Inspection on 23/05/08 for Arbour Lodge

This inspection was carried out on 23rd May 2008.

CSCI found this care home to be providing an Good service.

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

Arbour Lodge 31/05/07

Arbour Lodge 06/08/06

Arbour Lodge 12/01/06

Arbour Lodge 14/06/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Arbour Lodge 92 Richmond Road Compton Wolverhampton West Midlands WV3 9JJ Lead Inspector Keith Salmon Key Unannounced Inspection 09:30 23rd May 2008 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 Arbour Lodge DS0000020879.V362290.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. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arbour Lodge Address 92 Richmond Road Compton Wolverhampton West Midlands WV3 9JJ 01902 771136 01902 771136 arbour.lodge@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Arbour Lodge Ltd Vacant post Care Home 29 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (22) of places Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All DE category service users must be accommodated on the ground floor. The agreed staffing levels are: 8am - 12noon Senior Carer 4 care staff 12noon - 6pm Senior carer 3 care staff 6pm - 9pm Senior carer 4 care staff Night staffing 2 waking care staff Care Manager hours are supernumerary Separate catering/domestic/laundry staff/activity organiser must be provided in addition to care hours. These are minimum staffing levels - and must be increased in the event of any increase in dependency of service users accommodated. CSCI will continue to monitor the staffing levels and may require levels to be increased should CSCI feel that care needs are not being met. All care staff must complete agreed training programme before March 2006. Until such time as all staff have completed the required training, staff rotas must ensure that at least one member of staff that has completed the training is on shift at all times day and night. 3. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 5 Date of last inspection 20th December 2007 Brief Description of the Service: Arbour Lodge is a large, semi-detached Victorian property, extended and adapted for its present use as a care home for older people. The home is located in a residential area of Compton, approximately a quarter of a mile from local shops, with good access to public transport. The home is registered to provide care and accommodation for a maximum of 29 older people up to 7 of whom have dementia related care needs Accommodation is located over three floors with access via a passenger lift, and comprises 27 single bedrooms and 1 double room all with en-suite facilities. There are several communal rooms, varying in size, with one specifically for use by visiting relatives and friends. The Home has a large garden at the front and side of the building and ample road parking. Fees for care, which are published in the Service User Guide, range from £357.00 to £408.00 per week, and are reviewed annually. Additional charges are made for hairdressing, newspapers and chiropody. The fee information given above applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Unannounced ‘Key’ Inspection of the service commenced at 9.30am, concluded at 3.30pm. Present, on behalf of the Home, was the Ms. Tracey Watton, acting manager. Unannounced ‘Key’ Inspections address all essential aspects of operating a care home and seek to establish evidence, which shows continued safety and positive outcomes for residents. Relevant information is gathered through observations made during a tour of the Home, a review of care related documentation, staff files and duty rotas, plus a range of other documents/records reflecting the general operation of the Home. The report also utilises information sent to us by the Home before the inspection, through the Annual Quality Assurance Assessment (AQAA). The content of this, which includes information relating to the Home’s policies, procedures, achievements, and plans for improvement, provides a useful framework for us to evaluate quality of service and progress made. Individual discussions were held with 6 residents, 3 visitors, the acting manager, and several other members of staff. What the service does well: What has improved since the last inspection? Improvements have been made in response to comments made by the Commission at the time of the previous ‘key’ inspection. Namely: Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 7 • • • • Redecoration of the downstairs corridor More detailed entries in care plans in respect of assessed care needs and daily records Introduction of regular staff supervision Improved training arrangements, i.e. attendance at dementia awareness and medicine administration 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. The summary of this inspection report can be made available in other formats on request. Arbour Lodge DS0000020879.V362290.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 Arbour Lodge DS0000020879.V362290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, (6 - not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the Home are provided with information to assist them in making an informed decision. