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Inspection on 12/12/05 for Derwent Lodge Care Centre

Also see our care home review for Derwent Lodge Care Centre for more information

This inspection was carried out on 12th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Registered Manager has worked hard in the past months to highlight and address issues within the home, and has an open approach to the inspection processes. Staff were seen to converse with service users in a courteous manner and service users spoken with expressed their satisfaction with the home. Service users are assessed prior to admission and the home also obtains copies of Social Services needs led assessments to assist in the process. Complaints are well managed. Systems for staff employment are robust. There is evidence of good induction training for new staff.

What has improved since the last inspection?

There has been an improvement in the service user plans, especially with wound care and risk management. It is important that these improvements be maintained. Staffing management had also improved, and the Registered Manager is very aware of the need to ensure all areas are staffed appropriately to meet the needs of the service users. There was an improvement in staff morale and team working, and with further management support this should improve further. Overall service users and visitors spoken with were satisfied with the care provision in the home.

What the care home could do better:

Although there has been an improvement in the service user plans, continued work is required to attain and maintain a consistent good standard in this area. The management of medicines requires work to address shortfalls identified. Systems for infection control, to include cleanliness in bath and shower areas,need addressing. Some items of equipment were out of order and required repair. Management of service users personal monies is poor and systems need to be improved as a matter of priority. Management of administration and servicing records is poor and again systems need to be improved to safeguard service users. Health & safety training records did not evidence that all staff had undertaken mandatory training at the required intervals, and again, this must be addressed. A full health & safety audit of the home needs to be undertaken and an action plan to address the shortfalls identified drawn up and implemented.

CARE HOMES FOR OLDER PEOPLE Derwent Lodge Care Centre Fern Grove, Off Hounslow Road Feltham Middlesex TW14 9BE Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 12th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Derwent Lodge Care Centre Address Fern Grove, Off Hounslow Road Feltham Middlesex TW14 9BE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8844 4490 020 8844 4190 manager.derwent@lifestylecare.co.uk Life Style Care Plc Ms Lorna Esmay Thomas Care Home 62 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0) Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service can be accommodated on the YPD unit, as agreed by the Commission for Social Care Inspection, on 31st January 2005, for as long as there is no deterioration which affects the well being of other service users. The home must advise CSCI when the service user no longer resides at the home. The home is registered to provide Nursing Care to 26 service users with Dementia and 10 service users who are aged 18 and over who have a Physical Disability. 21st June 2005 2. Date of last inspection Brief Description of the Service: Derwent Lodge Care Centre is situated in a residential area of Feltham. There are shops, restaurants, public houses plus a social centre with a cinema, bowling alley and restaurants, within walking distance from the home. The home can be accessed by bus and main line train services. There are weekly General Practitioner visits to the home, and healthcare services are accessed by the home for service users. Visits from local religious denominations are made on a regular basis. Two lifts are available in the home, one generally used for the transportation of meals and deliveries to the kitchen, which is located on the second floor. The accommodation is situated over three floors. All the bedrooms are single with en-suite facilities, comprising of a toilet and wash hand basin. Assisted bathrooms are located on each floor and there are separate toilets. There are lounges and dining rooms on each floor. There is wheelchair access to the well-maintained grounds and some of the bedrooms overlook the gardens. The car park is in front of the home. The home has a Registered Manager and the new Deputy Manager started on the day of inspection. There is also a Regional Manager for the home, who was present for part of the inspection. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 20 hours were spent on the inspection process. The Inspectors carried out a tour of the home, and inspected service user plans, staff files, financial records, servicing & maintenance records. 