Inspection on 10/06/08 for Devon Lodge

This inspection was carried out on 10th June 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Dalewood Respite Care

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Devon Lodge 23a Grange Road Hedge End Southampton Hampshire SO30 2FL Lead Inspector Beverley Rand Unannounced Inspection 10th June 2008 10:30 Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devon Lodge Address 23a Grange Road Hedge End Southampton Hampshire SO30 2FL 01489 785177 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) Hazelwood Care Limited Post vacant Care Home 14 Category(ies) of Learning disability (0) registration, with number of places Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 14. Date of last inspection N/A Brief Description of the Service: Devon Lodge is a care home for up to fourteen adults with a learning disability. There is a communal lounge/dining room and a conservatory. All bedrooms are single. There is a garden with garden furniture. The current fees range from £423 to £1036 a week. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was the first key inspection since the service has been registered. Further to concerns raised by the local authority adult services, we brought the inspection forward from the date it was planned for. The inspection took place over two days and was unannounced on the first day. During the inspection we looked at records, saw the communal area, spoke with one service user, four staff and the acting manager. On the second day we were able to speak with the provider who was visiting the home. What the service does well: What has improved since the last inspection? What they could do better: Care plans were in place for all service users but some were not accurate or up to date. Care plans were not always followed and were not all detailed enough in specific areas. Activities are offered but did not always appear to meet individual needs. Some service users did not receive attractive meals or Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 6 adequate choice. Some service users did not receive medication as prescribed and the home could not account for all the medication which entered the home. Recruitment procedures were not followed and staff had been employed without the correct checks being in place. There is a quality assurance system in place but this needs further development to be fully effective. The provider has not provided the necessary feedback to the acting manager and she has not been able to dedicate all her hours to management tasks. 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. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that prospective service users have their needs assessed before moving into the home. EVIDENCE: We looked at an assessment for a new service user who has recently moved into the home. The acting manager explained that the person had moved into the home at short notice so the process had not followed what would usually happen. There was a care management assessment on file and the care plan was being developed. The acting manager said that she would usually visit the person and invite them to spend time in the home as part of the assessment process. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users have a care plan but they are not all up to date or relevant to current assessed needs and not always followed. Service users can make decisions and can take responsible risks. EVIDENCE: We looked at the files for five service users which contained daily records, care plans and risk assessments. Each file had a lot of information about the service user and there were risk assessments for activities and environmental risks. However, the risk assessments identified risks but were not always detailed enough to show how risks might be reduced without restricting service users’ every day lives, for example, going into the kitchen. Plans identified challenging behaviours and did detail strategies. However, we had concerns about the nature of the strategies and the implementation of the plans. One service user’s file noted that the service user was not to go out with another Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 10 named service user as part of the strategy to manage behaviours. When we spoke to staff about this, they said they did go out together and got on well when out. We spoke to the acting manager about this but she was not aware that the care plan was not being followed. The care plan for another service user identified a particular issue and clearly stated that the action stated could be done, ‘against their will’. The procedure required three staff to do what was written in the plan. We spoke to staff who said they had never done this particular task against the service user’s will and had never needed three staff to undertake it. We spoke to the acting manager about the care plan and she said she did not know this was in the plan as it had been written by previous management. We were concerned that although staff were not following the plan, new staff could. We were also concerned as there was no evidence showing how the plan had been agreed and with whom. Daily records were completed but content was often limited, stating that a service user, ‘had a quiet night’, ‘had a good day’, or was, ‘okay’ and ‘fine’. Incidents of challenging behaviour were recorded but violent incident reports were not always completed. Care plans identified mental health issues, such as the risk of depression for a particular service user but there did not appear to be any monitoring of this, such as what could bring on episodes, what action to take and so on. A service user with diabetes did not have a care plan with regard to how or when blood tests should be taken. We did not see evidence that care plans were developed or reviewed together with service users. However, we spoke with the deputy manager who said that plans are reviewed each month and staff sit with service users and involve them. We saw evidence that service users make their own decisions about every day life and undertake responsible risks, for example, going for a walk. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides activities but service users may benefit from closer attention to individual and more varied choices and from closer monitoring of care plans. Relationships are promoted and individual choices were observed by staff. Service users benefit from varied menus but some may benefit from improved presentation of food and more choice. EVIDENCE: Some service users attend a day centre during the week. Other activities include going out for a drive (often whilst picking up service users from the day centre), going shopping, going to the bank with staff, dancing, visiting the Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 12 garden centre or going for a walk. Musical entertainment comes to the home once a week. An aromatherapist also visits the home. Staff told us that activities have improved as they can go out more with more staffing. Some service users go to church and one goes to football. Staff also said they had seen a flyer for line dancing classes and were thinking about who may like to go. Activities often appeared the same for each service user and a staff member who was asked agreed with this observation. Generally an activity was recorded every few days. The care plan for one service user stated that due to the risk of depression, they needed to have a structured day with plenty of activities of their choice. Records showed those activities included those detailed above the amount of activity did not sufficiently reflect the care plan. We spoke to a service user who said they would like to go out more, but we spoke to staff who said that different activities had been provided, but that service users had chosen not to continue with them. We saw evidence in files that service users see family members and go out with them. Throughout the inspection we saw service users spending time as they wished, for example, completing puzzles. The home has pet guinea pigs which service users can help look after if they wish. We spoke with the cook who said there was a two week menu which was not always followed. We were told that service users would have a cooked meal at lunchtime unless they have been out all day. We asked how service users could choose their meal and we were told that those who ‘could respond’ were asked. For those who could not respond, if they were eating well, the menu would be kept to. A service user told us they did not have any choice of food and that there were things they did not like but were given anyway. However, whilst we were talking to the service user, the cook asked the service user what they would like as she knew they had said they did not want the meal on offer. The service user told the cook very clearly what she wanted. Records showed alternatives to the main meal although the staff had stopped recording what people ate at teatime if they did not have the main option. Some service users had special dietary requirements such as food cut up or pureed and drinks thickened. We spoke to the cook and staff about these needs and found they knew who needed what and ensured that they followed the guidelines. However, we were told that the components of a meal were pureed together. Good practice would be to puree the food separately to enhance visual presentation and taste. We spoke to staff about this and one said they had left messages for staff to puree separately but another staff member felt it was all right as the service user could not see. We spoke with the acting manager about this who said she had identified this issue when she Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 13 started working at the home, but that staff had continued with pureeing the food together. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was able to evidence that staff work with service users in ways they prefer and that healthcare professionals are involved. Medication administration practices and procedures put service users at risk and training may not be adequate. EVIDENCE: We did see evidence that staff were working with service users in ways which reflected service users’ preferences. The acting manager told us that male staff would not support female service users with personal care. Specialist support has been provided from professionals such as speech therapists. Guidelines have been given to the home, for example, to puree food or thicken fluids for particular service users. Staff confirmed that they follow these guidelines. Records showed that healthcare professionals are involved with service users and that service users visit them in the community where possible. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 15 The Medication Administration Records, (MAR) contained photographs of service users which is seen as good practice. However, there were numerous gaps in the MARs sheets where they had not been completed. We were not able to determine whether the medication or prescribed creams had been administered but not signed for, or not administered. One MAR sheet had tiny pieces of paper stuck over the signature for two occasions. No-one knew why this was the case and surmised that perhaps someone had signed in the wrong place. The MAR sheet for one service user showed a gap from the previous evening. The tablets were still in the blister packs and no-one knew why the service user had not had the tablets. Records showed that another service user missed five doses of a painkiller within 3 days. Four daily doses were prescribed. The reason noted on the MAR sheet was, ‘could not find any’. We found that there was a supply of the painkiller stored in another part of the home, apparently because the medication cupboard was not big enough. Other staff had known where the supply was and another staff member had phoned the deputy manager to find out where they were. No-one had noticed the reason the medication had not been given or sought to address the issue before the next medication was due. The acting manager felt that the service user did not really need the painkiller and that it had been continued to be prescribed for other reasons. We also found that a service user had been prescribed anti-biotics on a Friday evening but had not had the first dose until Sunday