Inspection on 15/05/07 for Claydon Lodge

This inspection was carried out on 15th May 2007.

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 12/12/06

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 Unannounced Inspection 15th May 2007 09:05 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.V337205.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.V337205.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 Vacant 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.V337205.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 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. 12th December 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 service users. 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 inspection report available in the entrance hallway was not the most recent one. The Statement of purpose and service user guide available was out of date. The range of fees charged at the home are £300.00 - £331.60 per week with extra charges made for Chiropody, toiletries and newspapers. This information is taken from the Pre Inspection Questionnaire completed by staff from the home. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which focused on assessing compliance to previously listed requirements and on assessing all key standards. 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. The person in charge at this visit was the Acting Manager Stephen Booker who had been in post fro less than two weeks at the time of the visit. What the service does well: What has improved since the last inspection? What they could do better: An improvement plan submitted to the Commission for Social Care Inspection on 14thn February 2007 following the last inspection has been largely unmet. There has been inconsistent management of the home and poor monitoring by the Provider to ensure that standards are met. The care plans in place were found to be poor in describing assessed needs or how these were to be met. Some significant gaps in assessed needs were evident. There was a lack of knowledge and records regarding when chiropodist care was last given or next due. There is poor attention paid to some aspects of health and safety such as testing the fire alarm, water temperatures and checks of the unused ground floor being completed to ensure there are no potential hazards present. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 6 The recruitment of staff is taking place without all required checks being completed and the induction of staff is inadequate in ensuring staff have the skills necessary to care for service users. There were no evidence from discussions with staff or records to evidence that there was any staff supervision was taking place. The staff group are poorly training but some mandatory training is not being completed. This included kitchen staff not receiving accredited Basic Food Hygiene training. There has been no Protection of vulnerable adults training and some situations have not been considered as safeguarding adult issues when there were implications for the safety of staff, service users 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. The summary of this inspection report can be made available in other formats on request. Claydon Lodge DS0000020213.V337205.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.V337205.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): 1,3,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is poor communication and recording of pre admission assessments that adversely affect the admission process for service users. There is not up to date information available for service users to enable them to make informed choices. EVIDENCE: The file of a recently admitted service user was examined. Communication difficulties were evident in the process of this admission as although the admission was planned the pre admission information was missing and not available to staff in the home that the service user was expected. No recorded information was available to the staff and further information from the service user and their relatives was sought at the time of admission. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 9 Information was later sought from the Care Manager; this was provided and included a Care Management plan of care. Feedback given from the Care Manager following an initial review was that the service user had settled and compared the care staff favourably to experiences in other establishments saying staff were ‘kind’. Where there was pre admission assessments in place poor information was recorded for example The answer ‘Fair ‘ was recorded to a range of headings including ‘breathing’, ‘hearing’ and ‘sight’. This gives little information on abilities or needs. The Service User Guide and Statement of purpose were found to be out of date and no information regarding the home had been given to the service user or their relatives. The home does not offer intermediate care as defined by National Minimum Standards 6. Claydon Lodge DS0000020213.V337205.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 poor. This judgement has been made using available evidence including a visit to this service. The care plans in place are not sufficiently detailed in recording assessed needs or how care is delivered. The provision of healthcare is inconsistent and poorly recorded. This has the potential for service users needs to be unmet. EVIDENCE: A sample of two service users care files were examined to assess how standards were being met. Some were assessed in part to explore different aspects. The care plans in place were poor in describing assessed needs. Some key areas were not considered or recorded in care plans these included continence and communication. Care plans for mobility did not describe where specific aids were being used. