Inspection on 28/02/06 for Denron Lodge

This inspection was carried out on 28th February 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denron Lodge 15/05/07

Denron Lodge 01/09/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Denron Lodge 120 Dowsett Road Tottenham London N17 9DH Lead Inspector Karen Malcolm Unannounced Inspection 28th February 2006 13.45 Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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 Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Denron Lodge Address 120 Dowsett Road Tottenham London N17 9DH 020 8216 9875 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) Wimbourne House Limited Edem Fiawoo Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection Brief Description of the Service: Denron Lodge is a part of Wimbourne Houses Ltd an organisation who supports service users with mental health disorder in the community. The first home was registered in 1996. Denron Lodge was registered in August 2005 and is able to accommodate up to five service users between ages of 18-65 years with mental health disorder. Denron Lodge is a five-bedded house situated in North Tottenham in London. All bedrooms have en-suite facilities and are appropriately sized. The communal areas include a lounge/activity area, kitchen/diner, and a separate bathroom on the first floor, a computer room that is accessed by the front door and a large garden accessible through the kitchen/diner. Denron Lodge is near to Bruce Grove shopping area and Bruce Grove main line station, which runs regular trains to Liverpool Street Station. There are also other good transport links. The other areas of interest close to the home are Bruce Castle Park museum, Tottenham Green sport centre and Tottenham Hotspur football ground. The aim and objective of the home is to ensure an efficient level of work with the service users. All attempts have been made to ensure an effective community rehabilitation of the service users. Service users are encouraged to pursue their interests in relation to social activities, education and hobbies. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Denron Lodge’s first inspection with The Commission for Social Care Inspection (CSCI) since being registered. The duration of the inspection was completed approximately over four hours. The manager and the registered provider assisted the inspector throughout the inspection. In the home were four service users, whom during the inspection entered in and out of the home independently. Another member of staff was also on duty, but at the time of the inspection they were supporting one of the service users on an appointment. Both the service user and staff returned back to the home later. It was evident that all the service users are very able and access the community independently. This inspection involved sampling a number of care plans and records pertaining to service users care a tour of the building which involved the inspector completing a fire risk assessment, observing staff, and speaking to service users, this was found to be friendly and positive. Feedback was given to the manager at the end of the inspection. The inspector found the manager and the rest of the staff very open and helpful throughout the inspection and would like to thank them for their time and patience. What the service does well: What has improved since the last inspection? What they could do better: This inspection has identified nineteen areas of improvement and five recommendations. It is therefore required that the registered person submits an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters. The action plan must describe how the registered person plans to complete the following: • Ensuring that all service users healthcare needs or any changes are followed up and recorded on file • The registered person must notify the Commission in writing regarding the specific service user who has a pressure area Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 6 • • • • • • • • • • • • • • • Dosette trays must have recorded on the back of the tray all the medication prescribed for each individual service user All staff must undertake medication training, evidence of this must be kept on file Records of the room temperature, where the medication is stored must be kept Guidance notes must be on file with regards to how service users are supported in the community Cultural dietary needs of each service user must be discussed and evidence kept on file An annual check of the gas boiler must be completed and evidence kept on file Control of Substance Hazardous to Health (COSHH) file must be maintained Hot water outlets must be tested regularly and a record kept Annual environmental and fire risk assessment is to be completed and reviewed accordingly Quality Assurance questionnaires regarding service users and stakeholders views are to be completed annually and reviewed accordingly The staffing levels in the home must be reviewed Adult Protection policy and procedures, including the local authority’s procedures must be in place Service users personal and domestic hygiene must be satisfactorily maintained A facsimile machine must be brought for the home on each shift there must be at least one qualified first aider. The recommendations highlighted in this report are seen as good practice. 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. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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 Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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 Prospective service users’ are confident that their needs will be fully met by the home, because prior to moving in a comprehensive assessment of needs is completed. EVIDENCE: Denron Lodge opened in August 2005 with one service user. Since then, four other service users have moved into Denron Lodge, the last service user to move in was in December 2005. The home at present is now fully occupied. The home supports five men with mental health disorder. Islington Social Services and Tower Hamlets Social Services have each placed two service users in the home, and Newham Social Service has placed one service user. The home is situated in the Borough of Haringey in North Tottenham. Service users care plans are in place. On examining the files it was evident that the home has taken the correct steps to ensure that service users’ needs are met by the home. Prior to each individual service user, moving into the home the placing authority submitted a comprehensive assessment of needs. It was evident that these assessments have been carried forward into each service users care plan. The admission forms in place were dated and signed by both parties. Contacts of care were seen and were on file. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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&9 There is a clear, consistent care planning system in place providing care staff with the information they need to satisfactorily meet service users needs. However, as the documents are prepared and produced by the manager, it is not evident whether care staff are fully aware of each individual service users’ needs. EVIDENCE: The information recorded on each service users care plan addresses individual’s, admission needs, illicit substances/alcohol abuse, physical condition, finance, occupation/education needs, management of identified risks, legal issues and missing person/unexplained absences. On examining the service users files, it was clear that each file has a comprehensive risk assessment in place, addressing, identifying needs and behaviour management guidelines for care staff to follow. This was impressive and commended by the inspector, as the information presented ensures that each service users individual needs are addressed, managed and monitored appropriately by the home. The inspector observed one of the care staff on duty interacting with one of the service users. This was found to be positive and appropriate. The home Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 10 ensures that individuals’ rights are respected and their independence is supported and monitored appropriately when needed. From the discussion with the manager, it was evident that the manager is the key worker for all the service users. The manager’s roles and responsibilities were also discussed at length with the inspector. It was the opinion of the inspector that the manager’s roles and responsibilities within the team seemed a bit blurred and not clearly defined, due to the number of tasks the manager has to deal with on a day-to-day basis. Progress reports (daily logs) and monthly summaries were found to be in good order good. Monthly summaries addressed each service users’ support and care needs within that particular month. These were presented well and were very informative. However, it was evident that the manager had completed each monthly summary. Care plans were kept securely in a locked cabinet. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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): 11, 13, 15 & 17 Service users are able to access the local community independently, engaging in social, recreational and educational activities. Service users maintain contact with family and friends and they are offered a healthy balanced diet daily. However, their cultural dietary needs are to be addressed by the home. EVIDENCE: The service users living at Denron Lodge are all independent and able to access the local community without needing support. However, care staff from time to time do support those service users who may need additional support with healthcare appointments. A requirement under ‘Personal and Healthcare Support’ has been made in this report regarding guidelines for care staff, when supporting those service users whom may need additional support. The service users’ notice board is situated in the hallway near the front door. A timetable of activities provided by the organisation was in place. The home provides different support or unsupported activities weekly. The organisation employs an activity co-ordinator, whom visits each home at least once a week. On the day of the inspection the activity co-ordinator arrived at the home and Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 12 briefed the inspector on his role and responsibilities. The activity co-ordinator was also asked about the types of activities provided, his experiences and how long he had been in post. The feedback given was that activity co-ordinator has been in post for a number of years. The activity provided varies from week to week and today’s activity was a cinema trip. One service user spoken to informed the inspector that the activities preferred was those activities that are meaningful and have a sense of purpose, and just riding on the bus. This was fed back to the manager and it was evident that this particular service user activity needs was a priority. Next of Kin details for each service users are recorded on their care plan. The menu plan showed that the meals prepared in the home were nutritious and balanced. Each week service users are given a request sheet regarding their choice weekly and this is added to the shopping list. A number of service users are from several ethnic cultural backgrounds. However, the menu plan in place did not indicate individuals’ cultural diets. This was discussed with the manager and it was advised that those service users whose cultural needs are not being met are to be discussed with each individual, on how this could be met. Evidence of this disucssion is to be recorded and reviewed accordingly. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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 & 20 Service users healthcare needs are met by the home. However, this is not always documented to ensure that service users health is being monitored appropriately. Service users are protected by the home’s policies and procedures for dealing with medicines. However, this is not always consistently monitored, and therefore service users could be potentially placed at risk from harm. EVIDENCE: Service user’s healthcare needs are addressed by the home. Each service user has a named GP and consultant on file. Upon arrival the manager informed the inspector that one of the care staff was supporting one of the service users at the clinic. Apparently this specific service user has an ulcerated leg, which the service user had prior to being admitted into the home. The manager also informed the inspector that the service user has the leg dressed twice a week by the local district nurse. It was advised by the inspector that according to the Commission Regulation 37 guidance it advises that the registered person is required to notify the Commission if any service user is admitted into the home with a pressure area and a record maintained on file. After the service user returned from the clinic the inspector was able to speak with the service user and asked whether or not Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 14 the treatment received was helping the healing process. The service user informed the inspector that the ulcer was much better. The specific service user’s care plan was examined. It was evident that there were no healthcare records on file regarding the service users weekly treatments. It was advised that any treatment, appointment or change to an individual’s healthcare needs must be recorded separately on each service user’s file with any action taken or any follow-up treatment needed. It was also evident that the specific service user, menu plan, request sheets did not include fresh fruits or vegetables, which would help in the healing process for the individual. This was discussed with the service user whom stated that he was not partial to fruit and vegetable, although he was aware that it is good for him. The inspector spoke to the member of staff who accompanied the specific service user to the clinic. The staff member was asked, if she was aware of the specific service user health and support needs and how this was maintained. It was evident from the discussion that the staff member was not fully aware of the individual’s needs. This was concerning, as the specific service user, although had some health issues, also could be at times challenging. It was advised that the manager must ensure all care staff familiarize themselves with each service user care plan and all care staff must undertake challenging behaviour training with regards to meeting individual’s needs appropriately within the home. Guidelines are to be put in place on how individuals are supported by staff on different activities in the community and who to contact if an incident occurs. The medication policy and procedures were examined. Four of the five service users have prescribed medication kept in the home. All service users have monthly depot injections administered by their allocated Clinical Psychiatric Nurse (CPN); records of this are maintained on file. The manager informed the inspector that a nominated person within the organisation collects all the monthly prescriptions and delivers the monthly supplies to the home. The pharmacist is not local to the home and any mistakes or issues with the medication supplied cannot always be rectified immediately. The manager is the only person whom administers the medication to the service users daily. It was not evident whether or not care staff have undertaken appropriate medication training. This was discussed with the manager and it was advised that if any mistakes or discrepancies are made how this is then managed, as the manager is the sole responsible person for the medication being administered. The medication is supplied in weekly dosette boxes for each user. However, there is no information recorded on the back of each dosette box. This was addressed with the manager at the time of the inspection. Medication Administration Records (MAR) charts were also examined and found to be in good order. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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 & 23 The home has a comprehensive complaints and abuse policy. However, the abuse policy does not relate fully to local adult protection procedures and therefore service users are not fully protected by the home. EVIDENCE: The home has a complaint policy in place. There were no records of any complaints made since the home has opened. Adult protection was discussed with the manager. It was evident that the manager is aware of the sign of abuse; however, he is not familiar with the local procedures with regards to abuse. It was advised that the home’s policy and procedure must reflect the local authority’s procedures and the manager must be aware of this. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 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, 27 & 30 The overall fabric of the home is good and provides the service users with a comfortable dwelling that they can call ‘home’. EVIDENCE: The home consists of five single bedrooms with en-suite shower facilities. One bedroom is situated on the first floor, three bedrooms on the first floor and one bedroom on the top floor. There is a bathroom on the first floor and a separate toilet on the ground floor. The communal areas include a lounge/activity area, kitchen/dining area, a garden and computer room, which is accessed via the front door. The manager’s office is situated on the first floor. The main communal areas were found to be reasonably clean on the day of the inspection. Individual bedrooms shown were not as clean. The manager stated that it was individual’s choices to maintain their bedroom as they wish, but he does encourage them on a daily basis to ensure that they are clean and safe at all times. During the tour of the home one service user refused the inspector to view their bedroom due to the untidiness. This was discussed with the individual. The manager also informed the inspector, that part of the care staff role is to clean and maintain the home. It was recommended that the registered person consider employing a cleaner to ensure that individual’s bedrooms are cleaned regularly. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 17 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): 33 & 34 Service users’ benefit from a supportive staffing team. However, the staffing levels within the home need reviewing to ensure that the service users’ are being appropriately managed and supported on a daily basis. EVIDENCE: While the rota was seen, there was no rota in place from the 1st March 2006 onwards. Three full and six part time care staff support the five service users. It was evident that the manager is rota’d on each day and the staffing levels are not appropriate for the home. It was advised this must be reviewed. The rota in place only covered, up to 28th February, beyond this there was no indication of who was working. The manager stated that the rota is completed centrally on a rota basis, as a number of carers work across the different homes. It was advised that the manager should be responsible for the rota to ensure the home is covered appropriately on a daily basis and that staff are working within the ‘Working Time Directives’. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 18 It was evident that the manager’s shift patterns each day is 8 to 9 pm and he is one of the two carers rota’d on shift. The manager stated that whilst on shift he has to complete all supervisions, any meetings and support the other staff member on duty. It was observed by the inspector that this was not ideal. As well as the manager conducting an inspection, he was part of the shift, and responsible for answering the telephone, liaising with staff regarding the service users and advising the service users. It was difficult for the manager to engage fully with the inspection as well as being part of the shift. The job description of the manager was seen. It was evident that the manager’s job description in place defines the manager’s roles more as a carer than of a registered manager. This was discussed with the manager and the provider on the day. It is recommended that the registered provider ensure that at least two days per week the registered manager is supernumerary. This is to ensure that the manager can effectively fulfil his management responsibilities. In discussion with the one of the carers, it was evident that the staff member is supervised; however, areas of induction and key worker roles are not discussed. The carer did state that they are at undertaking an NVQ course soon. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 There is evidence that overall the manager provides good clear leadership. The system of service users being consulted have not been put into play, therefore service users are not confident that their views are being sought or acted upon. The registered person, has also failed to ensure all parts of the home to which service users have access to are free from potential hazards to their safety. EVIDENCE: The manager has been in post since the home opened in August 2005. It was observed that service users and staff respect the manager. However, it was also apparent that although the manager is managing the home, his roles and responsibilities and were not always. This has been addressed under ‘Staffing.’ Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 20 At least four of the service users have now lived at the home for over six months. Therefore it is required that the registered manager ensures that the service users are confident that their views of living in the home are being reviewed. It was advised that the manager must seek the views of the service users, relatives and friends and any stakeholder, for example their social worker regarding the service users care and support. This must be reviewed and completed at least once annually. The provider submits regular monthly Regulation 26 reports to the Commission. Upon reading these documents it is evident that all the areas required under Regulation 26 are covered in each document, however, it was not evident whether the manager undertakes any actions made, as these are not addressed in the following months report. It was recommended that all action/s should be addressed clearly in each report and if there are any ongoing issues these that must be highlighted clearly. All health and safety checks were in good order, except the gas certificate. The manager stated that this will completed the following week by British Gas. It is also required that the temperature of hot water from all outlets in the home (other than the kitchen sink) must be tested at least once monthly, with any necessary action taken to ensure that it does not exceed 43°C. The bath must be fitted with an appropriate tamper proof, pre set, fail safe, thermostatic mixer device, so that hot water cannot exceed a safe temperature. Part of the inspection process included the inspector completing a fire risk assessment whilst touring the building. The purpose of the fire risk assessment was discussed with the manager. It was identified during the tour that all hallways and corridors were free from obstruction, doors were in good order fire drill and checks were completed. The area of concern related to the fire panel; it did not indicate what each zone represents each area within the home. No environmental and fire risk assessment were in place. Fire drill evacuations were recorded; however, it was not evident from the records of who took part in each of the evacuations completed. It was recommended that the fire evacuation drills take place at least four times a year and that the records should include the names of the service users and staff present. The records will give a clear account of which service users and staff members have taken part in any of the four fire evacuation drills that have been completed over the year. Those staff or service users who have not completed a fire drill can then be earmarked for the forthcoming planned fire drills. It is also good practise to complete at least one of the evacuations during the night. It was evident that the home did not have in place a facsimile machine or a computer. It was also evident that there was no qualified first aider indicated on the rota. This was raised with the manager at the time. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 21 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 1 X X 2 X Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 22 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA18 Regulation 17 Sch 3(m) Requirement The registered person must ensure all healthcare needs or any changes must be followed up and evidence of this must be recorded and monitored accordingly. The registered person must notify the Commission without delay regarding the specific service user who has a pressure area. The registered person must record on the specific service user’s care plan evidence that support and advice regarding the specific service user’s diet and health have been given and how this is to be supported by the home. The registered person must ensure that clearly written on the back of each dosette tray supplied by the pharmacist is the name of the service user’s, name/s of medication supplied, the dosage/strength and times of the day the medication is administered. The registered person must ensure all care staff undertaken DS0000062333.V279432.R01.S.doc Timescale for action 30/04/06 2. YA18 37 30/04/06 3. YA18 13(1b) & 17 Sch3m 30/04/06 4. YA20 13(2) 30/04/06 5. YA20 18(1)(c)(i) 30/04/06 Denron Lodge Version 5.1 Page 23 6. YA20 13(2) 7. YA20 13(2) 8. YA18 17(1)(a) Sch 3.3m 9. YA17 16(2)(i) 10. YA42 13(4) a comprehensive medication training. Evidence of this must be available for inspection. The registered person must ensure that the temperature of the areas where medication is stored is monitored, recorded daily to demonstrate that the temperature is maintained at 25oC or below. The refrigerator temperature must also be monitored and recorded daily to ensure it is maintained between 2-8oC. The registered person must ensure that where, if possible, service user’s consent to take medication is recorded in their individual care plan. If they are unable to give informed consent care staff must indicate this in their care plan. The registered person must have recorded in each service user’s care plan guidelines for care staff when supporting service users on any activity in the community and if any incident occurs what are the emergency contact details if out on their own. Therefore guidelines must be in place for the specific service user who is supported twice weekly to the clinic regarding a dressing. The registered person must ensure that those service users whose cultural needs are not being met by the home are discussed with the individual including how they would like this met. Evidence of this disucssion is to be recorded and reviewed accordingly. The registered person must ensure that the gas boiler is serviced annually. A copy of the works completed must be kept DS0000062333.V279432.R01.S.doc 16/04/06 30/04/06 30/04/06 16/04/06 30/04/06 Denron Lodge Version 5.1 Page 24 on file. 11. YA42 13(4)(a)(c) The registered person must have in place a Control of Substance Hazardous to Health (COSHH) file of the entire chemicals being used in the home. This must be reviewed accordingly if any changes occur. 13(4)(a)(c) The registered person must ensure that the temperature of hot water from all outlets in the home (other than the kitchen sink) are tested at least fortnightly, with any necessary action taken to ensure that it does not exceed 43°C. The bath must be fitted with an appropriate tamper proof, pre set, fail safe, thermostatic mixer device, so that hot water cannot exceed a safe temperature. The registered person must have in place on the fire alarm panel a zone map that indicates clearly what area of the home each zone represents. The registered person must complete an environmental risk assessment that includes a fire risk assessment. This is to be reivewed at least once annually. 14. YA39 24 The registered person must establish and maintain a system for reviewing at appropriate intervals the quality of care being provided by the home. Evidence of this must be kept on file. The registered person must review the staffing levels. The registered person must devise an adult protection DS0000062333.V279432.R01.S.doc 30/05/06 12. YA42 30/05/06 13. YA42 13(4) 30/04/06 30/05/06 15. 16. YA33 YA23 18 13(6) 30/05/06 30/04/06 Denron Lodge Version 5.1 Page 25 procedure for the home, which informs staff on what to do if they have a suspicion or allegation of abuse of a service user. The procedure must be in line with the local authority’s procedures. The registered person must obtain a copy of the local authority’s procedures. 17. YA30 The registered person must ensure that service users’ personal and domestic hygiene are appropriately maintained. 16(2)(a)(ii) The registered person must provide the home with appropriate facilities for communication by facsimile transmissions. 13(4)(c) The registered person must have on each shift at least one qualified first aider. 23(2)(d) 16/04/06 18. YA42 30/04/06 19. YA42 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA33 Good Practice Recommendations The registered person should try and obtain a pharmacist whom is local to the home. It is recommended that the registered provider ensure that at least two days per week the registered manager is supernumerary. This is to ensure that the manager can more effectively fulfil his management responsibilities. The registered person should ensure action made at the previous Regulation 26 visit are addressed in the following report The registered person should record the names of all service users and staff who were presernt when a fire drill evacuation practice has taken place. Therefore the registered person will have a clear account of which DS0000062333.V279432.R01.S.doc Version 5.1 Page 26 3. 4. YA37 YA42 Denron Lodge 5. YA30 member of staff over the year have been a part of the fire drill evacution. It is also good practice to complete at least one of the fire evacution drills during the early evening. It is reccomended that the registered person employs a cleaner to assist the staff in maintaining the home. Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Denron Lodge DS0000062333.V279432.R01.S.doc Version 5.1 Page 28 - 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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