Inspection on 23/05/06 for Autumn Lodge

This inspection was carried out on 23rd May 2006.

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 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

Autumn Lodge 28/09/07

Autumn Lodge 23/01/06

Autumn Lodge 17/10/05

Autumn Lodge 21/02/05

Autumn Lodge 10/08/04

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

CARE HOMES FOR OLDER PEOPLE Autumn Lodge 35-37 Rutland Gardens Hove East Sussex BN3 5PD Lead Inspector Melanie Freeman Key Unannounced Inspection 23rd May 2006 10:00 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 Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Autumn Lodge Address 35-37 Rutland Gardens Hove East Sussex BN3 5PD 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) 01273 271786 Mrs Sheila Clare Bravery Ms Maria Theresa Howe Care Home 35 Category(ies) of Dementia (35) registration, with number of places Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is thirtyfive (35). Service users must be older people aged sixty-five (65) years or over. Up to thirty-three (33) service users with a dementia type illness to be accommodated. One (1) service user with a dementia type illness and one (1) service user without a dementia type illness or two (2) service users without a dementia type illness may be accommodated in the designated respite flat. 23rd January 2006 Date of last inspection Brief Description of the Service: Autumn Lodge is a private care home registered to provide care and accommodation for up to 33 older people with a dementia type illness; there is also a respite flat available for couples where a person with dementia can be cared for by their relative. Most of the care is long-term; however, the home does also offer respite and holiday care. The home does not provide nursing care. The home is located in a residential area close to the centre of Hove, with all local amenities and the seafront close by. The area is well served with bus and rail services, and parking is available on the private forecourt and in the street outside. The home also has its own mini-bus for outings. It has also received a Clean Food Award from Brighton and Hove City Council. The property comprises three converted houses that have been linked together, and service user accommodation, including 23 single and five shared bedrooms, plus the respite flat, is arranged on three floors that are accessed by a passenger lift or stairs. There is also a stair lift to the first floor in the ‘wing’. Communal areas include a sitting and dining room and further communal space in the ‘wing’ area in addition two conservatories and an attractive courtyard area with a fishpond and an aviary. The fees vary from £390 to £600 a week depending on the room occupied and the package of care required. These fees include all services and facilities apart from hairdressing, chiropody and newspapers, toiletries, outings and dry Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 5 cleaning. These extras are either itemised separately on the monthly invoices or paid for by small amounts of money held by the home on behalf of the service user. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Autumn Lodge Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and a further visit, which was completed via an appointment to follow up issues with the homeowner and registered manager and to provide direct feedback. The inspection visit was carried out over one full day in May 2006. During the unannounced visit the inspector reviewed in depth the care provided to 3 residents and followed this review up with contacting a relative and 2 health care professionals involved in their care. Four visitors were interviewed in private staff were spoken to throughout the inspection and were observed while they worked. A selection of documentation was reviewed and this included the statement of purpose and service users guide, staff duty rota, training records, 3 recruitment files, records relating to health and safety and a number of policies and procedures. The inspector was able to eat a mid-day meal with the residents during the unannounced visit. 10 survey questionnaires were sent to the home prior to the inspection, seven of which have been returned, mostly completed by friend/family member. A further 5 staff surveys were left in the home for completion and return. The information contained in the returned surveys has been incorporated into this report. What the service does well: The home provides both prospective and existing residents, with a good level of information about what services are provided and what to expect when living at the home. All feedback received about the home reflected a satisfaction with the care provided and the approachable manner of the staff and manager. Three visiting relatives spoken to were very complimentary of the care saying ‘I am a great fan of the home’ and ‘my brother is well looked after’. Positive comments about the staff were also received and included ‘I am very happy with the care Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 7 and help my mother receives, she is very happy with the staff’ ‘all staff when approached are supportive and helpful’. Residents receive a varied diet with meals being of good quality and plentiful both residents and visitors spoke highly of the food. The provision of activities and entertainment are given a high priority and staff promote residents involvement in these. A relative spoken to after the inspection said how much residents enjoyed the activities, which recently included a St Georges Day celebration. Autumn Lodge provides an attractive environment that is well maintained. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 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 Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Although the pre-admission assessment process is thorough the homes procedures do not ensure appropriate admission and suitable accommodation within the home. