Inspection on 27/11/07 for Davigdor Lodge Rest Home

This inspection was carried out on 27th November 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 no outstanding requirements from the previous inspection report, but made 7 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 27/06/06

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 56-58 Tisbury Road Hove East Sussex BN3 3BB Lead Inspector Caroline Johnson Key Unannounced Inspection 27th November 2007 11:10a Davigdor Lodge Rest Home DS0000014196.V356125.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.V356125.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.V356125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davigdor Lodge Rest Home Address 56-58 Tisbury Road Hove East Sussex BN3 3BB 01273 726868 01273 726868 e.hyslop1955@hotmail.co.uk 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.V356125.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 twentyfive (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. 17th October 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 two registered care establishments within the East Sussex area and has owned 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 dining room plus a rear garden. A new conservatory has been built recently and this is now the designated smoking area. 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 home’s 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.V356125.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 Home’s 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’. As part of the inspection process a site visit was carried out on 27th November and lasted from 11.10am until 6.10pm. During the visit there were opportunities to meet with the manager, with three staff and with several of the residents. A full tour of the building was undertaken. A wide range of paperwork was examined including the pre-admission assessment for one resident and three care plans. In addition record keeping was seen in relation to staff training, quality assurance, staff meeting minutes, health and safety, maintenance and medication. Following the inspection attempts were made to contact the relatives of two of the residents to hear their views about the home. Unfortunately contact was only achieved with one relative. Comments received included: That they were ‘very happy with the care’ their relative receives. Their relative attends a day centre, which they travel to and from independently. They also stated that ‘the home would be in contact if there was a problem, the home is kept clean and the food always looks good’. What the service does well: What has improved since the last inspection? A new conservatory has been built increasing the communal space available to the residents. The conservatory is now the designated smoking area. The toilet Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 6 in close proximity to the conservatory has also been refurbished and a urinal has been installed. Whilst it is unusual to have such a facility in a care home the manager advised that this works well for the home. New carpet has been fitted in the hallways and corridor areas. A new quality assurance system has been put in place and now needs to be tested further to monitor that standards are achieved and improved upon as a result. The home has amalgamated two forms of care planning so that there is now only one system in place. There are still some improvements to be made to the system but the manager is aware of the work required to improve the standards in this area. The systems in place for the management of medication have improved and more detailed record keeping is now kept as a result. The manager and deputy manager are both studying for the RMA (Registered manager’s Award and one staff member is studying for NVQ (National Vocational Qualification) at level 4. 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. Davigdor Lodge Rest Home DS0000014196.V356125.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.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with detailed information about the home, which enables them to make a decision about accommodation. EVIDENCE: The statement of purpose provides detailed information about the home, the facilities and what to expect from the service. Records were seen in relation to one resident recently admitted to the home. The home had carried out an assessment of the individual’s needs and the social worker had also provided limited information. The manager advised that the social worker has yet to provide a CPA. This resident had had a trial overnight stay prior to making a decision about accommodation. There was a detailed terms and conditions of residence in each case file seen. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Progress has been made in relation to care planning. Further progress is needed to ensure that care plans reflect fully the work carried out by staff in relation to assisting residents to achieve their goals. EVIDENCE: As required at the last key and random inspections, the home now has one system in place for documenting care plans. Three care plans were examined in detail. The manager advised that care plans are reviewed once a month or whenever needs change. A detailed assessment is carried out of the needs of the residents. Staff spoken with were able to describe the needs of the residents that they are keyworker to and what they do to support them. There was evidence that the care plans and risk assessments were reviewed on a regular basis. Each of the residents has set goals that they are working Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 10 towards achieving. In one care plan there was a long-term objective for the resident to be debt free and able to deal with their finances independently. The action to be taken by staff was to ensure that the resident had their personal allowance on a daily basis. There was no reference to how much debt the resident had and how their debts