Inspection on 06/06/06 for Conifer Lodge

This inspection was carried out on 6th June 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conifer Lodge 22/09/08

Conifer Lodge 23/10/07

Conifer Lodge 08/11/05

Conifer Lodge 12/07/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Conifer Lodge 134 North Brink Wisbech Cambridgeshire PE13 1LL Lead Inspector Elaine Boismier Key Unannounced Inspection 6th June 2006 9:30 Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 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 Conifer Lodge DS0000062547.V295983.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 Adults 18-65. 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. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifer Lodge Address 134 North Brink Wisbech Cambridgeshire PE13 1LL 01945 474912 01945 583951 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) Ermine Care Ltd Ms Dianne Pauline Eaton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of places not to exceed 15 at any one time One named male under 18 years of age Date of last inspection 8th November 2005 Brief Description of the Service: Conifer Lodge is an adapted two-storey domestic dwelling situated on the outskirts of the Cambridgeshire market town of Wisbech and is in walking distance from the town centre. Local amenities include shops, pubs and leisure facilities. The home provides accommodation care and support for a maximum number of 15 people, between 18 and 65 years of age, with a learning disability. All bedrooms have ensuite facilities and are for single occupancy. In addition to the ensuite facilities the home provides 3 toilets and has two bathrooms. There are two communal rooms and a large garden that provides space for games and gardening activities. Care Principles Ltd became the new owner of Ermine Care Ltd, the registered provider of Conifer Lodge, on 1st April 2005. Fees range from £900 to £1800 and additional costs include toiletries, cigarettes and spending money for holidays. A copy of the inspection report is available at the home or via the CSCI website. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of Conifer Lodge for 2006/7. The inspection was unannounced and was carried out between 9:30 and 14:30 and took 5 hours to complete. At the time of the inspection there were 14 residents living at the care home and 4 of these were spoken to, although not all of them chose to speak to the Inspector about their views of the home. On duty were a number of staff, including the Registered Manager and these people were also spoken to. Documentation was seen and a tour of the premises was made. Information provided by adult protection services and information provided by the registered provider has also been included as part of the inspection process. The home has a condition of registration for one named person, under 18 years of age, to be allowed to live at the home. This person has now reached 18 years of age. The Registered Manager agreed to formally request that the Commission removes this condition of registration. Conifer Lodge provides a good service and has the potential of becoming an excellent service should satisfactory action be taken to meet the requirements, and consider any recommendations, made in this inspection report and to sustain any improvements that might be made. What the service does well: The service does well in the following areas: • • • • • Residents live a good quality of life in a home that is a part of the local community. Residents are well supported by a range of health care and social care professionals. The home has a good system in place in responding to complaints, concerns and allegations of abuse. Residents receive therapeutic care and support from a well trained, and supported, team of staff. The home is well maintained and has become more homely in its presentation. DS0000062547.V295983.R01.S.doc Version 5.2 Page 6 Conifer Lodge • Good quality assurance systems are in place to include monthly visits made to the home by a representative of the registered provider. What has improved since the last inspection? The home has improved in the following areas: • • • • • The standard of care plan documentation is excellent. Residents have opportunities to engage in an excellent range of both educational and leisure pursuits. Some carpets have been replaced, new garden furniture has been obtained and the kitchenette area for residents has now been completed. The staff team has become more stabilised and the home has a more settled and happier atmosphere. Two recommendations were also made following the inspection of November 2005. The first recommendation made was for the care home to provide evidence that residents were actively consulted when drawing up their care plans. The second recommendation was for the registered manager to have successfully completed the registered manager’s award by the end of March 2006. Both these recommendations have been considered. What they could do better: The service could do better in the following areas: • Information contained in the Statement of Purpose must be updated and a copy of this submitted to the Commission. A requirement has been made about this. The Service User’s Guide must be updated to include the details in the associated regulation. A requirement has been made about this. The Service User’s Guide should be in a format that can be understood by people who are choosing a place to live. A recommendation has been made about this. • • Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 7 • The home must not assemble medication from containers that have been dispensed by a registered pharmacist. A requirement has been made about this. Medication must not been given to residents unless the label on the outside of the container is intact. A requirement has been made about this. A recommendation has been made for the home to consider if any resident is able to become independent with their own medication. Records for the administration of medication must be accurate and up to date. A requirement has been made about this. Records for residents’ monies should be accurate. A recommendation has been made about this. Following the last inspection of the home, on 8th November 2005, there was an requirement made as this requirement was carried forward from the inspection of the home in July 2005. This requirement was related to the lack of all required information that was to be obtained about staff before they worked at the Conifer Lodge. This requirement has not been met and a strongly-worded letter has been sent, by the Commission to the home, about this continual non-compliance with the regulations. Staff must attend training in fire safety matters. A requirement has been made about this. • • • • • • 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. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Information is adequate for prospective residents to make a choice of where to live. EVIDENCE: The information in the Statement of Purpose and Service User’s Guide is outof-date as both these documents are dated July 2004 and changes have been made since the implementation of these required documents. Two requirements have been made about these findings. The Manager stated that a Service User’s Guide has been developed that is suitable for individuals who use Makaton method of communication although this document has not been needed. Examination of the current Service User’s Guide, however, is in a format that might not be suitable for prospective residents. As a result of this finding a recommendation has been made for the Service User’s Guide to be in a format that is suitable for prospective residents. An application for a minor variation of registration was approved by the Commission in January 2006. With this application there was additional information, that the care home had received, about the assessed needs of the prospective resident. Examination of three residents’ care files indicated that full admission information is obtained about newly referred prospective residents. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 10 According to the Manager the home also assesses newly referred prospective residents who are able to visit the home, meet the staff and residents and engage in activities, such as having a meal, before making a decision about where to live. Information provided by Ermine Care Limited, and confirmed by staff at the time of the inspection, indicates that should the home not be able to meet the changing needs of residents, then a more suitable placement is found for these people. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 The standard of consulting with residents about how they choose to live, within a risk assessed framework, is good. The standard of care plan documentation is excellent. EVIDENCE: A recommendation was made following the inspection of November 2005 for the home to demonstrate that service users have been actively consulted in drawing up their care plans. Examination of 3 residents’ care files was carried out, and staff and a resident confirmed that this recommendation has been considered. The 3 care residents’ care files that were examined contained clear, and excellent, guidance on managing behaviours, therapeutic care and setting of goals, in consultation with the residents. Care was reviewed each month and recorded within the care files Observation of staff interacting with residents noted that residents were actively consulted about their activities for the day. Residents confirmed that their choice of activities was validated by the home. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 12 Information provided in a copy of the Regulation 26 report of May 2006 indicates that residents are supported in handling their own personal monies., and this was confirmed by staff and Manager of the home. Examination of records of monies kept for safe-keeping by the home, included the signatures of residents confirming that they had withdrawn their money. Residents’ meetings are held on a regular basis and minutes of the last to meetings, held in December 2005 and February 2006, were seen and comments/suggestions made by residents were recorded. Staff reported that any resident, who is not confident in speaking up at the meetings, offers their contribution to the meetings, via their key worker or another member of staff. The home has developed a kitchenette area for residents to prepare food. A resident confirmed that he was able to use the kitchenette with supervision of care staff. Examination of this resident’s care file indicated that the risk of this activity had been assessed. Information provided in a copy of the Regulation 26 visit report for February 2006 states, “’Kitchenette’ finished and being used by the residents on a risk assessed basis.” Information provided in a copy of the regulation 26 visit report for May 2006 states, ”’Kitchenette’ regularly used by the residents on a risk assessed basis.” Risk assessments for going into the community, smoking, sexual behaviours and leisure activities are carried out and these were seen recorded in the residents’ care files that were seen at the time of the inspection. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Residents live a good quality of life in a home that is part of the community. The range of educational and leisure activities is excellent. EVIDENCE: The majority of residents attend local colleges and information about days and which college are marked against the names of the residents on a white board in the main office of the home. Information provided in a copy of the regulation visit reports for December 2005 and January 2006, stated that, “Most out at college and other day activities.” Information provided in a copy of the regulation visit report for February 2006 states, “Residents continue to benefit from a full and varied activities programme. Visits to a variety of different venues have been undertaken.” During this inspection residents confirmed that they were able to out into the local community and had plans to go shopping and meet up with friends. The Manager reported that some residents were enjoying coaching sessions, held Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 14 at weekends, provided by the local football club and this was confirmed by a resident. Residents reported that activities have