Inspection on 09/05/06 for Camberley Lodge

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Camberley Lodge 25/07/08

Camberley Lodge 01/05/07

Camberley Lodge 03/02/06

Camberley Lodge 12/10/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Camberley Lodge 99 Fronks Road Dovercourt Harwich Essex CO12 4EQ Lead Inspector Francesca Halliday Unannounced Inspection 9th – 18th May 2006 09:30 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 Camberley Lodge DS0000063329.V293179.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. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Camberley Lodge Address 99 Fronks Road Dovercourt Harwich Essex CO12 4EQ 0208 270 9777 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) Mrs Bibi Shimintaz Mohedeen Mrs Bibi Shimintaz Mohedeen Care Home 13 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (13) of places Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, over the age of 65 years, who require care by reason of old age only (not to exceed 13 persons) Three service users, over the age of 65 years, who require care by reason of dementia, whose names were made known to the Commission The total number of service users accommodated in the home must not exceed 13 persons 3rd February 2006 Date of last inspection Brief Description of the Service: Camberley Lodge is situated in a residential area of Dovercourt, close to the sea front and within easy reach of the shops. The home is registered for 13 people over the age of 65 years. There are 10 bedrooms, 7 single and 3 double. The majority of the rooms are on the first floor. A chair lift gives access to the first floor. There is a small garden and a patio to the rear of the property. The fees at the time of inspection on 18th May 2006 ranged from £360 to £380. There are additional charges for private chiropody and hairdressing. The home has a range of information available for prospective residents and their representatives. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection visit took place on 9th May 2006. The inspection process included: discussions with 5 residents, 1 relative and 3 members of staff including the deputy manager. The premises and a sample of records were inspected. Further information was requested at the time of inspection, which arrived on 18th May, and this concluded the inspection process. What the service does well: What has improved since the last inspection? What they could do better: There were a number of areas where the premises needed to be improved for the safety and comfort of residents. A Notice of Immediate Requirement for action was issued at the time of inspection, in relation to the safety of some windows and radiators, and parts of the paving in the garden. Action was taken promptly following the inspection to repair the uneven paving, fix the loose radiator covers to the walls and repair the window restrictors that were in place. New radiator covers and window restrictors were still needed for a few rooms used by residents. The locks on residents’ bedroom doors were difficult to use and not suitable for older residents, and the majority of residents did not have a lockable drawer for money, valuables or medicines. Leads from the call bell were needed so that residents could call for assistance from different parts of their rooms. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 6 The pre-admission assessment process was not sufficiently thorough to ensure that residents were only admitted if the home could meet their needs. The specialist needs of one resident were not being fully met. The care documentation and medicines management were both in need of considerable improvements. The home offered some activities, but this was an area that needed to be developed. The deputy manager was in day-to-day control of the home, as the manager lived some distance away and was only in the home for three and a half days each week. This did not meet the requirements for the registered manager of a care home. 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. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 7 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 Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 8 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): 3 and 4 (standard 6 not applicable) Staff do no not always carry out detailed assessments before admission, to ensure that they can meet residents’ needs. Quality in this outcome area is adequate, but the formal assessment process needs to be improved to ensure that residents are not admitted outside the registration categories and competencies of staff. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The preadmission assessments sampled did not provide evidence of comprehensive assessments. There was evidence of an inappropriate admission of a resident with a mental illness, who had very challenging behaviour. Staff reported that other residents were at times frightened of this resident. The home was not registered to care for residents with a mental illness, and staff did not have the appropriate training and qualifications to care for them. There was evidence that staff were generally able to meet the needs of other residents, and were taking steps to obtain staff training in order to meet some more specialist needs of residents in the home. Residents spoken with were happy with the assessment process before admission, felt Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 9 that staff met their needs and said that they had been made to feel very welcome when they first came to the home. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Residents consider that their health and care needs are met, and that staff respect their privacy. However, care plans and risk assessments do not provide staff with the guidance they need to deliver a consistent standard of care. Medicines management needs to be improved. Quality in this outcome area is adequate. Residents are generally very satisfied with their care, but the care documentation and medicines management need to be considerably improved. