Inspection on 20/07/06 for Chapel Lodge

This inspection was carried out on 20th July 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

Chapel Lodge 23/11/09

Chapel Lodge 27/09/07

Chapel Lodge 15/11/05

Chapel Lodge 27/04/05

Chapel Lodge 18/11/04

Chapel Lodge 20/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Chapel Lodge 11 Hall Street Worsthorne Burnley Lancashire BB10 3NR Lead Inspector Mr Jeff Pearson Key Unannounced Inspection 09:30 20th& 21st July 2006 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 Chapel Lodge DS0000009502.V298833.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. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chapel Lodge Address 11 Hall Street Worsthorne Burnley Lancashire BB10 3NR 01282 413901 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) Dr Zahid Mahmood Dabir Mrs Naila Dabir Mrs Julie Patricia Harrison Care Home 23 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registered provider should, at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. The home can accommodate 22 older persons and 1 older person with dementia DE(E) making a total of 23 residents. 15th November 2005 Date of last inspection Brief Description of the Service: Chapel Lodge is registered to accommodate up to 22 older people over the age of 65 and 1 person with dementia over 65. The residents are either privately or Local Authority funded. The home is a converted chapel with some bedrooms overlooking the cemetery. Chapel Lodge is in a residential area in the village of Worsthorne about two miles from Burnley town centre. There are some local facilities nearby such as a general store, post office, public houses and a Church quite close to the home. There is a small parking area to the front of the home, also a gardens and a patio area. Garden furniture is provided. A ramp provides access to the front door. The home has inter-connecting sitting rooms and a dinning area. All the bedrooms are single, some have en-suite toilets. Staff are available to provide assistance with personal care and support. The home can provide for recreational activities. The registered providers live next door to the home. At the time of the inspection visit, the range of fees charged were between £315 and £355 per week, there were additional charges of £25 per week for en-suite toilets, also variable amounts for hairdressing. Written information about the home was available in the entrance hallway. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit took 10 hours and was carried over two days by one inspector. There were 19 residents accommodated. Prior to the inspection visit, survey forms were sent to the home for the residents and their relatives/representatives to complete. Five were received from residents and four from relatives/visitors. Information was gathered from a pre inspection questionnaire completed by Mrs Harrison, registered manager. The files/records of 2 residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. During the inspection, the residents, registered manager, one registered provider, staff and visitors were spoken with. The records of the most recently recruited staff were looked at. Some policies and procedures were looked at. A tour of the premises was carried out. What the service does well: The atmosphere at Chapel Lodge was welcoming, supportive and friendly. “We liked the feel of the home my dad loves it, staff are wonderful, I have never felt so welcomed” said one visitor. The home was clean and pleasantly decorated, the furnishings and fittings were of a good standard; the residents said they liked the accommodation provided, one resident wrote “the home is always clean and tidy” Another commented, “I don’t think I could find a better place” The home was being well run and there were lots of good practices in place. The residents’ were generally happy with the activities available and residents meetings were being held so people could get involved and be consulted. One resident wrote “I am very happy at Chapel Lodge, the staff are very caring and I class them as friends. They always make me and my family feel at home. I wouldn’t want to be anywhere else. And my family have peace of mind knowing I am being cared for in the best possible way. A big thank you to all at Chapel Lodge” Daily routines were fairly relaxed so people could be flexible in how they spent their time. People were being encouraged as far as possible, to make their own decisions and choices about things which affected them. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 6 The catering arrangements were generally good, all the residents spoken with appreciated the food provided, one said, “the food is very good” another wrote, “the meals are very good. And members of my family are asked if they would like a meal if they are visiting around mealtimes which is lovely” Staff training and development was high priority at Chapel Lodge. The residents appreciated the staff and relationships between everyone in the home were good. One resident described staff as “ really good, sociable and helpful” “They have a good sense of humour” said another and a relative/visitor wrote “All staff are very pleasant and caring, within seconds of ringing the buzzer – they are there” What has improved since the last inspection? What they could do better: The resident’s individual care plans still needed to include full details of all their needs and how they are to be met, to ensure staff know exactly what to do for each person. When people are at risk of falling this needs to be properly assessed and dealt with in their care plan. To make sure people are getting the care they need, care plans should be reviewed each month with residents, and any changes are written into their plans. The food for liquidised/soft diets should be blended separately, to provide a more appealing meal in terms of texture, flavour and appearance. A more detailed record needed to be kept of meals served to show a suitable diet is being provided. To make sure proper action is taken when dealing with abuse and protection matters, clearer details should be noted in the referral guidelines. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 7 To keep medication safe, the fridge must be kept locked. Clear individual guidelines were still needed about when to give the residents ‘when required’ medication. Better practices and guidelines were needed for dealing with medication leaving the home with residents. Medication reviews needed to be prompted. The quality assurance system still needed more work to make sure everyone is consulted and to show plans are being made to make improvements for the benefit of the residents. To make sure everything in Chapel Lodge is as safe as possible, all areas and routines must be carefully considered to reduce the risk of harm to people living there, staff and visitors. 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. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had been assessed prior to moving into the home, to make sure their needs and wishes could be met. EVIDENCE: The records of the two most recently admitted residents showed assessment information from Social Services had been obtained. The registered manager had also been out to meet and assess the residents prior to admission. The document used by the home for assessing people covered various health and social care needs and abilities. One new resident spoken with said the manager and home owner had visited him in hospital, “they asked lots of questions and gave me a brochure, which I feel gave a true reflection of the home” Comments from the five residents completing surveys, indicated they had received enough information about the home before they moved in. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not provide sufficient details to fully address the residents’ health, personal and social care needs. Some improvements were needed in medication management practices for the protection of the residents and staff. Support with personal care was provided sensitively in a way which promoted the resident’s privacy and dignity. EVIDENCE: Although improvements had been made, care plans seen as part of case tracking, were lacking in specific details of actions to be taken by staff to meet identified needs. Some care needs were not properly specified. There was still no clear difference between ‘assessment’ and ‘action’. One care plan had not been reviewed for more than two months; this matter was addressed during the visit. The residents’ surveys indicated they always get the medical support they needed. There were records of residents receiving attention from health care Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 11 professionals, such as District Nurses and GPs. On resident was described as having a history of falls, but no specific risk assessment had been completed. As indicated, health care needs and responses; were not always adequately reflected in care plans. Health care matters, such as nutrition were being considered as part of the initial assessment process. The monitoring of health care needs such as pressure area care, nutrition and continence was discussed with the manager. Staff responsible for administering medications had received accredited training; two staff were undertaking this training. Records showed staff had been given training in providing support with blood glucose monitoring. Medication management policies had been revised to include covert administration. Procedures for medication leaving the home with residents; needed further expansion to ensure a proper audit trail. There was secure storage for items needing refrigeration, this was found to be unlocked. There were no individual guidelines for managing ‘when required’ medication. Medication reviews were not being specifically requested. Residents spoken with felt they were “treated with respect”. The homes aims and objectives included reference to privacy and dignity. Staff spoken with explained how they promote privacy when providing personal care and support. The care planning system considered people as individuals and therefore dealt with diversity matters, this approach was also observed in care practices. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents had a degree of independence, opportunity to take part in activities, make choices and decisions and keep in touch with families and friends. The catering arrangements were sufficient in providing for the residents tastes, choices and diet. EVIDENCE: Routines in the home seemed fairly flexible, the residents said they could get up and go to bed when they wished and people were seen having breakfast at a later time. The residents spoken with were generally satisfied with the activities on offer, which included various games, theme nights, sing-a-longs and quizzes. A small group of residents were seen playing dominoes. Residents meetings were being held, records showed various matters had been raised and discussed. One resident commented, “we have residents meetings for suggestions and complaints, we are hoping to go to Chester Zoo” Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 13 The visiting arrangements were outlined in the homes guide. All five comment cards from