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied, and subsequent findings are utilised to ensure appropriate placement and care provision. EVIDENCE: Whilst the Home does have a Service User Guide, which includes most of the information required by the standard, the need to update this document has been recognised by the Home. We were informed the document has been rewritten and is awaiting printing. It is recommended that a copy of the revised Guide be issued to existing residents in addition to future admissions. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 10 A review of care plans, and related documentation, provided evidence that care needs assessment is undertaken by suitably experienced staff (i.e. the acting manager or senior care staff), prior to admission. However, the form used to record data is lacking in some important elements of detail, e.g. date of assessment, where assessment completed and by whom. It is recommended the assessment sheet be revised to include those elements. We also noted the home currently does not write to prospective residents informing them that, following pre-admission assessment, the Home is able to provide their assessed care needs. It is recommended the Home commence this practice forthwith. Arbour Lodge DS0000020879.V362290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The content, and quality of entries within care plans, indicate residents’ individual assessed care needs are met. The storage, reception, disposal, and record keeping, relating to medicines’ administration are generally in accordance with accepted ‘good practice.’ The care provided is delivered considerately and effectively with residents’ privacy and dignity being respected. EVIDENCE: At the previous ‘key’ inspection it was recommended • … that all care plans of people using the service contain clear and detailed goals, aims and objectives recorded, and detail and quality of daily care recording should be improved… DS0000020879.V362290.R01.S.doc Version 5.2 Page 12 Arbour Lodge Review of care documentation, relating to four ‘case tracked’ residents’, demonstrated Care Plans show an improvement in the detail of content relevant to assist in ensuring provision of good quality care, together with up to date entries. This included entries and risk assessment in relation to personal hygiene, mobility, nutrition, continence and pressure sores. Evidence was also observed confirming regular care needs review is undertaken by the acting manager on at least a monthly basis. However, the structure/organisation of care planning documentation, which has recently been revised, does not appear conducive to ease of use, e.g. some elements, such as pre-admission assessed care need and daily records, are to be found in separate files. Also many care plans/residents’ files lacked the resident’s photograph. It is recommended care planning documentation be subject to further review/revision with the aim of easing day to day use by staff, and for all care plans to contain a recent photograph of the resident. We saw specialist equipment necessary to meet assessed care needs in use e.g. variable air pressure mattresses, cot-sides, and mobile hoists. The Home maintains records of all health checks carried out by the GPs, dentists, opticians, chiropodists and district nurses. It was also evidenced that the home ensures detailed nutritional screening is undertaken, including weight gain/loss records with appropriate action taken as required. Throughout the tour of the home, and during our movement within the Home (e.g. going to visit residents, who chose to remain in their bedrooms) for private discussion, it we noted staff were considerate and friendly towards residents and visitors alike. Practical examples of this included staff knocking on doors before entering bedrooms, and ensuring privacy by closing bathroom doors. Residents and visitors told us how thoughtful and kind staff were towards them. Comments include - “Can’t speak too highly (of staff), wonderful place.” “I have known nothing but kindness, could do with more bingo, very happy here though.” Inspection of the Home’s systems relating to the ordering, reception, storage, administration, and disposal of medicines demonstrated that practices meet the guidelines of the Royal Pharmaceutical Society, but with two exceptions, which were – • • In some instances, Medicine Administration Records (MAR Sheets) lacked a photograph of the particular resident The home does not maintain a list of staff approved to administer medication, including an example of each staff member’s signature and initial Recommendations will be included in this report in respect of these areas. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Those residents, who are able, choose their life style, social activity and keep in contact with family and friends. However, the range of activities, and specific support, for residents with dementia related care needs, is limited. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on residents’ preferences. EVIDENCE: The Home has a notice board in the entrance hall advertising events for the coming month. Each resident has an ‘activities diary’, maintained by the resident’s ‘key worker’, recording activities in which the resident has partaken. We were also told by resident, and by staff, that each ‘key worker’ engages with the resident, for whom they are responsible, to discuss how their overall ‘package’ of care might be improved. