Inspection on 13/11/06 for Derwent Lodge Care Centre

This inspection was carried out on 13th November 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 but made no statutory requirements on the home.

Other inspections for this house

Derwent Lodge Care Centre 08/05/07

Derwent Lodge Care Centre 24/04/06

Derwent Lodge Care Centre 12/12/05

Derwent Lodge Care Centre 21/06/05

Derwent Lodge Care Centre 11/01/05

Derwent Lodge Care Centre 30/09/04

Derwent Lodge Care Centre 04/11/03

Derwent Lodge Care Centre 19/06/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Derwent Lodge Care Centre Fern Grove, Off Hounslow Road Feltham Middlesex TW14 9BE Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 10:00 13 , 14 & 20th November 2006 th th 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.V317885.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 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.V317885.R01.S.doc Version 5.2 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 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.V317885.R01.S.doc Version 5.2 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. 24th April 2006 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. Two lifts are available in the home, one of which is 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 bathroom and shower facilities 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. Fees range from £554.81 to £900 per week, dependent on assessed need. Derwent Lodge Care Centre DS0000010946.V317885.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 inspection carried out as part of the regulatory process. A total of 31 hours was spent on the inspection process. A tour of each unit was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The CSCI pharmacist Inspector carried out a medication inspection on 20/11/06 and a separate report is available. The requirements and recommendations from the pharmacist inspection have been incorporated in this report. 10 service users, 6 visitors, 12 staff and 1 healthcare professional were spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. The preinspection questionnaire and comment cards sent to the home prior to the inspection have also been used to inform this report. What the service does well: What has improved since the last inspection? Admission information regarding specialist mental health needs was available. Improvements had been noted in the environment, with ongoing work to replace damaged and marked flooring in various areas of the home. The home Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 6 has had a management review and an action plan to address any shortfalls is in place. This, together with the annual budget provides business and development information for the home. 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. The summary of this inspection report can be made available in other formats on request. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 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.V317885.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and representatives are provided with the information they need to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood. Service users are assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Shortfalls regarding preadmission information for emergency admissions could place service users at risk of their needs not being fully identified and met. Prospective service users and their representatives are encouraged to visit the home, thus providing them with information to make an informed choice. EVIDENCE: Copies of the Statement of Purpose and Service User Guide are available in the main entrance and in some service users bedrooms. On the dementia unit Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 9 these are not provided in all rooms, but are available. These were up to date. A copy of the last inspection report was also available in the main entrance. The Acting Manager had identified a shortfall in contracts for service users, and has taken action to address this. Contracts viewed contained details of the fees payable and the services provided. Pre-admission assessments were sampled. The documentation was comprehensive and gave a clear picture of the service users needs. Copies of Social Services and/or Primary Care Trust assessments plus discharge information from hospital were also available. For one service user who was an emergency admission to the home a copy of the Social Services needs led assessment was not available. Visitors spoken with confirmed that they had been able to visit the home prior to their relative being admitted. They had been provided with information and had toured the home. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Overall the service user plans were up to date, however shortfalls in completion could place service users at risk of their needs not being fully met. Shortfalls in risk assessment documentation could potentially place service users at risk. Medications are being well managed at the home, however some shortfalls need addressing to fully safeguard service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Service user plans were sampled on each floor. On the second floor the service user plans viewed were comprehensive and up to date, and there was evidence of new care plans being formulated for newly identified needs. The documentation had been reviewed monthly and whenever the service users condition had changed. There was evidence of input from service users representatives. Risk assessments were seen, with one falls risk assessment being completed at the time of inspection. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 11 On the first floor both care plans viewed were up to date and were being reviewed monthly. However there was no evidence of involvement from service users and/or their representative. Risk assessments were in place to include the risk of falls. Admission information to include mental health needs had been completed. However, some admission information had not been completed, and inappropriate entries had in some instances been made, for example ‘N/A’ being recorded for service users employment history. This was discussed with the staff, and explanations given, but the need to ensure documentation is correctly completed with explanations for any gaps was stated. On the ground floor some of the information was very general and in some cases the care plans did not accurately reflect the service users condition. In one instance the service user plan had not been fully reviewed following a hospital admission, and therefore some information had not been reviewed for several months. No risk assessment for falls was seen in one service user plan, and in the other the assessment had not been reviewed for some months. Some input from representatives was seen, but it was clear that the service users and their representatives had not been involved in the actual formulation and review of the service user plans. Issues with the completion of admission documentation as identified for the first floor were also identified in some instances on the ground floor. On the second floor wound care documentation was in place and clearly recorded the progress of the wound. Wound care documentation on the first floor was unclear and in both instances individual care plans and documentation for each wound had not been formulated, and the information in each instance was written on one document. For one service user it was not clear as to when one wound had healed. Wound care documentation on the ground floor was comprehensive and detailed the treatment required. Care plans for pain associated with wounds had not been formulated on the first and ground floors. Pressure relieving equipment had been identified on each floor. Waterlow assessments on the ground floor had not always been correctly calculated. Moving & handling assessments were available in each service user plan viewed, but for one service user on the ground floor this had not been reviewed for some months and did not accurately reflect the service users needs. Continence assessments had been completed. For one service user on the ground floor this did not accurately reflect their condition. Nutritional assessments had been completed, however for one service user on the ground floor this had not been reviewed following a change in nutritional status. With one exception, consents for the use of bedrails were in place, however bedrail risk assessments were not in place for all service users for whom they were in use. The home has weekly visits from the GP and one Inspector spoke with the GP who expressed their satisfaction with the way the home manages the GP visits. There was evidence in the records viewed of input from other healthcare Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 12 professionals to include tissue viability, dietician, speech & language therapist and chiropody. Training in all aspects of service user plan documentation has taken place with the registered nurses in the home, and still shortfalls are being identified. The Acting Manager agreed that there is a need for further training in this area. Thereafter any poor performance in this area must be managed effectively. The CSCI Pharmacist Inspector carried out an inspection on 20/11/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen caring for service users in a gentle and professional manner and generally service users and visitors spoken with expressed their satisfaction with the care they receive at the home. Service users were appropriately dressed and clothing viewed in the laundry room was individually labelled. Bedrooms were quite personalised, and service users are encouraged to bring in personal belongings in line with fire safety. For those service users who were unable to communicate, they appeared content and well cared for. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision within the home is good, however for some service users the lack of staff knowledge on the relevance of certain significant events in the calendar does not meet their individual expectations and preferences. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with service users choices being respected. EVIDENCE: The home has a full time activities co-ordinator, and also a part time activities assistant. Up to date activities programmes were seen on each floor, and had been placed in service users bedrooms. Service users spoken with said that they enjoy the activities and can choose if they wish to join in, with their choices being respected. The budget for activities was discussed with the Acting Manager and the Regional Manager present on the second day of inspection, and it was clear that the expenditure on activities had been significantly below the budget allowed for this purpose. This needs to be Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 14 addressed to ensure that the budget available for activities is utilised fully, and the activities co-ordinator can plan with the budget available to them. On the second day of inspection a service users bowling competition with Coniston Lodge, another Life Style Care plc home situated nearby, took place, and service users and visitors alike enjoyed the afternoon. On the first day of inspection comment was received regarding the seeming lack of understanding from some staff in respect of Armistice Day, which had recently occurred. The importance for all days of significance, to include all religions, cultures and traditions, to be celebrated or marked appropriately was discussed with the managers and it was recommended that a piece of work be undertaken to research all such days and formulate a document to identify and briefly outline the significance of each. In this way staff would have an understanding of any significant events across all cultures. The home did not have a firework display this year, and this was explained to