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide and a full home brochure that is provided to any prospective resident or their representative. During the inspection visit the inspector was able to discuss an admission to the home that was completed without a variation to the registration being finalised and resulting in an inappropriate placement in the home. Discussion confirmed that the admission procedures would be reviewed to prevent a reoccurrence. The inspector was also very concerned to note during her visit that two residents with dementia were being accommodated in the flat area which is Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 10 only registered to accommodate a couple where a person with dementia can be cared for by their relative. This was a matter of serious concern and an immediate feedback form was left with the homeowner that required that she ensures residents safety and moves the residents to suitable accommodation at the earliest opportunity. One of the residents is currently in hospital and the homeowner confirmed that he would not be returning. These assessment and registration issues need to be fully addressed to ensure residents receive appropriate care within a suitable and safe environment at all times. It is however acknowledged that the home owner was out of the country when these placements were completed and once she became aware made immediate arrangements to rectify the situation and to ensure no reoccurrence. A review of the admission process followed for the most recently admitted residents confirmed that pre-admission assessment had been completed in accordance with the homes procedures. The home manager confirmed that she completes all the pre-admission assessments and involve a visit to the prospective residents, either at hospital or current address, to gather information about their needs. Where appropriate, information about a prospective residents needs is also gained from other sources including resident’s representatives and health and social care professionals. Resident’s representatives confirmed that they are involved in the admission process and visited the home before an admission being agreed. Intermediate or rehabilitative care is not provided at Autumn Lodge Care Home. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Although care documentation is full the plans of care are not providing clear guidance to staff on how to meet the care needs of residents. Resident’s care needs are well met taking into account resident’s dignity with evidence of regular input from health care professionals as necessary. Procedures and practice in the home allow for the safe administration of medicines. EVIDENCE: The care documentation pertaining to 3 residents was reviewed as part of the inspection process. Comprehensive information is gathered about each resident and compiled into several documents. Although the documentation is extensive the care plan did not clearly identify the individualised care to be provided and therefore did not provide clear guidance for care staff on how to Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 12 meet residents needs. For example resident who had a problem with continence did not have a plan of care that identified what aids were to be used and what promotion of continence measures were to be followed. The challenging behaviour of residents was also poorly documented without guidance for staff of how to respond to residents in these cases. Contact with health/social care professionals confirmed that the home maintains good links and uses their services as necessary working with them to achieve good care for residents. Carers spoken to had a good understanding of residents care needs and all residents spoken to felt comfortable in the home. The three visiting relatives spoken to were also very complimentary of the care saying ‘I am a great fan of the home’ and ‘my brother is well looked after’. A visiting health Care professional contacted following the inspection confirmed that the standard of care is good and staff are responsive to the health and welfare needs of residents. The medicine administration practice observed was seen to be safe and the records demonstrated that systems have been established to ensure staff are appropriately trained and records are accurate and provide a history of what was given by who and why. Only the manager and three other senior staff, who have all been trained, are able to administer medication. The home has a good relationship with the pharmacy that visits regularly and has recently confirmed that they are satisfied with the arrangements in the home for medicines in the home. Staff observation recorded that staff were respectful and considerate to all residents and visitors. Each of the residents preferred term of address was recorded and used and dressed appropriately in well-laundered clothing. Residents rooms are respected as their private areas however contact with a visiting health care professional identified that an occupied resident’s room on the ground floor has been used for the completion of treatments. This issue was raised with the manager for her to ensure this practice is not repeated. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The homes activities and entertainment is well managed and ensures a varied provision. Meals provided for residents are excellent. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The home offers a varied programme of entertainment and events, and staff were seen to be engaging with residents in both individual and group activities to stimulate their interest and keep their minds active. Functions and celebrations are well developed and enjoyed by residents and visitors. There are records and photographs that record these events. Feedback received within the surveys returned identified an overall satisfaction with the activities provided for those residents able to join in. Comments included ‘because of my mother’s difficulties she now finds it impossible to join in. When she first attended she was able to join in lots of activities and thoroughly enjoyed them’ ‘There are plenty of activities laid on for the residents’. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 14 Contact with relatives and friends is encouraged and the home has on ‘open house’ visiting policy. The policy also confirms that guests can enjoy the homes hospitality at no extra cost. A regular visitor was spoken to and she said that ‘she felt relaxed in the home and welcomed with staff being kind to her as well as her father’. Autumn Lodge is proud of its social programme of daily activities and seasonal events which has included a comprehensive Christmas programme, these are clearly supported by the staff and management who work hard to maintain this very important aspect of residents lives, and has made this a special area of the home. Resident’s rooms were found to be personalised with many personal photographs and pictures being displayed. All residents, due to their condition, are unable to handle their financial affairs. Choices around daily live activity is encouraged and residents were seen to be exercising their choice in relation to where they spent their time and what they did. The meal eaten by the inspector was found to be well presented and to have a very good taste with an emphasis on home cooking and fresh ingredients. Most residents chose to have their meal in the dining rooms and it was noted that all residents had a choice of meal and were offered extra portions. The food was very well presented with the vegetables being served separately and all desserts being displayed on a trolley. Staff assisted residents as necessary and encouraged independent eating whenever possible. All the feedback received about the food has been very positive and comments included ‘the food is good and my father enjoys the food here’ ‘Dad really enjoys his meals. They are varied and attractively served up’. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. People are confident that complaints when raised will be responded to appropriately. Procedures in the home do not ensure that allegations or suspicions of abuse will be responded to appropriately in order to safeguard residents from abuse. EVIDENCE: The CSCI referred two written complaints back to the home for investigation this year. The investigations completed by the homes management were full and the named complainant confirmed a satisfaction with the response to her complaint the other complaint was anonymous. Contact with relatives and visiting professionals confirmed that they felt confident that any issues or concerns raised with the homes management would be responded to quickly and effectively. The records examined in respect of complaint investigation were not clear and did not maintain the necessary confidentiality of these investigations. Complaints procedures are readily available to all interested parties and are included in the homes brochure. Although the adult protection policy is full there was no clear procedure to follow if an allegation or suspicion of abuse is raised in the home. Discussion with the home manager did not demonstrate that she had a clear understanding of what action should be taken if an allegation of abuse was raised in respect of a staff member. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 16 One adult protection issue has been dealt with in conjunction with the community mental health team and has been resolved with the resident being moved following a hospital admission. Contact following the inspection visit to the home has confirmed that new Adult Protection policies and procedures along with further staff training has been provided. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in an attractive home that is well maintained and clean. Infection control practice the promotion of resident’s safety in some areas is poor. EVIDENCE: The home is centrally located within walking distance of the local amenities including shops, pubs and bus routes. There is a door entry system in operation, to enable staff to be aware when people are entering or leaving the building for security reasons. The home is well furnished and decorated and it has its own dedicated maintenance staff. The home has various communal areas that allow for residents to have different space around them and to mix with people they feel comfortable with. These areas however appear rather cramped and discussions Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 18 with health and social care professionals who visit the home confirmed that the communal environment can limit resident’s mobility. The homes management is aware of this problem and have moved some furniture and are reviewing all the areas to maximise the space available. The promotion and maintenance of mobility should be further maintained and monitored through individualised care documentation. The home has very attractive outside space where residents can sit in the sun. Resident’s bedrooms are decorated and furnished to a good standard with appropriate furniture and fixtures. Individual rooms were found to be personalised and clean. It was however noted that carpets had been replaced with laminated flooring in a number of rooms, whilst it is acknowledged that this may be necessary in some rooms it should not be used routinely. During the visit the inspector checked the hot water supplied to some areas and it was confirmed that the hot water supplied to a communal bath was at an unsafe temperature in excess of 50 degrees C. It was confirmed that the hot water supplied to en-suite bathing facilities and all hand basins accessible to residents is not being controlled to a safe temperature (close to 43 degrees C). The maintenance man was able to confirm during the inspection that the hot water supplied to bathing areas have been fitted with control valves and that these have been adjusted to ensure hot water is supplied in these areas at a safe temperature. Records on the checking of hot water supplied to areas accessible to residents were found to be inadequate. The inspector also identified two unguarded radiators during her visit, which were identified to the homeowner. It was confirmed that these radiators had been guarded when the inspector returned to the home on the following Friday. Some practice in the home did not promote good infection control and this is included tablets of soap being used in communal areas a lack of any hand washing facilities in two communal toilets. It was also noted that resident’s creams and personal toiletries were being left in communal bathrooms. At the follow up meeting the homeowner advised that staff had been reminded about infection control practice and that liquid soap had been provided to all communal hand washing areas. The home was found to be clean and hygienic in all areas. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing level at inspection was for five care staff on duty during the day and three waking staff at night. The home employs sufficient ancillary staff including housekeeping and laundry staff, a secretary and maintenance staff, and the chef and kitchen staff. Staff spoken to said that they were busy but had enough staff to meet the needs of residents. Each shift is lead by a senior carer and the manager is in the home on a supernummery basis only. Staff rotas were clear and available in the home and identified where staff were allocated to work. Visitors spoke highly about the staff and the surveys confirmed a satisfaction with the staff with the following comments ‘I am very happy with the care and help my mother receives, she is very happy with the staff’ ‘all staff when approached are supportive and helpful’. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 20 One survey identified that a resident has ‘had to wait to be taken to the toilet but they try their best to meet her needs’. Staffing levels obviuosly need to be kept under review to ensure continued appropriateness. NVQ training continues and staff spoken to along with training records confirmed that staff training was well organised. The home uses a “training matrix at a glance” to monitor that staff are completing core-training updates as required. Three recruitment files were selected for review. These included one recently recruited member of staff. The records demonstrated that references are obtained and applications forms are completed however the manager needs to ensure the employment history is full and that the last employer is contacted for a reference. On the whole the recruitment practice was found to be complete with the necessary checks being completed and the necessary documents retained by the home. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The new home manager is developing her skills in order to manage the home effectively. Resident’s financial interests are safeguarded and quality-monitoring systems take into account residents and staff views. Procedures and practice in the home promote resident and staff safety. EVIDENCE: The registered manager was appointed in November 2005 and is developing her management skills with the support of the management team, which includes the homeowner. She is completing an NVQ level 4 in management and should attend relevant training to underpin her knowledge with specific Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 22 reference to working within the care home sector legislation. It was clear from observation and feedback from staff and visitors that she is approachable and works with the staff promoting and open and positive environment. The home uses a variety of systems in order to monitor the quality of care, services and facilities provided at Autumn Lodge. These include a monthly visit and report completed by the registered owner and staff and residents/ representatives satisfaction surveys. An audit of documentation regarding the environment, records and procedure is maintained along with daily environment checks. Weekly management meetings are held and reports are provided by the senior carers. The home now need to report on their Quality monitoring and provide an annual report to the CSCI. The home has a financial controller who deals with residents’ accounts. Systems for dealing with residents money indicated that each person has a dedicated representative to deal with their money and the home only holds a small amount of money for most of the residents to pay for extras. A check of these records confirmed that appropriate records were being maiantained with receipts. Records relating to health and safety in the home were reviewed and although these on the whole are full and extensive on the day of the unannounced visit a number of missing records were identified. At the follow up vsisit the homeowner was able to demonstrate that most of these shortfalls had been addressed and that an electrical installation certificate of safety is to be completed in the near future. Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 1 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 23(1) 23(2) Requirement That residents are only admitted or accommodated in certain areas of the home if their needs can be fully met and the home is suitably registered. That care plans provide clear guidance for staff on all aspects of the health, personal and social care needs of service users and which make explicit the actions needed to meet these needs. That all staff have access to a clear procedure to follow when an allegation or suspicion of abuse is made. That staff receive training on this procedure. That all areas where hot water is accessible to residents are risk assessed to minimise the risk of scalding. That all hot water supplied to en –suite bathing facilities is controlled to a safe temperature i.e. close to 43 degrees C. That all hot water accessible to residents is controlled to safe temperature i.e. close to 43 degrees C with priority given to high risk areas. DS0000014177.V294655.R01.S.doc Timescale for action 01/06/06 2. OP7 15(1) 01/07/06 3. OP18 13(6) 01/06/06 4. OP25 13(4) 01/06/06 5. OP25 13(4) 01/08/06 6. OP25 13(4) 01/05/07 Autumn Lodge Version 5.1 Page 25 7. OP26 13(3) That appropriate hand washing facilities are provided in all communal hand washing areas. 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP16 OP20 Good Practice Recommendations That a suitable recording system is operated in respect of all complaints received. That the communal space available is reviewed as planned to make best use of all areas in the home. That each resident has a mobility plan to promote their mobility in a safe environment. That an assessment of the home is completed by an Occupational Therapist. That the manager ensures that a full employment history of all prospective staff is provided and that the previous employer is always contacted for a reference. 3. 4. OP22 OP29 Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Autumn Lodge DS0000014177.V294655.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!