Inspection on 09/11/05 for Deer Lodge

This inspection was carried out on 9th November 2005.

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

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

Other inspections for this house

Deer Lodge 02/10/07

Deer Lodge 01/06/06

Deer Lodge 18/05/05

Deer Lodge 10/01/05

Deer Lodge 29/06/04

Deer Lodge 05/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Deer Lodge 22 Sandy Lane Teddington Middlesex TW11 0DR Lead Inspector Sharon Newman Unannounced Inspection 9th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Deer Lodge Address 22 Sandy Lane Teddington Middlesex TW11 0DR 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) 020 8943 3013 Mr S N Patel Care Home 14 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (14) of places Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: Deer Lodge is registered to provide residential care to fourteen older people. The Home is a three storey building situated on a main road running along the boundary of Bushy Park close to local amenities in both Kingston and Teddington. Accommodation is provided on the ground and first floors. A large, well-kept garden is situated to the rear of the property, providing a patio area with seating, lawns and a variety of mature trees and shrubs. As the home is situated opposite Bushy Park, a small number of bedrooms have fine views across the nearby parkland. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Inspection Team: Sharon Newman Simon Smith Jeremy Howe Regulation Inspector Regulation Inspector Pharmacy Inspector This unannounced inspection took place over one day on the 9th November 2005. The Inspection Team consisted of two Regulation Inspectors and a Pharmacy Inspector. Records examined at this inspection included care planning documentation, health and safety information and staff files. A tour was also taken of the premises. The inspection team were informed that there are currently ten service users living at the home. The Inspection team were made to feel welcome by the staff who demonstrated a helpful and professional attitude throughout the inspection visit. It is acknowledged that there have been improvements in some areas since the last inspection visit and that some of the requirements set in the previous inspection report have been met. However, a number of requirements have been re-stated in this report as they have not yet been fully met but evidence was seen to suggest that the home is working to address these requirements and some have been partially met. The acting manager was noted to have a very enthusiastic approach and staff, relatives and service users gave positive feedback about her. However, the home must ensure that that an application is put forward to the CSCI for registration of the manager. Service users spoken to at the time of inspection said they liked the home and the staff. One service user commented ‘I am very happy here.’ What the service does well: Staff have a good rapport with service users and were seen to interact well with them and demonstrate kindness and respect when talking to them. The cook also interacts well with service users and was seen to speak to them individually to inform them of the lunch on offer. Staff sit down to take meals with service users creating a pleasant, unhurried and homely atmosphere. The maintenance person was observed to have a good rapport with the service users and they demonstrated a genuine fondness for him. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 6 The manager is enthusiastic about her role and demonstrates a conscientious attitude stating she is committed to making improvements at the home. There is a large beautifully maintained garden, the maintenance person obviously takes pride in their work. Relatives and service users spoken to commented positively about how lovely the garden is. The home now presents as clean and homely and there is a relaxed atmosphere throughout. What has improved since the last inspection? What they could do better: Areas requiring improvement were discussed with the manager at the inspection visit. These included: Not all residents’ files contained assessments and the information did not always correspond with the care plan. Full assessments must be in place for all service users. Service users contracts also need to be obtained and attention needs to be paid to the care planning system as regular updating of this documentation must take place. Risk assessments also need to be regularly reviewed. Service user meetings are not being held regularly to enable them to express their views and should be held. The area of complaints and protection still needs to be addressed, the home must ensure that adequate POVA First checks and CRB (Criminal Record Bureau) checks are carried out on all staff. Inadequacies in these areas could place service users at risk. A full complaints log should be kept to ensure there is a clear record that can be easily audited. This should include details about Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 7 the complaint, how it was investigated and by whom and what the outcome was. Staff supervision needs to take place on a one to one basis at least six times a year to ensure staff have the support and direction to carry out their jobs safely and efficiently. Staff meetings need to be held more regularly to ensure good communication and to allow staff to voice any opinions or suggestions. The home needs to ensure all staff have up-to date training in areas such as abuse awareness, dementia care, first aid, food hygiene and moving and handling. Staff files should also contain all the information required by the Care homes Regulations 2001. Only one meal choice was observed to be offered at lunchtime, with the onus being on service users to ask if they wished to have an alternative choice. The home should ensure that an alternative choice is offered each day. 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. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. 2. 3. 