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was evidence of good reviews of residents’ care and condition at staff meetings and staff demonstrated an understanding of residents’ needs. However, the care documentation was generally very confusing and did not provide clear guidance for staff. There was evidence that the lack of clear guidance for staff was on occasions resulting in different approaches to care, and lack of continuity for residents. The care plans were all on one page, which made it difficult for staff to review and evaluate each aspect of care separately. The care plans did not reflect residents’ current care needs and problems, and had not been evaluated or updated following changes in Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 11 condition. The daily records were held in separate folders and did not link to the care plans. Risk assessments did not reflect residents’ current condition and risk. However, information about a number of residents’ care was being held together in separate folders, rather than in their individual records. For example information was held in the minutes of the meeting instead of being used to update residents’ care plans and risk assessments (See standard 37). Staff were reminded that all entries in the care documentation should be in black ink, in case the records should be required to be photocopied for legal reasons. Both staff and residents reported that they had good support from GPs and local health services. The home also had support from community nurses and community mental health nurses. Residents were happy with their care, and appreciated the fact that staff escorted them to hospital appointments when necessary. A relative said that they were very happy with the standards of care, and were kept very well informed about the health of the resident they visited. The medicine administration records (MAR) were generally well completed, but allergies to medicines were not always included on the MAR. Controlled drugs (CDs) were being stored appropriately, but were not being recorded in a CD register. Liquid medicines and topical creams, with a limited shelf life on opening, were not being dated on first use. One medicine dispensed in June 2005 was still in use. The deputy manager was advised to obtain new stock for two medicines where the prescription label was not legible. Topical prescription only creams (POM) were not always being stored in a locked drawer or cupboard when not in use. The medicines fridge did not have a lock on it, and the temperature of the fridge was not being monitored. One resident was self-medicating, but there was no risk assessment or evidence that staff were regularly monitoring the resident’s safety. There was not always evidence that staff were applying prescribed topical creams. Staff who administered medicines had received training. Residents spoken with considered that staff were generally very good at respecting their privacy and dignity. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The home has some social activities but this is an area that still needs developing. Residents maintain contact with family and the local community. Staff do not always uphold residents’ right to make choices and exercise autonomy. Residents have a varied and nutritious diet, but staff do not always follow appropriate procedures when entering the kitchen. Quality in this outcome area is adequate, but social activities need further development and staff need to ensure that they consistently promote residents’ independence and autonomy. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Residents said that there was an activity once a week, but none on other days. An activity organiser provided activities for approximately 2.5 hours each week. The activity programme on display was dated 2005 and did not reflect the activity levels in the home. The home had an active monthly residents’ meeting, which was very much appreciated by residents. Two residents went out regularly to local clubs and used facilities in the community. The British Legion visited the home, and musicians and entertainers were arranged periodically. A “Songs of Praise” was held every month. One resident said that they had enjoyed a trip to the sea front with one of the care staff that morning. However, there was no member of staff designated to organise and Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 13 initiate activities each day. Staff said that an exercise session was not held on a regular basis. Staff had not received any training in the range of activities suitable for older people and people with dementia. There were some records of activities but they were not always specific to individual residents. A relative said that they were made to feel very welcome when they visited. One resident said that staff did sometimes try to persuade them to go to bed at a time that did not suit them. The menu was on display on the dining room tables. Residents spoken with said that the quality of food was good. There was evidence that the menu was changed following feedback from residents, and they confirmed that alternatives were available if they did not like what was on the menu. One resident said “I can’t fault the food”. The chef said that she visited the residents every day to find out what they wanted to eat. Residents confirmed that snacks were available if they felt hungry later in the evening or at night. During the inspection some staff were seen to go in and out of the kitchen without protective clothing on a regular basis. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents consider that any concerns raised are addressed very promptly. Residents are confident that they are protected from abuse, and further staff training had been organised. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was evidence that staff took action to address concerns raised by residents. One resident said that staff “go out of their way to put things right”. Staff spoken with had an understanding of abuse and the action to take if abuse was suspected. Residents and a relative spoken with had no concerns about the way that care was delivered. The deputy manager said that seven staff needed to have protection of vulnerable adults (POVA) training, and that this had been booked for June 2006. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26 The home is clean and in reasonably good condition. New carpets are being fitted in the main communal areas. Residents’ rooms do not fully meet their needs. Quality in this outcome area is adequate, but the proprietor needs to ensure that the call bells and door locks can be fully used by all residents and that they have a lockable facility in their room. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The deputy manager said that new carpets were due to be installed in the lounge/dining room, passageway, stairs and landing. The locks on residents’ bedroom doors were extremely stiff and difficult to use. Residents said that they were frightened of being locked in their room because the lock was difficult for them to use from the inside. Residents’ call bells were generally situated by their bed. However, there were no call bell leads in their rooms, so that residents with limited mobility could not access a call bell in different parts of their room. The majority of residents’ rooms did not have a lockable Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 16 storage space for money, valuables or medicines. A few of the drawers and cupboards in residents’ room were in need of adjustment, to make them safe and easy to use. A number of residents said that there were occasional problems with heating in the home, and that the radiator guards were too solid to allow the heat through. The deputy manager said that residents who particularly felt the cold would be provided with additional heating in their room. Thermostatic valves had been installed since the last inspection, at all water outlets used by residents. The deputy manager said that a weekly water temperature check was made. Water outlet temperatures checked during the inspection were within safe limits. A physiotherapist had assessed the home and the need for grab rails in different parts of the home. They considered that the home did not currently need any additional grab rails in communal areas. However, in some bathrooms and toilets where there were no grab rails by the toilet. A few toilet roll holders were broken, and looked as if they had been used by residents to help them stand up. The home did not have liquid soap and paper hand towels available in all bedrooms, and in areas where staff needed to wash their hands. The deputy manager said that liquid soap and paper hand towels had been put in all residents’ rooms following the inspection. The home was clean on the day of this unannounced inspection, and there were no unpleasant odours. Residents said that they were generally very happy with the laundry service and said that any problems were promptly sorted out. A new industrial washing machine, with a sluice cycle, had been installed since the last inspection. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): Staff supervision of residents is not at a consistent level, despite having a resident with challenging behaviour in the home. Recruitment practices are improving. There is a greater emphasis on training than in the past. Quality in this outcome area is adequate, but staff supervision of residents needs to be improved and some training needs were identified. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home generally had two care staff from 07.30-22.00, one carer from 07.30-12.00 and one carer from 18.30-21.30 during the day. At night the home had one carer from 22.00-08.00 and one carer on a sleepover from 22.00 and awake from 06.30-08.00. There was a cook from 08.00-14.00. The deputy manager was supernumerary to the above numbers on two days a week. The manager was supernumerary and was at the home on approximately three and a half days each week. During the morning the majority of residents were in the lounge. However, for a period of over one hour it was observed that there was no staff supervision of residents in this area. This was particularly of concern as one resident had very challenging behaviour. There was evidence of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks in the sample of records seen. The deputy manager confirmed that all staff had undergone these checks. The Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 18 personnel files generally had all the required information. However, one member of staff had been employed before both references and full identification had been obtained. Only three out of the twelve care staff had completed a National Vocational Qualification (NVQ) at level 2 or above, which did not meet the standard of 50 of staff achieving NVQs. However, the home had a twelve-week induction for new staff, which was linked to the Skills for Care standards and led on to the National Vocational Qualification (NVQ) level 2. The home had two residents with early dementia and one with Parkinson’s disease. The deputy manager said that she was trying to organise some training in care of the older person with Parkinson’s disease. The majority of staff also needed training in dementia care and the management of challenging behaviour. Some staff were undertaking a four part diabetic course to enable them to administer insulin to residents. One of the residents had very unstable diabetes. The deputy manager was advised that staff should only accept the delegation of this task if the resident’s diabetes was stable. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 36, 37, 38 The manager is not present in the home for sufficient time to fulfil the role and requirements of a registered manager. Some records are not maintained in line with the Data Protection Act. Systems for reviewing and improving quality need to be developed further. Supervision of staff has improved. A number of potential hazards were identified during the inspection. Some training in safe working practices was needed. Quality in this outcome area is adequate. Following the inspection the registered manager was taking steps to address the management cover of the home, and to reduce the obvious hazards in the environment. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A resident said, “The owner (registered manager) of the home is very nice, if you have problems she sorts it out”. The manager was only in the home for Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 20 3.5 days each week, so the deputy manager was in day-to-day control of the home. The deputy said that she had started the course leading to the Registered Manager Award. The management style in the home was open and inclusive. Following the inspection the registered manager said that she was exploring different methods of providing consistent and appropriate management cover. The deputy manager confirmed that surveys were sent to residents and relatives at least twice a year, but was not aware of a quality assurance programme or whether any report was produced. In addition to the surveys the management get regular feedback from residents at the monthly residents meeting. The deputy manager confirmed that staff in the home did not handle residents’ monies and that all invoices, for extras such as chiropody and hairdressing, were sent direct to the residents’ representatives. The deputy manager confirmed that she was now providing formal staff supervision every two months. Community nurses’ records were not being kept securely in a locked cupboard. Information about a number of residents’ care was being held together in separate folders, rather than in their individual care records. This did not comply with the Data Protection Act 1998 There was evidence of maintenance and servicing of equipment. However, there was no evidence of a recent electrical safety check for the home. The following hazards were noted during the inspection. Some windows on the first and second floors did not have window restrictors, and on some windows the restrictors had been disabled. Some radiators in rooms used by residents did not have radiator guards, and some guards were not fixed to the walls. One resident had requested not to have a radiator guard in their room, but no risk assessment had been completed. The paths in the garden had loose paving stones and a section of broken concrete. Action was taken following the inspection to fix the radiator guards to the walls, to repair the paths in the garden, to fix the window restrictors that were in place and to restrict access to the rooms that required restrictors. All staff had received fire safety training. A number of staff needed training in health and safety, food hygiene, infection control and one member of staff needed moving and handling training. There were not sufficient staff with a first aid certificate to ensure that there was a first aider on duty at all times. Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 1 X 1 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 3 1 1 Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 22 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. Standard 1 OP3 Regulation 14 Requirement The registered person must ensure that comprehensive pre-admission assessments are carried out prior to admission. Informed at the time of inspection. The registered person must ensure that the resident with a mental illness and challenging behaviour is reassessed as to the suitability of their placement. Informed at the time of inspection. The registered person must ensure that: 1. Care plans are developed with residents, cover all identified needs, state how these needs will be met, and are updated following changes in the residents’ condition. 2. Care and care plans are evaluated monthly or sooner if residents’ condition changes, and the resident is involved in this evaluation. 3. The daily records link to the care plans, and provide evidence that staff are monitoring residents’ care and care needs. Informed at the time of inspection. Requirement in previous reports - timescales of 31/01/06 and 31/03/06 not met. DS0000063329.V293179.R01.S.doc Timescale for action 09/05/06 2 OP4 14 01/06/06 3 OP7 15 01/06/06 Camberley Lodge Version 5.1 Page 23 4 OP8OP9 14 5 OP9 13(2) 6 OP9 13(2) 7 OP12OP8 16(2) (m)(n) The registered person must ensure that risk assessments cover all identified risks, are regularly reviewed and are updated following changes in residents’ condition. Informed at the time of inspection. The registered person must ensure that: 1. Allergies to medicines are recorded on the medicine administration record (MAR). 2. Liquids and creams with a limited shelf life on opening are dated on first opening, and discarded within a safe timescale. 3. Prescription only medicines (POM) are kept locked up when not in use this refers to topical creams in residents’ rooms (POM only). 4. Risk assessments are carried out for residents’ who self-medicate. 5. The temperature of the medicines fridge is recorded daily, and action taken if the safe temperature is exceeded. 6. Medicines are only administered from containers with a clear prescription label. 7. Staff record the administration of prescribed topical creams on the MAR or in the daily care records. Informed at the time of inspection. The registered person must ensure that: 1. The administration of controlled drugs is recorded in a controlled drugs register. 2. A lock is provided for the medicines fridge. Informed at the time of inspection. The registered person must ensure that: 1. A member of staff is designated to organise social activities for residents every day. 2. A weekly session of appropriate exercise and physical activity is held. DS0000063329.V293179.R01.S.doc 01/06/06 09/06/06 01/08/06 09/05/06 Camberley Lodge Version 5.1 Page 24 8 OP12 18(1)(c) 9 OP14 12(2) 10 OP15 16(2)(j) 11 OP18 18(1)(c) 12 13 OP22 OP22 13(4) 12(1)(a) 14 OP9 23(2)(m) 15 OP24 12(4) 16 OP24 23(2)(m) 17 OP25 23(2)(p) 3. A records of activities is made for each individual resident. 