Inspection on 08/05/07 for Derwent Lodge Care Centre

This inspection was carried out on 8th May 2007.

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

Other inspections for this house

Derwent Lodge Care Centre 13/11/06

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 8th May 2007 10:25 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.V335861.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.V335861.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 Manager Designate (if applicable) Type of registration No. of places registered (if applicable) 020 8844 4490 020 8844 4190 Southern Cross (LSC) Manager post vacant 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.V335861.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. 13th November 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. Southern Cross (LSC) has recently purchased the home. Derwent Lodge Care Centre DS0000010946.V335861.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 16 hours was spent on the inspection process and two CSCI Inspectors conducted the inspection. A tour of the home was carried out, and service user plans, medication records, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The pre-inspection questionnaire has also been used to inform this report. 10 people living at the home, 5 visitors, 12 staff and 2 visiting healthcare professionals were spoken with as part of the inspection process. Completed CSCI questionnaires received from people living at the home, visitors and healthcare professionals have also been used to inform this report. The term ‘service user’ refers to a person living at the home. What the service does well: What has improved since the last inspection? Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 6 This is the first inspection since the home has had new owners. However, the majority of the management and staff are unchanged and it is fair to say that there has been a marked improvement in several areas 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. The summary of this inspection report can be made available in other formats on request. Derwent Lodge Care Centre DS0000010946.V335861.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.V335861.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is available to people interested in being admitted to the home, thus providing them with a good picture of the home and what it provides. People wishing to live at the home are fully assessed prior to admission, to ensure the home is able to meet their needs. EVIDENCE: The Service User Guide information had been updated to reflect the new owners. The document is informative and copies were seen in each bedroom. The Statement of Purpose was also being updated. A list of fees charged and additional expenses information are contained in the Service User Guide. Contracts with terms & conditions were being completed for new admissions and there are several types of contract available, dependent on the payment arrangements for each individual. Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 9 Pre-admission documentation was viewed on each floor. The information was comprehensive and gave a good picture of each persons needs. Additional assessment information was also available, from Social Services or the Primary Care Trust. At the time of inspection some relatives of a person wishing to come and live at the home were shown around and any questions they had were being clearly responded to by the Manager Designate and the Deputy Manager. Derwent Lodge Care Centre DS0000010946.V335861.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 good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is comprehensive and up to date, thus providing staff with the information to meet peoples’ individual needs. The home has input from healthcare professionals and medications are well managed, thus ensuring peoples health care needs are being met. Staff care for people in a gentle and professional manner, respecting their privacy and dignity. EVIDENCE: Service user plans were sampled on each floor. Overall these were comprehensive and provided a good picture of each individuals needs and how these are to be met. There was evidence of service user plans being reviewed monthly and whenever an individuals’ condition changes. Risk assessments for falls had been completed and for one person who had recently had a fall the information had been updated to reflect this. The home is in the process of transferring over to the Southern Cross service user plan documentation. The Manager Designate said that people living at the home and their Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 11 representatives are being consulted regarding their involvement in the compiling and review of the service user plans, so that they can have their say. Four people at the home had pressure sores. Wound care documentation was viewed and this was up to date and recorded the progress of each wound. Pressure relieving equipment in use for each individual had been identified. Some of the information had not been fully transferred to the new care plans and this was discussed with the staff at the time of inspection. It is acknowledged that the old style documentation had also been kept up to date. Assessments for moving & handling were in place and the care plans identified the equipment to be used. Continence assessments had been completed and care plans to address these needs were in place. Nutritional assessments had been carried out and there was evidence of monthly weights being done, with more frequent weights carried out should a person be identified as being at risk. Visits from the GP and other visiting healthcare professionals had been recorded. The Inspectors spoke with 2 healthcare professionals