Inspection on 12/12/06 for Claydon Lodge

This inspection was carried out on 12th December 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

Claydon Lodge 06/10/09

Claydon Lodge 05/11/07

Claydon Lodge 15/05/07

Claydon Lodge 16/01/06

Claydon Lodge 06/09/05

Claydon Lodge 18/11/04

Claydon Lodge 19/07/04

Claydon Lodge 27/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Claydon Lodge Crich Place North Wingfield Chesterfield Derbyshire S42 5LY Lead Inspector Bridgette Hill Key Unannounced Inspection 12th December 2006 09:15 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 Claydon Lodge DS0000020213.V312232.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. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Claydon Lodge Address Crich Place North Wingfield Chesterfield Derbyshire S42 5LY (01246) 852435 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) Mr Diwan Chand Dr. Anjuman Diwan Chand Dianne Taylor Care Home 29 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (11) of places Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider is registered to provide personal care and accommodation for service users whose primary care needs fall within the following category:- Old age, not falling within any other category (OP) 11, Dementia over 65 years of age (DE(E)) 18 The maximum number of persons to be accommodated at Claydon Lodge is 29. This registration to be seen only as phase 1 (as outlined in letter dated 9/12/04) of the full application of the home. 16th January 2006 2. 3. Date of last inspection Brief Description of the Service: Claydon Lodge Care Home is located in the village of North Wingfield, which is to the south east of Chesterfield. The home is purpose built and it is registered to provide personal care for up to 29 elderly persons. The registered accommodation is on the first floor of the building. The ground floor accommodation is not registered. Registration certificate pending for Dementia (18) and Personal Care (11) The range of fees charged at the home are £289.70 - £319.70 per week with extra charges made for Chiropody, toiletries and newspapers. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection a sample of service users care files and a range of documents were examined. A tour of the building was conducted. During the visit opportunity was taken to have discussions with management, staff, service users and visitors. Questionnaires were sent out to service users prior to the visit. Two of these were returned and the findings incorporated into this report. One service user was spoken to during the inspection. Some service users did not have the capacity to participate. The person in charge at this visit was the Manager Diane Taylor. What the service does well: What has improved since the last inspection? What they could do better: There were a range of significant concerns identified which had the potential to affect the health and safety of service users. This included lack of servicing of fire safety alarm and equipment, and gas appliances. There was poor checking by staff of fire prevention system and staff training in fire safety was overdue. There was poor recruitment practices identified with staff working with service users without relevant checks being completed. This included Criminal Records Bureau checks which were reportedly not completed until a 3 month probationary period had been completed by staff. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 6 There was no evidence of a range of mandatory staff training being completed and in date. This included moving and handling and Basic Food Hygiene. Not all staff had completed safeguarding adult training. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 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 Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst most recent admissions to the home have been done on an emergency basis service users needs were assessed and recorded within acceptable timescales. EVIDENCE: The admission procedure was discussed with the Manager who stated that where admissions were planned there would always be a pre admission assessment completed by the home. The last 3 admissions to the home were all on an emergency basis so it was not possible to establish if this was completed. For the service users admitted as an emergency there was evidence of assessments and care plans being formulated within 48 hours. There was also copies of Care Management assessments being file which gave details of assessed needs. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care as defined by National Minimum Standards 6. Claydon Lodge DS0000020213.V312232.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. 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. Generally care plans were found to be variable in describing how service users needs were to be met. It is therefore possible that service users needs may not be met. EVIDENCE: A sample of three service users care files were examined to assess how standards were being met. Two different care planning formats were being used. One format positively detailed the actions to be taken by the service user and the staff involved. The format was weak however on detailing the assessed need and the impact this had on the service user. The older format being used had little space for detailing for recording how service users needs were to be met. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 11 Some care plans were not specific in detailing how staff were to approach a service user to deal with a particular problem. One care plan for pain was not specific in where the service user experienced pain. Some service users preferences were recorded within care plans and some advocated giving service users choices for examples baths or showers. A range of standardised risk assessments were in place for tissue viability, nutrition and moving and handling. These were completed and were reviewed. There was some documentation of other risks that were evident for example smoking where service users had the potential to smoke in their bedrooms. There were some identified concerns recorded where there was not a risk management plan and associated care plan in place. Daily entries into logs were made by staff detailing how service users had been each day. The storage and administration of medicines was examined at his visit. A monitored dosage system is in use at the home and the supplying pharmacists periodically visits to review practice and procedures in the home. Most medication administration records were supplied in a typed format from the supplying pharmacists however where additions or changes were made part through a monthly cycle some entries were handwritten. Some handwritten entries did not contain signatures of staff and were not checked or verified by a second staff member. The drug reference book available was dated March 2004. Topical preparations seen had a recorded date of opening. Where variable dosages of drugs were prescribed staff were not consistently recording the actual dosage administered. Records of receipts of medications were kept as were records of returns. The policies and procedures in place were personalised and reflective of practice in the home. There were no controlled drugs stored in the home however there was not a controlled book available to record any which may be required by service users at a future date. The healthcare of service users was met by local GP’s with one practice being generally used by service users at the home. Care records for service users had evidence of GP, chiropody and district nurse visits. Service users had also been seen by a visiting optician. From the Pre Inspection Questionnaire and records there was one service user in the home with pressure areas which the District Nurse visited to monitor and dress. Claydon Lodge DS0000020213.V312232.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A limited range of activities was offered to service users although some of these did not always appear to meet the needs of some service users. EVIDENCE: A daily schedule of activities was located on the notice board which were typically organised for each afternoon. The activity on the day of the visit was skittles. It was the responsibility of staff on duty to organise the days activities. A record of activities was kept for each service user. The range offered included bingo, sing a longs, skittles, manicures, current affairs and reminiscence. The staff spoken said that one GP sometimes bought in there dog and ‘Patdogs’ occasionally visited which was said to be popular with service users. The provision of activities appeared to be basic and some records indicated that the activities offered may not be suitable for or preferred by service users Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 13 as ‘refused’ or ‘confused’ was found to be frequently recorded as reasons why service users had not participated. There was a wide range of needs abilities within the service users being cared for. The individual lifestyles of service users was respected and independence outside of the home encouraged where this within the service users capacity. Discussions with staff on service users spiritual needs confirmed that one service user was visited by a minister of their faith on a regular basis. The lunchtime meal which is the main hot meal of the day was observed. A choice of foods was available to service users and discussions with a service user confirmed a choice was routinely offered. The meal was attractively served and offered to service users who were in various location in the home depending on their preference. Staff wore aprons to serve food and sat at the side of a service user to help them to eat. There was one vegetarian service user in the home and meals were provided which were suitable. Staff were also observed discussing their option of meal for Christmas day with them. One service user said that a friend sometimes visited and had a meal at the home with them. Claydon Lodge DS0000020213.V312232.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of staff training and recording of complaint outcomes has the potential to adversely affect the care given to service users. EVIDENCE: The pre inspection questionnaire received by Commission for Social Care Inspection recorded that one complaint had been received at the home in the past 12 months. The concern raised was regarding service users personal hygiene. The records available gave details of the complaint but there was no documentary evidence of what action was taken and what response was given to the complainant. The Commission for Social Care Inspection had also received one complaint since the last inspection on 16th January 2006. A response written by the manager was received on 23.8.06. This concerned service users hygiene, provision of incontinence products and food, odours and activities, maintenance light bulbs working. Aspects of this complaint were considered at this visit. There was an odour affecting one bedroom and light bulbs were out of order in two areas used regularly by staff. There was adequate food and Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 15 incontinence products in the home. Service users appeared to be clean although records of service users having baths/showers were found to be poor. There have not been any investigations relating to safeguarding adult concerns since the last inspection. A procedure was in place regarding safeguarding adults. A copy of locally agreed procedures was available along with the relevant reporting card. Staff spoken to said they would report concerns to a range of agencies which included the Commission for Social Care Inspection, police and Social services. The procedure in place was not however specific in referring to locally agreed procedures of descriptive of at what stage referral should be made to Social services. There was only one certificate on file to confirm that any staff had completed safeguarding adult training. The Manager confirmed that not all staff had received training as has been highlighted at a previous inspection visit. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is poor maintenance of the fire safety systems in the home which have the potential to seriously affect the safety of service users. EVIDENCE: The home is a purpose built home. The ground floor is not currently registered as a care home and is unused. The registered care home is the first floor of the home with some facilities such as the kitchen and laundry area’s being on the ground floor. The Pre Inspection Questionnaire and records at the home indicated that the fire safety equipment and fire safety alarm have not been serviced since 13th September 2006. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 17 The staff have not done in house checks on the fire alarm since October 2006. Staff fire safety training had also not been undertaken since November 2005. Petrol and oil were found stored in an unused bedroom on the ground floor of the home. Staff on duty stated that they would remove these to an appropriate area immediately. A fire drill was last held in April 2006. There were no records to indicate that checks were made on the emergency lighting system or fire doors. A Fire Risk assessment had been completed however the findings and shortfalls identified would indicate the Provider is not ensuring that all risks are being managed and limited appropriately. An immediate requirement was issued at the time of inspection regarding fire precautions. A response was received from the Provider on 14th December 2006 indicating that required servicing is being arranged and that certificates will be forwarded to Commission for Social Care Inspection when they have been completed. The home was generally well kept regarding décor. The Manager said that window restrictors had been fitted to all first floor windows however one service user had removed this. There was not a risk assessment in place of this and service users in the home potentially could access this room placing them at risk. The home appeared to be clean and domestic staff were employed. The laundry area was on the ground floor and was equipped with industrial type machinery. Light bulbs were not working in the kitchenette and sluice areas. This had been the basis for one aspect of a complaint received by the Commission for Social Care Inspection. Odours were evident in the bedroom of one service user. This again had been raised as a concern to Commission for Social Care Inspection. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Provider is not ensuring that staff are appropriately recruited and trained. This may adversely affect the suitability and competency of staff being able to meet the needs of service users. EVIDENCE: The occupancy of the home on the day of the visit was 6 service users requiring personal care only. The home does not provide nursing care. The typical staffing levels at the home were2 care staff for morning shifts,2 care staff in the afternoons. 2 care worked night shifts. From the pre inspection questionnaire there were 10 care staff employed at the home of which 8 held NVQ (National Vocational Qualification) level 2 in care qualifications. A sample of three staff files were examined and significant deficits were found. One staff member had begun employment without references being in place and a Criminal Records Bureau check of PovaFirst check being in place. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 19 Discussions were held with the Manager who said that it was usual practice at the home to employ staff with a written confirmation from themselves regarding criminal convictions and checks to be completed formally with the Criminal Records Bureau only after a 3 month probationary period had been completed. It was stated that staff have to pay for their own Criminal Records Bureau checks and uniforms. The files examined did not contain photographs or proofs of identity of staff. Staff training records were examined. These indicated that a range of mandatory training was overdue. This included moving and handling, fire safety and Basic Food Hygiene. The only evidence of safeguarding adult training was one staff member did have a certificate to confirm attendance at this. One certificate in place confirmed that one staff member had received first aid training which was in date. The Manager stated that a skill based induction pack was available but there were no completed examples of this seen as the Manager said staff held these records personally. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are ineffective quality assurance and management systems in place to ensure that statutory matters related to health and safety are dealt with. This has the potential to place service users at risk. EVIDENCE: Since the last inspection a new manager has registered by the Commission for Social Care Inspection. The Registered Manager held a relevant managerial qualification. The Manager at the home works as part of the required staff compliment and as there are some service users who require care from two staff time for managerial work was said by the Manager to be limited. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 21 The quality assurance process was examined. The Provider had completed monthly reports during visits to the home; the last one available was dated 3.10.06. Whist these do record that some records have been examined they are is insufficient monitoring of the training, required servicing checks and recruitment processes despite recruitment processed being recorded as one of aspects examined on 3.10.06. The quality assurance process in place is therefore not effectively identifying issues that may affect service users. Infrequent staff meetings were held and minutes recorded. Service user survey had been completed; these indicated a general positive response to the service received. A valid public liability certificate was on display. Small amounts of service users monies were stored safely on behalf of service users. Records examined confirmed that these were accurately recorded and receipts retained for purchases made. The Pre Inspection Questionnaire and records at the home indicated that: • • • The fire safety equipment and fire safety alarm have not been serviced since 13th September 2006. Staff had not done in house checks on the fire alarm since October 2006. The gas appliances in the home have not been serviced since 29th September 2005. Some checks were in date for example the lift servicing, electrical wiring and portable appliance testing. Some monitoring of water temperatures had been recorded but not since May 2006. Accidents records were checked and where accidents had occurred to service users these were documented. Petrol and oil were found stored in an unused bedroom beneath the registered home. Discussions with staff confirmed that there was no documented checks on the safety aspects of the ground floor despite staff having to access areas of this and service users potentially being at risk if there is not maintenance of this area. Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 22 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 1 Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 23 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 14, 15 Requirement Care plans must clearly set out the detail of action that needs to be taken by staff; For example, to meet needs identified from risk assessments and known concerns Where variable dosages of medications are prescribed the actual dosage administered must be recorded Where complaints are received there must be a documented audit trail of response and actions taken The provider must ensure that all staff receive training in safeguarding adults The Provider must ensure the fire safety equipment is serviced by suitably trained persons and regularly checked by staff at the home Timescale for action 31/03/07 2 OP9 13 (2) 28/02/07 3 OP16 22 31/12/06 4 5 OP18 OP19 18 23 31/03/07 18/12/06 6 OP19 23 Immediate requirement issued at time of visit The Provider must ensure the 18/12/06 fire safety alarm is serviced by DS0000020213.V312232.R01.S.doc Version 5.2 Page 24 Claydon Lodge suitably trained persons and regularly checked by staff at the home Immediate requirement issued at time of visit The Provider must ensure that all 31/12/06 staff receive fire safety training at intervals suited to the posts held The findings of the latest Health 28/02/07 & Safety inspection of the home must be addressed (with priority to ensuring that all first floor windows have suitable window restriction) The provider must ensure staff do not commence employment until all required checks and documentation are satisfactorily in place as detailed in Regulation 19 and Schedule 2 18/12/06 7 OP19 18 8 OP25 13 (4) 9 OP29 19, Schedule 2 10 OP30 18 11 OP30 18 (1) Immediate requirement issued at the time of the visit Staff must receive mandatory 31/01/07 training updates in moving and handling, fire safety and Basic Food Hygiene There must be records available 31/03/07 for inspection to provide evidence of staff training e.g. copies of course certificates The registered person must ensure that the home has a quality assurance system with a systematic cycle (previous requirement timescales of 18/02/05 & 30/11/05 not fully met) The provider must ensure the gas installations at the home are serviced by suitably trained DS0000020213.V312232.R01.S.doc 12 OP33 24 31/03/07 13 OP38 13,23 18/12/06 Claydon Lodge Version 5.2 Page 25 persons and are safe to use Immediate requirement issued at the time of the visit The provider must ensure there 31/12/06 is recorded monitoring of water temperatures where full body immersion is possible and that the temperatures are within 43º or – 2 degrees The Provider must ensure there 31/12/06 is a system in place to ensure the unregistered premises below the registered home are checked regularly and safe so they do not potentially endanger the service users being cared for on the first floor 14 OP38 13 15 OP38 13 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 OP7 OP7 Good Practice Recommendations Care plans should be more explicit in detailing assessed needs and how these affect the service user There is more than one format of care plan in use. The processes should be reviewed to provide a standardised system of documentation of care needs Not actioned at the visit made on 12.12.06 The drug error procedure should include instructions to inform the Commission for Social Care Inspection of errors identified as per Regulation 37 notifications Where medication administration records are handwritten these should be checked and verified by two staff members The safe guarding adult procedure should be explicit in describing at what stage there is referral to locally agreed multi agency procedures Staff should receive refresher training on adult protection from a creditable source e.g. by attending social services DS0000020213.V312232.R01.S.doc Version 5.2 Page 26 3 4 5 6 OP9 OP9 OP18 OP18 Claydon Lodge training (Some staff still to attend, as of 16/01/06) 7 8 OP26 OP30 Not actioned at the visit made on 12.12.06 Adequate cleaning procedures should be implemented to ensure that all parts of the home are free from unpleasant odours There should be records to support that care staff currently employed have undergone recognised induction training Not actioned at the visit made on 12.12.06 Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Claydon Lodge DS0000020213.V312232.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!