were to be repaid. In another care plan there was a similar objective but this was a short-term goal. This goal was for the resident to learn some budgeting skills. The action to be taken by staff was broad and included, to encourage the resident to spend money wisely and to prioritise and buy appropriately. There was no reference in either of the daily notes about any progress made with budgeting. In relation to one resident who hoards paper there was a risk assessment in place stating that the room should be checked on a daily basis and if large amounts of paper are found they should be removed. It also stated that staff should ensure that the resident concerned is present when the paper is removed. Records showed that during September five bags of papers being removed from this resident’s room but there was no reference to the resident being present or how they coped with this. Over the course of the inspection residents were seen to make decisions such as choosing to have lunch out rather independently and choosing to have fruit, drinks and cigarettes. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are informal and suit the needs of many of the residents but more emphasis on planning a wider variety of activities could be very beneficial to a number of residents. EVIDENCE: A day care facility that some of the residents used to attend regularly has closed down recently. Staff advised that the residents are missing this facility and also the fact that they used to get therapeutic earnings. A couple of residents had trial sessions at another day centre but did not choose to attend regularly. Three residents attend church services, one independently and two with staff support. In-house activities include bingo, scrabble and other board games, painting and watching films. A couple of staff spoken with stated that they would like to Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 12 see a wider range of activities available and more planning in advance of activities. The owner has recently purchased a holiday camp. Two groups have already been for a holiday. Staff reported that on one occasion twenty residents went, on the second eight residents went and a further trip has been planned for twenty residents. In addition occasional day trips are planned and the home has occasional parties and seasonal events such as barbeques in the summer months and Christmas parties. A pay phone is available for residents to make and receive calls. A staff member advised that a number of residents have friends that they visit and who visit them. This was seen on the day of inspection as a number of residents came and went throughout the day. A very small number of residents have relatives that visit them and where necessary staff support them to maintain contact with their relatives. A relative spoken with stated that her relative likes to help with the dishes. Another resident helps to clean the conservatory. Menus seen were varied and well balanced. The menu is distributed to residents one day in advance. There is a choice of main meal but the cook advised that in addition to this there are always other choices available also. Fresh fruit is available at all times. It was also noted that a number of residents also have there own supply of fruit in their individual bedrooms. Those who choose to and are assessed as able, have tea-making facilities in their bedrooms. Some also have mini-fridge facilities. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the management of medication and this needs to be enhanced further with improved storage arrangements. Attention needs to be made to record keeping in relation to the monitoring of health needs. EVIDENCE: It was reported that there are no visiting professionals. The home used to benefit from having a psychiatrist visiting every six weeks but due to a local reorganisation there is a reduced service available. However, staff advised that whenever residents need specialist advice or support arrangements are made for this to happen. Residents are supported where necessary to attend healthcare appointments. Staff were seen to treat residents with respect and dignity and there was a very friendly rapport between staff and residents. The majority of the residents are able to attend to their own personal care needs. Staff advised that some residents require prompting and a couple of residents regularly Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 14 refuse to attend to their personal care. Where necessary advice and support has been sought from social workers to assist in this matter. Medication is stored in two trolleys. At the time of the inspection the trolleys were stored in the staff toilet. Staff advised that the trolleys are then brought to a different area for administration. Storage of medication in the staff toilet is not considered appropriate. Records of medication administered to residents were in order and staff are using the rear of the MAR chart to explain any changes. A returns book is kept to record all medication returned to the pharmacy. A book is also kept to record any as required medication and a book is kept to record any controlled drugs administered. A CD register is kept and there are staff signatures recorded. Only one signature is recorded on the MAR chart. It was reported that all staff have completed a course on the care and control of medication. The local pharmacist was also called upon to provide advice and support and will also provide more detailed training for some of the staff team. Three of the residents have diabetes. One resident is insulin dependent and the other two residents receive medication to control their diabetes. Staff advised that in each case the diabetes is well controlled. Staff occasionally check the blood sugar levels for one of the residents. There is no risk assessment in place advising staff of the action to be taken if blood sugar readings are too high or too low. In relation to one resident, there were records in the their care plan showing that their weight had been monitored monthly. However, it was May 2007 when the actual weight was last recorded. Each month since then there was a record stating how many pounds lost but it was not clear if the weight lost was in total from May 2007 or the stated amount each month. Either way the records showed that there was a marked weight loss but there was no link to any care plan about action being taken as a result. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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: There is a detailed complaint procedure in place and a copy of the procedure is on display in the home so that anyone wishing to make a complaint can do so. It was reported that there have been no formal complaints. Staff advised that occasionally residents raise minor complaints but these are dealt with immediately and never reach a formal stage. To encourage residents to have more of a say in their home a suggestions box was installed but to date none of the residents have made any suggestions or complaints. No complaints have been made to the Commission about this service. It was reported that the majority of the staff team have had training on the protection of vulnerable adults. There is a detailed policy and procedure in place on the subject. There have been no adult protection referrals in the past year. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and decorated to a good standard. Emphasis must be placed on ensuring that all areas are cleaned on a regular basis. EVIDENCE: A tour of the building was carried out and the majority of the bedrooms were seen. All bedrooms have been personalised and reflect the personalities of the residents occupying them. A number of bedrooms have been redecorated and residents spoken with stated that they chose the colour schemes for their rooms. Communal areas consist of two lounges and a conservatory. New carpet has been fitted in the hallways and corridor areas. The manager advised that the hallways are to be painted and all woodwork on the stairwells is also to be painted. The woodwork on stairwells was dirty in many areas and it is essential that these areas be cleaned as soon as possible. Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 17 The conservatory was built during the summer months and is now the designated smoking area. The toilet in close proximity to the conservatory has also been refurbished and a urinal has been installed. Staff advised that the dining room is next on the list to be redecorated and this work will be carried out prior to Christmas. There is also a kitchenette available for residents’ use. However, it was apparent that this area is not used much and was not kept very clean. The light/fan in the shower room blew as it was switched on so it was difficult to see in this area. However, the shower mat appeared dirty and there was possible mould/rust around the seating area in this area. The manager confirmed before the end of the inspection that the light fuse had been replaced. In one of the top floor bathrooms the bath panel needs replacing and the flooring also needs replacing. Some of the bedrooms were dusty. One room in particular was very dusty. The resident has birds, which were kept in cages on a table. The floor space under the birds was very dirty. There was a strong smell of cigarette smoke in one bedroom. There were trailing wires in one room that could pose a trip hazard. Following the last inspection a record was drawn up detailing all action that has been highlighted and completed since the last inspection. Once completed the item is ticked and signed. The cleaner has been off sick for a period of time and one of the staff team is working extra hours to try to keep up with cleaning tasks. A role of the individual Keyworkers is to spring clean the bedrooms for their key clients once a month. Whilst some bedrooms were very clean others were less so and require attention. The manager also advised that there is a checklist on all toilet facilities. These areas are cleaned daily and monitored at least four times a day to ensure they remain clean. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive regular training updates to ensure that they remain equipped to meet the needs of the residents. The home must get back on track with the provision of formal staff supervision. EVIDENCE: The manager advised that the job description for the post of team leader has been updated. A staff member spoken with was clear about the extent of their individual role and responsibilities and advised that when they had been promoted they had been given a copy of the updated job description. Staff advised that they felt well supported. It was reported that formal supervision sessions have not been carried out as frequently as required but that the owner has recently provided supervision for some of the staff team. They had yet to be typed up. The home has not recruited any staff since the last inspection although they have recently appointed a staff member and are awaiting references and CRB Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 19 check before they can commence working in the home. The induction package in place is an old system and advice was given about the need to ensure that the package is updated to the Common Induction Standards. At the time of inspection there was no staff training matrix in place so it was not possible to determine (without checking all staff files) the numbers of staff that have attended mandatory training. All staff spoken with stated that they have attended a wide variety of training courses. One staff member stated that they are putting together a staff training matrix but it has yet to be typed up. The manager advised that training is ongoing. Two staff have recently attended training on infection control and another two have been booked to attend this training. Training on fire safety is arranged annually. Two staff were due to attend training on food hygiene on the day of inspection but due to staff sickness this did not happen. All staff receive training on understanding mental health issues. Three staff have completed NVQ level three and one member of staff is currently studying for NVW level 4. Davigdor Lodge Rest Home DS0000014196.V356125.