and both said that the staff were helpful and identified any problems. With one exception, risk assessments and written consents for the use of bedrails had been completed. Where this had not been carried out this was discussed with the registered nurse. Medication management was sampled on each floor. Room and fridge temperatures were within safe limits, with air conditioning in place in all the clinical rooms. Lists with specimen signatures and initials of staff were in place. The front page for each person had a photograph and recorded relevant information to include any known allergies. Copies of the new procedures for medications were available. Where a person was refusing their medication this had been clearly recorded and discussed with the GP and the family. For people being fed via a percutaneous endoscopic gastrostomy tube clear instructions for this were in place, and daily recording of the feeding regime maintained. Individual lancets for professional use were being used for blood glucose monitoring and records of blood glucose results and insulin dosages given were clearly maintained. All receipts, administration and disposal of medications had been signed for. Liquid medications had been dated when opened. Controlled drugs are securely stored and records viewed were up to date. Stock control of medications is good with stock balances recorded on the medication administration record (MAR). For one person, two medications were written up ‘as required’ without a dosage being recorded. The Manager Designate explained that discussion was taking place with the GP to ensure all administration instructions are recorded in full. A dietary supplement that requires refrigeration after opening was found in one persons bedroom. This situation was discussed and appropriate action taken to address this. Three registered nurses had recently completed a 6 month medication training course and more staff were booked to attend. A comprehensive monthly audit of medications is carried out and any issues identified are addressed. Medications are being well managed at the home. Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 12 Staff were seen caring for people living at the home in a gentle, caring and professional manner. People spoken with expressed their satisfaction with the care at the home and said that staff are kind and helpful. There was a good atmosphere throughout the home and staff were working well together. Bedrooms viewed had been personalised and people are encouraged to bring in personal belongings in line with fire safety. Personal clothing is labelled and people were dressed appropriately showing individuality. On the morning of the inspection a combined Church of England and Roman Catholic service took place. The Manager Designate said that attention is paid to meeting the religious and cultural needs of all people living at the home. Derwent Lodge Care Centre DS0000010946.V335861.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 is good and information regarding individuals’ hobbies and interests is obtained, thus enabling the activities co-ordinator to plan a programme to reflect these wherever possible. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has a full time activities co-ordinator and an activities assistant. On the day of inspection there was a church service in the morning and a bingo session in the afternoon. The activities co-ordinator has compiled an activities file for each floor. This includes individual information for each person to include interests and abilities. It also states their preference for group and/or 1:1 activities. A diary of activities is kept for each person. The activities programme for the current week was on display and copies were seen in each bedroom. The activities included are varied to include games, quizzes and entertainments. A list of dates throughout the year has been compiled and displayed, to include a variety of religious, cultural and other significant dates, Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 14 so that people living at the home, their visitors and staff are aware of them and they can be discussed, planned for and celebrated. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home. People can receive their visitors in their own rooms or in one of the communal rooms, depending on individual wishes. The home has a useful list of contact details on display in the lobby area, and this includes contact details for the Alzheimer’s Society, Age Concern and advocacy services via the Hounslow Patients Liaison Officer. One Inspector viewed the kitchen. It was clean and tidy and all the records were up to date. The home has a 4 week menu and this had been reviewed in recent months to include more fresh fruit and vegetables. People spoken with expressed their satisfaction with the food provision at the home and confirmed that choices are offered. Drinks and snacks are available at all times. Staff were providing assistance to people who needed it in a gentle manner. One person said that tea was not always served hot and the Manager Designate said that prompt action would be taken to address this. For people being fed via a percutaneous endoscopic gastrostomy tube clear records of the feeding regimes were being maintained. Derwent Lodge Care Centre DS0000010946.V335861.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 good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the people who live there. EVIDENCE: The home has a clear complaints procedure with and this is on display in the home and contained in the Service User Guide. There had been 6 complaints/concerns raised since the last inspection and there was written evidence that these had been recorded and addressed. Overall the people living at the home and visitors spoken with said that any concerns raised had been listened to and promptly addressed. The home has POVA documentation in place and also follows the Hounslow Safeguarding Adults procedures. Training from the Hounslow Safeguarding Adults team had recently taken place, with more planned. There had been no adult protection issues since the last inspection. Derwent Lodge Care Centre DS0000010946.V335861.