relatives/visitors indicated they could visit their relatives/friends in private. Several visitors were seen in the home. One relative spoken with commented, “we can come anytime, the staff are wonderful” Some links with the community had been developed, with representatives from a local Church visiting each month. Families and friends had also been invited to the theme nights and other events. Relatives could stay for meals at the home if they wished, which was very much appreciated by the residents. The care planning system and residents meetings; showed that systems were in place to enable the residents to make choices and decisions, individually and as a group. The residents had been encouraged to bring their own personal possessions and furniture with them, detailed records were seen of such items. One residents’ family had chosen to decorate and furnish his room. Information about advocacy agencies was available and some progress had been made in providing an access to written information procedure, it was suggested this information be included in the homes guide. The residents spoken with said they were happy with the quality, variety and choice of meals provided, this was also reflected in the residents surveys. A four-week menu system was in place; two meal choices were routinely available. Options were discussed with residents each day and were on display in the dining area. Diets such as diabetic and low fat were being catered for. The residents had been able to influence the menu options within their meetings. Residents were observed to be offered something else, when they did not want what they had asked for. The dining area and table settings provided a pleasant environment for the residents. The record of meals served did not include enough detail to show all meals actually served. Liquidised meals were not being properly produced. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place to provide for the effective management of complaints. Policies, procedures and staff training promoted the protection of the residents. EVIDENCE: There had not been any recent complaints made at the home. The residents spoken with said they had no complaints, but were aware of the complaints procedure. The procedure for making complaints was in the homes guide and on display in each bedroom. The procedure was seen to include all the necessary details and contact information. Complaints/compliment forms were available. The management of complaints was discussed with manager and it was agreed some training would be useful. The homes protection/abuse policies included information based upon the ‘No secrets ’ guidance. Guidance and procedures were available on dealing with aggressive behaviour. A policy on physical intervention was seen. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training and 16 staff had received additional training on protection and abuse matters. The staff whistle blowing policy was seen, this had been given to all employees at a staff meeting. The procedure for referring and managing suspicions, allegations and incidents of abuse provided only basics instructions. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the accommodation was good, providing the residents with an attractive and homely place to live. Some improvements were ongoing to provide the residents with more suitable facilities. EVIDENCE: The residents spoken with said they were happy with the accommodation provided and expressed an appreciation of the front garden area. The lounge areas were pleasantly decorated, another television had been provided. Systems were in place to identify and attend to and repairs and refurbishment. All the bedrooms were single, some had en-suite toilets. Some bedrooms had been decorated with new carpets fitted. The ground floor bathroom had been decorated and the washbasin moved to provide better access to the bath. Work was underway to improve the ground Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 16 floor walk in shower and toilet. The heating system had been improved by the installing of new central heating boilers. The home was clean and fresh smelling. The manager explained an enzyme based cleaning product was being used. A clinical waste policy was available and the infection control policies had been updated, most staff had undertaken ‘in-house’ infection control training. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. An improvement in staff recruitment practices, showed attention was being given to protecting the residents. Induction training and ongoing staff development, promoted effective support and care for the residents. EVIDENCE: Residents spoken with were complimentary about the staff team. The required numbers of staff were on duty. Staff rotas and records of hours worked, showed that appropriate staffing levels were in place. There were enough catering and cleaning staff employed. Staff records checked were found to have all the required information and clearance checks had been carried out. Interview notes had been kept, but only provided minimal information. Further safeguards were discussed with the manager. Staff had been provided with contracts of employment. Records were seen of completed and ongoing induction training, new, unqualified staff were being supported to start NVQ training as a matter of course. Records of training showed staff development was ongoing. Copy Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 18 certificates were available on staff files. Discussions with staff confirmed various training courses were provided and staff meetings were being held. More than 70 of the carers had NVQ (National Vocational Qualifications) in care, level 2. Four carers had NVQ level 3 in care and six were to commence this course of learning. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager had the ability, experience, qualifications and support to effectively manage the home. Further safeguards were needed to promote health and safety of residents, visitors and staff. EVIDENCE: The atmosphere at Chapel Lodge was found to be relaxed and welcoming. The residents, staff and manager seemed to get on well together. The manager had attained NVQ level 4 in management and had completed the Registered Managers Award, her certificate being seen. She had also attended other relevant training courses. Lines of accountability within the management structure were clear. The manager said the homeowners were accessible and supportive. Residents spoken with were happy with management of the home; Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 20 staff said the manager was approachable and helpful. Internet access had been obtained. A new quality assurance policy had been defined and introduced. New quality assurance questionnaires had been obtained for residents. Some questionnaires had been completed. There was no annual development plan available The homes’ guide included information about financial matters. Records seen indicated accountable systems were in place to manage residents’ pensions, monies and charges and payments. Secure storage was available. Staff said they were receiving individual supervision sessions and appraisals: records were available in support of this. The home was found to be free from any obvious hazards to health and safety. The pre-inspection questionnaire showed equipment had been serviced and that installations and maintenance checks were ongoing. Documents were available in support of this. Records were seen of various checks including water temperature and fire equipment. All senior staff had completed First Aid training. Training in safe working practices was ongoing, or being arranged. Detailed fire risk assessments had been completed. Health and Safety risk audits had been completed on residents’ bedrooms. There were no health and risk assessments on all areas of the home and grounds. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 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. 1. Standard OP7 Regulation 15 Requirement Care plans must include all identified needs and be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents health and welfare needs. Instructions following specific assessments and risk assessments must be included in care plans. (Timescale of 17/02/06 not fully met) Medication storage facilities (including refrigerators) must be kept locked when not in use. Records of the food provided for residents, must be in sufficient detail to show whether the diet is satisfactory. Bathing facilities must appropriately meet the needs of the residents (Timescale of 31/03/06 not fully met) The registered persons must, with the involvement of residents and others, establish and maintain a system for evaluating the quality of the services DS0000009502.V298833.R01.S.doc Timescale for action 25/08/06 2. 3. OP9 OP15 13 17 (2) 20/07/06 31/07/06 3. OP21 23 25/08/06 4. OP33 24 30/09/06 Chapel Lodge Version 5.2 Page 23 5. OP38 13 (4) provided at the home. Health and safety risk assessments should be carried out on all areas of the home, outside pathways and grounds. Health and safety risk assessments must be carried out on all areas of the home, outside pathways and grounds. Matters identified as a result of health and safety risk assessments must be attend to. 30/09/06 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. 3. Refer to Standard OP7 OP7 OP8 Good Practice Recommendations The care planning system should ensure all the residents’ needs and wishes are fully recorded and the specific action to be taken by staff, clearly noted. Care plans should be reviewed with the involvement of residents each month. More detailed and specific risk assessments should carried out and actioned, in respect of residents identified at risk of falling. Systems for monitoring and reviewing health care needs should be further developed. Individual protocols should be written to provide clear agreed instructions for staff, on when to give ‘when required’ medication (Outstanding from last inspection) Records of medication leaving the home/returning with residents should provide a clear audit trail. Instructions to carry out this practice should be reflected in the medication management policies and procedures. A system should be introduced to prompt medication reviews at least 6 monthly, for residents aged 75 or above, prescribed 4 or more medicines. (National Service Framework for Older People) The food in liquefied meals should be blended separately. The protection of vulnerable adults procedure should provide clearer details of the actions to be taken, and in DS0000009502.V298833.R01.S.doc Version 5.2 Page 24 4. 5. OP9 OP9 6. OP9 7. 8. OP15 OP18 Chapel Lodge 9. OP29 10. OP33 what circumstances, when referring allegations, incidents and suspicions of abuse. The employment application form should be revised to prohibit references from relatives and should request details of any disciplinary action. More detailed notes of responses in employment interviews should be kept. The quality review process should result in an annual development plan. Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Chapel Lodge DS0000009502.V298833.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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