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 11 One care staff member said they did read care plans but said they did not give enough information. Daily records were generally well kept by staff. These also included a log of personal care delivered. The records for personal care indicated that service users were infrequently bathed/showered. One service user spoken to said they had a bath twice a week but could not say when they were bathed last. Some care plan reviews were documented the last being completed in mid March 2007. Some risk assessment tools were included in the care plans. One for tissue viability was a tool designed for settings where nursing was provided and included medical terminology that may not be understood by staff without medical training. Some tissue viability equipment was observed in use for example pressure relieving cushions. There were high scores on risk assessments and details on admission recorded that a pressure relieving mattress was required but none was in place on the service users bed. The storage and administration of medicines was examined at his visit. Generally the storage arrangements were found to be adequate with good recording on the medication administration records. An audit was possible of what medications were received into the home and disposal records when drugs were returned. A medication fridge was said to be available downstairs but was not in use. Some homely remedies mediations were available but these were not supported by agreements from the service users GP’s or protocols and procedures as to when they should be used. Staff spoken to were a little unsure about some aspects of returning drugs. Care records were kept for professional visits. One service user had been asking for a chiropodist visit and staff spoken to said there was a chiropodist who visited regularly however records were poor in determining when they last visited and it was not known when they were next due. An optician had visited the home in the past year and prescriptions were within care records. One service user had poorly fitting dentures due to weight loss which they no longer wore. There was no records to demonstrate that a dentist had been consulted regarding this. For one service user the GP recorded in their care file was not the GP they were actually registered with. Claydon Lodge DS0000020213.V337205.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 poor. This judgement has been made using available evidence including a visit to this service. There was poor social stimulation and few choices offered at the home, this adversely affects the lifestyles of service users. EVIDENCE: There was a schedule of activities listed on the dining room wall although from specking to staff and examining records it was evident that this was not followed. Some records were kept for activities which indicated that occasionally bingo, skittles and board games were offered. Some service users had dementia and records indicated that ‘confused’ or ‘refused’ was recorded which would indicate that activities which are offered are not always suited to the group of service users being cared for. A frequent term used in logs was ‘resting in lounge’ which would suggest little stimulation is offered to service users. There was no indication that service users were involved in deciding what was arranged either on an individual or group basis. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 13 A small snooker table was available but staff spoken to said that only one service user had the ability to use this. There were no evidence provided that would suggest any community involvement in or out of the home. There were no visitors present during the visit but staff said there were regular visitors to the home who were welcomed with drinks. One service user spoken to said they chose what time they went to bed and got up. The kitchen staff in the home had not received accredited Basic Food Hygiene training but said they had watched a video on the subject. Records of foods served were held as were temperatures of fridges, freezers and cooked food. When asked about the temperatures of cooked and calibration of equipment poor knowledge of this was demonstrated by staff. Foods were also temperature checked at the point of cooking finishing but not at the time of serving which according to records could be 40 minutes later. No routine choice of meals was offered with one main meal being cooked at lunchtime. A choice of sandwiches was offered at teatime. Service users spoken to said they enjoyed the lunch but said pudding was ‘sponge and custard’ ‘same as usual’. Service users could choose where they wished to eat their meal with some service users preferring to eat in the lounge. Vegetarian food was cooked on a regular basis and records indicated that little choice was offered with sometimes the same meal served on consecutive days. There was a high use of quorn fillets/mince and vegeburgers. Claydon Lodge DS0000020213.V337205.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 poor. This judgement has been made using available evidence including a visit to this service. There are insufficient procedures and training in place to ensure service users, staff and visitors are protected as far as possible from harm. 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. Records at the home indicated that there were two complaints received. As has been found at previous visits there were no outcomes recorded and it was not possible to assess if any action taken was appropriate. This remains unmet despite the improvement plan supplied by the Provider indicating that this had already been addressed as of 14th February 2007. The Commission for Social Care Inspection had received no complaints since the last inspection on 12th December 2006. A complaints procedure was on display in two areas of the home, this included the address of the Commission for Social Care Inspection but was out of date with respect to the manager in post with a number of managers having been in post since the named person. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 15 One service user spoken to said they would go to the Manager who they were able to name if they had any concerns. There have not been any investigations relating to safeguarding adult concerns since the last inspection. Staff training in Protection of vulnerable adults has previously been identified as a requirement. This remains unmet despite the improvement plan supplied by the Provider indicating that this would be met by 31st March 2007. Some issues/incidents recorded in log entries had implications for the safety of service users, staff and visitors but had not been considered as potential safe guarding adults issues and had not been referred for further consideration/investigation. This maybe due to poor staff knowledge and training regarding the safeguarding of adults. The in house Protection of vulnerable adults procedure required amending to ensure that the process was clear as to when to report to Social services and the locally agreed procedures. This has been previously recommended. The Protection of vulnerable adults procedure in place. There were copies of locally agreed Derbyshire County Councils procedures and reporting cards at the home. Claydon Lodge DS0000020213.V337205.