Inspection on 27/06/06 for Davigdor Lodge Rest Home

This inspection was carried out on 27th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Davigdor Lodge Rest Home 27/11/08

Davigdor Lodge Rest Home 27/11/07

Davigdor Lodge Rest Home 03/02/06

Davigdor Lodge Rest Home 05/07/05

Davigdor Lodge Rest Home 15/02/05

Davigdor Lodge Rest Home 11/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Davigdor Lodge Rest Home 56 Tisbury Road Hove East Sussex BN3 3BB Lead Inspector Melanie Freeman Key Unannounced Inspection 27th June 2006 10:00 Davigdor Lodge Rest Home DS0000014196.V292890.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 Davigdor Lodge Rest Home DS0000014196.V292890.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. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davigdor Lodge Rest Home Address 56 Tisbury Road Hove East Sussex BN3 3BB 01273 726868 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 G Rawat Mrs B Rawat Mrs. Susan Lyn Dubeau Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25) of places Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty five (25). Service users should be aged between thirty five (35) and sixty-five (65) years on admission. Service users with a past or present mental health illness only to be accommodated. 3rd February 2006 Date of last inspection Brief Description of the Service: Davigdor Lodge is a privately owned residential care home for up to 25 people who have a past or present mental health illness. The registered provider also part owns a further four registered care establishments within the East Sussex area and has owned and managed Davigdor Lodge since 1992. Davigdor Lodge comprises of two converted Victorian terraced houses No 56 and No 58. In 2002 the houses were separated with No 58 de-registered and used to provide supported living accommodation. The home has recently converted the supported living back into residential care. The home is situated within walking distance of the amenities of Hove town centre and bus routes into Brighton. Accommodation is presented across four levels, lower ground, ground, first and second floors. Resident’s accommodation consists of twenty-five single bedrooms. Shared facilities comprise of a separate lounge and dinning room plus a rear garden. The registered owner is also going to provide a conservatory within the next six months. The home provides care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 July 2006 range between £387- £550 per person per week. Additional costs are charged for chiropody and newspapers. The homes literature states that one of its aims is to provide a safe homely environment in which residents have as much control over their lives as possible, enabling them to achieve the maximum degree of independence, whilst retaining their dignity. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Davigdor Lodge will be referred to as ‘residents’. This was an unannounced key inspection that was completed over one full day. The registered manager was in the home throughout the inspection process facilitating and received the inspection feedback. The registered owners were also available and spoken to during the inspection process. The home has recently increased its registration from 10 to 25 and once this registration was agreed 15 residents were moved from an associated care home. When this unannounced inspection visit was carried out this move had only been completed 2 weeks before. This inspection therefore focussed on this transition for residents and staff and the facilities and services now provided in the home. During the home visit the care documentation pertaining to four residents were reviewed in depth, along with documents relating to risk assessment. In addition a selection of records were reviewed and included the staff duty rotas, training records, 3 recruitment files and records relating to health and safety. The CSCI pharmacist completed an inspection visit the following week. Pre-inspection questionnaires were received from both homes before the homes were joined together and resident/representative surveys were returned for 13 residents along with 4 staff surveys provided to staff at the site visit. The information contained in the returned surveys has been incorporated into this report. Following the inspection visit telephone contact was made with a resident’s relative and representative in addition health and social care professionals were also contacted. What the service does well: Davigdor Lodge provides a good standard of individualised care within a friendly and homely environment. The staff have a good understanding of the residents personalities, needs and preferences and respond in a considerate manner to these. Links with resident’s family and friends are actively encouraged along with any community link that a resident wishes to maintain. Residents receive a varied diet with meals being of good quality and plentiful. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 6 Staff provision is adequately maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. All residents consulted mentioned flexibility in the daily routines and respect for personal freedom and lifestyles being respected. The home works closely with health care professionals to ensure residents receive the necessary health care intervention. What has improved since the last inspection? 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. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 7 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 Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 8 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): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place to ensure that no one is admitted to the home, whose needs cannot be met. All residents have a statement of the terms and conditions of residency within the home. EVIDENCE: Although there have not been any admissions since the Davigdor Lodge’s increase in registration and amalgamation with Davigdor House. The assessments completed on residents before admission in the two separate homes were found to be comprehensive and have been completed by the respective registered managers. These included input from other health and social care professionals and include the assessment of individual aspirations and needs. The contract arrangements for 4 residents were checked and found to be in place. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect and individualised approach to care, which encourage residents to make decisions and take reasonable risks as part of an independent lifestyle. Constant review of documentation however is needed. EVIDENCE: Four individual plans of care were reviewed in depth and it was found that two systems of care documentation are currently being maintained and there needs to be some consolidation of the systems used to ensure consistency and clarity. On the whole the plans of care inspected provided a good standard of recording the assessed needs of residents and the actions needed to meet these. They all demonstrated a holistic and multi-disciplinary approach to care although evidence of regular review and updating needs to be maintained. Residents confirmed when spoken to that they were able to make choices about their lives, one resident said ‘he was able to do what he wanted’ another residents was able to discuss how he was involved in the planning to move out of the home. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 10 Written risk assessments are completed on core risks and include the actions needed to manage any risks. It was however noted that a resident had a medicine that she was a possible risk and a risk assessment had not been completed. This matter was brought to the manager’s attention for her to address as a priority. Through observation and discussions with residents and others following the inspection, it was evident that residents are encouraged by care staff to be as independent as possible and participate in aspects of living in a home within a community. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 11 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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead a varied and lifestyle and staff support residents to spend their time usefully, but balance this with the understanding that residents have the choice to become involved or not as they wish. Meals are varied and cater for individual choice. EVIDENCE: Case tracking and discussion with residents and staff demonstrated that emotional and social contacts are taken into account however due to the recent amalgamation of the home this has not been consolidated to clearly identify how varying needs are to be met. Although the residents from the home have met and had joint activities and parties in the past it appeared that the residents and staff have not integrated yet. The home needs to be established as one home with the individual needs of service users being identified and responded to. The mix of residents is varied with differing ages and mental health needs. One resident had greatly enjoyed a night out at the bingo and the inspector noted a good rapport between all staff and residents. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 12 Residents attend day centres, and therapeutic work placements during the week and they are supported to continue their hobbies and interests whilst at home. Residents do not tend to get involved in cleaning or cooking although some have their own facilities for making drinks and snacks. Meals are flexible and individual the home manager explained there had been some difficulties at meal times as the area is small and this caused some agitation between residents. This has been resolved with meals being provided over a longer period of time and two sittings for main meals being provided. Residents said that they liked the meals. Residents were observed interacting with each other and the staff on duty; the atmosphere was pleasant and inclusive. Some were coming in and out of the garden and going to the local shops many chose to watch television in the ground floor smoking room. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The healthcare needs of residents are well met with evidence of specialist care services being involved on a regular basis although the home’s medicine management procedures need to be made consistent so that safety is ensured in respect to residents health and welfare needs. EVIDENCE: During the site visit it was clear that residents are encouraged to be as independent as possible and are given as much autonomy as possible within safety parameters. Most residents are able to meet their own personal care needs with staff prompting and encouraging residents to maintain their personal appearance. One resident was pleased that he had bathed himself cleaned the bath and dealt with his own laundry. Some residents do not welcome any support and staff have to be sensitive in their approach and ability of balancing the rights of the individual to maintain their lifestyle with those of other residents and community living. Resident’s rooms are respected as their own area and residents spoken to confirm that they felt their rooms were ‘their own space’ and staff did not intrude. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 14 Each resident is allocated a named worker/keyworker and staff spoken to seem to have a good understanding of the key workers role. The CSCI pharmacist completed an inspection on the 6 July 2006 and noted that there are two separate systems for medicine management running concurrently. In the main both systems are similar however some differences exist. This means that there is an inherent risk but the staff have recognised this and are to implement one system throughout the home. For one medication, which is received directly from the hospital, senior staff put out the required dosage for a week at a time with labels and dosage directions. This is classed as double dispensing and introduces an element of risk. The Controlled drugs register entries were examined. Senior members of staff were filling in the last column in advance. This column gives a running balance. The reason given for this was that night staff couldn’t subtract correctly. The balance shown in the controlled register matched the actual levels in stock. Training was discussed and it was pointed out that this should be external, ongoing and competence skills assessed. It should also underpin the policies and procedures of the home. This would ensure safe handling and management of medicines. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 15 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints and any suspicion or allegation of abuse is dealt with appropriately. EVIDENCE: The home has a detailed and clear complaints procedure in place. It gives clear guidance with regard to how a complaint can be made and how the complainant can expect it to be dealt with. A relative spoken to confirmed that she felt very comfortable with speaking to the home manager about any issue and small problems that had been raised with her have been listened to and responded to affectively. In order to have further feedback from residents and visitors it was suggested that the manager used a suggestions box. Clear Adult Protection procedures are in place and staff spoken to had a good understanding of Adult Protection issues. Senior staff are always available for staff to contact if any suspicion or allegation of abuse is made. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 16 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, 26, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment with their bedrooms personalised in accordance with their lifestyles. Parts of the home are in need of general maintenance to include the provision of a working call bell system, redecoration with general cleaning to ensure a safe and pleasant environment throughout. EVIDENCE: The home is situated in a residential road within easy access of local amenities and bus routes into Brighton and Hove. The home is furnished to provide a domestic feel, however a tour of the home found a number of areas that needed attention and general maintenance. These were discussed with the home manager and the deputy and the home was asked to provide a programme to identify the areas that need attention throughout the home and a time scale to address them. During the inspection it was noted that the home was not clean. Communal areas had not been cleaned and included soiled bathroom areas ingrained dirt on doors and in corridor areas. The manager agreed that the cleaning was poor and that they were short of a cleaner. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 17 All bedrooms are provided with locks with nearly all residents having their own key. All bedrooms have been individualised with resident’s personal belongings. The lifestyles of some residents and the level of respect and privacy afforded means that some bedrooms could not always be cleaned but staff are mindful of promoting good standards of hygiene. Shared space consists of a dining room, lounge and quiet lounge on the first floor. The homeowner also confirmed that a conservatory is to be provided to improve the communal areas further. The rear garden provides an inviting space for residents to enjoy. The home is not designated to offer services to people with physical disabilities and the stairs and other access arrangements would make it unsuitable for residents with a permanent restricted mobility. During the tour of the home it was noted that the call bell system was not working in part of the home and one resident was concerned that she would not be able to seek help when needed. An immediate feedback form was left with the manager at the end of the inspection visit in regard to this matter for her to address as a priority. The laundry room is rather small however the home manager said that it was adequate and was appropriate for the needs of residents and it was noted that a further hand basin has been provided since the last inspection to promote good infection control practice. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 18 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): 31, 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and the skills of staff are appropriate to ensure that all the care needs of residents are met. Robust recruitment policies and procedures are followed in order to protect residents. Staff are well supported to carry out their roles by the manager and the deputy manager although the roles of senior staff need to be clarified. EVIDENCE: The staffing team of two care homes have been brought together with the increase of registration at Davigdor Lodge and closure of Davigdor House. As this amalgamation has only recently been completed the staff and residents have not integrated completely yet. It was however clear that the individual needs of residents are being met by and adequate number of staff who understand their needs and are able to respond to them. The inspector observed a good standard of interactions between residents and staff, which included humour and indicated that there were, close bonds between them. Residents spoken to said ‘everyone is good here’ ‘ Staff spoken to had an understanding of the key worker system and have worked hard to make the recent changes and moves as smooth as possible. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 19 Davigdor Lodge needs to be established as a home with integrated staff and residents with clearly identified roles for senior staff. The personnel files of three staff members were reviewed and confirmed that all the necessary checks were completed and good employment practice was followed. Staff training is being formalised and organised by a newly appointed training manager who covers three homes. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 20 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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was found to be managed in an open and friendly manner. Systems to monitor and demonstrate the quality of care provided need to be established. The health, safety and welfare of residents and staff are generally promoted and protected although further attention is needed in respect to generic and individual risk assessment. EVIDENCE: As previously recorded in this report although there is a registered manager the staff team although working well together have not integrated and the home is running as two separate homes within one premises. The management arrangements need to be clarified with clear roles and responsibilities being established. The registered manager and the deputy have both had extensive experience in the care of residents with mental health disorders and have recently completed management qualifications. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 21 All residents spoken to were comfortable with the management arrangements and were able to say whom they would speak to with any concerns. On the whole residents feel that the move and changes have been wellmanaged one saying that ‘I know a lot of the residents that have moved in and like mixing with them’. All residents were involved in the changes and those residents moving into the home were able to choose the room they wanted to occupy. Another resident said that she was ‘settling well following the move’. One resident expressed that she was very unhappy with the move and wanted to move to another home and the management of the home were arranging for her to be seen by a CPN. Quality Assurance systems in the home have not been fully established and the manager advised the inspector that these are currently under review and that they plan to re-instate resident’s meetings. There are extensive policies and procedures relating to health and safety and on the whole residents and staff safety is promoted. During the inspection visit it was however noted that a number of fire doors were being held open with wedges and furniture. This was identified to the home manager to address. The last fire risk assessment was completed last year and the home manager confirmed that she was in contact with the Fire Brigade to ensure appropriate documentation is used this year. It was also noted hot water at a temperature up to 56 degrees C was according to the homes records accessible to residents in the home, in addition radiators are not guarded. Appropriate and full risk assessments in respect to these issues were not clearly documented. Both these areas were identified within an immediate feedback form left for the manager at the end of the inspection. Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 5 3 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 1 25 X 26 3 27 X 28 X 29 3 30 1 STAFFING Standard No Score 31 2 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15(2)(b) Requirement That all care documentation is consolidated, up to date to reflect changes in care needs and preferences of services users, and reflect all the care needs of residents and a regular review. Timescale for action 01/09/06 2. YA20 13(2) To have one system for medicine 01/08/06 management for all the residents in the home. To stop the practice of preparing medication in dosette boxes to give later. To make entries in the controlled drugs register at appropriate times. To ensure supervision includes 01/09/06 competence skills assessment for medicine management. That a plan of re-decoration and 01/09/06 repair be developed, which addresses the areas of redecoration and repair identified at inspection and includes timescales for their completion. That the rear external balcony steps are maintained and DS0000014196.V292890.R01.S.doc 3. 4. YA20 YA24 13(2) 23(2)(d) 5. YA24 23(2)(d) 01/10/06 Davigdor Lodge Rest Home Version 5.2 Page 24 repainted. (Made at inspection of 05/07/05 with timescales of 30/10/05 not met) 6. 7. YA24 YA30 13(4) 13(3) That a suitable call bell system is available throughout the home. That the cleaning in the home is improved to ensure all a pleasant and safe environment for residents and staff. That all staff have clearly defined job descriptions and understand their own and others roles and responsibilities. That an effective quality assurance system is established and reported on. That an up to date fire risk assessment is completed and control measures are adhered to. That generic and individual risk assessments are used to ensure resident’s safety. These should include risks presented by hot water, unguarded radiators and self-medication. Any identified control measures must be acted on. That the CSCI is provided with a copy of the homes safety certificate for the gas and the electrical installation. 01/08/06 01/08/06 8. YA31 18(1) 01/08/06 9. 10. 11. YA39 YA42 YA42 24 13(4) 13(4) 01/10/06 01/09/06 01/08/06 12. YA42 13(4) 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Davigdor Lodge Rest Home DS0000014196.V292890.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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