the Inspector as being due to health & safety reasons. It is recommended that this be reviewed for the next relevant celebration in order to ensure there is a full risk assessment in place and, if appropriate, a display that meets health & safety requirements organised. The home has an open visiting policy and visiting is encouraged. Visitors spoken with, plus comments received from the comment cards said that visitors are made welcome at the home. Service users can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. The home has a list of useful addresses on display in each unit and this includes contact details for Age Concern and the Alzheimers Society for contacting advocacy services. One Inspector viewed the kitchen. It was clean and tidy and the documentation to include temperature recordings, cleaning schedules and risk assessments was up to date. Foodstuffs were being correctly stored, and any open items had been dated when opened. The Inspector sampled the lunchtime meal on the first day of inspection and this was well presented and tasty. The menus are in the process of being reviewed and the importance of ensuring the menus continue to contain a good variety of meals, in accordance with service users likes, was discussed. The use of more fresh vegetables in the diet was also discussed, as currently the majority of vegetables in use are frozen or tinned. Service users spoken with generally were satisfied with the food provision, although comment regarding the quality of some of the food was received. Staff were available to assist service users with their meals and were seen doing so in a sensitive manner. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Documentation for complaints is comprehensive, however the 28 day timescale had not always been fully met, thus not dealing promptly and effectively with complaints in all instances. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has had 3 complaints since the last inspection. The documentation evidenced that these had been investigated and responded to. In one instance a complaint sent directly to Life Style Care plc had not been fully addressed, and the need to ensure all elements of any complaint are responded to within the 28 day period has been discussed with the person responsible for the response. Representatives spoken with said that the Acting Manager does have an open door policy and does respond promptly to any concerns raised. There have been 2 POVA issues since the last inspection. One has been investigated and resolved. The second is currently being investigated. Both have been reported and appropriately managed. Training records viewed showed that staff have received POVA training, and staff spoken with said that they would report any concerns and were aware of the Whistle Blowing procedure, a copy of which is displayed on each floor. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Work is ongoing with redecoration and refurbishment of areas of the home to maintain an attractive and safe environment for service users to live in. Equipment and facilities are available to meet the needs of the service users and the home. Bedrooms are personalised, thus providing service users with a homely environment to live in. Infection control procedures are in place and generally being adhered to, thus safeguarding service users. EVIDENCE: A tour of each floor was carried out. Overall the home was clean and, with the exception of some isolated areas on the first floor already identified by the Acting Manager, the home smelled fresh throughout. The maintenance man had last carried out a health & safety audit in August 2006 and work was progressing on the areas identified for redecoration, with a redecoration programme in place. The Acting Manager had identified several carpets for Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 17 replacement, and work was in progress on the two days of inspection. On the first floor the heater opposite room 38 had come away from the wall, and this was being addressed. The home has appropriate assisted bath, shower and toilet facilities to meet the needs of the service users. Generally these were clean and in good order. Some of the floors were quite marked, and the Acting Manager said that work is being progressed to fully clean or replace flooring where such issues had been identified. Moving and handling equipment was available to meet service users assessed needs. Rails were available in the corridors plus grab rails in the assisted facilities. A pressure relieving cushion and an empty box were found in one of the ground floor bathrooms, and was addressed at the time of inspection. Otherwise there were no issues noted with storage. Some concerns were raised regarding the provision of wheelchairs appropriate to the needs of specific service users. This was discussed with the Acting Manager who explained that the wheelchair service had stated that they were unable to provide this equipment and private purchase by the service users or their representatives would be necessary. All the bedrooms are single with en suite facilities. All the beds are adjustable and the bedrooms were appropriately furnished. Some carpets have been replaced with flooring suitable for service users with specific continence needs. All the doors have suitable locks to allow staff access in an emergency. The bedrooms viewed were clean, personalised and homely. The home was pleasantly warm throughout. Room temperatures are recorded regularly, to monitor them. Radiators have low surface temperatures. The lighting was satisfactory, and there is emergency lighting in place throughout the home, with weekly checks carried out. Hot water temperature checks are carried out weekly and were within safe range. Monthly checks of water storage temperatures are also carried out and were within safe range. The risk assessment for legionella was last carried out in June 2006 and action taken to address the shortfalls identified therein. The laundry room was clean and tidy. Good practice information and washing instructions were on display. The washing machines are industrial and have sluice programmes for the effective washing of foul or infected laundry. Protective clothing to include gloves and aprons were available on each unit. Care plans for infection control issues had been formulated. Staff had received training on infection control. Toiletries were found in a shower room on the first floor and were removed at the time of inspection. No other such issues were identified. Separate sluice rooms are situated on each floor, with electronic disinfector machines. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be reviewed in line with service users dependencies in order to ensure service users needs can be met at all times. Staff had received training to provide them with the skills and knowledge needed to meet the needs of the service users, however further training is required to promote effective communication between staff, service users and their representatives. Shortfalls identified in the recruitment and vetting procedures could place service users at risk. EVIDENCE: The staffing on the second floor was appropriate to meet the needs of the service users. The service users on the first and ground floors were still having breakfast mid-morning. Staff were working very hard to meet the service users needs and did not have much opportunity to spend time chatting with service users. There are many service users who are high dependency, and a review of the staffing on both units to reflect the service users dependencies must be carried out. Staffing must be increased in line with the needs of the service users. The home has been without an administrator for many months and this was reflected in the shortfalls identified in staff employment records and management service users personal monies. The Acting Manager stated that Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 19 the post had been advertised and interviews were being arranged. It was clear that the home is in need of an effective administrator. Currently 39 of the care staff are qualified to NVQ in care level 2 or 3, or the equivalent. More care staff are presently undertaking NVQ in care training, and the Acting Manager said that this is to be an ongoing process to ensure the home has 50 or more care staff trained. One Inspector viewed a sample of staff employment records. Several shortfalls were identified. These included some lack of detail regarding employment history and reasons for leaving previous employment not given. References had not always been obtained from the previous employer, and although in some cases there were valid reasons for this, this information had not been recorded. POVA first checks were available. Criminal Records Bureau checks had not all been recorded, however a pile of these were seen. The Inspector expressed concern at the shortfalls identified and on the second day of inspection the Life Style Care plc peripatetic administrator attended the home and carried out a full audit of employment records for staff employed since the last such audit. Assurance has been given to CSCI that prompt action is being taken to address the situation. Life Style Care plc induction and foundation programmes meet the Skills for Care standards. Staff confirmed that they had received induction training and this was also evidenced in the training records. Staff had also received training in topics relevant to the diagnoses and care needs of the service users accommodated at the home. Comments received did include some difficulties in understanding some members of staff, due to strong regional accents. The importance of providing training where a need is identified for staff to improve their communication skills was discussed with the Acting Manager and Operations Manager. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Continuity in management would enhance the effective managing of the home. The Acting Manager is working hard to create an open and positive atmosphere within the home, encouraging good communication throughout. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Shortfalls in the system for management of service users monies do not allow for service users financial interests to be fully safeguarded. Systems for the management of health and safety are generally good, thus safeguarding service users, staff and visitors. EVIDENCE: The Acting Manager has been in post for 6 months. The Acting Manager is a first level registered nurse, with post-graduate qualifications in topics relevant Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 21 to the care needs of the service users accommodated at the home. The Acting Manager is aware of the need to undertake an NVQ level 4 in management qualification or the equivalent in order to meet part of the requirements for a Registered Manager. Over the last 3 years the home has had a high turnover in managers plus periods of time without a manager in post. Staff, service users and visitors spoken with said that the Acting Manager is approachable and acts promptly on any concerns raised. The home also has a Deputy Manager and the importance of team working throughout the home was discussed at inspection. It was clear that some of the staff do feel the home is now working better overall, however some areas still require work to ensure staff are enabled to work to their full potential and as part of an effective team. The Acting Manager was helpful and open with the Inspectors throughout the inspection. The home has a Home Action Plan, which is based on the annual management review. This is comprehensive and sets out the areas to be addressed in line with quality assurance and development of the home. There is also an annual budget, divided into monthly sections. Audits are carried out for each unit each week, and an action plan is completed. Relatives meetings are held so they can air their views and make suggestions. Staff