8 service users, 5 visitors, 10 staff and a visiting healthcare professional were spoken with as part of the inspection process. This was the second unannounced inspection in this inspection year, plus there have been 3 additional visits and a separate CSCI pharmacy inspection in the time between the two unannounced inspections. It must be noted that it is not always easy to ascertain the views of service users with dementia care needs. It is acknowledged that some of the areas where shortfalls are identified, particularly with the administration, have been inherited by the Registered Manager and she and the administrator are aware that these need to be addressed promptly. What the service does well: What has improved since the last inspection? What they could do better: Although there has been an improvement in the service user plans, continued work is required to attain and maintain a consistent good standard in this area. The management of medicines requires work to address shortfalls identified. Systems for infection control, to include cleanliness in bath and shower areas, Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 6 need addressing. Some items of equipment were out of order and required repair. Management of service users personal monies is poor and systems need to be improved as a matter of priority. Management of administration and servicing records is poor and again systems need to be improved to safeguard service users. Health & safety training records did not evidence that all staff had undertaken mandatory training at the required intervals, and again, this must be addressed. A full health & safety audit of the home needs to be undertaken and an action plan to address the shortfalls identified drawn up and implemented. 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 Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 The information provided to service users and their representatives about the home requires updating to provide them with current information. Written agreements are available for service users, thus providing clear information about the services provided. Staff have received training to ensure that they are able to meet the specialist care needs of the service users. Service users are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide required updating, and this was to include information about the new Registered Manager. It was agreed that this would be completed and copies forwarded to the CSCI. Copies have since been forwarded to the CSCI, but the Service User Guide needs reviewing to contain all the information required under the Care Homes Regulations 2001. The Registered Manager reported that all service users had a contract and terms & conditions in place. However, a recent audit had identified some shortfalls where service users or their representatives had not signed the terms & conditions. This was in the process of being addressed. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 9 Pre-admission assessments viewed were completed and also the home obtains copies of Social Services needs led assessments, and/or continuing care assessments. There was evidence that the home has identified service users with dementia care needs who are accommodated on the general nursing unit, and are taking steps to address this finding, with input from Social Services and from the service users’ families. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Overall the service user plans were comprehensive and up to date, providing staff with a clear picture of each service users needs. Minor shortfalls should be easily addressed. There had been an improvement in the management of medications, although shortfalls identified pose a potential risk to service users. Staff are courteous to service users and generally personal support is provided in such a way as to promote and protect the service users privacy and dignity. EVIDENCE: Service user plans were sampled on each floor. On the second floor the 2 service user plans viewed were comprehensive, up to date and there was evidence of monthly updates plus additional review and formulation of care plans for new needs identified. Risk assessments for falls and for any other risks identified had been formulated and were updated monthly and whenever there was a change in a service users condition. Risk assessments, care plans and written consents for the use of bedrails were in place. Wound care documentation was complete and up to date and showed the progress of the wound. Assessments for continence, moving & handling Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 11 and nutrition had been completed and where necessary care plans formulated to address any identified needs. On the first floor two service user plans were viewed. These were comprehensive and up to date. Risk assessments and care plans for falls were in place, plus risk assessments for other identified risks. Care plans to address service users needs had been formulated in a manner to include the effects of the service users dementia. The documentation for one service user regarding wound care needs to be reviewed as two documents contained differing information. Risk assessments, care plans and written consents for the use of bedrails were in place. Assessments for continence, moving & handling and nutrition had been completed and where necessary care plans formulated to address any identified needs. In one service user plan viewed there was conflicting information regarding their preference for a male or female carer, and this needed clarifying. Also, for one service user it had been recorded that they could not manage to use the call bell, but in another section of the service user plan reference was made to ensuring the service user had the call bell to hand, and this needed reviewing to provide clear and consistent information. Some of the care plans for one service user were somewhat general and the content needed to be personalised to the individual. In one service user plan some of the documentation required completing, and this was discussed at the time of inspection. Three service user plans were viewed on the ground floor. These were generally up to date with care plans in place to address the service users identified needs. Risk assessments for falls were in place. A risk assessment, care plan and written consent for the use of bedrails were