Inspection on 08/01/07 for Doubleday Lodge LSC

This inspection was carried out on 8th January 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

Doubleday Lodge LSC 18/12/08

Doubleday Lodge LSC 14/02/06

Doubleday Lodge LSC 22/07/05

Doubleday Lodge LSC 03/12/04

Doubleday Lodge LSC 14/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Doubleday Lodge LSC Glebe Lane Sittingbourne Kent ME10 4JW Lead Inspector Sue McGrath Key Unannounced Inspection 8th January 2007 09:30 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 Doubleday Lodge LSC DS0000037864.V326010.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. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Doubleday Lodge LSC Address Glebe Lane Sittingbourne Kent ME10 4JW 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) 01795 671411 Kent County Council Mrs Jennifer Langthorne Care Home 36 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (36) of places Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration applies to one (1) person whose date of birth is 03.12.1924 and should revert to Older Persons only should this placement cease. 14th February 2006 Date of last inspection Brief Description of the Service: Double Day Lodge is owned and run by Kent County Council. It is an Old Persons Direct Service Unit (OPDSU). It is located on the edge of a large residential estate to the east of Sittingbourne and offers accommodation on two floors for up to 36 older people, all in single rooms. It is close to a bus route and there are small shops within walking distance. There is ample parking to the front and the side. There are two garden areas to the rear of the building. The home has 36 bedrooms, 9 of which are on the ground floor and 27 on the first floor, 13 of these have en-suite facilities. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on 8th January 2007. The key inspections for care home services are part of the new methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and further feedback is gained through surveys sent to service users and relatives and information provided from professionals associated with the home, wherever possible. The actual date of the site visit is unannounced. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Some judgements have been made through observation only. Overall this was a positive inspection with generally good outcomes for service users. Fees: £343.33 per week-Care managers assess individual clients. What the service does well: Double Day Lodge provides a homely, comfortable environment in which to live. The feedback received from residents, families and other professional connected with the home was very positive. Comments like ‘‘Staff always help me in a wheelchair’, ‘I am very happy here’ ‘I could not be looked after better’ were made by some residents. One care manager stated ‘‘I have always found Double Day Lodge to be one of the elite home’s in the county. Everyone from the manager to the housekeeping staff are always very polite and keen to help. They are all very proud of their home and rightly so in my opinion (PT). A local G.P. was also very complimentary. Residents confirmed the food was very good and they could have snacks and drinks when they wanted them. All of the residents spoken with said how much they enjoyed the recent Christmas celebrations. Staff morale appears good and good interaction was seen between staff and residents. Residents were very complimentary about all staff. Comprehensive care plans are in place for all residents and the residents needs were well met. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Doubleday Lodge LSC DS0000037864.V326010.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 Doubleday Lodge LSC DS0000037864.V326010.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, 4, 5, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the information they need to make an informed choice about moving into the home. A written statement of terms and conditions protects resident’s legal rights to occupancy. Residents benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home had a comprehensive Statement of Purpose and a Service User Guide, however with the home now only admitting short term care clients this needs to be reflected in these documents. The home currently has thirteen short-term beds and twenty-three permanent beds. Five residents files were viewed; some of permanent residents and some short term care clients. All were found to contain comprehensive information about the service users. Some core assessment or a joint assessment (undertaken by a care manager and hospital or community nurse) were seen. This enabled dependency levels to be accurately assessed and ensured the home could met the needs of the service users. Families were involved in the development of care plans and one comment seen in the home’s comment book was ‘I have just read my mums Care Plan and think that is a very accurate assessment of her needs. I am very pleased with the way she is being looked after. She is very happy here.’ All files contained written statements of terms and conditions. The home has also produced a admission procedure checklist to ensure a smooth admission into the home occurs. The home is sometimes asked to take ‘emergency’ or urgent admissions. There are guidelines to staff about this and checklists that need to be used to ensure that the home does not admit residents out of category. The registered manager confirmed that every effort is made to encourage service users and /or their families to visit prior to admission. The home does not offer intermediate care. Doubleday Lodge LSC DS0000037864.V326010.