Inspection on 11/01/07 for Colton Lodges Nursing Home

This inspection was carried out on 11th January 2007.

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

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

Other inspections for this house

Colton Lodges Nursing Home 02/05/09

Colton Lodges Nursing Home 04/06/08

Colton Lodges Nursing Home 11/12/07

Colton Lodges Nursing Home 25/01/06

Colton Lodges Nursing Home 19/07/05

Colton Lodges Nursing Home 07/12/04

Colton Lodges Nursing Home 20/07/04

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

CARE HOMES FOR OLDER PEOPLE Colton Lodges Nursing Home 2 Northwood Gardens Leeds Yorkshire LS15 9HH Lead Inspector Sean Cassidy Key Unannounced Inspection 11th January 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Colton Lodges Nursing Home DS0000001332.V299301.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. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colton Lodges Nursing Home Address 2 Northwood Gardens Leeds Yorkshire LS15 9HH 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) 0113 2645288 0113 2326676 brownch@bupa.com.ur www.bupa.com BUPA Care Homes (CFHCare) Limited Mrs Christine Mary Brown Care Home 120 Category(ies) of Dementia - over 65 years of age (48), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (90), Physical disability (4) Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Garforth, Elmet and Whitkirk Houses - Old age (30 beds each house) Newsam House - Dementia and Mental Disorder over 65 years of age (30 beds) Whitkirk House - Physical disability age 21 , who are three named service users with chronic brain injury. Specific dementia (age over 65) service users as identified in BUPA Care Homes letter dated 28 October 2003 Garforth House 7 places, Whitkirk 6 places and Elmet 5 places) The fourth PD place is specifically for the service user named in the variation application dated 27.6.05 25th January 2006 Date of last inspection Brief Description of the Service: Colton Lodges is in a residential area of Colton, close to local amenities and public transport routes. There is a car park to the front of the home and gardens are accessible to residents. The home is registered as a care home with nursing for 120 older people. Three places are registered for residents with a physical disability who are under pensionable age. Colton Lodges is purpose built comprising of four bungalows- Newsam, Garforth, Whitkirk and Elmet, each accommodating 30 people. Newsam provides nursing care for older people with dementia. Each bungalow provides 30 single rooms, a communal lounge and dining area and three communal bathrooms. There is level access throughout the bungalows. Kitchen and laundry facilities are located centrally, although each unit has its own kitchenette for making drinks and light snacks. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information submitted by the registered provider in the pre inspection questionnaire. Information received from service users, relatives, staff and other professionals. An Unannounced visit to the home was conducted by two inspectors and lasted two days. The majority of this time was spent speaking to residents, management, staff and relatives. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety details. What the service does well: What has improved since the last inspection? Improvement has been identified with the care planning system used by the home. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Colton Lodges Nursing Home DS0000001332.V299301.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 Colton Lodges Nursing Home DS0000001332.V299301.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. With the exception of one resident, the home does generally ensure residents are assessed prior to moving into the home. All residents would benefit from receiving a copy of the home’s Terms and Conditions. EVIDENCE: The care files of six new residents were examined and five had evidence in place to show each resident had been assessed prior to being admitted to the home. The assessment documentation was substantial and enabled the assessor make the correct decision as to whether the care home could meet the resident needs. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 9 During the inspection day a new resident had been admitted from another BUPA service. The care documentation was examined and it showed that this individual was admitted without an assessment being carried out. The person in charge confirmed that information was obtained verbally and written. However, it was identified that this resident’s care needs did not match those in the information received. The implications of not ensuring that an appropriate assessment was carried out meant that the resident was placed at risk unnecessarily. The home does provide residents with a contract that breaks down what fees are to be paid and by whom. They do not provide a copy of the Terms and Conditions. The Terms and Conditions are given to all private funding residents. The manager agreed that they would commence a programme of ensuring all residents received a copy of this document. Colton Lodges Nursing Home DS0000001332.V299301.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good care plans that are person centred in their approach. There is a good awareness of the health care needs of the resident group. But, carers need to be more aware of maintaining records to show nutritional and pressure area care are provided. Although care staff were seen as kind and courteous, there were some privacy and dignity issues identified that suggest this area is not as robust as it should be. EVIDENCE: Care plans seen were holistic, person centred and regularly reviewed to reflect changing need. Staff said that they always involve the residents and their families in the care planning process and the home’s records confirmed this. