senior carer (28 hours per week) and a laundry assistant to cover the weekends(8 hours per week) are filled as a matter of priority. The Registered Provider must ensure that there are minimum of four carers and a senior carer on duty through out the day, and sufficient numbers of ancillary staff to adequately cover laundry, cleaning and cooking duties throughout the whole week for 29 service users with varying degrees of dependency levels and accommodated on three floors. The Care Managers hours are in addition to the above staff hours and should be considered supernumerary to allow her to manage the home effectively and efficiently. The Registered Provider must ensure that there is a minimum ratio of 50 trained members of staff NVQ Level 2 or equivalent by the end of 2005. The Registered Provider must ensure that all those members of staff who as yet have not received training in safe working practice topics must do so as part of the homes training programme and as a matter of priority. The Registered Provider must provide an annual Quality Assurance development plan for the home, based on a systematic cycle of planning, action, review, 15/11/05 The home states this has benn completed. 31/12/05 31/12/05 The home states this has been completed. Page 24 Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 reflecting aims and objectives and outcomes for service users. 10. 11. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP30 Good Practice Recommendations The Registered Provider should consider providing training courses for staff in Dementia, disability awareness and adult protection from all forms of abuse. Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Arbour Lodge E56 000020879 Arbour Lodge v225662 AI 140605 Stage 4.doc Version 1.30 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!