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are clearly set out in care plans ensuring that their assessed needs will be met. Residents are protected by the home’s policies and procedures regarding medication and they can be confident that their privacy and dignity will be considered important and their independence promoted. EVIDENCE: Five care plans were viewed and were found to clearly laid out and contain all the relevant information to ensure a high level of care is offered. During the last inspection it was recommended that risk assessments for pressure ulcers, nutrition and falls to be improved; although this work had not been fully Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 11 completed it was evident that some work had been undertaken and was ongoing. The recommendations will remain in place. Care plans were signed by residents or families were appropriate. The care plans clearly show that health care professionals were involved with residents as required. General practitioners were called when necessary and the registered manager explained that there is a very good working relationship with local community nurses who regularly come into the home. One comment card from a local G.P. stated ‘the home is excellent in all respects’. Chiropody, sight tests and other health care providers were facilitated on behalf of residents. Evidence was seen that care plans were regularly reviewed. The home’s system for administering medication followed the guidelines produced by the Royal Pharmaceutical Society of Great Britain. No errors were found on the recording sheets and the home had a robust system in place when re-ordering medication to ensure that regular supplies were maintained. Only one resident chose to self medicate. This medication was held securely in a locked drawer in the resident’s bedroom and a full risk assessment had been completed. During the inspection staff were seen to be treating residents with respect and courtesy. All of the residents spoken with were very happy with the way they were treated at Double Day Lodge and comments like ‘Staff always help me in a wheelchair’, ‘I am very happy here’ ‘I could not be looked after better’ were made. Talking to staff confirmed that they always encouraged residents to make as many decision about their personal lives and choices where possible. Support was given when choices were difficult to make. Residents also confirmed that at private times like when having a bath staff respected their dignity and privacy. One resident said ‘It’s nice because I don’t get embarrassed during bath times’. All residents had single rooms. Residents’ preferences for how they wish to be addressed were recorded within their care plans. The facilities for making phone calls in private were no longer available, however residents could use the phone in the office. Staff and residents confirmed that personal mail is passed to residents unopened. There were facilities for meeting with visitors in private. A comment from a local Care Manager stated ‘I have always found Double Day Lodge to be one of the elite home’s in the county. Everyone from the manager to the housekeeping staff are always very polite and keen to help. They are all very proud of their home and rightly so in my opinion (PT) Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents’ expectations and preferences regarding activities are being satisfied. Residents are supported to maintain contact with family/friends and are able to exercise choice giving them control over their lives. Residents receive a wholesome, appealing and balanced diet in pleasant surroundings. EVIDENCE: Many of the residents spoken with were unhappy with the level of organised activities offered. Comments like ‘I get very bored’ ‘There used to be more activities and ‘I really miss the trips out’ were made to the inspector. This was discussed with the registered manager who confirmed that staff did not have dedicated time for activities and although they tried to organise some activities they were very busy carrying out care tasks. When staff were spoken with they confirmed that they would like to spend more time on activities but the rota Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 13 did not allow for this. Serious consideration must be given to dedicating regular activities hours to ensure that residents are given the opportunity through leisure and recreational activities in and outside the home, which suit their needs, preferences and capacities. This is a major issue for some of the residents. All residents spoken with stated how much they enjoyed the Christmas activities, which included a pantomime and sing a longs. Some said they wished entertainers came in ore often. All commented on how nice the Christmas food was and how hard staff worked to ensure they all had a good time. Relatives said that they were always made welcome when they visited and they could visit their relative in private if they wished. There were no restrictions on visiting times although people were asked to avoid mealtimes if possible. There was information available about advocacy services, which could be provided to residents and/or their relatives if required. The home was fully aware of its responsibilities under the Data protection Act (1998) and there were policies in place regarding access to personal records. Residents could bring personal items into the home if they wish but this had to be agreed with the home prior to admission. Residents were supported to manage their own finances if they wish. It was evident during mealtimes that staff responded to individual’s wishes and preferences. Drinks and snacks were available throughout the day and night. Records are kept by staff indicated what choices residents made and what they actually ate. It was evident that staff knew individual resident’s needs concerning cutlery, there were different sized plates and therefore portions and some residents like a protector for their clothes and some did not. There were water coolers within different areas of the home. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home takes complaints seriously and they are handled objectively and in keeping with the home’s published procedures. Residents and their representatives can be confident that concerns are listened to, taken seriously and responded to. Staff are aware of safeguarding adults procedures and there are systems in place, which protect residents from abuse. The home continues to train and update its staff to ensure residents’ needs are met at all times in this important area. EVIDENCE: The home has a clear complaints procedure with appropriate timescales for resolution of complaints and concerns. The home maintains records of complaints received and also records the outcome of complaints. Since the last inspection the home has received two complaints. One was mainly directed at Care Management and concerned charges and was not related to care practises. Both were dealt with within the appropriate timescales. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 15 The home had a robust Adult Protection policy in place. Staff spoken with were aware of safeguarding procedures and how to raise an adult protection alert and who they needed to contact. Staff training in safeguarding adults continues. Residents’ rights were promoted. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment within the home is mostly satisfactory but there is a clear need for further redecoration and refurbishment of some areas. The care of service users may be being compromised because bathing facilities are not currently adequate. Residents can be confident that they have access to outdoor areas and comfortable communal areas. Residents benefit from living in a home that is clean, pleasant and hygienic. EVIDENCE: Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 17 The general internal environment is beginning to show signs of wear and tear with some corridors in a poor state. It would appear the urgent repairs are carried out but the home does not have a programme of planned redecoration. Only three bedrooms have been decorated this year. Four rooms had been fitted with new carpets One of the bathrooms the held a Parker bath was out of use. Apparently the rook leaked and damaged the ceiling. Although the roof had been repaired the ceiling had not and therefore the room could not be used. One resident who needed to use the specialist bath complained that she had been unable to have a proper bath for many weeks. Staff did offer a bed bath but she preferred to use the parker bath. The registered manager said that the ceiling contained traces of asbestos and had to be removed by a specialist company. She would endeavour to ensure this work was carried out soon. The majority of the residents spoken with stated they were happy with their bedrooms and they felt they met their needs. The furnishings and lighting in the communal rooms were domestic in style and generally the home looked homely. Several residents said how much they liked the library. Kent County Council is currently introducing a smoking policy for the benefit of all residents and staff. Residents will retain a smoking lounge but smoking will not be permitted in any other areas in the home. Everyone who is connected with the home has been informed of the decision. The home has purchased a new hoist recently and all lifting equipment was seen to be well serviced and well maintained. Wheelchairs were also seen to be clean and appropriately stored. Other specialist equipment required to maximise resident’s independence was seen. The home was clean and tidy on the day of the inspection and was free from offensive odours. The domestic staff clearly work hard to maintain this level of hygiene. Staff had received relevant training i.e. Control of Substances Hazardous to Health (COSHH). Doubleday Lodge LSC DS0000037864.V326010.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Low staff levels could put some residents at risk. Residents needs are met by staff who are competent and trained. Residents are supported and protected by the home’s recruitment procedures. EVIDENCE: Staff figures taken from the home’s monthly management information report (MMIR) indicate that the home had 32 team leader hours per week, 685 care worker hours per four weeks, 25 assistant cook hours per week and 25 housekeeping hours per week vacant. The registered manager explained that KCC did not have a recruitment freeze however permanent hours had not been approved for recruitment. Only permanent relief hours had been approved. The registered provider must ensure that she remains within employment law when Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 19 recruiting to these hours. The registered manager has to produce a copy of the following weeks rota to her line manager for approval every week. This is often not returned until Friday, sometimes making it difficult to find relief staff. This level of staffing has also made it difficult to release staff for training events, as the permanent relief staff that would normally be used for cover are already working. Often the duty team leader has to work on the floor and this means some areas of her work have to be done by the senior team leader. This has an impact on the entire senior team. Although it is acknowledged all of the home’s staff work very hard to maintain the high level of care within the home, some areas beginning to show signs of slippage. Supervision and training are areas that are at risk. The lack of dedicated activity hours is also a cause for concern. Staff records indicated that robust recruitment procedures were in place with all the required documentation completed. All staff have now received copies of the General Social Care Council’s code as recommended in the last inspection report. 