4. A weekly activity programme is developed following consultation with residents. Informed at the time of inspection. The registered person must ensure that care staff receive training in the range of activities suitable for older people and older people with dementia. The registered person must ensure that staff help residents to exercise choice and control over their lives. Informed at the time of inspection. The registered person must ensure that staff do not enter the kitchen without protective clothing. Informed at the time of inspection. The registered person must confirm that all staff have received training in the Protection of Vulnerable Adults. The registered person must ensure that all toilets are fitted with grab rails. The registered person must ensure that all call bells are fitted with a lead so that residents can call for assistance from anywhere in their room. The registered person must ensure that all residents have a lockable storage space in their room for medication, money or valuables. Informed at the time of inspection. The registered person must ensure that residents’ rooms are fitted with locks suited to their capabilities, and accessible to staff in emergencies. Informed at the time of inspection. The registered person must confirm that all residents’ drawers and cupboards have been checked and any faults rectified. Informed at the time of inspection. The registered person must ensure that all parts of the home are DS0000063329.V293179.R01.S.doc 01/09/06 09/05/06 09/05/06 01/07/06 01/08/06 01/09/06 01/07/06 01/08/06 16/05/06 01/07/06 Page 25 Camberley Lodge Version 5.1 18 OP26 13(3) 19 OP27 12(1)(a) 20 OP28 18(1)(a) 21 OP29 19(1) 22 OP30 18(1) 23 OP30 18(1) 24 OP30 18(1) 25 OP31 8(1) 26 OP33 24(1)(2) appropriately heated to meet the needs of individual residents. Requirement in previous report timescale of 03/02/06 not met. The registered person must confirm that liquid soap and paper hand towels, in appropriate dispensers, are available in all parts of the home where staff need to wash their hands. The registered person must ensure that residents are supervised when in the lounge. Informed at the time of inspection. The registered person must ensure that all care staff with a supervisory and management role are trained to a minimum of National Vocational Qualification (NVQ) level 2. The registered person must ensure that all the information required by Schedule 2 of the Care Homes Regulations is obtained prior to staff commencing employment. Informed at the time of inspection. The registered person must ensure that all staff have received training in the management of challenging behaviour. Informed at the time of inspection. The registered person must ensure that all staff have received training in dementia care. Informed at the time of inspection. The registered person must ensure that all staff have received training in care of the older person with Parkinson’s disease. Informed at the time of inspection. The registered person must appoint a manager if they are not able to be in full time day to day control of the home. The registered person must provide the Commission with a copy of the quality assurance policy, and send a report on the quality review of the home. DS0000063329.V293179.R01.S.doc 01/07/06 09/05/06 01/10/06 09/05/06 01/07/06 01/10/06 01/09/06 01/07/06 01/07/06 Camberley Lodge Version 5.1 Page 26 27 OP37 17(1) 28 29 OP38 OP38 23(2)(b) 13(4) 30 OP38 13(4) 31 32 33 OP38 OP38 OP38 13(5) 13(4) 13(4) The registered person must ensure that confidential information about residents’ care and care needs is held in their individual folders, in line with the Data Protection Act 1998, and not with information about other residents. Informed at the time of inspection. The registered person must ensure that an electrical safety check of the home is carried out every five years. The registered person must ensure that all radiators in areas used by residents have radiator guards. If a resident has requested that the radiator is unguarded in their room, a risk assessment must be completed and kept under review. Informed at the time of inspection. Confirmation was received on 18/05/06 that the loose radiator covers had been fixed to the walls and that steps were being taken to purchase and install guards on the remaining unguarded radiators. The registered person must ensure that all rooms on the first and second floor that are accessible to residents have window restrictors in place. Informed at the time of inspection. Confirmation was received on 18/05/06 that the window restrictors in place had been secured and that the rooms with no restrictors had been locked until such time as window restrictors were put in place. The registered person must confirm that all staff have completed moving and handling training. The registered person must ensure that all staff have undertaken health and safety training. The registered person must ensure that sufficient staff have first aid training to provide a first aider on duty at all times. DS0000063329.V293179.R01.S.doc 09/05/06 01/07/06 01/07/06 01/07/06 01/07/06 01/08/06 01/08/06 Camberley Lodge Version 5.1 Page 27 34 35 36 OP38 OP38 OP38 16(2)(j) 13(3) 13(4) The registered person must ensure that all staff have undertaken food hygiene training. The registered person must ensure that all staff have undertaken infection control training. The registered person must ensure that the concrete path and loose paving stones are repaired. Confirmation was received on 18/05/06 that this work had been completed. 01/09/06 01/10/06 09/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Camberley Lodge DS0000063329.V293179.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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