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant progress has been made in developing a quality assurance system and with further work this will ensure that the home is continually monitoring and improving their practice. EVIDENCE: The manager and deputy have both completed the RMA (Registered Manager’s Award). Staff spoken with all stated that they felt well supported by the manager and her deputy. One staff member stated that they particularly valued the support provided by their team leader in relation to studying for their NVQ. Staff meetings are held regularly and a staff member advised that they are very useful. Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 21 Since the last inspection the home has introduced a new quality assurance system. As part of this process a detailed document has been prepared identifying the standard of practice to be achieved in all areas and how this is to be evidenced. However, an assessment now needs to be carried out to assess whether the home is achieving what it has stated. The manager advised that a resident satisfaction questionnaire was drawn up but that the residents did not want to complete it. As an alternative a suggestion box was made available but this has not been used. A food and menu meeting was held with the residents in September to hear views and the menu was revised accordingly to accommodate resident suggestions. The manager advised that it is easier to get the views of residents when speaking with them individually. A system needs to be introduced to formally capture the views raised by the residents. Following the inspection contact was made with a relative of one of the residents. They stated that they were very happy with the care their relative receives. Their relative attends a day centre, which they travel to and from independently. They also stated that ‘the home would be in contact if there was a problem, the home is kept clean and the food looks good’. Prior to the inspection user surveys were sent to the home for distribution to residents so that they could comment on the quality of the care provided. Seven surveys were returned. Residents choose to use the tick box to record their responses and overall the responses were positive. Comments included ‘ I am happy where I live’, ‘I like to keep myself to myself, but I do have friends here’. Six of the seven residents advised that they knew how to make a complaint and some also stated that their keyworker would support them. One resident stated that they did not know how to make a complaint. Records showed that portable appliances were last tested in December 2006. The manager advised that the handyman would test all appliances again this December. A company was contracted to carry out a fire risk assessment earlier in the year. The manager confirmed that with the exception of the seals around fire doors in house (56) all other recommendations have been addressed. It was confirmed that this work would be carried out next year but the timescale is not clear yet. It was acknowledged that this work must be carried out as a priority. There are certificates in place showing that the alarms, lights and extinguishers are all serviced on a regular basis. The gas was serviced in September this year. Hot water temperatures were tested on the day of inspection at three outlets. All three readings were within agreed safety standards. The provider had delegated an individual to carry out monthly-unannounced visits to the home to report on the running of the home. However, there are no records in place to show that this has happened since June 2007. Staff advised that the provider visits the home every week. Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 22 Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 3 X 4 3 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 3 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 2 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 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 X X 3 2 Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 24 No 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 Home’s 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 In relation to care plans and goals set for residents, there must be a system in place to record any action taken to implement them. Risk assessments must be drawn up to determine risks associated with unstable diabetes. Records of residents’ weights must be recorded accurately so that action can be taken if necessary where there is significant weight loss. Arrangements must be made to ensure that the home is kept clean. All staff must receive supervision at regular intervals. The quality assurance system must be expanded further to capture the views of the residents and to monitor that all work detailed in the newly designed quality assurance system is carried out. The provider or a representative on his behalf must visit the home on a monthly basis unannounced and a report must be carried out of the findings. DS0000014196.V356125.R01.S.doc Timescale for action 31/01/08 2. 3. YA19 13 13 15/01/08 15/01/08 YA19 4 5 6 YA24 YA36 YA39 23(2 18 24 15/01/08 31/01/08 31/01/08 7. YA42 26 31/01/08 Davigdor Lodge Rest Home Version 5.2 Page 25 Reports must be available for inspection. 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 YA32 YA32 Good Practice Recommendations The home’s induction package should comply with advice from Skills for Care. A staff training matrix should be maintained showing all training attended and due. Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Davigdor Lodge Rest Home DS0000014196.V356125.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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