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 11 Progress records were seen on file for each resident. These were completed in detail and there was evidence that relatives are kept informed of any changes. It was noted that risk assessments had been undertaken for those identified as being at risk of falls. For one resident who is receiving end stage care, it was clear that their wishes and the wishes of their relatives have been sought and understood and arrangements for after death were clearly set out. A Palliative Care nurse regularly visits the home to oversee this placement and assist in any way with pain management and end stage care. For another resident there was consent from relatives to restrain in certain circumstances, which were clearly defined. Files contained evidence that residents have had all their needs assessed and regularly reviewed. This included their level of dependency and any support needed because of mobility needs. Care staff spoken to confirmed that the care files are accessible to them and they do read them when they get the chance. Staff spoken to were aware of the care needs of the residents that they were caring for. Each resident is provided with a life plan document but these were not all completed. Each resident was risk assessed in a number of areas including pressure area care, falls, nutrition and moving and handling. These documents were reviewed monthly. One resident had wounds dressed by the nursing staff had clear documentation in place to ensure the appropriate care was being given. Correct records were in place. There were at least two residents in one unit on bed rest. Both were dependent on staff for all care needs. The care plans stated that they should be regularly turned but there was no evidence in place to show that this did happen. The records showed that both residents were to receive appropriate fluid and nutrition but there was no written evidence in place to show that this was provided. The home’s medication records were in good order. Medications are stored securely in a designated room and controlled drugs are kept in a separate locked cabinet, which is attached to a security alarm. Staff said that medications are administered only by qualified staff and that daily audits are undertaken to ensure that any errors are promptly spotted and rectified. Care plans showed evidence to show consent was obtained to allow the home to store and administer medications belonging to the residents. This is good practice. Staff appeared to work well with the client group in the dementia unit. They were courteous and helpful. Residents’ relatives praised the staff group for the role they performed in caring for the residents. A number of concerns were highlighted with the manager that related to privacy and dignity. Some Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 12 residents were dressed in clothes that were stained with food, or were not the correct size. Some residents that clearly needed assistance with eating their meals did not receive it. Plastic aprons were put on all residents when they were eating their meals. These gave residents a dishevelled appearance. The manager said that there were cotton aprons. These were not used. Two relatives said that more attention could be paid to personal care as it was “sometimes lacking.” Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents receive structured and appropriate activities that are flexible and suit their preferences and capacities. A wholesome diet is provided to the residents. EVIDENCE: In one unit it was clear from what was said and from looking at the case files that the residents are respected as individuals with their own interests and preferences. A “Map of Life” is produced for all the residents, which helps staff to understand the whole person, their background and where their interests lie. Individual time in spent with the residents when the Activities Organiser spends time with a resident in order to break down social isolation. They often provide nail care for residents. The Activities Organiser was seen, as they were going shopping for resources, such as nail varnish. In addition to this group activities are organised regularly so that the residents have meaningful Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 14 daytime occupation. This includes bingo, ball games and bowling. Staff work hard to maintain links with the community. For example residents visited a local primary school in mid December to see the children perform a play and went to the theatre to see a pantomime, which residents said they very much enjoyed. Key workers also spend valuable time with the residents they care for. Staff said that they help with letter writing and arranging the flowers in a resident’s bedroom to make their environment homely and attractive. The activity coordinators have a large workload and they try to provide mostly group activities. The dementia unit differs from most of the other units, as there are fewer residents that are able to be involved with group activity such as skittles and exercise groups. Staff were very busy and there was little time to interact with the resident group. This was confirmed by talking with staff and relatives of residents visiting the home. Feedback from staff confirmed that activities and interests of the residents is the activity person’s role. This should not be the case. Little evidence was seen to show how the activities provided for the specialist dementia needs of the resident group in the dementia unit are being met. The care files did contain life maps but from the three that were looked at only one was suitably completed. Residents’ relatives in the dementia unit felt staff were too busy in other areas and didn’t really get involved with any activity roles. The specialist dementia unit has a reminiscent room and a therapy room is under construction. This is a great asset to this unit. The reminiscent room was not used during the inspection. Staff spoken to said they did not have the time to provide this care at present. Visiting times are flexible and relatives and friends are encouraged to maintain contacts at all times. For one resident who had lost contact with their family, staff made every effort to re-establish this contact. This is an example of good practice and shows that the home do all they