CARE HOME ADULTS 18-65
Derby Lodge 2a Blackbull Lane Fulwood Preston Lancashire PR2 3PU Lead Inspector
Mrs Marie Cordingley Unannounced Inspection 7th November 2007 10:00 Derby Lodge DS0000009861.V350236.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 Derby Lodge DS0000009861.V350236.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. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Derby Lodge Address 2a Blackbull Lane Fulwood Preston Lancashire PR2 3PU 01772 718811 01772 716581 derby.lodge@btinternet.com 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) Derby Lodge (Preston) Limited Mrs June Nicholson Care Home 23 Category(ies) of Physical disability (20), Physical disability over registration, with number 65 years of age (3) of places Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. This house may accommodate 20 physically disabled adults who may also have a learning disability. 26th March 2007 Date of last inspection Brief Description of the Service: Derby Lodge is situated in Fulwood, in easy reach of Preston City Centre and all the amenities that the City has to offer. There are also many services and facilities close by. These include banks, churches, GP surgeries and Preston College. The home provides accommodation for 23 adults who have a physical disability and who may, also have, a learning disability. The home is arranged over two floors and is fully accessible to residents. A passenger lift operates between floors. Much has been done to minimise the institutional appearance of Derby Lodge, the premises are well maintained and there is an ongoing programme of decoration and renewal of the physical environment. The home offers a mixture of accommodation including single rooms, some of which are en suite and flatlets that include a sitting room and kitchen. There is a large car park at the front of the premises and extensive gardens to the rear. During the summer months various recreational activities take place in the garden area. The fees at the home vary between £422 and £679 depending on the individual resident’s need. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of Derby Lodge included a site visit to the home which was completed over two days. This visit was unannounced therefore the manager, staff and residents did not know it was going to take place until we arrived. During our visit we spent time with residents talking to them about life at the home. We also spent time observing the day-to-day routines of the home and care staff, as they provided support. We held discussions with the registered manager and members of care staff and viewed a selection of documents such as residents’ care plans and staff personnel files. We also carried out a case tracking exercise which involved us looking closely at the care provided to selected residents from the point of their admission to the home. A tour of the home was undertaken and included bedrooms, lounges, dining areas, toilets and bathrooms. This was to assess whether the home provided a safe, comfortable and homely environment for residents. Prior to our visit we asked the manager to complete a very comprehensive questionnaire. This gave us a great deal of information about procedures within the home and also told us about the people who live and work there. We wrote to a selection of residents, their relatives and visiting health care professionals before we visited the home. We asked them to complete written surveys which asked their opinions about the standards of care at Derby Lodge. A number of completed surveys were returned to us. What the service does well:
We received a good response to our satisfaction survey and 14 people wrote to us to give us their views. In general the responses were very positive and a number of people made additional comments expressing their satisfaction. These included; ‘I am well cared for.’
Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 6 ‘I am given my own choices and my family visit very regular.’ ‘I can choose when I get up and go to bed.’ ‘I am allowed my own time, space and privacy.’ ‘I feel very welcome with staff who care.’ ‘The service does everything well. The residents are well looked after, they go out a lot which they enjoy.’ We talked to a number of residents during our visits who told us that they were very satisfied with their support. One resident told us ‘‘This is the happiest I have ever been.’’ Another person said ‘’The staff are all very kind, they are kind to everyone.’’ We observed a number of residents during our visit who were unable to talk to us, but appeared very happy and relaxed in their surroundings. We watched the residents spending time with carers, which they seemed to enjoy very much. The interaction between staff and residents appeared natural and very pleasant. People who are thinking about moving to the home are given a lot of information to help them make their decision, In addition people are encouraged to visit the home, have a meal and spend time getting to know the residents and staff. The home has a very good approach to assessing the needs of residents and planning their care. We viewed a number of care plans and found them to be of a very good standard. These documents were very detailed covering all aspects of residents’ daily care needs whilst taking into account their personal preferences. For example, one person’s plan said that he would like to sleep with his bedroom light on and keep his radio on all night. Another resident’s plan detailed the cosmetics and facial products she liked to use on a daily basis. At Derby Lodge