4. Assessments of need are not in place for all service users and in some cases the information is not consistent with the care plan. This could prevent service users needs from being met. EVIDENCE: A Statement of Purpose is in place at the home and has been updated by the acting manager, however it still requires amending to include the sizes of all the bedrooms at the home. A Service Users Guide is available and consideration needs to be given to adapting this document to a large print and pictorial format. The manager stated that she is continuing to work on this documentation to ensure that it is comprehensive and accessible to read. Six service users’ files were examined at this inspection visit. Five of these contained statements of terms and conditions, which were signed by residents and/or their representatives. Whilst the majority of files did contain this documentation the home needs to ensure that all residents have statements of terms and conditions in place. All six files contained evidence of six week and six monthly reviews taking place. Three files out of the six sampled contained appropriate pre-admission assessments. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 10 The home’s assessment of prospective residents remains a cause for concern. As demonstrated above, not all residents’ files contained a formal needs assessment. Where assessments had been carried out, the information gathered was not consistent with the care plan developed for the resident. For example, one pre-admission assessment showed no history of falls but the resident’s care plan stated that she “had a history of falls when she was living at home”. Three service users spoken to during the inspection visit reported that they liked living at the home. One resident commented that ‘it is lovely here and I have settled in well.’ Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. 8. 9. 10 Service users health care needs are appropriately met. The home has arrangements for the ordering, storage, recording, administration and auditing of medication and has access to a pharmacist for advice. The home has shown improvement since the last visit. On the day of this visit minor errors in recording and inappropriate storage were found that might have an effect on the health and welfare of residents. EVIDENCE: Residents’ files did demonstrate that the home seeks appropriate, specialist support to meet residents’ needs. For example, one resident’s care plan demonstrated that the resident was referred to a specialist nurse following a high incidence of falls. Another care plan demonstrated that district nurses currently visit the resident regularly to provide wound care. A medical file is kept at the home in which visiting health professionals and doctors may write their notes. However there was insufficient evidence that care plans are reviewed regularly or when a change in need occurs. A number of the care plans examined contained information that was out of date. Risk assessments were in place addressing a range of issues but were not regularly reviewed. In some cases, information contained in risk assessments Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 12 did not match the information recorded on care plans. For example, a risk assessment for one resident reported that bed rails were used at night, whilst the resident’s care plan stated that bed rails were not to be used following advice from a healthcare professional. All medications administered by staff along with the policies and records relating to receipt, storage, administration and disposal of medication were examined. The person in charge was interviewed and the amount of medication counted and compared to the amount that should be in stock for all medication not supplied in a monitored dosage system. This is to ensure residents receive their medication as prescribed. From these observations and discussions policies and procedures were seen covering all aspects of medication management and risk assessments around medication storage and administration are in place. These identify potential risks and how to manage the risks. Alterations and discontinuations to medications are clearly indicated on the administration record in accordance with directions from a prescriber and any changes are faxed to the pharmacist. Two residents did not have the time one of their medications was given recorded accurately. This medication must not be given with food and therefore the time of administration is important. Two items requiring cold storage were not stored in the fridge. The acting manager stated that these items had not been stored in the fridge since arriving in the home. At the end of the month the quantity of medication in stock is audited and the quantity carried over to the next month recorded. In one instance the actual amount carried over had been recorded inaccurately, although it was still possible to audit the medication. In all instances the amount of medication agreed with the amount that should be in stock. All other records had been completed accurately and provided evidence that all medication had been administered correctly, changes to medication clearly identified, all other medication was stored and administered safely by appropriately trained staff to ensure that the health and welfare of service users are protected Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. 13. 14. 15. Activity provision is improving at this home and service users are encouraged to participate in activities. They are also encouraged to maintain contact with family and friends. Relatives are made to feel welcome at this home. Service users are offered nutritious meals in a pleasant, homely setting. However, service users would benefit from being offered an alternative choice of meal. EVIDENCE: The manager reported that a new activities person has recently been employed at the home. Two service users were taken out by staff members to a local community centre for tea and cakes during the inspection visit. A staff member was observed encouraging service users to participate in activities. A few of them were seen to play a ball game in the lounge area and after this some service users engaged in individual activities with staff members. An armchair exercise class was held before lunch and was observed to have been much enjoyed by the participants. Staff were seen to be talking to service users and helping