included a trip to a premiership division football match and arrangements are in place for some residents to attend a one-day test cricket match. Residents and staff stated a number of residents went on a bicycle round the evening before the inspection (evidence seen suggested that this had been risk assessed) and on the day of the inspection some residents were eating bacon, lettuce and tomato sandwiches whilst being escorted to the sea-side in the homes mini-bus. Residents’ care files that were seen contained details of contacts with families. A resident said that he had become a close friend with another resident. Staff were seen to knock on residents’ bedroom doors before entering and staff were noted to interact with residents in an appropriate, and inclusive, manner. Information provided in copies of the regulation visit reports detail residents’ views about the menus and variety and choice of food. Information provided in the regulation 26 visit report of February 2006 states, ”Residents continue to provide feedback on the menus that they would like to have….there is a variety of meals being provided that appear to be meeting the dietary requirements of all the residents. Ethnic needs being catered for.” Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 The standard of health care is adequate and could be improved upon. EVIDENCE: Residents were noted to be dressed in clothes that were suitable to their age and preferences. Information provided in the regulation 26 visit reports indicates that residents benefit form input from multi-disciplinary teams to assist staff to support residents in therapeutic care and rehabilitation. Information provided in the regulation 26 visit report, of May 2006, states,” The MDT input to the home is becoming well-established and is aiding the skills of the staff team.” Residents’ care files, and discussion with residents, indicate that residents have access to a range of other health care professionals that include opticians and general practitioners. Medication records were seen and there were some gaps in these, with particular regard to prescribed creams. Due to the risks posed with this practice a requirement has been made about this. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 16 A prescription label had been removed with the outside wrapper of a box of medication and the label had not been replaced. Due to the risks posed with this practice a requirement has been made about this. Staff reported that a dosset box is used for secondary assemblage of medication for residents who are away form the home for week end leave and holidays. Due to the risks posed with this practice a requirement has been made about this. Staff reported that no resident is currently supported in self-medicating although this self-care activity might be possible for a small number of residents. A recommendation has been made for the home to consider if any residents might be able to self-medicate. The air temperature of the treatment room where medication is stored, was recorded daily and temperatures were satisfactory. No medication was stored in the drug refrigerator, although the temperature of this was recorded below two degrees centigrade. Staff, including the Manager, were alerted to this, should any medication be stored within this facility. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 The home has good systems in place in responding to complaints and allegations of abuse. The record of balances of residents’ monies is adequate. EVIDENCE: Information provided in a copy of the regulation visit report, of December 2005, stated, ”One resident raised an issue with…. which was dealt with to his satisfaction.” The home’s record of complaints had no entries as staff, including the Manager, reported that no complaints had been made against the home. A resident confirmed who they would speak to if they were unhappy about something. In October 2005 the home was subject to an investigation under the local adult protection procedures. Evidence suggests that the home took appropriate action to ensure the protection of residents from similar harm. Records of management of challenging behaviours (that had been presented by some of the residents) were seen and actions that were taken, as part of this management, were appropriate and made according to the level of the presenting risk to both staff and other residents of the home. Information provided in the Regulation 26 visit reports indicates that residents’ personal monies are checked and that there have been no discrepancies between the amount available and the related records. The Regulation 26 visit report of May 2006 states, “Money balances correct…..Money system in place Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 18 is robust and effective.” During this inspection 3 residents’ amount of monies was counted and records of balances were checked against the amounts. Two of three records correlated with the amount. There was a shortfall of £10 in the remaining amount. A recommendation has been made for records, and amounts,to be accurate. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Standards of maintenance, refurbishment and cleanliness of the home is good. EVIDENCE: Information provided in copies of Regulation 26 reports indicates that the home is well-maintained and that there is an audit of the condition and cleanliness of the carpets and the care home in general. Information provided in the Regulation 26 visit report, for March 2006, states, ”New carpeting through the top corridor and in the small lounge/diner. Now looks much better.” And, “ There are many more personal pictures etc around the home which it gives it a more homely feel. The home is very clean and tidy throughout.” Confirmation of the above was made during the tour of the premises, including the garden area that has been provided with new furniture. At the time of the inspection repair work was being carried out on fixtures of the home. At the time of the inspection the home was clean and free of offensive odours. A report of an inspection, carried out by the Environmental Health Officer in April 2006, was seen and this report indicated that food temperatures and cleanliness of the kitchen was of a “Good Standard”. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 20 Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34, 35 & 36 The standard of staff training is good and residents are cared for by a stable team of staff although staff recruitment procedures are only adequate. EVIDENCE: Staff files, and discussion with staff, indicates that staff attend training that is specific to the specialist needs of the residents that live at Conifer Lodge. Staff indicated that they were knowledgeable of the needs of the residents. The majority of care staff have NVQ level 2 equivalent or above and staff considered that, due to the wide range of skills and experience of staff, including qualified nurses, residents’ health and social care needs, including changing needs, are well-met. Residents spoken to felt that they were wellcared for by the staff. Since the inspections of 2005 Conifer Lodge has become a relaxed and happier environment with a more stable and settled team of staff and this observation was confirmed by staff. Regular staff meetings are held and minutes of these were seen. Following the announced inspection of July 2005 a requirement was made for the registered person to take action by 1st September 2005 to ensure that all required information had been obtained about staff working at the home. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 22 During the unannounced inspection of 8th November 2005, evidence suggested that this requirement had not been met and an immediate requirement was made. Timescale for action, to meet this requirement was 8th November 2005. This requirement has not been met due to lack of required information in one of the 3 staff files that was examined. A letter has been sent to the home to remind them that this requirement has not been met and that action must be taken to protect residents from the risk of potential harm from unsuitable staff. Discussion with staff, and examination of staff files, indicated that staff are supervised on a regular basis. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Residents live in a home that has good management systems in place. Staff training in fire safety is adequate. EVIDENCE: A recommendation was made, following the inspection of November 2006, for the Registered Manager to have successfully completed the registered managers award by March 2006. According to her, she has now completed the course and is waiting for formal signature of approval by the external assessor. This recommendation has been considered. Information provided in the Regulation 26 visit reports indicates that residents’ meetings are held and minutes were seen of the meetings held in December 2005 and February 2006. The results of a survey, that sought residents’ views and knowledge about the home, were seen. The Manager reported that another survey has been carried Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 24 out since the first survey, and it is intended that results of both surveys will be compared against each other. The Commission receives information of monthly visits carried out by a representative of the registered provider, Ermine Care Limited. These visits include information of audits carried at that includes audits of the environment and audits of records that include care files and information about staff. The summary /comment part of the regulation 26 visit reports include an overview of the standard of care provided. The report of the Regulation 26 visit of March 2006 states, “The home continues to provide a high quality service to the service users.” A copy of the CSCI inspection report is available in the main office of the care home: staff confirmed that they had seen this. According to the Manager this has been also made available to care managers and representatives of residents. Records of hot water checks, checks for Legionella bacteria, fire alarms and emergency lighting checks, PAT tests and fire drills were seen and these were satisfactory. Records for staff attendance in fire safety training were seen and information provided, and confirmed by staff, indicated that this training was overdue. A requirement has been made about this. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 x x 2 x Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 4 Requirement The Registered Person must revise the Statement of Purpose and a copy of this to be submitted to the Commission. The Registered Person must revise the Service User’s Guide and a copy of this to be submitted to the Commission. The Registered Person must ensure records for the administration of medication are accurate. The Registered Person must ensure the safe administration of medication by ensuring prescription labels are adherent to the relevant container. The Registered Person must ensure the safe administration of medication with particular regard of service going on leave from the home. The Registered Person must make sure full and satisfactory information in respect of care staff is obtained and kept in the home. Timescale for action of 8/11/06 has not been met. New timescale for action has been made DS0000062547.V295983.R01.S.doc Timescale for action 30/09/06 2 YA1 5 30/09/06 3 YA20 17(2) 14/07/06 4 YA20 13(2) 14/07/06 5 YA20 13(2) 14/07/06 6 YA34 17(2) & 19 06/06/06 Conifer Lodge Version 5.2 Page 27 7 YA42 23(4)(d) The Registered Person must ensure that all staff attend training in fire safety matters. 07/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA1 YA20 YA23 Good Practice Recommendations The Registered Person should consider methods to make the Service User’s Guide in a format suitable for all prospective service users. The Registered Person should consider ways to establish if any service user is able to self-medicate. The Registered Person should consider methods of recording that will demonstrate that service users’ monies, kept by the home, are safe at all times. Conifer Lodge DS0000062547.V295983.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Conifer Lodge DS0000062547.V295983.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. 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!