residents are encouraged to make choices and have a say in how they spend their time. There is an emphasis on promoting independence when planning people’s care and residents are supported to access independent advocates regularly. In addition, some of the people who live at the home are part of a local community advocacy group. Residents have the opportunity to take part in a variety of activities both inside and outside the home. Each person’s individual plan describes their hobbies and the pastimes they enjoy. We found that people regularly took part in various activities including pub visits, shopping trips and home based activities such as craft sessions and discos. The manager and staff at the home have a positive approach to risk taking and have an understanding that well managed risk taking is positive and often necessary for personal growth. As such, there are processes in place to ensure that risk assessments are carried out where appropriate. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 7 There is a comprehensive health care plan in place for each resident. Daily care records demonstrate that residents’ health and well being is closely monitored and that they are supported to access medical advice whenever they need it. Each person’s individual plan contains in depth information about their communication. For residents who do not communicate verbally, there is guidance in the ways they express themselves. This information assists staff greatly in getting to know residents and understanding their needs. There are a number of ways in which the manager ensures that residents are involved in the running of the home and have the opportunity to express their views. For example, regular residents’ meetings take place where a number of items are discussed such as menus and activities. During our visit we saw evidence that the manager had made a number of changes as a result of listening to residents. What has improved since the last inspection? What they could do better: Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 8 All prospective residents are provided with a very useful document called a Service User Guide which gives information about daily life at the home such as the activities available and the people who work there. Currently the document is only provided in a written format. We recommended that the manager consider making this guide available in other formats such as pictorial or as a video. We also recommended that the manager consider making the complaints procedure available in alternative formats. When viewing medication administration records, we found some errors in relation to a course of medicine that had been prescribed for one resident. We advised the manager to ensure that regular checks are carried out of medicines and administration records to ensure no similar errors occur in the future. We also noted that there was little information on medication records about PRN medicines (medicines prescribed as and when required). We advised the manager to ensure that enough information is available to help staff decide when PRN medicines should be administered. The home has a general communication book and in viewing this we noted that there was some personal information about residents recorded in it. We advised the manager to ensure that this didn’t happen in the future. The communication book should only be used for staff to refer the reader to the relevant resident’s individual file. Currently, 10 out of 22 staff members hold National Vocational Qualifications in care at level 2 or above. This means that the home are falling slightly short of the national minimum standard of 50 . However measures are being taken to address this shortfall and several carers at the home are enrolled on the course. Some residents need help to manage their behaviour at times. In situations like this carers need to be aware of what might cause a person to become upset and what strategies they should use to help them become calm. There should be detailed guidance in the care plans of people who have these complex needs to help staff deal with challenging situations consistently and confidently. In addition, we recommend that staff are provide with training in positive behaviour support. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 9 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. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 10 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 Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 11 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): 1&2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People considering a move to this home are given a good deal of information so that they can make an informed choice about whether they want to live there. Staff receive comprehensive information about new residents so that they can plan care which meets their individual needs and preferences. EVIDENCE: A Service User Guide is provided to any person considering a move to the home. This is a useful document which gives information about daily life at the home such as activities and mealtimes. Currently the Service User Guide is only produced in a written format. We recommend that consideration be given to providing this guide in a variety of formats such as audio or pictorial. One resident we spoke with described how she had been enabled to visit the home on a number of occasions before moving in. She told us that she had been invited for some meals and to spend time getting to know residents and staff, and that she found this very helpful.
Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 12 Prior to any new residents moving into the home, a pre-admission assessment is carried out. This helps the manager to understand their personal care needs and be sure that these can be met within the home. We viewed a number of assessments and found them to be very comprehensive. Assessments covered all areas of daily living and the information included in them was addressed in each resident’s individual plan. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 13 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): 6, 7 8 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a person centred approach to care planning which means that care is provided in line with people’s individual needs and preferences. Residents are encouraged to make decisions about their lives. EVIDENCE: As part of the case tracking exercise we examined a number of residents’ individual plans. The plans we viewed were of a very good standard, covering all areas of daily life and having a strong emphasis on people’s individual needs and preferences. Preferred daily routines were covered in great detail and included information about all areas of daily living such as personal care, diet and mobility. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 14 The level of information included in people’s individual plans was of sufficient detail to help staff provide person centred care, which is tailored to each individual. When we talked to residents and viewed their care plans we found that people are supported to make decisions. One resident we spoke to said, ‘’If I want to do something new they don’t stop me, they encourage me and make sure I have the help I need.’’ This was also demonstrated in discussion with the manager and staff. There is a positive approach to risk taking at the home and an understanding that well managed risk taking is positive and often necessary for personal growth. As such, there are processes in place to ensure that risk assessments are carried out where appropriate and any necessary measures to keep people safe are taken. We were able to determine that people have access to independent advocates when they need them. Advocates are people who are specially trained to support people in expressing their views and opinions. Some residents at the home are part of a local advocacy group which meets on a regular basis. There are a number of ways in which the manager ensures that residents are involved in the running of the home and have the opportunity to express their views. For example, regular residents’ meetings take place where a number of items are discussed such as menus and activities. During our visit we saw evidence that the manager had made a number of changes as a result of listening to residents. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 15 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at this home are provided with regular opportunities to take part in fulfilling and enjoyable activities. Residents are supported to maintain contact with their family and friends. EVIDENCE: We talked with residents and staff about activities. People told us that there were plenty of activities available and that they could choose whether or not they wanted to be involved in them. All the individual plans we viewed contained detailed information about people’s preferences in relation to hobbies and activities. We were able to confirm that people were offered the chance to take part in things they
Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 16 enjoyed. For instance, on the day of our visit, two residents went to a car boot sale, an activity that they had personally requested. Records showed that activities such as football matches, pub visits and shopping trips are regularly available. Within the home residents can take part in activities such as craft sessions or games of pool. The home also has regular visiting entertainers such as musicians. We viewed a number of residents’ individual files and they all detailed the help that they needed in maintaining contact with friends and family. In addition, all the residents we spoke to told us that they could receive visitors at any time and see them in private if they wanted to. We also spoke to some relatives of a resident who told us they were always made welcome and offered snacks and drinks. Everyone we spoke to was very complimentary about the quality and variety of food provided. In addition, it was confirmed by everyone that there were plenty of choices available on a daily basis. One resident told us ‘’there are always two choices but if you don’t feel like either one, the cook will make you something else.’’ Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 17 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): 18, 19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ health and well being is closely monitored by staff. Support is provided to enable residents to access health care when they need it. The manager should carry out regular checks of medicines and medication records to ensure that residents’ medication is being carefully managed. EVIDENCE: The individual plans we viewed were of a very good standard and were clearly developed in line with people’s own needs and wishes. Each resident’s individual plan contains very detailed information about their health care needs and where appropriate there are very thorough plans in place to maintain people’s good health, for example in relation to pressure care.
Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 18 Daily care records demonstrate that people are supported to access community health care whenever they need it. This was also confirmed by a visiting district nurse we spoke with during our visit. She told us that staff at the home were very good at picking up and reporting any concerns about a resident. In addition, she said that carers always included any advice she gave into people’s individual plans. We were able to confirm that all carers who handle residents’ medicines have received training in this area, and the carers we spoke to had a good understanding of the procedures they should follow to ensure that residents’ medicines are handle safely. However, when viewing medication paperwork we found some errors on one resident’s administration record. We were able to establish that the errors were in relation to paperwork and hadn’t directly affected the resident concerned. We advised the manager to ensure that regular checks are carried out of medicines and administration records to ensure no similar errors occur in the future. We also noted that there was little information on medication records about PRN medicines (medicines prescribed as and when required). We advised the manager to ensure that enough information is available to help staff decide when PRN medicine should be administered. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 19 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): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at this home are encouraged to express their concerns. There are systems in place to protect people from abuse. EVIDENCE: The home has a complaints procedure which explains to people how to raise a concern and what will happen if they do. The complaints procedure is only provided in a written format at the moment. We advised the manager to consider making the complaints procedure available in DVD or video format for the benefit of people who do not read. A record of complaints is kept within the home which also details any action taken in relation to the complaint and subsequent outcome. We viewed the record and found that the home had received 4 complaints since their last inspection. These had all been dealt with appropriately and within expected timescales. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 20 There are written procedures in place which give staff guidance on the action they should take if they become aware or suspect that an incident of abuse has occurred. New staff members are made aware of these in their staff handbook which is provided at the start of their employment. In addition, whistleblowing is covered in their induction which is in line with Skills for Care standards. Some residents need help in managing their money and we were able to confirm that careful records are made of any assistance residents have received in this area. We also viewed records of charges made to residents in respect of transport they had been provided. These were extremely detailed and completed very carefully to ensure that no one is charged unfairly. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 21 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): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents at Derby Lodge are provided with a good standard of accommodation. EVIDENCE: Derby Lodge is a spacious home with all accommodation being offered on a single room basis. The majority of bedrooms have en suite facilities. Those that don’t are located close to a toilet. There are also a number of flats within the home. These include a lounge, bedroom and small kitchenette. One resident who lives in one of the flats said ‘’I like having my own space here, it’s like having my own front door.’’ We carried out a tour of the home and found all areas to be clean, warm and comfortable. We noticed that people’s bedrooms were all very different and personal to the individual resident. The manager explained that when any new
Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 22 resident moves into the home they are given a blank canvas and encouraged to choose colours and personalise their room with pictures and ornaments. There is a large wide screen television in the main dining room, a pool table and a computer for the use of residents. Many residents have Sky television and some residents have their own telephones. There is a variety of specialist equipment within the home to assist people including hoists to help people move. Some residents have specialist equipment within their rooms which helps them control their environment for example, to put on their lights, stereos, television and DVD players. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 23 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): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a thorough recruitment procedure in place to ensure that only suitable people are recruited to work with residents. EVIDENCE: We viewed a selection of staff files which contained the necessary information such as original application forms and full employment histories. We also noted that the necessary background checks had been carried out for all new staff members including references and Criminal Record Bureau checks. We viewed training records that confirmed all new members of staff are provided with induction training. This training has recently been improved and brought into line with Skills for Care standards. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 24 Ongoing training is provided for all staff members including the mandatory courses such as moving and handling. At the time of our visit the core training provided to seniors had been updated to include more courses to help them develop their supervisory skills. Currently, 10 out of 22 carers hold National Vocational Qualifications in care at level 2 or above This means the home are falling slightly short of the national target of 50 . However, there are a number of carers currently doing the course and the home should meet this standard in the near future. We received a number of completed survey forms from staff members and the responses were very positive. Staff told us that they enjoyed working at the home and that they felt very well supported. A number of staff members commented that the manager of the home was very approachable. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 25 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): 37, 39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This is a well managed service which is run in the best interest of residents. EVIDENCE: Throughout our visit a number of residents and staff members commented that the manager of the home was very approachable and always available to discuss any concerns. The manager spends time with residents on a daily basis for example, when eating meals and told us that she thought it was very important that she was constantly available should anyone want to speak to her. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 26 Prior to our visit we asked the manager to complete a very detailed questionnaire which we received back in timely fashion. It was apparent that a great deal of thought had gone into the completion of this document and the manager had identified a number of areas for development. There are a number of measures in place to assist the manager in monitoring all areas of the service. Such measures include resident satisfaction surveys and meetings. During our visit we saw evidence that the manager had made a number of changes as a result of listening to residents. There is a health and safety officer employed at the home who oversees all health and safety procedures and provides health and safety training to staff at the start of their employment. We viewed a selection of health and safety records including records of safety checks on equipment within the home which were found to be in good order. Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 27 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 x 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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. 4. 5. 6. 7. 8. Refer to Standard YA1 YA10 YA18 YA18 YA19 YA20 YA20 YA22 Good Practice Recommendations The Service User Guide should be made available in a variety of formats. Personal information should only be written in residents’ individual files. A positive behaviour plan should be developed for each resident who would benefit from one. Communication passports should be developed for all residents who wish to have one. A hospital information plan should be developed for all residents. The manager should carry out regular audits of medicines and medicine administration records. More information should be included on residents’ medication records regarding any PRN medication they are prescribed. Consideration should be given to making the complaints procedure available in a variety of formats.
DS0000009861.V350236.R01.S.doc Version 5.2 Page 29 Derby Lodge 9. 10. 11. 12. YA30 YA32 YA32 YA24 The home should refer to the Department of Health Guidance ‘Essential Steps’ to assess their own infection control procedures. Staff should be provided with training in positive behaviour management. 50 of staff should hold National Vocational Qualifications in care at level 2 or above All doorways under 800mm that are used by residents should be widened (if physically possible). Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Derby Lodge DS0000009861.V350236.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