them to read newspapers. Three residents reported that they had enjoyed the visit of the entertainer/pianist and would like to see this again. Two residents reported that they were satisfied with the activities provided, although stated, “it would be good if we could get out a bit more but it depends on the [staffing] Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 14 situation”. A staff member reported that a number of relatives had stated at recent reviews that an increased range of activities would be beneficial. The menu was displayed on a large board in the dining area. Lunch was observed to be taken in an unhurried and relaxed atmosphere and staff ate their lunch with the service users. This helped to create a homely environment. The lunch looked healthy and nutritious and portions were served at the table enabling service users to choose their portion size. The lunch served was shepherds pie, cabbage, carrots and sweetcorn followed by fruit cocktail. Soft drinks were served with the meal. However, only one meal choice was observed to be offered at lunchtime, with the onus being on service users to ask if they wish to have an alternative choice. The home must offer an alternative choice each day. A service user commented that ‘the food is good.’ It was discussed with the manager that more regular service users meetings should be held at the home. Only two meetings were seen to be recorded this year and the manager stated that they are going to increase the frequency of these meetings. Refreshments were observed to be brought to visiting relatives. One relative commented ‘this is a small and very friendly home’ and ‘I give it a hundred percent.’ Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. 18 Appropriate checks have not been made on staff and not all of them have received adequate information or training on recognising and reporting abuse. Complaints are not fully recorded so it is unclear whether appropriate action has been taken to prevent bad practice. However, the correct procedures are followed when complaints or incidences of abuse are suspected. EVIDENCE: An organisational abuse policy is in place at the home and the home has adopted the London Borough of Richmond Protection of Vulnerable Adults Policy and Procedure. A whistle blowing policy was seen to be available in the home. A staff member spoken to demonstrated a very good knowledge of abuse awareness and whistleblowing procedures. Although staff have been undergoing training in the area of abuse awareness and the Protection of Vulnerable Adults, not all staff have attended this training and this requirement remains outstanding from the last inspection report. As found at the previous inspection visit the complaints file was found to be incomplete and did not contain sufficient details of the complaints made or the conclusion reached. During the course of this inspection year there has been a Protection of Vulnerable Adults (POVA) complaint at the home and one further complaint concerning the care in the home. A further POVA issue has also arisen recently at the home and the manager reported that the appropriate social services procedures were invoked. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 16 As highlighted in the previous inspection report management activities at this home could put service users at risk. Insufficient checks were seen in some of the staff files examined (refer to Staffing Standards 27 – 30). The manager stated that one new member of staff had commenced their induction at the home without clearance from a POVA First check. All staff must undergo the necessary checks prior to starting work at the home. The home must also ensure that it obtains satisfactory Criminal Record Bureau (CRB) checks for all staff at the home. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. 20. 21. 22. 23. 24. 25. 26 Service users live in a homely and attractive environment with access to a beautiful and well-maintained garden. The bedrooms are well personalised and comfortable. The home is clean and hygienic. EVIDENCE: Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 18 The home was seen to be clean, tidy and hygienic on the day of inspection. The lounge/dining area had a homely and pleasant atmosphere. However, there is limited communal space available at the home. As stated in previous inspection reports there is no alternative quiet room, service users must use their bedrooms if they wish to see visitors privately. The large garden is very attractive and well maintained and the maintenance person obviously takes a pride in their work. A relative commented that the garden was ‘lovely.’ The equipment that was previously stored in one of the WC’s has now been removed and the broken toilet seat has been repaired. As reported in the previous inspection report there has been no assessment of the environment by an Occupational Therapist. There has been a history of a significant amount of falls and accidents at the home this year. It is recognised that staff at the home have asked for advice from a falls specialist nurse and the manager stated that they have been endeavouring to contact an Occupational Therapist. However the environment and the needs of the service users must be appropriately assessed in order to effectively reduce the risk of these accidents. The bedrooms seen at this inspection visit were comfortable, well personalised to individual taste and well decorated. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. 28. 29. 