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 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Audits of the home have been carried out to identify areas of redecoration and refurbishment required, and action is required to bring the home up to a good environmental standard throughout for people to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: Areas of each floor were viewed. Many bedrooms are in need of redecoration and some furnishings also needed attention or replacement. The Manager Designate said that she has identified all furniture in need of replacement in the budget request. A recent environmental audit had been carried out to identify areas needing redecoration, new carpets and replacement soft furnishings. The Manager Designate said this information would be forwarded to the Facilities Manager. The maintenance man does have a list with dates of bedrooms that have been redecorated in the past. The majority of bedrooms Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 17 plus some other rooms have been identified for redecoration, and currently the maintenance man does the painting as well as keeping all the maintenance and health & safety checks up to date and any minor repairs needed. A full redecoration and refurbishment programme, with timescales for completion, must be drawn up and the work completed in a timely fashion. The home has a garden with furniture for people to sit out in during the good weather. 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. Separate sluice rooms are situated on each floor, with electronic disinfector machines. Protective clothing to include gloves and aprons plus disinfectant hand gel was available on each floor. Where infection control issues had been identified for individuals, care plans to address this were in place. Staff had received training on infection control. The home was clean and smelled fresh throughout. Derwent Lodge Care Centre DS0000010946.V335861.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 good. This judgement has been made using available evidence including a visit to this service. Staffing has been reviewed to provide appropriate levels of staffing for the assessed needs of the people living at the home. Training provision is good, thus providing staff with the skills and knowledge to care effectively for people living at the home. Systems are in place for the vetting and recruitment of staff, thus safeguarding people living at the home. EVIDENCE: At the time of inspection the home was staffed appropriately to meet the needs of the people living at the home. Since the last inspection dependency levels had been reviewed and as a result an additional member of staff is now employed on both of the first and ground floors for the morning shift. It was clear from speaking with people living at the home and staff and visitors that this had been a positive move and peoples’ needs are now being better met. There has been an administrator in post since December 2006 and there has been a marked improvement in the administration of the home, especially the maintaining of information for people living at the home and the completion of staff employment records and checks. Ancillary staff are employed in such numbers to meet the needs of the home. Consideration must be given to the possible need for additional hours for redecoration work to bring the home up to a good standard in a timely fashion. (see Standard 19). Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 19 The Deputy Manager said that 65 of care staff are qualified to NVQ level 2 in care or above. A further 9 staff are doing NVQ level 2 and 4 staff are doing NVQ level 3, both in care. 3 sets of staff employment records were viewed. These were up to date and generally contained all the information required under Schedule 2 of the Care Home Regulations 2001. The Southern Cross application form asks the reason for leaving for all previous periods of employment, which is a requirement of the Care Home Regulations 2001. The administrator was able to answer any questions regarding the employment records and had worked hard to bring the files into good order. New care staff receive the Skills for Care Common Induction Standards progress booklet and an example of a part-completed booklet was seen for a new member of staff. The registered nurse responsible for training explained that this booklet is usually completed within 12 weeks. The training records also detailed other training being undertaken. The list of staff training carried out up to April 2007 listed topics to include dementia care training, continence care, medications, wound care and auditing processes. Southern Cross has its own Training Manager and they are due to visit the home in June 2007 to discuss the future training schedule for all staff. Derwent Lodge Care Centre DS0000010946.V335861.