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 14 The task of planning activities falls largely to the acting manager with support from outside workers who visit on a monthly basis and offer ‘arts and crafts’ activities, aromatherapy, nail care, hand massage, ‘fit 4 all’ sessions and reminiscence therapy. Activities arranged within the Home include bingo and trips out e.g. shopping trips, visits to Cadbury World and the Birmingham Botanical gardens, and a day on narrow boats. One area for development, and recognised as such by the acting manager, is addressing the social/leisure and other particular care needs of residents with dementia. A recommendation is made in relation to this. It is noted staff are to begin attending training sessions regarding provision of care for residents with dementia related illness. The Home operates a four weekly menu, with choice available for residents who wish something different to that offered on the menu for the day. Drinks and snacks are available throughout the day. Residents commented to us how much they enjoyed the food, both the quality and quantity and, those who wish, can take meals in their bedrooms. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that residents and relatives feel that their views are listened to and acted upon. Robust procedures and practices are in place to ensure that individuals are protected from abuse. Residents are provided with up to date information about adult protection. EVIDENCE: Review of relevant records and documentation evidenced the Home has a clear complaint’s procedure, and which is given to residents and their relatives before they move into the Home, and the Home’s Complaints Procedure is displayed within the entrance to the Home. The Home has an Adult Protection policy and procedure to protect people who use the service from all forms of abuse. Two members of staff spoken with said they were aware of action they should take if they felt a resident’s wellbeing and protection was at risk from abuse. However the acting manager told us that additional training had been provided during March to ensure there was no complacency in respect of safeguarding vulnerable adults in their care. Staff training records confirmed this to be so. Residents and visitors, who spoke with us, stated they had no concerns, or complaints, but would feel very comfortable raising matters with the acting manager or staff at any time. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 16 We were informed a programme of staff training, in relation to complaints and the protection of vulnerable people, will commence for all staff during June 2008 under the auspices of the local Social Services Department. Accident Records were reviewed and found to be current, presenting no areas for concern. During the inspection, we were able to investigate concerns, raised by relatives during the weeks before the inspection, relating to staffing levels at certain times of the day. Review of documentation, discussion with a visiting relative of the family raising the concern, and discussion with the manager and staff, led us to conclude that for much of the day staffing levels, i.e. total numbers and skill are arguably satisfactory. However, there may be an issue in relation to the numbers, and deployment, of care staff during the evening period when residents are wishing to go to bed. It is possible that staff committed to the task of escorting, and settling residents to bed, might be distracted from ongoing responsibilities relating to the needs of residents wishing to remain in the lounge areas. Whilst residents with whom we had discussion were not able to confirm this to be so, it is recommended the acting manager review ‘late’ shift staffing levels, particularly provision of cover in the lounge areas during the evening period time. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people using the service live in a reasonably comfortable, generally safe, though rather worn environment, with some areas of the Home in need of redecoration/refurbishment. Specialist equipment is available, appropriately serviced and maintained. EVIDENCE: The standard of décor throughout the Home, whilst generally satisfactory, is beginning to appear rather worn in some areas, e.g. the wall of the hallway stairs is ‘grimy’. Whilst there is evidence of recent redecoration, as recommended at the previous ‘key’ inspection, e.g. painting of the ground floor corridor, the Home does not have an ongoing refurbishment/ redecoration programme. It is recommended one be established as soon as possible, together with dates for planned replacement of worn furnishings and redecoration. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 18 Records showed maintenance, and servicing, of care related equipment (e.g. passenger lift, hoists, wheelchairs, call bells) is regularly undertaken, and appropriately documented. In one or two areas of the Home evidence was found of the Home not achieving fully effective management of continence problems experienced by a resident. As discussed with the acting manager the carpet in one bedroom should be replaced as soon as possible. A recommendation is made to this effect. The laundry operates on a split rooms basis, i.e. comprising the main reception/washing room on one side of a corridor with the drying/ironing room on the opposite side. An area of concern in respect of these rooms is the locking arrangements. At the time of this inspection the unattended ‘washing room’ was not locked. It was explained the room has a non-functioning keypad lock. In the interests of the health and safety of residents, it will be a requirement of this inspection that the provider must ensure risk assessment is carried out and necessary action identified completed without delay. One further concern in respect of the laundry (washing room) was access to the wash hand basin being blocked by laundry skips. The acting manager agreed to ensure general tidying of the area so as to enable free access to the wash hand basin. The above points aside the laundry is spacious, well organised with effective labelling, and ‘return to owner systems to ensure laundered items are returned to the rightful owner. This was reflected in residents being dressed in wellfitted, clean clothes. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty, and skill-mix, might not be sufficient to meet, at all times, the assessed care needs of current residents. Recruitment and employment practices are consistent with the safeguarding of residents. Staff receive, and benefit, from training which prepares and supports them in carrying out their care role. EVIDENCE: A Requirement from previous key Inspection was: • The Registered Provider must ensure that the ancillary staffing levels are reviewed and increased sufficiently in order to ensure that the care needs of people using the service are appropriately met. At that time minimum staffing levels for each shift were recorded as follows; • • • Early shift (8am to 3pm) 5 carers including one senior carer Late shift (3pm to 9pm) 5 carers including one senior carer Night shift 2 carers plus a senior carer on call. DS0000020879.V362290.R01.S.doc Version 5.2 Page 20 Arbour Lodge It was reported the acting manager is sometimes supernumerary to the above day time numbers – although there did not appear to be a planned minimum number of occasions when this would be so. In addition, the Home had staff to cover functions of catering, domestic cleaning and laundry. Maintenance is covered through input as necessary from visiting maintenance staff, shared with other Homes in the group. Since that inspection adjustment has been made to the deployment of staff per shift, although with no overall increase in available staff during each 24-hour period, i.e. • Early shift (8am to 3pm) 5 carers plus one senior carer thus providing an increase from a total 5 to 6 per shift. This is a welcome increase at a busy period of the day. • However, staff levels for the late shift are now reset to a lower level at 4 carers including one senior carer. As referred to in the Complaints and Protection section, there is concern that the above adjustment to staffing levels may have reduced the quality of service provision at times during the ‘late’ shift. Specifically, review of documentation, discussion with a visiting relative of the family raising the concern, and discussion with the manager and staff, led us to conclude that for much of the day staffing levels, i.e. total numbers and skill are arguably satisfactory. However, there may be an issue in relation to the numbers, and deployment, of care staff during the evening period when residents are wishing to go to bed. It is possible that staff committed to the task of escorting, and settling residents to bed, might be distracted from ongoing responsibilities relating to the needs of residents wishing to remain in the lounge areas. Whilst residents with whom we had discussion were not able to confirm this to be so, it is recommended the acting manager review ‘late’ shift staffing levels, particularly provision of cover in the lounge areas during the evening period time. We undertook full review of staff employment files relating to three staff members (two recently employed staff, one a long standing). These demonstrated evidence of satisfactory Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) checks. Staff training files evidenced the proportion of care staff, which hold National Vocational Qualification Level 2, or higher, exceeds the minimum 50 required by the Standard, with more than 60 having attained NVQ Level 2. The commitment of the Home in providing training for care staff is satisfactory, and in accordance with individual staff member’s learning needs. Staff training Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 21 records also showed staff have undertaken appropriate induction training, plus mandatory training, including - moving and handling, medication administration, adult protection, care planning, risk assessment, infection control, and fire awareness. We were informed all staff would shortly commence a twelve-week course in the provision of care related to the needs of residents with dementia. Staff will also be undertaking refresher training in respect of the administration of medicines. Staff members told us they had received training which fitted them to provide care which was safe and of good quality. Arbour Lodge DS0000020879.V362290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified and experienced person manages the Home. The ambience is warm, friendly, and inclusive. Transactions involving expenditure of resident’s personal monies are safeguarded by the financial procedures operated within the Home. The systems for consultation with residents require development. Staff receive effective support with regular supervision. Health, safety, and welfare of residents, and staff, are generally well promoted. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 23 EVIDENCE: The ‘Registered Manager’s post has been vacant for more than a year with a series of incumbents temporarily serving as acting manager. However, the current acting manager, (Ms. Tracey Watton), who is first level Registered Nurse with many years experience working in the care home’s sector, is in the process of making application for registration with the commission as Registered Manager. It was clear in discussion with the acting manager that since appointment she has begun reviewing practices in a number of areas, e.g. in relation to care planning and care provision, staff training, and staff supervision and appears to be making progress in understanding the particular demands of being a Care Home Manager. The Home manages cash for a number of residents and a review of arrangements for safeguarding the interests of residents was undertaken. We concluded that accounting practices were appropriate, thorough, and in accordance with the Standard. However, one rider to this was in respect of audit of retained sums of money and related bookkeeping practices. Whilst these are generally satisfactorily it was suggested to the manager that as audit was mainly conducted ‘in-house’ it might be preferable, to safeguard all parties, to ensure the same individuals were not always the ones to carry out this task. We observed the Home seeks comments concerning the quality of service provision by means of a Suggestions Box, which is located in the entrance foyer, and conducts an annual survey by way of a questionnaire. In discussion the manager agreed that a more frequent issuing of the questionnaire would gather more up to date opinions and agreed the review the frequency. The Home has a formal staff supervision system in place, and the new acting manager has begun to implement supervision of staff, meetings with staff and meetings with people who use the service are already being held. Finally, the Home’s practices in the context of health, safety and welfare of residents, visitors, and staff were seen to be in accordance with the regulations. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Other ‘health and safety’ records examined related to fire risk management, lighting, nurse call bells, Legionella, portable electric equipment, hoists. All were found to be satisfactory. Arbour Lodge DS0000020879.V362290.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Arbour Lodge DS0000020879.V362290.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 OP19 Regulation 13. – 4 (a)(c) Timescale for action In the interests of the health and 18/07/08 safety of residents and in the absence of a security lock fitted to the laundry room doors, a risk assessment must be carried out and any action needed to safeguard residents taken so that the people who use the service are not placed at risk of harming themselves. Requirement 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 OP1 OP3 OP4 Good Practice Recommendations Following printing of the revised Service User’s Guide, the revised version should be issued to all existing residents. The form used to record the findings of residents’ preadmission assessment should be revised to improve validity of the document. Following the pre-admission assessment, and where there is intention to admit to the Home, prospective residents should be informed in writing as to whether the Home is DS0000020879.V362290.R01.S.doc Version 5.2 Page 26 Arbour Lodge 4. OP3 5. 6. 7. 8. 9. 10. OP9 OP9 OP12 OP19 OP26 OP27 able to meet the individual’s assessed care needs The organisation of care planning documentation be revised with a view to ease day to day use by staff and for all care plans to contain a recent photograph of the resident. Each resident’s Medicine Administration Record (MAR Sheet) should include a photograph of the particular resident to help ensure identification. An example of each staff member’s signature and initial should be held to help ensure a clear audit trail of medicines administration. A review of the organisation/provision of social/leisure activities should take place to ensure the needs of residents with dementia are fully met. An ongoing refurbishment/redecoration programme, with projected completion dates is introduced. The carpet in one identified bedroom should be replaced to ensure a more pleasant environment. A review of the ‘late’ shift staffing levels should be carried out to ensure sufficient numbers of experienced and qualified staff are available in the Home during the evenings. Arbour Lodge DS0000020879.V362290.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 DS0000020879.V362290.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. 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