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. The home is not being adequately maintained and managed to ensure that it provides a safe, clean and comfortable environment for service users. EVIDENCE: Claydon Lodge is a purpose built home located in a cul de sac in a residential area. Currently only the upstairs of the property is registered as a Care Home and the downstairs floor whilst being used for its kitchen and laundry facilities is not used but service users. A garden area is available but this was not secure and was somewhat overgrown and neglected. There was no seating available in the garden for Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 17 service users to use and as service users were located on the first floor the garden was not readily accessible. A tour of the upstairs and partial tour of the downstairs was completed at this visit. There were no domestic staff employed and care staff were responsible for laundry and cleaning. The home was found to be generally tidy and clean in the areas that were being used. However some aspects of the home had not been cleaned for sometime particularly stair wells, some bedrooms not in general use and marks were evident on furniture and carpets required hovering. Since the last inspection the fire system has been serviced. There has not however been regular checks of this by staff at the home to ensure it is fully functioning. This is despite an improvement plan being submitted from The Provider on 14th February to state this had been implemented. There was not a documented Workplace Fire Risk Assessment available at the home which is lawfully required. There does not appear to an ongoing maintenance programme in place or any systems which routinely check the health and safety of the building. Recently a large number of light bulbs have been replaced which were said by staff to have required replacement for some time. Further bulbs were still required to ensure all areas were fully lit. Due to low occupancy many rooms are unoccupied and items of furniture are missing and beds were not always made up. The soft furnishings and bed linen in use were very faded due to sunlight damage on curtains and frequent washing. The laundry area in the home is located on the ground floor and was considered to be a little untidy but generally suitable for purpose with one washer and two dryers. As care staff were responsible for doing laundry a bedroom on the first floor was being used as a make shift ironing room in order that staff would be near to service users. The sluice on the first floor was particularly odorous and unpleasant. Claydon Lodge DS0000020213.V337205.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. Staff are not being recruited, inducted, trained or supervised adequately which has significant potential to place service users at risk. EVIDENCE: The occupancy of the home on the day of the visit was 5 service users assessed as requiring personal care. The typical staffing levels at the home were 1 nurse on duty for all shifts with 2 care staff for all shifts over the 24 hour period. Some staff were working long shifts to cover gaps on the staff rota. There appeared to be small group of core staff who had worked at the home for many years with many new staff starting in the past few months. Staff at the home did not wear name badges and they said that some service user and visitors knew their names others did not. The Pre Inspection Questionnaire had not been fully completed regarding number of care staff or how many held NVQ (National Vocational Qualification) Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 19 qualifications. Discussions with the Acting Manager confirmed that there were 9 staff in post, 4 of whom had achieved NVQ (National Vocational Qualification) level 2 or above. 3 had begun NVQ (National Vocational Qualification) courses. The NVQ (National Vocational Qualification) Assessor visited the home to see staff during the inspection. There was no skill based induction package available for staff only a general checklist. There had been staff recently recruited who were due to commence work on the day of the visit. There was no pova first check or Criminal Records Bureau available but this was said the pova first check was said to be back and was being sent through. It appeared to be routine that staff were working without a Criminal Records Bureau being place but with a pova first check. The staff member due to start had no previous experience in care or any basic training. It had been planned that they commence work without moving and handling training as part of the staffing numbers after a two hour induction. After discussion with the Acting Manager reviewed this and stated that they would initially work on a supernumerary basis. A sample of other staff personnel files were also examined. Some references were on file where it was not clear if they had been independently sought by the home as they addressed ‘To whom it may concern’ and were undated. Staff photographs were on file. Verbal references had also been accepted. For one staff member who had been in post some time there was not a recruitment file and no Criminal Records Bureau check had been applied for despite them being in post for some time. Some recruitment for care and domestic staff was being currently done. Records of training were limited to moving and handling and fire training (both completed as a result of an immediate requirement issued at the last visit). There was no evidence on file that staff had undertaken any Protection of vulnerable adults training, first aid, medications or health and safety training. Some staff had undertaken basic Food Hygiene training by a video. Generally there is not considered to be a commitment to staff training and the staff are poorly trained. Claydon Lodge DS0000020213.V337205.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): 31,33,34,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is not sufficient management of health and safety aspects in the home. There is no commitment evident in ensuring there are improvements in the quality of the service provided. This has the potential to place service users and staff at risk. EVIDENCE: An Acting Manager has taken up post at the home in the past few weeks. They have previous experience of home management and a managerial qualification. They are in the process of applying for formal registration with the Commission for Social Care Inspection. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 21 The quality assurance process was examined. The Provider had recorded some monitoring visits to the home on an approximately monthly basis. It is evident however that the content of these was brief and there was no recorded consultation with service users or staff. Limited information was recorded and typically assessed if the home was clean, examination a small number of records, complaints and incidents. The Acting Manager had begun a list of items to discuss with the Provider regarding equipment that was required and concerns that they had identified. Included on the list were staffing, locks, Criminal Records Bureau checks and provision of washing powder. There were no service users/ relatives meeting held. Staff meetings have reportedly been held but there were no records to evidence when they have taken place or assess the content. The questionnaires supplied by Commission for Social Care Inspection to be given to service users to ask for their opinion were found in an envelope on top of a filing cabinet and had not been given to service users. They have not been given opportunity therefore to request to speak to an inspector or share their experience of the home through the questionnaires. A valid public liability certificate was on display. Records for establishing financial liability were not requested at this visit. Small amounts of service users monies were stored safely on behalf of some service users. The records retained correlated with the amount of money available. Receipts for purchases were retained; one staff member signed transactions. Due to there being some reorganisation of filing cabinets the monies were not stored securely during the visit but were usually reported to be locked away. There was no system in place to record if any valuable items/documents were being stored. There was no evidence in staff files that any supervision had taken place. Staff spoken to said they had had some supervision a while ago but could not be specific when. A book was available for recording any accidents but there were no completed examples that could be located to evidence accidents were being recorded and the actions being taken to prevent further accidents. There were no records to indicate that there was monitoring of water temperatures to ensure service users were not placed at risk of scalds. This is Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 22 an outstanding requirement from previous inspections. Water was also not being run in the unused ground floor which would increase the risk of legionella. The ground floor was not routinely checked for any health and safety hazards. These have been identified at previous visits and is an outstanding requirement from previous inspections. Discussions were held regarding staff with particular health needs or special circumstances. There was not risk assessments being undertaken to consider these in relation to the work being undertaken. These are required by health and safety law to protect staff. Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 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 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 3 x x 1 Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 4&5 Requirement The Statement of purpose and Service User Guide must be up to date and made available to service users to ensure they have sufficient information regarding the home All service users must have a fully recorded assessment by a competent person prior to a service being provided to ensure their needs can be met 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 Previous timescale 31/03/07 4 OP8 12 Care plans must consider if healthcare support is required from outside of the home and ensure this offered and organised There must be a protocol and procedure in place for homely remedies to ensure there is safe and appropriate administration DS0000020213.V337205.R01.S.doc Timescale for action 31/07/07 2 OP3 14 30/05/07 3 OP7 14, 15 30/06/07 30/06/07 5 OP9 13 (2) 30/06/07 Claydon Lodge Version 5.2 Page 25 6 OP12 16(2)(m) 7 OP16 22 to service users There must be consultation with service users with respect to the provision of activities and lifestyle choices Where complaints are received there must be a documented audit trail of response and actions taken Previous timescale 31/12/06 The provider must ensure that all staff receive training in safeguarding adults Previous timescale 31/03/07 31/07/07 31/05/07 8 OP18 18 30/06/07 9 OP19 23(4) A fire risk assessment of the premises must be completed by the Provider to ensure service users are protected as far as possible from fire The Provider must ensure the fire safety equipment is serviced by suitably trained persons and regularly checked by staff at the home Fire system serviced but not regular checks completed at this visit Previous timescale 18/12/06 31/07/07 10 OP19 23 31/05/07 11 OP28 19 12 OP29 19, Schedule 2 The Provider must ensure that at least 50 of staff hold NVQ (National Vocational Qualification) level 2 in care qualifications 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 Immediate requirement issued at visit made on 12/12/06 30/09/07 31/05/07 Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 26 Previous timescale 18/12/06 13 OP30 18 Staff must receive mandatory training updates in moving and handling, fire safety and Basic Food Hygiene The registered person must ensure that a registered manager is in post 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, 31/03/07 not fully met) 16 17 OP36 OP38 18 13 All staff must have regular individual supervision and an annual appraisal. The provider must ensure there is recorded monitoring of water temperatures where full body immersion is possible and that the temperatures are within 43º or - 2 degrees Previous timescale 31/12/06 18 OP38 13 The Provider must ensure there 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 Previous timescale 31/12/06 The agency must ensure that appropriate risk assessment are completed for staff with health conditions which may affect their DS0000020213.V337205.R01.S.doc 30/06/07 14 OP31 OP33 8 24 30/06/07 31/07/07 15 31/07/07 15/06/07 31/07/07 19 OP38 18 15/06/07 Claydon Lodge Version 5.2 Page 27 ability to work safely in the role they are employed RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The drug error procedure should include instructions to inform the Commission for Social Care Inspection of errors identified as per Regulation 37 notifications The vegetarian menu should be reviewed in consultation with service users to ensure that this is varied and appealing Service users should be given choices of food and consulted regarding the menu offered The safe guarding adult procedure should be explicit in describing at what stage there is referral to locally agreed multi agency procedures The sluice area should be thoroughly clean to eradicate offensive odours Staff should wear name badges to ensure that service users and visitors get to know them Two signatures should verify financial transactions for service users monies. A system should be implemented to record where valuables are being stored safely on service users behalf 2 OP15 3 OP18 4 5 6 OP26 OP27 OP35 Claydon Lodge DS0000020213.V337205.R01.S.doc Version 5.2 Page 28 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.V337205.R01.S.doc Version 5.2 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. 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