Inspection on 24/04/06 for Derwent Lodge Care Centre

This inspection was carried out on 24th April 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 13/11/06

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 Unannounced Inspection 09:45 24 & 27th April 2006 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.V286669.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V286669.R01.S.doc Version 5.1 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.V286669.R01.S.doc Version 5.1 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. 12th December 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. 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. The home has a Registered Manager and a Deputy Manager, plus there is also a Regional Manager for the home. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 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 18 hours was spent on the inspection process. One Inspector carried out a tour of the home, and a selection of service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 10 service users, 11 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: 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 Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 6 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.V286669.R01.S.doc Version 5.1 Page 7 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 & 3. The home does not provide intermediate care. Service users and their representatives are provided with information about the home. Service users are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide documentation was up to date. Copies of the Service User Guide had been provided to each service user able to cope with one, plus copies are available to service users’ representatives. Pre-admission assessments viewed were comprehensive, providing clear information about the service users needs. One had not been signed by the person who had completed it, and this was discussed with the Deputy Manager. Copies of Social Services needs led assessments had also been obtained. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 8 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, 10 & 11 The service user plans were generally up to date and identified the needs of the service users, thus providing staff with clear information of how the service users needs are to be met. The management of medications is improved, but shortfalls on the ground floor potentially put service users at risk. Staff treat service users with courtesy and respect. EVIDENCE: Service user plans were sampled on each unit. Overall these were comprehensive and up to date, giving a clear picture of the service users needs and how these are to be met. There was evidence of monthly updates and also of new care plans being formulated for newly identified needs. Risk assessments for falls had been completed, and there has been a marked reduction in the number of falls within the home. Clear supervision records for the lounge areas are kept for the first floor dementia unit. There was evidence of input from service users and/or their representatives into the service user plans. Documentation for wound care was comprehensive. Some of the old documentation, which had been superseded, needed to be archived and this was discussed with the registered nurses on the units. Assessments for skin Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 9 care, continence, nutrition and moving & handling were complete, and care plans had been formulated where needs were identified. For one service user with dementia care needs, the admission information in respect of their mental health had not been completed. For one service user a behavioural chart record had been maintained, but there was no further information as to the reason for this or the outcome of the findings. This was discussed with the Registered Manager. Risk assessments were in place for any risks identified, to include bedrails with written consents for use, plus incidences of noncompliance with any areas of care. Records of action to be taken in the event of deterioration in the service users health were clearly recorded, following discussion with service users and their representatives. The shortfalls identified in the service user plans are minor, and with more attention to detail this should be easily addressed. Medication records were sampled on each floor. Receipts, administration and disposal of medications had been recorded. It was noted that on all floors some administration instructions printed on the medication administration record (MAR) charts were printed as ‘as directed’ and this is not acceptable practice. This must be discussed with the GP to ensure that clear instructions are included on the MAR chart for all prescribed medications. The home uses a monitored dosage system, but some of the medications on each floor had been dispensed in boxes, and staff reported that this had also happened the previous month. The Registered Manager said that she had made an appointment to discuss this with the dispensing pharmacist, in order to maintain a consistent method of medication management. On the second floor the medications were being well managed and the only shortfall identified was the lack of dating one of the liquid medications when opened. On the first floor liquid medications had not been dated when opened. The maximum fridge temperature had been reading at 29° centigrade for some time. The registered nurse was asked to investigate and address this issue. Otherwise medications were being well managed. On the ground floor several shortfalls were identified. The administration instructions for one medication had not been re-written to clearly identify a dosage change, although it was ascertained that the correct dose was being administered. In some other instances instructions needed to be re-written for clarity. In one instance where a medication had been returned after a respite admission, this had not been recorded. There were overstocking issues noted, and the need to ensure that stocks of medications are checked before reordering was discussed. This is a repeat finding. On the second day of inspection action had been taken to address this. The need for vigilance when ordering repeat prescriptions was discussed. The wrong lancets had been ordered for the blood sugar monitoring system, and the correct ones were delivered on the day of inspection. Staff were seen caring for service users in a gentle and respectful manner. Service users spoken with said that they are well cared for at the home. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 10 Visitors spoken with said that they are made welcome and that representatives are kept up to date with any issues. Service users clothing is labelled. On the first floor dementia care unit, staff were observed being patient and gentle, especially with confused and agitated service users. Service user plans viewed contained information regarding the care wishes of service users and their families in the event of the service users condition deteriorating, to include information regarding their wish to stay at the home or to be hospitalised in their last days. This information was signed and dated. Visitors are able to stay with service users during periods of illness and during their final days should they wish to. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 11 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): 12, 13, 14 & 15 The home provides an activities programme to keep the service users active and stimulated. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Information regarding advocacy services is available, thus ensuring service users rights and interests are upheld. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: General care plans for service users social and leisure interests were seen. The home has an activities co-ordinator and an assistant activities co-ordinator. At the time of inspection activities were taking place to include a game of bingo. On the second day of inspection the Inspector met with the activities coordinator. An activities programme for the month was available and had a variety of activities throughout the week. The activities co-ordinator said that for most of the group activities she alternates between the three floors so that each unit has some activities in their area. Clear records of activity participation by service users are maintained, and also records of their individual interests. There was a good range of activity ideas available, and it was clear that the activities co-ordinator arranges activities that service users are interested in and able to participate in, and also plans seasonal activities. Outings are arranged every 2 weeks apart from during the cold winter months. The activities co-ordinator is due to attend dementia care training, to include Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 12 activities provision and thereafter will be reviewing the activities programmes to include activities specific to the needs of service users with dementia care needs. In conjunction with this, the importance of knowing and understanding service users diagnoses was discussed as this could provide valuable information regarding the manner in which some service users react to certain activities. The Activities Co-ordinator said that she would discuss this with the nursing staff. It was clear that the activities staff gain much satisfaction from their roles. Visitors spoken with said that they are made very welcome at the home. Service users can receive visitors in their own rooms or in one of the lounges, according to their wishes. The home has information on advocacy services available. At the time of inspection only one of the service users was managing their own finances, but some other service users sign for and collect money received on their behalf by the home. Bedrooms viewed were personalised and service users are encouraged to bring in some of their own possessions in line with fire safety. The kitchen was clean and tidy. Kitchen records to include cleaning schedules, temperature records, risk assessments and health & safety information were available and up to date. The menu corresponded with the meals being served. Service users meal choices are ascertained and recorded. There was evidence that some visitors have meals at the home and visitors spoken were pleased that this option is available to them. Service users spoken with expressed their satisfaction with the food, to include vegetarian and liquidised food options. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 13 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 & 18 The home has a satisfactory complaints system with evidence that service users and representatives concerns are listened to and acted upon. Staff have knowledge and understanding of adult protection issues which protect service users from abuse. EVIDENCE: The home has a clear complaints procedure, which provides contact details for the home, the head office and the CSCI. 5 complaints had been received by the home since the last inspection and these had been comprehensively recorded, with letters of outcome available. Two complaints have been received by the CSCI since the last inspection. In both cases the home was already aware of the issues and had taken action to address them. The Registered Manager is clear about the protection of vulnerable adults (POVA) procedures to be followed in the event of an allegation. Staff spoken with showed a clear understanding of POVA and Whistle Blowing procedures, and said that they would report any concerns. Staff had received POVA training. Several allegations of theft have been reported to the Safeguarding Adults Co-ordinator at Hounslow Social Services. The home has put in place systems to try and minimise this. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 14 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, 20, 21, 22, 23 & 26 The home is purpose built to meet the National Minimum Standards for Older People and Younger Adults. Programmes for redecoration and refurbishment are in place, and in the main this provides a well-maintained and homely environment. Infection control procedures are in place and adhered to, thus safeguarding service users. EVIDENCE: Following the last inspection, a copy of the redecoration and refurbishment plan for the home was forwarded to the CSCI. There were no obvious issues with fire safety or in relation to environmental health issues noted at the time of inspection. Each floor has a lounge and dining facilities. An activities room and a multi-use room were available. There is a well-maintained garden, which can be accessed from the ground floor and there was evidence that service users are encouraged to participate in gardening activities. The furnishings in the communal areas were satisfactory, and the Registered Manager said that replacements are ordered as necessary. The Registered Manager said that Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 15 external decorators have been contracted to redecorate the first floor communal areas and new flooring has been ordered for the two lounges on that floor. Some of the baths in the assisted bathrooms did not appear to be fully functioning, and on the second floor the bath shower attachment was broken. The Registered Manager said that she would investigate this and where necessary arrange for repairs. The shower room on the second floor smelled very damp and there was stagnant standing water noted in the drainage outlet, which was of concern. The flooring in this and one shower room on the first floor requires replacing as a matter of priority. Some of the flooring in bathrooms was quite marked and worn. The Registered Manager said that she is trying to address these issues. The sluice room on the first floor had empty boxes and full black bags in it, and was malodorous. Staff were asked to address this promptly. This area was reviewed on the second day of inspection and the sluice room was clean and tidy and no odour was noted. The home has two passenger lifts available, and a keypad system for the lift and the exit doors, for security. Suitable moving & handling equipment was seen in the home, and the specific equipment to be used for each individual is recorded on their moving & handling assessment. There is a call bell system in each room, and where service users are unable to use the call bell this is identified in the service user plan. It was noted that for service users in their bedrooms, call bell leads had been placed in easy reach. All bedrooms in the home are single and have an en suite to include toilet and wash hand basin facilities. Samples of bedrooms were viewed on each floor and these were personalised and suitably decorated. The redecoration & refurbishment programme identifies the bedrooms due for redecoration. Flooring in one room was very marked, and the Registered Manager said that this would be being replaced. The furnishings viewed were generally of good quality. All bedroom doors are lockable, and all beds are height adjustable. The home was pleasantly warm, with the exception of the first floor where it was very warm and somewhat uncomfortable. Whilst it is accepted that service users with dementia do not always recognise when they are cold, the temperature needs to be maintained at a comfortable level for all service users. The Registered Manager said that she would see what could be done to address this. The lighting was satisfactory throughout the home. Records of hot water temperature checks are maintained. The laundry room was viewed and was clean and tidy. A leak was noted on the washing machine liquid dosing system and is to be addressed. Items of clothing viewed were identified to the individual. With the exception of the aforementioned shower and sluice rooms, all areas of the home were clean, tidy and odour free. Infection control procedures are in place in the home. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 16 Protective clothing to include gloves and aprons were available, and eye protection is provided in the laundry, in line with COSHH procedures. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 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, 28, 29 & 30 The home was adequately staffed to meet the needs of the service users. Systems for vetting and recruitment practices are in place and protect service users. Staff receive training to enable them to meet the needs of the service users. EVIDENCE: The home was staffed to meet the needs of the service users. The staffing rosters showed evidence that any shortages in staffing had been covered. On discussion it was noted that registered nurses on the first floor dementia unit do not have a post-graduate qualification in dementia care. Two of the registered nurses have a qualification in mental health. This issue needs to be addressed, and action taken to ensure that the floor is managed in line with current dementia good practice. The home has 2 care staff with certificated NVQ in care level 2. The management reported that the home is awaiting certificates for 10 more care staff who have completed their training, plus 3 NVQ portfolios are in the process of being verified. There are plans for 12 staff to commence NVQ in care training in the near future. Staff employment records were sampled and those viewed were complete and contained the information required under Schedule 2 of the Care Homes Regulations 2001. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 18 The Registered Manager said that the company has introduced a new Induction and Foundation programme, combining the two sections of training. Copies of the training were seen on the second day of inspection, and contained the Skills for Care standards. The documentation does not identify that the induction and foundation programmes have been combined, and this needs clarifying. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 19 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, 35, 37 and 38 The Registered Manager has a good understanding of the areas in which the home needs to improve. Planning was in place to identify how this improvement is going to be managed and achieved. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Systems for the management of service users monies are in place and secure facilities are available. There has been a marked improvement in the record keeping in the home, thus ensuring the efficient running of the home and offering protection to service users. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with a diploma in management studies. There is also a Deputy Manager who works alongside staff within her role. Several of the staff spoken with said that the Managers are approachable and they do take time to visit the floors and find out what is Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 20 going on within the home on a day-to-day basis. One Inspector spoke with two student nurses on placement in the home and both said that the placement had been a good experience and they had been supported by management and staff. Visitors spoken with said that they can approach the management and staff with any issues, which are promptly addressed. The business and development plan for quality assurance had not yet been formulated for the current year. This is a repeat finding. The home has a quality assurance system in place and there was evidence of regular auditing taking place, to include service user plans, medications, accidents, pressure sores and a Regional Managers audit. Relatives meetings are held and minutes of these meetings are viewed. A stakeholder satisfaction survey was undertaken in November 2005 and a copy has been provided to the CSCI. Regulation 26 visits are carried out and copies of the reports are forwarded to the CSCI. Records for service users monies were sampled and these were in order. Clear systems are in place for the management of service users monies and receipts for income and expenditure were available. The administrator said that there had recently been a finance audit carried out by head office. There was a marked improvement in the standard of the record keeping in the home. Some further work is required, and the improvements made must be maintained. Generic risk assessments for safe working practices are place, and these are comprehensive. Servicing and maintenance records were viewed at random and were up to date. Fire drill and fire safety records were up to date and there was evidence of fire drills taking place for both day and night staff. There was also evidence that staff had undertaken moving & handling training. A health & safety audit had been undertaken and any shortfalls had been addressed. The certificate for Legionella testing carried out on 19/05/05 had not yet been issued, but there was clear evidence that the testing had been done and that the home was following this up to obtain the certificate. Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 3 3 Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 22 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 OP8 Regulation 17(1)(a) Requirement Admission information must include details of any specialist mental health needs and how these are to be met. 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. (previous timescale 14/01/06 not met) Where there is a dosage change new administration instructions must be clearly recorded on the MAR chart. A record of any medication returned to the service user must be kept. Ordering and checking of prescriptions must be more thorough to avoid stockpiling medicines. (previous timescale 01/01/06 not met) Administration instructions must be clear and contain all information. This must be discussed with the GP and the use of ‘as directed’ on medication instructions must cease. DS0000010946.V286669.R01.S.doc Timescale for action 01/06/06 2. OP9 13(2) 24/04/06 3. OP9 13(2) 24/04/06 4. 5. OP9 OP9 13(2) 13(2) 24/04/06 24/05/06 6. OP9 13(2) 01/06/06 Derwent Lodge Care Centre Version 5.1 Page 23 7. 8. OP24 OP21 23(2)(b) 23(2)(b) 9. OP21 13(3) 10. 11. OP26 OP33 23(2)(c) 25 The flooring in the two shower rooms and the ground floor bedroom must be replaced. The flooring in the bath facilities must be reviewed and where it cannot be cleaned, action taken to replace it. Action must be taken to ensure the water outlet in the second floor shower room drains effectively and that standing water is not left. The shower attachment on the bath must be replaced. The leaking washing machine liquid dosing system pipe must be replaced. 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. (previous timescale 01/04/06 not met) 01/06/06 01/07/06 01/05/06 21/05/06 01/06/06 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 OP8 OP25 Good Practice Recommendations It is recommended that wound care documentation be archived when superseded by up to date documentation, in order to keep the information current. It is strongly recommended that regular environmental temperature checks be carried out on the first floor to ensure the ambient temperature is maintained at a comfortable level for the service users. Training documentation should clearly identify the foundation element of the training programmed. 3. OP30 Derwent Lodge Care Centre DS0000010946.V286669.R01.S.doc Version 5.1 Page 24 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.V286669.R01.S.doc Version 5.1 Page 25 - 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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