Inspection on 31/05/07 for Arbour Lodge

This inspection was carried out on 31st May 2007.

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Arbour Lodge 92 Richmond Road Compton Wolverhampton West Midlands WV3 9JJ Lead Inspector Bhag Jassal Key Unannounced Inspection 31st May 2007 09:20 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.V339381.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.V339381.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 565522 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 Limited 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.V339381.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. 3. 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. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 5 Date of last inspection 6th August 2006 Brief Description of the Service: Arbour Lodge care home is providing personal care and accommodation for 29 older people, and 7 of these people can be with Dementia care needs. The home 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. The present Responsible Individual Mr Saroj Jakhu (on behalf of Arbour Lodge Ltd) has been operating this service since November 1999. Arbour Lodge Ltd makes their services known to prospective service users in the Statement of Purpose and Service Users’ Guide. The Inspection Report is mentioned in the Statement of Purpose and how a copy can be obtained. The care home charges (Fees) are reviewed annually and people who use the service are notified one month in advance. The only additional charges to people who use the service are for hairdressing, newspapers and chiropody. This is clearly laid out in the terms and conditions. The current fees charged at Arbour Lodge range from £345.00 to £398.00 per week. All people using the service pay monthly. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 31st May 2007. This unannounced visit started at 9.20.am and lasted 9 hours 20 minutes. The home had 28 places occupied and one remain vacant. The judgements made within this report are based upon information supplied by the home, from interviews with staff, people who use the service and their relatives. During the course of inspection the assessment information and care plans were inspected for 6 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observations of care practices and interaction between staff and people who use the service was also completed. Discussions took place with several members of staff and 15 people using the service were spoken to throughout the day of inspection. Acting Care Manager-Anita Hughes was present throughout the inspection process. All the information received from the care home was considered and discussed with the Acting Care Manager and the Registered Provider. What the service does well: The home provides for the needs of older people and older people with Dementia care needs in a very comfortable and homely environment. People using the service were seen to be treated in a respectful and dignified way and those spoken with confirmed this. People living in care are often vulnerable both physical and emotionally and the Registered Provider and the Acting Care Manager ensures that staff are recruited with ability to carryout personal services for people sensitively and tactfully. Recruitment of good caring staff is critical to running of care homes and the Registered Provider and the Acting Care Manager at Arbour Lodge undertakes this carefully. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 7 People using the service commented that life was good at Arbour Lodge, and were looking forward to good sunny weather so that they can go out and also make more use of the garden. What has improved since the last inspection? What they could do better: Some of the care plans had not been updated and reviewed for the last few months. Those members of staff who as yet have not received training in safe working practice topics, Dementia care and adult protection must do so as a matter of priority. This training would enable staff to improve further their care practices and professionalism. Review and increase in ancillary staff will assist in enhancing the staff team and improving the quality of care for people using the service. The quality Assurance monitoring for the year 2007 should be implemented. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 8 The Registered Provider must take swift action to ensure that the home has a registered manager in post, so that the people who use the service are protected and appropriately cared for, and staff are supported and supervised. The Inspector wishes to thank the Acting Care Manager, Registered Provider, people who use the service, their relatives and staff for their assistance and co-operation on the day of 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. The summary of this inspection report can be made available in other formats on request. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Arbour Lodge provides detailed and clear information to people who will be using the service and their families to enable them to make decisions about whether or not they wish to live at the home. Everyone receives full needs assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: Admission are not made to the home until a full needs assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessments by the Care Manager. Six files/care plans of people who use the service were inspected, which contained pre-admission assessments of their needs, both from assessments by the Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 11 home’s senior staff and other relevant professionals. Observations and discussions with people using the service, their visiting relatives, the Acting Care Manager and staff on duty indicated that the home continues to meet the needs of older people and those with Dementia care needs in a satisfactory and sensitive manner. It was noted from the staff training records that a majority of staff have received training in Dementia care. The Acting Care Manager stated that those members of staff who as yet have not undertaken this mode of training will do so as a matter of priority to increase their awareness and knowledge about the care needs of people using the service. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Everyone who use the service have individual plans of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People using the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: Everyone using the service undergo an assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Six care plans of people using the service were examined in detail and it was noted the short-term and long-term goals, aims and objectives are clearly Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 13 identified and appropriate interventions required to put them into action to meet the individual needs of people using the service are also clearly identified. It was noted that the care plans are now being reviewed on a monthly basis. However, it was evidenced that there were some gaps in recent reviews of care plans. The daily care recording formats were also examined and it was noted that the quality and detail of care recording needs further improvements. The new Acting Care Manager stated that all the care plans will be reviewed and updated as a matter of priority by the end of June 2007. The Acting Care Manager also stated that she will ensure the staff are made aware of the importance of including all the information regarding people using the service and their well-being, and all the entries made by the staff are always to be cross-referenced to their care plans. Further more the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of good practice. 