seen for one service user. For another service user who had recently been admitted to the home, written consent for the use of bedrails was in place, but there was no risk assessment or care plan seen. Much of the other service user plan documentation had been completed for this service user. Wound care documentation was in place and was comprehensive and up to date. Assessments for continence, moving & handling and nutrition had been completed and care plans formulated for identified needs. For one service user being fed via a PEG tube and also having some oral food intake, clear documentation to include assessment and guidelines from the Speech & Language Therapist were in place. On all floors there was evidence of referral to and input from the Tissue Viability Nurse Specialist, plus other health care professionals. The pressure relieving equipment and moving & handling equipment in use had been recorded for each service user. Shortfalls identified were discussed with the Regional Manager, Registered Manager and Deputy Manager at the time of inspection. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 12 The CSCI Pharmacist Inspector carried out an inspection on 12/12/05 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were heard to speak with service users in a gentle and courteous manner. Clothing is labelled individually for each service user. Service users who wish can have a telephone installed and the use of mobile telephones by service users is also permitted. At the time of inspection service users were being treated with dignity and respect. Service users spoken with expressed their satisfaction with the home and said that they are well cared for. Visitors spoken with said that they are made welcome at the home and kept up to date with any incidents that occur. Meetings are held for service users and their relatives. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: One Inspector viewed the lunchtime meal on one floor. A choice list had been completed and staff were seen to assist service users in a discreet manner. The Inspectors sampled the meat and vegetarian options for the lunch and these were well presented and tasty. Service users spoken with expressed their satisfaction with the meal provision. Information in the service user plans indicated that special diets for medical and cultural reasons are recorded, and service users likes and dislikes are also recorded, and this information is passed on to the kitchen staff. Care plans and feeding regimes were in place for service users being artificially fed via a percutaneous endoscopic gastrostomy (PEG) tube. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a clear complaints procedure in place to address any concerns raised by service users and their visitors. Systems are in place for the protection of vulnerable adults so as to protect them from possible risk of harm or abuse. EVIDENCE: The complaints policy and procedure were in place. 18 complaints have been received by the home since the inspection in June 2005. A register of complaints is maintained, with an overall summary of all outcomes and actions being recorded. There have been four protection of vulnerable adults (POVA) allegations since the inspection in June 2005. Two have been resolved and two are still being investigated. Staff spoken with were aware of POVA and Whistle Blowing procedures. The home has received input from the Hounslow POVA Team and this is ongoing. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 25 and 26 The home has a redecoration and refurbishment programme, and time needs to be identified to ensure that the timescales can be met in order to continue to provide a good, homely environment for service users. Bath and shower facilities are being used as storage areas, plus toiletries and other personal items are left in these communal areas, thus heightening the risk of cross infection. EVIDENCE: One Inspector carried out a tour of the home. Christmas decorations were in evidence on each floor and the reception area, which was very welcoming. There was evidence that some areas had been redecorated, but in other areas the walls were marked and needed attention. Washable paint has been used in several areas, so arrangements need to be discussed to ensure that any spills or marks are cleaned up promptly. The home has a redecoration and refurbishment programme with timescales in place. This was discussed with the maintenance man and it was explained that some rooms will require additional time to redecorate due to the level of personalisation, and it was clear that the maintenance man works hard to complete his work, and Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 16 additional time is required to complete the redecoration programme also. Appropriate plans to ensure that the redecoration plan can be completed within the timescales must be put in place. On the day of inspection some of the bedroom carpets were being replaced, and care was being taken to store the furniture and personal belongings from the bedrooms appropriately. One of the bath facilities on the ground floor was stated to be out of order, but there was no signage to this effect. Action must be taken to restore the bath to working order. The bathrooms on the ground and first floors were being used as storage and were very cluttered and untidy. This was discussed at the time of inspection. The home was pleasantly warm at the time of inspection. There had been an intermittent problem with the boiler and the Registered Manager explained that a part had been ordered so that the boiler could be fully repaired, and this repair work was in the process of being carried out. Several items of personal toiletries had been left in bath and shower facilities on the ground and first floors. Commode chairs, marked commode pots, used flannels and towels and other personal items were also found in these areas. The flooring in the ground floor shower rooms was marked and one was cracked and needed attention. One bedroom carpet was very stained and it was explained that the carpet cleaner was out of order. COSHH products were left out in the laundry room, which was not locked, and also seen in one shower room, and this was discussed with the Registered Manager at the time of inspection. The laundry room was clean and tidy. Personal laundry viewed was identified to the individual. Cleaning rosters had been completed. Protective clothing to include gloves and aprons were available on each floor. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The home is appropriately staffed to meet the needs of service users. Staff recruitment procedures are robust and safeguard service users. Staff undergo training to provide them with the skills to meet the needs of the service users. EVIDENCE: The floors were appropriately staffed at the time of inspection. Staffing is kept under review and this was discussed with the Registered Manager. A sample of staff employment records were viewed. These were up to date and contained the required information. The administrator reported that some of the Personal Identification Numbers for registered nurses held on the database had expired and she had written to those concerned to request evidence of their up to date registrations. The induction and foundation training programmes meet the Skills for Care (formerly TOPSS) core standards. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 37 and 38 The Registered Manager has the qualifications and experience to manage the home. The views of service users and their representatives are sought, but no evidence to show how shortfalls identified are to be addressed was available. The system of maintaining service users personal allowances is unsatisfactory and needs to be robust to ensure service users interests are safeguarded. Systems for the management of service users personal monies need reviewing to ensure that they are robust and fully safeguard service users interests. The Health & Safety systems in place in the home need to be reviewed to ensure that the safety of the service users, staff and visitors to the home is maintained at all times. Systems for office administration were poor and need to be reviewed. It is acknowledged that the home is aware of these shortfalls, and action to address them needs to be taken. EVIDENCE: The manager is now registered with the CSCI. She is a first level nurse and has a diploma in Management Studies. A Deputy Manager has been recently Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 19 appointed and commenced work on the day of inspection. The Registered Manager is in the process of identifying the areas of management to be undertaken by herself and by the Deputy Manager, and this will be revisited at future visits. Copies of the Regulation 26 visit reports have been forwarded to the CSCI. Due to frequent changes in management, the business and development plan was in need of formulation. The Regional Manager is providing input on this and a plan for 2006/2007 is in the process of being developed. The home has a quality assurance system, which is ISO 9001 standard. Audits of service user plans had been taking place. Medication audits had not yet been commenced and it was stated that this would be part of the Deputy Managers remit. Service users/representatives satisfaction questionnaires had been completed, however on some occasions where shortfalls had been identified there was no documentary evidence that these had been addressed. The results of the surveys are collated at head office and then forwarded to the home. The home must ensure that the CSCI receives a copy of any such survey results. The home has current employers liability insurance in place and the certificate was on display. Small amounts of service users personal monies are held securely by the home, and a running balance is maintained. Samples of service users personal monies records were viewed. For one service user £20 had been paid out but there was no record to identify what the payment was for. For another service user the dates of payment were not clear and there were no signatures for monies going in and out. One Inspector requested that the Regional Financial Administrator undertake a full audit of service users monies and the shortfalls in recording addressed. The systems in place for office administration were poor. For example, there were 3 files for staff training and the training manager had other training files. Out of date information was still being stored in the current files and needed archiving. It is acknowledged that the systems in place have been inherited from previous management and administration staff, and the Registered Manager and the new Administrator were very aware of the need to streamline these processes. Training records viewed did not evidence that all staff had received moving & handling training. This was discussed with the Registered Manager and the Training Manager. Servicing and maintenance records were sampled. Initially it was difficult to access the servicing records and the need to file these appropriately was discussed. The maintenance records were viewed and overall these were up to date. Fire alarm tests were being recorded as fire drills, and this was discussed and clarified. Actual fire drills for staff had taken place last for night staff on 17/05/05 and for day staff on 02/06/05, and the need to carry out both day and night fire drills in accordance with legislation and Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 20 guidance was discussed. An up to date list of all servicing records was requested and is to be sent through to the CSCI. Following the inspection copies of some of the servicing certificates have been forwarded to the CSCI. Health & safety risk assessments could not be found in the laundry room and this was discussed. A full audit of health & safety management, within the home, needs to be undertaken. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 3 X X 3 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 1 X 1 1 Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 Requirement The Service User Guide documentation must contain the information required under the Care Homes Regulations 2001 and be distributed to service users and the CSCI. The service user plan must be personalised to the individual, accurate and up to date, and information contained therein must be consistent. Prior to their use, risk assessments for the use of bedrails must be carried out and the appropriateness of their use clearly identified. All wound care documentation must be maintained accurately. All medicines must be recorded when received into the home, when administered and when disposed of. If variable doses are administered then the actual dose administered must be recorded. The home must work with the pharmacist to ensure that the MAR are current and do not include discontinued medicines DS0000010946.V273408.R01.S.doc Timescale for action 20/01/06 2 OP7 15 20/01/06 3 OP8 13(4)(7) 01/01/06 4 5 OP8 OP9 17(1)(a) 13(2) 23/12/05 01/01/06 6 OP9 13(2) 14/01/06 Derwent Lodge Care Centre Version 5.0 Page 23 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 11 OP9 OP9 13(2) 13(2) 12 OP19 23(2)(b) 13 14 OP21 OP22 23(2)(c) 23(2)(l) 15 16 17 18 OP25 OP26 OP26 OP26 23 13(3) 13(3) 13(3) Dates of opening must be written on all liquid medicines and in particular those with a short shelf life such as eye drops and insulin Oxygen cylinders must be secure in the home. If not required they must be returned to the supplying pharmacist Ordering and checking of prescriptions must be more thorough to avoid stockpiling medicines The home needs to ensure that medicines do not run out and are ordered well in advance The blisters and the MAR must be tidied up on the ground floor. Old MAR should be removed from the current folder and the current ones must be in the same order as the blisters to avoid error and save time. Action must be taken to ensure that the redecoration and refurbishment programme timescales can be met. An action plan to show how this is being addressed must be forwarded to the CSCI. All equipment must be maintained in working order, to include the bathing facilities. Bath and shower facilities must not be used as storage facilities. Adequate storage facilities must be available in the home. Evidence that the boiler has been repaired must be forwarded to the CSCI. Personal toiletries must not be left in communal areas. All areas and equipment must be maintained in a clean condition. COSHH products must be stored appropriately and securely in the home. DS0000010946.V273408.R01.S.doc 14/01/06 14/01/06 01/01/06 01/01/06 14/01/06 30/01/06 23/12/06 01/01/06 23/12/05 23/12/05 23/12/05 12/12/05 Derwent Lodge Care Centre Version 5.0 Page 24 19 20 OP26 OP33 13(3) 25 21 OP35 17(2) 22 OP37 17 23 OP38 17, 13(4) 24 OP38 18 25 OP38 23(4) 26 OP38 13(4) 27 OP38 12, 13(4) The carpet cleaner must be repaired and maintained in working order. A business and development plan must be available for the home. Thereafter this must be reviewed annually and whenever the needs of the home change. An audit of service users monies must be undertaken and action taken to address any shortfalls identified. Clear procedures for the recording of service users personal monies must be in place and adhered to. Records must be maintained in an orderly manner and be kept up to date. There must be appropriate systems in place for the correct maintenance of records, and these must be adhered to. Servicing records must be accessible and up to date. A list of dates of the most recent servicing for all equipment and facilities must be forwarded to the CSCI with an action plan to address any shortfalls identified. There must be evidence that all staff have undergone health & safety training to include moving & handling. Fire drills must take place for day and night staff in accordance with current legislation. An action plan to address this must be put in place. Risk assessments for equipment and all health & safety aspects of the home must be in place and easily accessible. This must include laundry equipment and practices. A full health & safety audit of the home must be carried out and an action plan formulated to address any shortfalls identified. DS0000010946.V273408.R01.S.doc 23/12/05 01/04/06 01/01/06 20/02/06 30/01/06 20/01/06 01/01/06 26/01/06 01/02/06 Derwent Lodge Care Centre Version 5.0 Page 25 Copies of the documentation must be forwarded to the CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP2 OP9 OP9 Good Practice Recommendations It is strongly recommended that contracts for all service users are up to date and signed. That the home purchases a new CD register for the first floor. That the pharmacist attaches labels to the actual container and not just the outer box. This was discussed with pharmacist after the inspection. Derwent Lodge Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Care Centre DS0000010946.V273408.R01.S.doc Version 5.0 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. 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