morning. The acting manager told us that she had faxed the chemist and she expected that they would provide the medication quickly in the blister pack system used by the home. However, she was informed by staff on the Saturday that the chemist did not do this type of work on Saturday and so the prescription was taken to a chemist on the Sunday. The acting manager again felt that the prescription had been given as a precaution rather than as a result of a proper diagnosis. The home has inadequate audit trails for medication coming into the home. The home could not account for two types of painkiller. The MAR indicated a certain number should have come into the home but that a lower number had actually come in. No-one was aware as to why the records did not tally and whether there were any missing on coming into the home. A message was seen in the communications book which stated a different number of the same drug could not be found yet no action was taken. The records for a different painkiller were also unclear and it was not possible to see if any were missing or not. We were told that all staff had undertaken training provided by the chemist about the blister pack system in use by the home. The acting manager said staff had also completed a course in medication and we saw certificates. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 16 However, it was unclear as to the content and depth of the course and the acting manager agreed to look into this and let us know. We have not yet received any other information in this regard. One staff member told us she had completed a three month course in the safe administration of medication. The home does not currently have any controlled drugs but we were told that if they did, the drugs would be stored in a tin inside a locked cupboard. The regulations have recently changed and are specific with regard to the type of storage needed to comply with the regulations. A recommendation is therefore made in this report. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place to enable service users to complain. Systems are not robust to ensure service users are protected from abuse. EVIDENCE: The home has a complaints procedure which is displayed in the hall and service users have a copy in their rooms. The procedure gives details of the timescales within which the home will respond if a complaint is made. The home has provided training regarding the protection of vulnerable adults to staff. A new staff member said they had received training as part of the induction process. We spoke with staff about what they should do if they suspected abuse had occurred. One said they would report it to the manager and thought the manager would give them a warning. Another said they would report it to the manager and that perhaps the provider would investigate. Both did say they could also report to the care manager. The home has a copy of the Hampshire County Council’s procedure but this was not the most recent. We advised that the latest one could be downloaded from the Internet. The home has its own policy which is generally based on the Hampshire procedure and was not clear about the lead role of the local authority adult services. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 18 The home is currently subject to a Safeguarding Adults investigation by the local authority adult services. The local authority started these proceedings in response to information it received about service users not as a result of the home making a referral. As detailed under the staffing standards outcome, staff have been recruited without the necessary checks being completed. This has the potential to put vulnerable service users at risk from people who may not be suitable to work in this environment. The home assists service users with managing their money. Care plans identified individual needs in this regard. We looked at the records and monies held for four service users and found that they matched. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and homely environment. EVIDENCE: We saw the communal areas, the kitchen and one of the service users’ bedrooms as the door was open. The lounge area had been moved around so that the medication and staff desk were in a corner of the room. The home was clean and homely in its appearance. Staff told us the bedrooms were clean and service users had their own furniture. The home has a maintenance log book where areas needing attention can be communicated to the maintenance person. The book showed maintenance was carried out in a timely fashion. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home provides training to staff and staff have relevant qualifications. The home does not have robust recruitment procedures in place which has potentially put service users at risk. EVIDENCE: We looked at the recruitment records for two new staff who were working in the home. The first file did not include an application form, a current Criminal Records Bureau, (CRB) check or a Protection of Vulnerable Adults, (POVA) check. The manager told us that the staff member had been interviewed under previous management and that the person was recruited through a recruitment agency. The agency had provided two references from the previous care employer but these had been written four months before the person started work. The acting manager had written to the previous employer again to seek a more recent reference but this had been received after the person started work. The acting manager said she had applied for a CRB check. During the inspection she telephoned the umbrella body who deals with the CRBs for the Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 21 home but was told she did not need a POVAFirst check. She did not know why and did not ask why. The second person was employed through the same recruitment agency. The file did contain an application form but there was no CRB or POVAFirst check. There was one only reference dated November 2007 which was not addressed specifically to the home. The acting manager said the person had brought a pack from the agency which had included references but she could not find the pack. She had applied for