meetings also take place. The Acting Manager was in the process of setting up a Newsletter for the home. Regulation 26 visits are carried out and copies of the report forwarded to CSCI. One Inspector viewed the service users personal monies management. Some discrepancies in recorded and actual amounts available were identified, and an audit was immediately conducted of all the monies held for service users and the shortfalls accounted for and a satisfactory explanation given. The Acting Manager does carry out audits of the service users monies, but some had not been done for some time, and the need to carry out regular audits for all service users monies was discussed. A receipt book is held for monies received. With the duplicate receipt book, care had not always been taken to prevent entries duplicating through several layers of the book, making entries difficult and confusing to read. Some entries were not dated and a receipt could not be identified in one instance. Copies of the receipts given to those handing in monies are kept in the receipt book. The need to ensure all entries are accurate, clear and up to date was discussed. The management of service users monies is the job of the administrator and the lack of administrator has had an effect on this. Samples of the servicing and maintenance records were viewed and were up to date. Staff training records viewed identified that staff had undergone training and updates in health & safety topics and the training co-ordinator ensures that any training due is identified in the individual staff training profiles and arrangements made to attend the training. Risk assessments were in place for equipment and safe working practices, and these had been updated annually and whenever any relevant changes had been made. The fire risk assessment Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 22 had been updated 15/10/06 and shortfalls identified at the fire safety inspection carried out by the London Fire and Emergency Planning Authority earlier this year have been addressed. Derwent Lodge Care Centre DS0000010946.V317885.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 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 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 3 3 X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 X X 3 Derwent Lodge Care Centre DS0000010946.V317885.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. 2. Standard OP3 OP7 Regulation 14 17 Requirement Pre-admission information must be obtained for all admissions, to include emergency admissions. Care plans must be up to date, accurate and individualised to reflect the needs of each service user and how these are to be met. Care plans must be reviewed monthly and whenever a service users condition changes. This must include a review following return from any hospital admissions. Risk assessments for falls must be in place for all service users. These must be reviewed whenever the service users condition changes. There must be evidence of involvement from the service user and/or their representative in the formulation and review of the service user plan unless it is not practicable to do so. Wound care documentation must be clear, accurate and up to date. Where a service user is identified DS0000010946.V317885.R01.S.doc Timescale for action 01/12/06 22/12/06 3. OP7 17 22/12/06 4. OP7 13(4) 22/12/06 5. OP7 15 22/12/06 6. 7. OP8 OP8 17(1)(a) 17 15/12/06 08/12/06 Page 25 Derwent Lodge Care Centre Version 5.2 8. 9. OP8 OP8 17 13(4) 10. OP9 13(2) 11. 12. OP9 OP9 13(2) 13(2) 13. OP12 12 14. 15. OP16 OP27 22 18 16. OP27 18 17. OP29 19 as being in pain there must be a care plan to show how this is to be addressed. All assessments must be accurate and kept up to date. Risk assessments for bedrails must be in place to identify the appropriateness of their use. Written consents for bedrail use must be in place. The Medication Administration Record must be correctly endorsed when residents go into hospital. There must be no crossings out in the Controlled Drug Register Administration instructions must be clear and contain all information. This must be discussed with the GP and the pharmacist and the use of ‘as directed’ on medication instructions must cease. This is a repeat requirement. There must be a system in place to ensure all significant dates throughout the year are identified and service users individual preferences respected. All complaints must be addressed within the stated timescales. The staffing on the ground and first floors must be reviewed in line with service users dependency levels. There must be appropriate numbers of staff on duty at all times to meet the assessed needs of the service users. A copy of the staffing review must be forwarded to CSCI. The home must have appropriate staff in place to meet the administration needs of the home. Staff employment records must contain all the information DS0000010946.V317885.R01.S.doc 15/12/06 08/12/06 01/12/06 01/12/06 01/01/07 22/12/06 01/12/06 22/12/06 01/01/07 01/12/06 Page 26 Derwent Lodge Care Centre Version 5.2 18. OP35 17(2) required under the Care Homes Regulations 2001. Staff must not be employed until all required information has been obtained and is satisfactory. Confirmation that all current records are up to date must be forwarded to CSCI. There must be robust systems in place for the management of service users personal monies, and these must be adhered to. Documentation must be accurate and clear. 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP15 Good Practice Recommendations That the thermometer on the fridge on the first floor is reset after each recording to ensure accuracy in recording. It is strongly recommended that the menu review be conducted in line with service user preferences and to include a varied provision of fresh vegetables. Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Derwent Lodge Care Centre DS0000010946.V317885.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!