can to meet all the residents’ needs. Mealtimes were observed in two units during the site visit. Staff spoke very reassuringly and it was noted that there is mutual respect between staff and residents. Staff showed a good knowledge of the preferences of the people they care for. The meals served looked pleasantly presented. Some residents were seen being supported by staff when they were eating their meals. However, there were some residents who needed the support and assistance of staff with their meals but they did not receive it. One relative was quite upset by this as she said her mother was a very strict individual and would be very upset if she knew she was eating her meal in this way. During the site visit there was an opportunity to visit the kitchen and talk to the kitchen staff. The menus were seen and it was clear that the residents are provided with a balanced diet. Staff pointed out a board on the wall, which indicates when residents have asked for an alternative meal to the one on the Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 15 menu. This is accommodated promptly. Staff said that they are adaptable to meeting the cultural and dietary needs of people from black and minority ethnic communities and would take all advice needed to ensure that food is stored and prepared appropriately. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from a more robust complaints and adult protection process being adopted by the home. EVIDENCE: The home has a complaints procedure, which is displayed within each unit. Relatives were aware of these documents and knew how to complain if they needed to. The home does have a complaints recording system. The complaints recorded had been dealt with appropriately. Concerns were highlighted about some of the content of the complaints that were made. At least two complaints contained information that should have been referred to the adult protection team but was not. This is poor practice Staff spoken to were clear on their responsibilities in reporting abuse if this was suspected, and the agency to be contacted. Some staff have still not received the adult protection training. Staff are receiving a rolling programme of adult protection training. Priority should be given to care staff first, who have more day-to-day contact with residents. It is vital that all staff within the home are aware of the need to communicate concerns upwards within the line management structure and that such Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 17 information is recorded and acted upon. An adult protection incident was identified during the inspection and the manager was asked to investigate it using the internal policy. There have been a number of recent adult protection issues dealt with by the home. The manager dealt with these in the correct manner. One other adult protection incident occurred after the key site visit. This has been referred to adult protection unit. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 18 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, 21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a well-maintained and clean environment. EVIDENCE: The layout of the home is suitable for the care provided. Residents and relatives provided positive comments about the physical environment. The houses have easy access to their own gardens. Newsam house has secure gardens for residents to access safely at will. These gardens are well kept and provide pleasant areas for residents to enjoy in good weather. Staff confirmed that residents are taken out into the grounds in order to enjoy the fresh air. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 19 The toilets, bathrooms and shower areas are spacious and clean and are suitable for the needs of the resident group living there. Sluices are located separately from service users’ toilet and bathing facilities. Grab rails are provided in all corridor areas. Aids, hoists and assisted toilets and baths are installed, which are capable of meeting the assessed needs of service users. Call systems are provided in every room. The Maintenance Officer was spoken with. He explained that a maintenance book is held in all the houses. This was seen and there was clear evidence of defects being logged and responded to. Staff said that works are carried out as promptly as possible. Three residents relatives in Newsam House were disappointed with the condition of the carpet in the dining area. It appeared stained and dirty and in need of refurbishment. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels in all units do not ensure the care needs of the residents are being met. Induction and Mandatory training provided to care staff is good but residents would benefit more if staff received training in the areas of care which are relevant to them. The home’s recruitment procedures do not properly protect residents. EVIDENCE: Each unit has a rota that clearly indicates the staff that are on duty for that day and the coming weeks. The home uses an internal bank system and an agency to fill any outstanding shifts. Staff said that that when they are short they can sometimes get help from another unit if they have extra staff. Each unit has the same numbers of staff allocated. Staff said that it was not uncommon to work shifts when extra staff could not be found. This places more stress on the workload. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 21 The evidence gathered from the two units regarding staffing provided a contrast in the care provided. Staff on Elmet did not appear rushed and were observed to have time to sit with residents individually and chat. Residents said that this did happen regularly and they enjoyed this time. In Newsam, staff were observed as being very busy and task orientated with little time to interact with residents who clearly needed it. All relatives and staff spoken to expressed concerns at the levels of staff provided on this unit. Some comments made were,”They don’t have enough time.” “There isn’t enough time for them to talk to just sit and talk to mum.” The nature of the care needs of the resident group with dementia requires increased staffing levels to ensure the care needs of the residents will be met. The manager is currently running a rolling programme to ensure staff are trained to NVQ Level 2 standard. At present, only 35 of the care staff have this training. A good standard of mandatory training is provided to staff. The home provides a self-learning pack for carers in dementia. Carers that had completed this learning felt it was informative about the condition. Two carers spoken to said further dementia training would help them greatly with providing a better care package to the resident group. A more thorough training package is offered to qualified staff. The house manager on Newsam has completed an introduction to Quality Dementia Care. Staff said that they have had the benefit of a good induction and that there are always opportunities for training. The recruitment files of three new employees were examined. The evidence showed that references are not being obtained prior to starting to work. This is poor practice. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 22 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management systems and processes of the home are good but there are some areas, such as communication, that are in need of improvement. EVIDENCE: Management processes and systems are in place, but recent incidents where abuse has been suspected were not reported to the manager or the appropriate authorities. There needs to be a clear mechanism for communication and for the dissemination of information throughout the home. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 23 The manager needs to be more visible with the staff team and to make sure that they monitor the operation of the home and have sight of records on a regular basis, in line with performance management. Discussions were held around the systems used to assure the quality of the care provided in the home. The manager is looking at reviewing information such as complaints and falls at regular intervals to establish patterns and take necessary action. The homes’ review of quality and plans for any action to improve quality needs to be made available to all interested parties. It was suggested that a newsletter would be an effective means of sharing information about the running of the home with residents, staff, relatives and multi-agency workers. This could be used to share information regarding perceptions of the service derived from surveys and other quality assurance mechanisms. The home looks after some resident monies. These were randomly checked and were in good order. The maintenance man is responsible for checking the equipment in the home and for ensuring fire drills and training takes place. The records were checked and some were behind schedule. It is possible that the maintenance person has an overload of work. Sharing out this work would reduce the risk of checks not being carried out on time. Fire drills are carried out every six months. This period is too long and should be reviewed. A recent outbreak of infection has occurred in the home. This has been managed well by the manager and the correct agencies have been informed and involved with controlling the outbreak. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 25 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 5 and Schedule 4 Requirement Timescale for action 31/03/07 2 OP3 14 3 OP8 14 The registered person must ensure that all residents receive a statement of the homes Terms and Conditions that highlight the room to be occupied and also the fees they are to pay. The registered person must 28/02/07 ensure all residents are appropriately assessed prior to moving into the home. The registered person must 28/02/07 ensure That appropriate records are kept to show residents receive appropriate nutrition and fluids. Evidence is needed to show residents’ pressure areas are relieved as highlighted in the care documentation. The registered person must 28/02/07 ensure the standard of personal care need provided to the resident group is improved. The home must provide activities 31/03/07 that meet the specialist dementia needs of the residents living in the home. 4 OP10 12 5 OP12 14,15 Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 26 6 OP16 22 7 OP18 13 The registered person must 28/02/07 ensure al complaints received are thoroughly investigated and appropriate referrals are made to other agencies when needed. All unit managers should be 28/02/07 aware of the process of reporting suspected abuse. (Previous timescale of 1/4/06 not met. The registered manager must review the adult protection systems adopted in the home to ensure residents are properly protected. The carpet in Newsome House must be assessed and either cleaned, replaced or a suitable alternative provided. The registered person must ensure appropriate numbers of staff are on duty in Newsome House. The registered person must ensure the required information is obtained prior to commencing employment. The registered person must ensure carers receive appropriate training in dementia care. The training should be clearly evidenced in every day practice, especially in Newsome House. Effective quality assurance and quality monitoring systems must be implemented and made available to interested parties. The registered person must ensure all equipment used in the home is appropriately checked. 8 OP26 23 31/03/07 9 OP27 18,19 31/03/07 10 OP29 19, Schedule 2 18 28/02/07 11 OP30 30/04/07 12 OP33 24 31/05/07 13 OP38 12 30/04/07 Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 27 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 OP18 OP33 Good Practice Recommendations It is recommended that a referral chart for adult protection is developed and placed in each unit. The home should develop a newsletter for all staff to assist with improving communication in the home. Colton Lodges Nursing Home DS0000001332.V299301.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Colton Lodges Nursing Home DS0000001332.V299301.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. 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