a CRB but the form had been returned as being incomplete. The acting manager said the deputy manager had received a telephone call from the umbrella body when she was on leave, saying that the POVA check was clear. The person started work on 14th in the absence of the acting manager, who said she would not have recruited the person that quickly as she had not sent off for other references. There was no record as to what date the telephone call had been made. During the inspection the acting manager asked the umbrella body to send her written confirmation of the completed check, which they did, dated the 11th June. The home has a training programme in place which includes health and safety; infection control; moving and handling; first aid; food hygiene and dispensing medication. New staff undertake induction training and four staff had also completed the Learning Disability Award Framework which is specific to the service users who live at the home. The training record showed that only one person had completed training in challenging behaviour but the acting manager said more had done training in this area and that there was a record on the computer. Some staff had some level of training about dementia. Staff have had training in specific areas such as diabetes and stoma care. Five staff have achieved the National Vocational Qualification in care, level 3 and two have achieved level 2. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management arrangements mean the home is not well run to ensure the wellbeing of service users. There is a quality assurance system in place but needs further development. The home is run with regard to health and safety guidelines. EVIDENCE: The home was registered in February as being run by a new organisation with the existing manager in place. However, the manager has since left and a new manager appointed. The acting manager is qualified and has applied for registration with the Commission. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 23 It is a requirement under the regulation of care homes that we are informed when management arrangements change. The provider did not write to us to advise us of the changing management. We wrote to the provider about this but he did not reply. He told us during the inspection that he had not received the letter. The acting manager told us that she only spends about half of her weekly hours working on management tasks. The rest of the time is spent working with the staff team and service users. Due to the issues raised in this report we are concerned that this arrangement is not sufficient to ensure the well being of service users and the good running of the home. The acting manager also told us that she did not receive any supervision or feedback from the provider. The provider has not provided the acting manager with his reports under Regulation 26. The acting manager told us that she has asked for them. On the second day of the inspection the provider visited the home and brought copies of the Regulation 26 visit reports, as the acting manager had asked him on the first day of the inspection. We looked at these reports following the inspection but found that they were a list of tasks rather than an in depth look at the conduct of the care home. Regulation 26 is clear about what the provider must do. Whilst the home does give some good and adequate outcomes, the issues raised as providing poor outcomes would indicate that management arrangements for the home do not protect service users. We saw six service user surveys which had been completed recently which were positive in their responses. The home has service user meetings which the acting manager said they were seeking a suitable format for. The home is run with regard to health and safety. We were told that cleaning fluids were locked away and that there were information leaflets about them. Risk assessments were in place for window restrictors and hot water temperatures. The portable electrical equipment was tested recently. Fire equipment has been tested regularly and updated as necessary. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 2 X X 3 X Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 25 N/A Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 (2,b) Requirement Service user plans must be reviewed so that they are accurate and up to date to ensure staff can support service users in ways which monitors and meets their needs. Service users must receive their medicines as prescribed by their doctor to meet their health needs. Complete and accurate records of medicines received into the home and given to people must be maintained so that the home can show that people get their medicines. Audit trails must be in place so that the home can account for all medication entering the home. 4 YA34 19 Persons must not be employed to work at the care home unless they are fit to do so. The information and documents specified in Schedule 2 must be obtained before a person is DS0000071476.V366283.R01.S.doc Timescale for action 31/07/08 2 YA20 13 (2) 24/06/08 3 YA20 13 (2) 24/06/08 24/06/08 Devon Lodge Version 5.2 Page 26 5 YA39 26 (4, 5) 6 YA37 12 allowed to work in the care home so that service users can be protected The registered provider must 31/07/08 complete written reports as detailed in the regulation and supply a copy to the person managing the home to assist with quality assurance and good outcomes for service users. The registered provider must 31/07/08 ensure that the person managing the home is able to spend sufficient time on management tasks to ensure the home is effectively managed. 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 YA17 YA20 Good Practice Recommendations Service users who need their food pureed should have their food presented in an attractive way and with regard to taste and choice. It is recommended that a Controlled Drugs cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973, is provided for the secure storage of any Controlled Drugs which may be prescribed for service users in the future. Devon Lodge DS0000071476.V366283.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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