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 that the detailed nutritional screening is undertaken, including a weight gain and loss records are maintained and appropriate action is taken if required. It was observed on the day of inspection that no personal care interventions were undertaken in communal areas. In addition, consultation with health and social care professionals are carried out within the bedrooms of people using the service. Visitors are able to meet people using the service in their bedrooms, in the lounges and visitors’ room on the ground floor, which offers privacy when not being used. It was observed that people using the service were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with several people using the service and all of them commented positively about their care and they felt that they have everything that they need. Six people using the service stated that “the carers are very good and kind and they look after us very well”. Two other people using the service said “the carers are always there to help”. Generally people using the service appeared to be content, comfortable and happy. They were complimentary regarding the quality of their lives and the care they are receiving at the care home. It was evidenced from the staff training records and from discussions with Acting Care Manager that all the senior carers have completed their training in safe handling of medication. However, it is the home’s policy that only the senior members of staff would be responsible for the safe handling and Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 14 administration of medication. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines have been given. Records seen included medication received, administered and leaving the home. It was noted that the mobile medication trolley was securely stored after use in the medication room/cupboard. The photographs of people using the service have been provided on the medication sheets to avoid any risks of maladministration of medication. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 15 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 and 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Everyone using the service are able to exercise choice with regard to social, and recreational activities at the home. Activities provided meet the needs of everyone who use the service. Relatives and friends are encouraged and assisted to maintain contacts with people using the service. The food provided at Arbour Lodge is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to–social, leisure and cultural interests. However, it was noted that the records of activities enjoyed by the people using the service were not recorded consistently and appropriately. The Acting Care Manager stated that the staff would be asked to record accurately in the format provided all the activities undertaken by people using the service and incorporated into their individual care plans. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 16 Several people using the service spoken to stated that they are in regular contact with their family members and friends. And spoke about their visitors’ involvement and interest in their daily care matters. The visitors’ book kept in the home showed a considerable activity. The relatives of two people living at the care home stated that visit the home at various times of the day as they wish. Three relatives who spoke to the Inspector said they are given warm and friendly welcome by the staff whenever they visit. The people who use the service also keep contacts with the local community-for example, church services, shops, pubs and park. One of the person living at the care home visits the City Centre independently on a regular basis and makes use of a range of services in order to pursue his various interests. The Acting Care Manager stated that the people using the service are positively encouraged and helped to exercise their choices and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Acting Care Manager also stated that a close liaison is maintained with relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people using the service told the Inspector “the home is very good and its peace and quite here”. “The food was very nice well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home caters for those people using the service, who have individual preferences and medical needs. The Acting Care Manager stated that the menu is changed on a regular basis in consultation with the people who use the service. The kitchen is well equipped and kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There is a clear Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaint made are listened to and acted upon. The home has an Adult Protection policy and procedure to protect people who use the service from all forms of abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the Home’s Service Users’ Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. The CSCI has not received any complaints about the care home. The people using the service were seen to speak easily to staff and were comfortable in their company. It was noted that there has one case of adult protection issue, which was dealt with through the Inter-Agency Safe Guarding Adults Procedure. The outcome of the investigation undertaken by Wolverhampton Social Services was concluded at an inter-agency case conference and specific actions to be followed up by the Adult Protection Team and the management of Arbour Lodge were agreed. The main issues to be addressed by the management of Arbour Lodge were to make improvements in the details of care plans and daily care recordings; monitoring and follow up action on healthcare of people Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 18 using the service. The home was asked to ensure that appropriate action was taken at all times in seeking relevant medical and healthcare help to protect and safe guard the people using the service. It was noted from the staff training records that several members of staff have received training in adult protection issues. The Acting Care Manager stated that the other members of staff who as yet have not undertaken this mode of training will do so shortly. A majority of staff have also received training in Dementia care. Several people who use the service stated that they were satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. General standard of the environment is good providing a homely and secure place to live. The ongoing cleaning schedule maintains the standard of hygiene throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to people who use the service. The home has ample communal space – three lounges, dining area and a visitors’ room. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas are also well - maintained. The home has implemented all the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 20 The home has provided suitable aids and adaptations in the home to meet the general and specific needs of people who use the service. There are adequate number of bathrooms/showers and WCs in the home. It was noted that the bedrooms have been “personalised” by the people using the service. It was noted that the dining room has been redecorated and new suitable flooring has been provided. However, it was noted that the ground floor corridors are still to be redecorated. The Registered Provider stated that this work will be completed by the end of August 2007. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. It was noted from staff training records that a majority of staff have completed their training in infection control. The Acting Care Manager stated that those members of staff who as yet have not received this mode of training will do so shortly. In addition, all members of staff have received induction training and they are made aware of the dangers of crossinfection. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 21 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 and 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Arbour Lodge is not adequately staffed by well - trained staff to meet the needs of people using the service. There are robust recruitment procedures in place to protect people who use the service. There is good training programme in place that ensures staff are competent to do their jobs. EVIDENCE: Information provided by the home and the available staff rotas for the month of May 2007 on the day of inspection indicated that the home is not adequately staffed. There is one senior carer and 4 carers on duty in the morning and one senior carer and 4 carers on duty in the afternoon and 2 carers on wakeful duty at night. The laundry cover is provided for 5 days a week Monday to Friday and laundry duties are covered by the care staff at the weekends in addition to their caring duties. The catering staff are provided for 7 days a week but not for evening teatimes. The carers are expected to cover catering duties. There are two cleaners, who work 5 days a week and there is no cleaner cover provided on Sundays. The carers are expected to undertake this duty in addition to their caring duties. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 22 The Acting Care Manager’s hours are in addition to the above minimum required hours and supernumerary to allow Ms Anita Hughes to manage the care home effectively and efficiently. In order to continue to provide a good standard of care and safe guard the people who use the service; and up keep the cleanliness of the home, the Registered Provider need to review the staffing levels and then need to take appropriate action to ensure adequate ancillary staff are on duty at the weekends. At least 90 of care staff group have achieved their NVQ Level 2 qualification. Those that have not yet achieved this award are to undergo this training shortly. The home does not employ Agency staff. The staff team is a wellbalanced group in terms of age, gender, experience and ethnicity. Six staff files were examined in detail in order to check compliance with the recruitment requirements. All six files contained copies of two written references and a full employment history. There was evidence on staff files that all six had been subject to satisfactory Criminal Records Bureau and POVA checks prior to being appointed. All staff were given copies of the General Social Care Council’s Code of Conduct and they sign to verify that they have received it. There was evidence on files that staff have received the statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38) staff also take part in Dementia care, Adult Protection and communication with people who use the service. Acting Care Manager has already commenced the induction training for new staff and formal supervision meetings. Staff spoken to also confirmed that they had received a full induction. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The new Acting Care Manager is managing the care home in the best interests of people using the service. There are satisfactory systems of communication in place to seek views and feedback from people who use the service and their families/friends. Monies of people using the service are kept securely and proper records are maintained. The health and safety of everyone using the service and staff are protected by the home’s policies and procedures. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home is without a Registered Manager. However, the Registered Provider has appointed a new Acting Care Manager – Ms Anita Hughes in April 2007. Ms Hughes appears to be managing the home well. The Registered Provider stated that a formal application to register Ms Hughes would be submitted to CSCI shortly. There are clear lines of accountability within the home and the Acting Care Manager is well supported by the Registered Provider. The home has a formal staff supervision system in place and the new Acting Care Manager have already begun to implement supervision of staff and meetings with staff and people who use the service are already being held. Observations made and discussions with people who use the service and their relatives and staff have indicated that the new Acting Care Manager is very approachable and she operates an open door policy. People using the service, who could express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. It was noted that the home has a Quality Assurance monitoring system in place. Quality assurance takes place throughout the service in both a formal and informal manner. Meetings, surveys, audits, day to day contact all provide records to show that satisfaction is at the heart of the service for people using the service. The Acting Care Manager confirmed that she is to design and distribute shortly the questionnaires to people using the service, their relatives and other visitors to the home. Ms Hughes stated that she will complete the report on the outcome of the feedback by the end of July 2007, and the report will be made available in the home and a copy to the CSCI. Financial records and administrative procedures relating to the handling of monies of six people who use the service were inspected and were found to be well ordered and maintained. The home actively encourages people using the service, where able, to manage their own money and one service user likes to go out daily to the City Centre for shopping. The home keeps records to show that health and safety of people who use the service is promoted and protected. A majority of staff have received their mandatory training in safe working practice topics. The Acting Care Manager stated that all members of staff who as yet have not received mandatory training in safe working practice topics would do so shortly. They will also receive training in adult protection and Dementia Care. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 25 People using the service spoken with were very complimentary about the new acting care manager and staff in the home. They knew who they were by names and looked at ease in their presence. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 26 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 X X 3 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 3 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 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 Requirement 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. Timescale for action 31/07/07 2. OP31 8 The Acting Care Manager of the 31/07/07 home must apply to register with the CSCI so that the people using the service can be confident in her suitability for this role. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that all care plans of people using the DS0000020879.V339381.R01.S.doc Version 5.2 Page 28 Arbour Lodge 2. 3. OP19 OP7 service contain clear and detailed goals, aims and objectives recorded, and detail and quality of daily care recording should be improved. It is recommended that the ground floor corridors are redecorated so that the people using the service live in a pleasant and homely environment. It is recommended that the care plans of people who use the service are reviewed at least once a month to ensure that any changes of need are identified and addressed. Arbour Lodge DS0000020879.V339381.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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.V339381.R01.S.doc Version 5.2 Page 30 - 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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