54 of care staff have achieved NVQ level 2, another one is currently undertaking the award. All senior staff had completed a twelve-week course on both The Safe Administration of Medication and Infection Control. Two care staff had completed a one-day course in infection control and other staff were waiting for course to become available. Manual handling training was up to date for all staff. The manager stated that sometimes it is difficult to release staff for training due to low staffing hours. All staff were trained in Adult Abuse and those spoken with displayed a good knowledge of the subject. Staff confirmed that training was offered but sometimes they cannot get on the courses. The manager was asked to provide the commission with a training matrix to ensure all staff have received mandatory training. Basic induction training took place, however a new induction course that meets the standards of Skills for Care was being developed countywide. Doubleday Lodge LSC DS0000037864.V326010.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, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from having a competent manager who is supported well by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. The home is run in the best interests of the residents Sound financial procedures protect residents. Current arrangements were sufficient to protect the health, safety and welfare of residents and staff. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager had National Vocational Qualification Level 4 (Care) and had also completed her Registered Managers Award. Policies and procedures were regularly reviewed and the registered manager demonstrated knowledge of up to date legislation and good practice. She has access to the Internet within the home and used this for maintaining knowledge about specific areas of care. The manager was already booked on further training course in 2007. The manager displayed a commitment to the home and her staff members; many staff said they felt very well supported. Residents spoken with were very complimentary about the manager and senior staff. It was evident that regular client meeting were held and that action was taken as a result of these meetings. There were clear lines of accountability within and external to the home. The home complies with Standard 26. Quality assurance was an area that could be improved as not all residents had the opportunity to express their opinion on how the home was run. Exit questionnaires were given to short term care residents. Effective quality assurance and quality monitoring systems, based on seeking the views of all residents need to be in place so that the manager can measure success in meeting the aims, objectives and statement of purpose of the home. The manager is advised to use standard 33 to ensure full compliance. Resident’s finances were well managed. At the last inspection the manager was advised to complete risk assessment for the uncovered radiators in the lounges, dining rooms and corridors. This had been completed and highlighted that eight radiators require guarding to make them safe. This work now needs to be carried out and a requirement will be made to that effect. The home had robust systems in place to ensure so far as is reasonably practicable the health, safety and welfare of residents and staff. The home’s accident book, fire log book and comments book were viewed. Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 22 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 x 2 3 x 3 3 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 Regulation 18(1) Requirement The registered person shall ensure that at all times suitably qualified, competent and experienced persona are working in the care home. The registered person shall ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair, in that the ceiling in the room housing the parker bath be replaced. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards and unnecessary risks to health and safety are identified and as far as possible eliminated in that: Radiators identified as being of high risk are guarded or have a guaranteed low temperature surfaces The registered person shall establish and maintain a system for evaluating the quality of the service provided at the care DS0000037864.V326010.R01.S.doc Timescale for action 01/03/07 2 OP21 23(2) 01/03/07 3 OP25 13(4) (a) (c) 01/03/07 4 OP33 24(1-5) 01/03/07 Doubleday Lodge LSC Version 5.2 Page 24 home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP7 OP12 OP30 Good Practice Recommendations Risk assessments for pressure ulcers, nutrition and falls to be improved. This remains from the last inspection The planned review of activities/ leisure pursuits should be undertaken. This remains from the last inspection It is recommended that an induction programme that complies with the Common Induction Standards framework introduced by Skills for Care needs to be introduced. It is recommended that changes are made to the home’s Statement of Purpose indicating that it will only admit short term care clients. 4 OP1 Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local 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. Extracts may not be used or reproduced without the express permission of CSCI Doubleday Lodge LSC DS0000037864.V326010.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!