30. Staff are enthusiastic and caring and have a good knowledge of resident’s needs. However, recruitment procedures do not guarantee the safety and well being of service users. Records required in staff files by Care Homes Regulations are not in place. Staff training is improving but all staff still do not have the necessary training in the areas listed below. EVIDENCE: Five staff files were examined and the files were found to lack documents required by the Care Homes Regulations (2001), (Schedule 2), including recent photographs, proof of identity and Criminal Records Bureau disclosures. A number of files also lacked statements of terms and conditions. Records demonstrate that the following training courses have been provided in the home in the last six months: dementia, medication, moving and handling, fire safety and POVA. Many staff have attended these training sessions and whilst this is encouraging, the remainder of the staff team still require training in the above areas. It was discussed with the manager that any staff involved in the preparation of food must have an up-to-date food hygiene certificate as this was not clearly apparent on the day of inspection. Staff’s terms and conditions state that training costs must be reimbursed by staff should they leave within 4 years of the training. The Registered Person is responsible for ensuring that all staff receive a minimum of three paid days training per year and that there is a staff training and development programme that meets the Skills for Care Standards. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 20 Concerns were identified regarding the time allocated to individual members of staff to complete training relevant to their roles. The acting manager advised that staff are currently expected to undertake training in their own time. One of the senior support workers stated that staff now participate in more training, which has proved beneficial for the home and means that staff are more confident and competent in their roles. They also reported that they had recently attended supervision training and will supervise their team members. They advised that senior staff have worked hard to improve staff interaction with residents. They stated that the manager is currently working towards NVQ level 3 and that a number of staff need to register on suitable NVQ training. They also reported that the Registered Person holds formal meetings with the acting manager and senior staff around once a month. The Registered Person visits the home on a weekly basis and meets with the staff and also attends the staff meetings. They felt that the Registered Person has become more involved with and supportive of the home in recent months. Two further staff members were spoken to and both reported that they felt well supported by the manager. One staff member reported that when the last manager left the home they found the period of change unsettling but that they feel happier at the home now and that the staff work more as a team. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31. 33. 36. 37. 38. Presently there is no registered manager in place at the home. Staff are still not adequately supervised on a one-to-one basis. However, there has been an improvement in the running of the home and the acting manager is enthusiastic and conscientious. EVIDENCE: The home still does not have a Registered Manager, the acting manager stated that they are going to forward their application for registration to the Commission for Social Care Inspection (CSCI). This Requirement remains outstanding from the previous inspection report as the home must ensure the manager is registered with the CSCI. The acting manager is enthusiastic about her role and gave the impression of a genuine commitment to her work. She stated she is committed to continuing to raise standards at the home and ensuring the home meets the National Minimum Standards. She said she is supported by the Registered Provider and Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 22 that the provision of an advisor has been a positive move and allows her to seek support and advice. This support needs to continue to ensure the manager is supported to fulfil her role. The inspection team were informed that there is no e-mail or internet services at the home. The Registered Person should consider having these services. This should improve communication and allow staff access to information needed for the development of their roles and the efficient running of the service. Staff files did not demonstrate that staff receive individual supervision at least six times a year. One staff member said that they only had one supervision session this year. Staff must receive one-to-one supervision at least six times a year. There is a quality assurance programme in place and completed questionnaires have been returned from residents and relatives. This will need to be compiled into a report to be distributed to the respondents. The manager reported that not all policies and procedures have been updated but that she is addressing this issue. She said that regular staff meetings are not yet taking place, consideration should be given to ensuring regular fully recorded staff meetings take place to ensure good communication and ensure their views are taken into consideration. Meat was observed to be stored in the refrigerator that had been opened but it did not contain a date of opening. The home needs to ensure that all opened food is clearly labelled with the date it was first opened. First aid boxes are not always being checked monthly and the manager said she would ensure this is done. An up-to-date gas safety certificate could not be found on the day of inspection and the five yearly electrical installation check was not available. Both of these certificates need to be obtained by the home. Records seen regarding legionella, portable appliance testing, and fridge and freezer temperatures were in order on the day of inspection. Water temperatures were observed to be recorded at temperatures above 45 degrees centigrade. Water temperatures must not exceed 43 degrees centigrade. The water in the home should be stored at 60 degrees centigrade, distributed at 50 degrees centigrade and only thermostatically lowered to 43 degrees centigrade at the actual outlet. The kitchen water temperature is 43 degrees centigrade and there is no dishwasher. Consideration should be given to the purchase of a dishwasher to ensure crockery is washed at the correct temperatures to meet health and safety requirements. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 23 An up-to-date certificate of insurance liability is now displayed at the home. Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 2 2 2 Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1) Sch1 Requirement The Registered Person must ensure that the Statement of Purpose contains all the information in Schedule 1 of the Care Home Regulations 2001. (Previous timescale of 01/10/05 not met). The Registered Person must ensure that every service user is issued with terms and conditions of residence which must include details of the rooms to be occupied. (Previous timescale of 01/10/05 not met). The Registered Person must ensure that full assessments are in place for all service users. These must be undertaken by people trained to undertake this task. (Previous timescale of 01/08/05 not met). The Registered Person must ensure that service users plans are reviewed regularly or when a change in need occurs. The Registered Person must ensure that assessments of risk DS0000017363.V264867.R01.S.doc Timescale for action 01/01/06 2 OP2 5(1b) 01/12/05 3 OP3 14(1) 01/12/05 4 OP7 12(1-3) 15(1&2) (a-d) 13(4)(6) 15 01/01/06 5 OP8 01/12/05 Deer Lodge Version 5.0 Page 26 6 OP9 13(2) are sufficiently detailed and identify action to be taken to minimise risks. Risk Assessments must be kept under regular review. (Previous timescale of 28/07/05 not met). The Registered Person must ensure that: 1. The administration of all medication is recorded accurately. 2. All medication is stored under the appropriate conditions. 01/01/05 7 OP15 12(2&3) 8 OP16 22(3)(4) (8) 9 OP18 13(4&6) 18(1c) 10 OP18 13(4&6) 19(1a) 11 OP22 13(1) 16(1) 4(3) The Registered Person must ensure that service users are given a menu offering a choice of meals. The Registered Person must ensure that a full record of complaints is maintained at the home with actions / timescales / outcomes fully recorded. (Previous timescale of 31/07/05 not met). The Registered Person must ensure that all staff are trained in recognising and reporting abuse. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that the Manager is aware of the procedures for making criminal record and POVA checks on staff. Satisfactory checks must be received prior to the commencement of employment. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that an assessment is made of the premises and DS0000017363.V264867.R01.S.doc 01/02/06 01/01/06 01/01/06 01/12/05 01/02/06 Deer Lodge Version 5.0 Page 27 23(2n) 12 OP28 13(4&6) 18(1c) 19(1a) 13 OP29 19(1a) Sch 2 14 OP30 18(1c) 19(1a) 15 OP30 18(1a) (c)(ii) 16 OP31 9(1) 12 (1a&b) 12(1-3) 24(1) 17 OP33 facilities by a suitably qualified person, including a qualified occupational therapist, with a specialist knowledge of the service users catered for. This is with particular reference to the number of falls and accidents at the home. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that any person preparing food is qualified in food hygiene. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that staff records are complete and that there is sufficient evidence of the recruitment process, including two written references. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that all staff are up-todate in training relevant to their role. This must include food hygiene, first aid, abuse, dementia care, health and safety and moving and handling. (Previous timescale of 01/08/05 not met). The Registered Person must ensure that the persons employed to work at the care home receive time off for the purpose of obtaining further qualifications appropriate to such work. The Registered Person must submit an application for a Registered Manager to the CSCI. (Previous timescale of 01/09/05 not met). The Registered Person must ensure that regular service users meetings are held and fully recorded. DS0000017363.V264867.R01.S.doc 01/01/06 01/01/06 01/02/06 01/12/05 01/12/05 01/01/06 Deer Lodge Version 5.0 Page 28 18 OP36 18(2) 19 OP37 17(1) 20 OP38 13(4) 21 OP38 12(1a) 13(4) 22 OP38 12(1a) 13(4) 23 24 OP38 OP38 13(4) 13(4) (Previous timescale of 01/08/05 not met). The Registered Persons must ensure that all care staff receive supervision at least six times annually with full records kept. (pro-rata for part-time staff). (Previous timescale of 01/07/05 not met). The Registered Person must ensure that all policies and Procedures are in place in the home and are regularly updated. (Previous timescale of 01/09/05 not met). The Registered Person must ensure that First Aid boxes are checked on a monthly basis with full records kept. (Previous timescale of 01/06/05 not met). The Registered Person must ensure that the water system in place at the home meets health and safety requirements. It should store water at 60 degrees centigrade, distribute it at 50 degrees centigrade and then it should be thermostatically lowered to 43 degrees centigrade at the outlets. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that the tap water in the kitchen is of sufficient temperature to prevent infection and that it meets Health and Safety Requirements. (Previous timescale of 01/07/05 not met). The Registered Person must ensure that an up-to-date gas safety certificate is obtained. The Registered Person must ensure that a Five Yearly electrical installation check certificate is available for inspection at the home. DS0000017363.V264867.R01.S.doc 01/02/06 01/03/06 01/12/05 01/02/06 01/01/06 01/12/05 01/01/06 Deer Lodge Version 5.0 Page 29 25 OP38 13(4) The Registered Person must ensure that all decanted/opened items of food are clearly labelled with the date of opening. 01/12/05 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 OP1 OP9 OP31 Good Practice Recommendations Consideration should be given to presenting the Service User Guide in a more user friendly format using large print and pictures. It is recommended that the quantity of medication carried over each month be recorded accurately. Consideration should be given to having access to E-mail services or internet. This will enable them to access information quickly and efficiently and allow for good communication with other services and health and social care bodies. Consideration should be given to ensuring regular fully recorded staff meetings take place. Consideration should be given to the purchase of a dishwasher to ensure crockery is washed at suitable temperatures. 4 5 OP36 OP38 Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Deer Lodge DS0000017363.V264867.R01.S.doc Version 5.0 Page 31 - 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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