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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the experience to manage the home, and is doing so effectively. Further training will enhance her good practices. Good systems for quality assurance are in place, thus providing an ongoing process of management and practice review. Monies held on behalf of people living at the home are being well managed and securely stored, thus safeguarding them. Overall systems for the management of health and safety throughout the home are good, thus safeguarding people living at the home, staff and visitors. EVIDENCE: The Manager Designate is a first level registered nurse and has undertaken recent training in marketing and disciplinary procedures. The Manager Designate was confirmed in post in February 2007 and is in the process of applying for registration with CSCI to become the Registered Manager. Staff Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 21 and visitors said that the Manager Designate is approachable and her door is always open, to allow people to discuss any issues. The Manager Designate was observed conversing with people living at the home in a courteous manner, answering their questions clearly. The Manager Designate is aware of the need to undertake the Registered Managers Award, NVQ in management level 4 and is applying to start the training. She has also undertaken POVA and health & safety update training. Southern Cross has a comprehensive auditing system for quality assurance. This includes a monthly audit of the home and also of the medication management. These audits are thorough and cover most aspects of the home. There is a separate catering audit carried out weekly. These provide a good quality assurance monitoring process for the home. Regular staff meetings are held and minutes taken. Relatives meetings take place every 3 months and minutes of these meetings are available. The Manager Designate and the Deputy Managers visit the people living at the home individually to give them the opportunity to express any issues they may wish to discuss. The administrator manages any monies held on behalf of people living at the home. Individual wallets are available and all monies are held individually, with clear records of income and expenditure being maintained. Receipts are given for all monies received. There is a ‘Personal Allowance Contract’ and this clearly states who is handling the money for each individual and the areas of expenditure. One Inspector checked 3 amounts of money against the records and these were correct. The administrator explained that there had been a change to the system with Southern Cross and a letter had gone out to all representatives managing monies on behalf of people living at the home explaining the new system of the home holding small amounts of money for each person living at the home so that money is available for any expenditure. Records are clear and thorough and the home has a safe facility. One Inspector sampled the servicing and maintenance records. These were up to date and in order. The maintenance man is to receive training in the completion of the new Southern Cross maintenance records and the Manager Designate said that this was being planned. The staff training records viewed recorded that the staff had attended training in moving & handling, fire safety, infection control, food hygiene and other health & safety topics. The Manager Designate explained that action is being taken to train a member of staff to be an in-house trainer for moving & handling. The fire risk assessment had been completed on 23/04/07 and this was a comprehensive assessment of the whole building. No immediate concerns had been identified and routine servicing and maintenance checks had been included in the document. Fire drill records showed that both a day and night time fire drills had been carried out in the last 2 months. Risk assessments are available for equipment and safe working practices, with the new documentation for Southern Cross being introduced. The home has an health & safety committee and they meet and minutes are taken. One recurring issue is the fact that footplates are removed Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 22 from wheelchairs and not replaced. There were several wheelchairs that could not be used due to the loss of footplates, and despite regular discussions with staff this problem persists. Staff must be vigilant and where it is necessary to remove a footplate for any reason, it must be replaced promptly. Derwent Lodge Care Centre DS0000010946.V335861.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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X 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 2 X X X X X X 3 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 3 X 3 X X 2 Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 13(4)&(7) Requirement Risk assessments for bedrails must be completed prior to use, demonstrating the appropriateness of their use for the individual. Written consents must also be obtained. This will ensure that their use is appropriate and any risks minimised for the person concerned. A redecoration and refurbishment plan with timescales for completion must be drawn up to include all areas identified on the budget plan and the recent environmental audit. This is to bring the home up to a good environmental standard. Timescales for completion must not exceed 01/04/08. Wheelchairs must be maintained in safe working order. Footplates must be in place in order for safety to be maintained. Timescale for action 01/06/07 2. OP19 23(2)(b)& (d) 01/06/07 3. OP38 13(4) 01/06/07 Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 25 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 OP19 Good Practice Recommendations Action should be taken to ensure all meal supplements are stored correctly at all times. Planning should take place to allow for the additional hours required to carry out the redecoration necessary to bring the home up to a good standard. Derwent Lodge Care Centre DS0000010946.V335861.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local 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.V335861.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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