Inspection on 17/07/06 for Derwent Lodge

This inspection was carried out on 17th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Derwent Lodge 19/07/07

Derwent Lodge 10/11/05

Derwent Lodge 01/06/05

Derwent Lodge 06/09/04

Derwent Lodge 16/04/04

Derwent Lodge 30/10/02

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Derwent Lodge Derwent Lodge 11 Beaufort Street Chaddesden Derby DE21 6AX Lead Inspector Jo Wright Key Unannounced Inspection 17th July 2006 09:45 Derwent Lodge DS0000031165.V304458.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 Derwent Lodge DS0000031165.V304458.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. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent Lodge Address Derwent Lodge 11 Beaufort Street Chaddesden Derby DE21 6AX 01332 347597 01332 347597 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) www.rethink.org Rethink Mr Aaron Mauracheea Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: Derwent Lodge care home provides nursing and personal care for up to sixteen people, eight males and eight females, aged 18 to 65 years, with mental health needs. Residents are supported to take part in daily living and social activities, and lead a more independent lifestyle. The home is a purpose built detached bungalow in Chaddesden, close to local shops, facilities and a bus route, and is a short distance from Derby city centre. All bedrooms are single rooms with ensuite facilities. The home has male and female facilities, with separate lounges (smoking and non-smoking) dining room and kitchen. The home has a large garden. The local Primary Care Trust funds the residents currently living at the home. This is because these residents moved from the local hospital to this accommodation. Consequently information about the fees was not available. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, carried out by one inspector, and lasted 8 hours. A review of the evidence available prior to site visit was undertaken, for example, the pre inspection questionnaire, resident surveys (9 surveys received) and other information received by the Commission, and used to identify areas to be examined during the site visit. The information available was used to identify those residents whose care was to be cased tracked. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents) were examined in depth during this inspection. Time was spent taking with residents and staff on duty and observing the daily routine. A small selection of bedrooms was viewed during this visit. Other records such as medication records, staff files and service certificates were also examined. The registered manager was on duty during this visit and the findings of this site visit were discussed with him. What the service does well: Derwent Lodge provides a comfortable and homely environment for the people who use the service. Residents were encouraged to personalise their rooms with their own possessions. Residents are encouraged to make choices and decisions about their lives. Staff recognise the importance of encouraging residents to maintain as much control over their lives as possible, including developing and maintaining life skills. Residents made good use of the community facilities and were encouraged to participate in leisure activities. The staff team are committed to providing a good standard of care for residents, and are supported to do this through training opportunities. Staff had a good understanding of residents needs and abilities, although this was poorly documented in the files. Residents were offered a choice and variety of meals, and residents comments that they enjoyed the meals. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission procedure did not ensure that there was a proper assessment was recorded for each resident. Without this there was no assurance that care needs will be met. EVIDENCE: The files of two residents were looked at in detail during this inspection. No new residents have been admitted since the last inspection, so the files of two existing residents were reviewed. Case tracking did not confirm that admission procedure ensured that residents needs were properly assessed. The initial assessment documentation had not been fully completed for one of the residents, although the other assessment had been completed in detail. Information about the residents needs, abilities and preferences had also been supplied by other professionals involved in the residents care. The licence agreement between the home and the resident was only available in one of the files. The manager reported that the information in the files was being updated, and this may be why the information was missing. Residents spoken with indicated that they felt well cared for by the staff team, and staff were able to meet their needs. Staff were provided with appropriate training to assist them to meet the needs of the resident group. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a clear and consistent care planning system does not provide staff with the information they need to satisfactorily meet residents’ needs. EVIDENCE: Care plans had been developed for both of the residents whose care was case tracked. The care plans seen did not provide sufficient guidance for staff on the delivery of care. The care of one resident had been planned when they were first admitted to the home in 2002, and the majority of the care plans had not been amended since that date. However, discussion with staff, the daily logs and observation of the resident clearly demonstrated that this person needs had changed considerably since admission, and the placement was no longer considered appropriate. The care plans in place for the other resident were medically orientated and did not fully reflect the needs, preferences and abilities of the resident. Risk assessments were not completed as required. For example, the mobility of one of the residents whose care was case tracked was poor and they used a Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 10 walking aid, yet a moving and handling risk assessment had not been completed. Both residents whose care was case tracked were at risk of choking, but risk assessments were not available on file. Care plans were not being evaluated consistently on a monthly basis, although six monthly reviews through the care programme approach were taking place. The evaluation statements did not indicate whether the planned care was still appropriate and effective. Discussion with residents and staff supported that residents were encouraged to make decisions and choices about their lives, and were involved in all aspects of life in the home. Residents said that they had a say in the running of the home through the residents meetings, and that they were able to express their views. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home were supported to live as ‘normal’ a life as possible. Residents were supported to develop as individuals and to join in with appropriate activities. Friendships and family contacts were encouraged and supported as appropriate. EVIDENCE: Discussion with residents and staff supported that people were encouraged to develop as individuals and learn new skills, such as simple household tasks, making hot drinks and preparing snacks.. However, this information was poorly documented in the care plans. This issue has been highlighted in the previous two inspection reports. The people living at Derwent Lodge were settled in their routine, and a number of residents attended activities outside of the home. Residents commented that the routines were flexible and they were able to choose how to spend they day. Residents made good use of the local facilities, such as the local shops and a local gym. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 12 Residents talked about a recent holiday that they had enjoyed, as well as trips and holidays planned for the future. Residents also talked about the regular activities that take place in the home, and also the two weekly list of activities that had been planned and agreed during a recent resident meeting. Residents were encouraged to maintain regular contact with family and friends outside the home. Indiviudal residents religious and cultural needs were recognised and valued. Residents talked about the links they had with their churches and groups that met their cultural and religious needs. The relationships between residents and staff were observed to be postiive and respectful.. Staff recognise the importance of building relationships with residents, whilst having a consistent approach and clear boundaries for residents in relation to acceptable behaviour. Discussion with the cook indicated that she had a good knowledge of the residents dietary needs and preferences. The cook had worked with the residents to develop menus and residents spoke highly of the meals provided at the home. The menus seen offered variety and a choice of foods. The cook indicated that the home was in the process of recruiting a weekend cook. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs were met with support and assistance from staff and other health care professionals. The the administration of medication needs to improve in order to ensure that residents receive the medication that they are prescribed. EVIDENCE: The majority of people currently living at Derwent Lodge required minimal help with personal care, mainly support and encouragement. This was demonstrated in the care plans. Staff had a good understanding of each person’s abilities and support needs. Residents were treated as individuals and this was reflected in their appearance. Residents were supported and encouraged to attend to their personal appearance. Residents access health care facilities in the community. Staff supported residents to attend appointments, at the doctors and the hospital. Health care needs were not always well documented in the files or incorporated into care plans, ahthough the files demonstrated that staff recognised any deteroration in health and sought medical advise as appropriate. The multi-disciplinary Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 14 team supported residents, and information provided by health care professionals available in the residents files. The qualified staff were not managing the administration of residents medication in an effective and safe way. A number of discrepancies were found on the medication records, which did not support the residents were receiving medication as prescribed. These were brought to the attention of the manager, as there is a potential for staff to be unsure whether the medication has been given or not. The records had been signed to indicate that the medication had been given, when it had not, as it remained in the blister pack, or had not been signed when the medication had been given. A system was not in place for identifying the resident with the medication record. Storage of medication was satisfactory. There were no regular audits of the medication records. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure with evidence that residents feel that their views were listened to and acted upon. The staff team had an understanding of the policies and procedures in relation to safeguarding vulnerable adults, thereby protecting residents from potential harm. EVIDENCE: Systems were in place for raising and dealing with complaints. The complaints procedure was available to all residents and displayed in the home, and each person received their own copy as part of the licence agreement. People spoken with were aware of how to raise concerns, and indicated that they would tell the manager or any member of staff, and it would be dealt with. This was generally supported by the comments made on the resident surveys. Residents also commented that they could raise any issues during the regular residents meetings. The manager reported that no formal complaints had been received since the last inspection in November 2006. Procedures were in place to safeguard vulnerable adults. Discussion with staff and staff files supported that staff had received training and when asked, staff were aware of how to make a referral. There have been no allegations of abuse at the home since the last insepction. Residents were encouraged, with support from staff, to manage their finances whenever possible, and residents have their own savings accounts. However, the systems in place were not robust enough to safe guard residents money . Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 16 The records and the money held on behalf of three residents were cross referenced and all three were inaccurate, as the amount of money was greater than the amount recorded. The manager stated that staff did not always record when small amounts of change were returned to safe keeping. Discussion with staff and information supplied on the pre-inspection questionnaire indicated that a policy for dealing with physical and verbal aggression was not in place, and training on this aspect of care had not been routinely provided. The manager reported that classroom based training on managing violence and agression and de-escalation techniques had recently been introduced. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 17 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, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was good and provided residents with an attractive and homely place to live. EVIDENCE: Residents viewed Derwent Lodge as their home, and commented that they liked their bedrooms, and had been able to arrange them as they wished. Several residents commented that their bedrooms had been redecorated whilst they were on holiday. The home was clean and tidy, and free from odours at the time of this site visit. A dedicated maintenance person has taken up post since the last inspection, and deals with any maintenance within the home. The manager reported that since the last inspection, the carpets in the main corridor areas had been replaced, and there was a planned programme for replacing bedroom carpets. However, the carpet in the female dining room was badly stained and required cleaning or replacing. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 18 Residents were observing making good use of all areas of the home, including their bedrooms. The garden area was well maintained and garden furniture provided. Residents sat out in the garden during this visit, and made use of the washing line to dry their laundry. Residents also made use of the garden area to grow vegetables. Domestic style kitchens were provided within each section of home and residents were observing using the domestic style washing machine to do their personal laundry. All bedrooms have ensuite facilities with showers, and bathrooms were available for both male and female residents. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 19 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): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team as a whole was competent and trained to fully support the residents. Inconsistent recruitment practices did not provide safe guards to offer protection to people living in the home. EVIDENCE: Residents and staff considered that staffing levels provided sufficient staff with the appropriate skills to meet their needs. Residents benefit from a stable staff team, which any shortfalls covered by regular ‘bank’ staff. The staffing levels enabled staff to spend one to one time with residents, as well as small group work. Discussion with staff and the manager supported that the staff team were provided with a range of training opportunities. Staff have access to an annual training programme provided by the company. The manager reported that individual training needs and attendance at training courses were discussed during supervision, and the records supported this. The manager confirmed that each member of staff had an individual training and development plan, and that the dates for supervision were planned in advance. Two of the senior members of qualified staff were studying towards NVQ Level 4. Newly appointed staff complete an induction that meets the requirements, and the Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 20 home has achieved the 50 target of care staff trained to NVQ Level 2 or equivalent, resulting in a staff team that is competent and trained to do their jobs. Arrangements were in place to ensure that all staff attended mandatory training sessions. Procedures were in place for the recruitment and selection of staff. The human resources department within the company carried out the majority of the recruitment and selection process, and provided copies of the information to be held on file in the home. However, the records seen in the home did not support that the required safeguards were in place to protect residents. The two files looked at during this inspection did not contain all of the required information (proof of identify, full employment history). There was no recruitment information available for staff who had transferred from one of the company’s other homes. Evidence to support that criminal record bureau checks had been obtained was not available for all staff working in the home. The manager reported that these had been sent for and he had seen them. The manager was advised to ask the human resources department to provide evidence to support this. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home, which benefits from formal quality assurance and quality monitoring systems. EVIDENCE: The manager has been in post since December 2005, and has recently been registered with the Commission. The manager is a qualified nurse, and continues to update his skills and knowledge through training. The manager has completed a management qualification. Quality assurance systems were in place, and the company was committed to improving the quality of care and services provided at the home. The manager reported that the dedicated quality team within the company had recently audited the home, and as part of this process, residents were asked their views on the home. A resident questionnaire is carreid out annually, and the Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 22 manager was in the process of comparing this years information against last years. The manager reported that the results of this survey were not published. The manager indicated that a review of the service by the company was also underway at the time of this site visit. The manager reported a representative of the company visis the home on a regular basis, to carry out the review on the conduct of the home. Residents confirmed that this occurred, and that the representative of the the company sits and talks to them about the home. Systems were in place to ensure that staff attended mandatory training. A sample of service/maintenance records was examined (including equipment, gas and electricity services) and there was confirmation that equipment and services are properly maintained. However, as noted at the time of the previous inspection, the records did not support that the fire alarm was being tested weekly. Regular checks on the temperature of the hot water were undertaken, and the records indicated that the temperature in the some areas was slightly above the maximum temperature. The manager reported that the maintenance person alters the valve so that the temperature is correct, but this was not supported by the records. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation Requirement Timescale for action 31/08/06 2 YA6 3 YA6 4 5 6 YA20 YA23 YA34 7 YA42 14(1) & (2) The assessment of residents needs must provide sufficient detail to enable staff to meet the person’s needs. The assessment must be kept under review and having regard to any change of circumstance be revised as necessary. 15(1) All residents must have care plans that set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met. (Previous timescales of 31/08/05 and 31/01/06 not met) 12(1)(a)(b) Risk assessments must be 13(4)(c) completed for all identified risks, 14(1)(a) for example, choking, moving and handling and pressure area care. 13(2) Residents must receive their medication as prescribed. 13(6) Robust systems must be in place to safeguard residents money. 17(2) Sch Staff files must contain all of the 2&4 required information in accordance with Schedules 2 and 4. 13 The hot water temperatures to DS0000031165.V304458.R01.S.doc 31/08/06 31/08/06 31/08/06 31/08/06 30/09/06 31/08/06 Page 25 Derwent Lodge Version 5.2 8 YA42 23(4) the baths and showers must be maintained within safe temperatures. (Previous timescale of 31/01/06 not met) The fire alarm system must be tested weekly as recommended by Derbyshire Fire and Rescue service 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA6 YA20 YA20 YA39 Good Practice Recommendations Care plans should be reviewed and updated on a monthly basis. The evaluation statements should indicate whether the planned care was still appropriate and effective. A system for identifying the medication record with the resident, for example photographs, should be put in place. Regular audits of the medication records should be carried out in order highlight and address any shortfalls in staff practice. The results of any quality assurance survey should be published. Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Derwent Lodge DS0000031165.V304458.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!