Inspection on 23/02/06 for Drewstead Lodge

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Drewstead Lodge 09/11/06

Drewstead Lodge 01/09/05

Drewstead Lodge 16/02/05

Drewstead Lodge 18/08/04

Drewstead Lodge 26/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Drewstead Lodge Drewstead Lodge 93 Drewstead Road Streatham London SW16 1AD Lead Inspector Ms Rehema Russell Unannounced Inspection 23rd February 2006 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 Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Drewstead Lodge Address Drewstead Lodge 93 Drewstead Road Streatham London SW16 1AD 020 8769 4912 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) fowasil@hotmail.com Mr M Owasil Mrs Sairah Bibi Owasil Mrs Sairah Bibi Owasil Care Home 9 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (9) of places Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Drewstead Lodge is a large two storey detached house in a quiet residential street with on street parking. It has a small front rose garden and a large landscaped garden at the rear. It has two bedrooms and communal rooms on the ground floor, a chair lift, four bedrooms on the first floor and a selfcontained flat for the proprietors on the top floor. It provides a home for 9 elderly residents in a family-run, homely atmosphere with particular emphasis on providing individualised care that maintains residents independence, privacy and self-esteem. Currently one of the bedrooms on the first floor is being kept vacant and being converted into an office. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 23rd February 2006. Since the previous inspection one service user had transferred to a nursing home and one service user had died. As one previous bedroom is being used as an office, this meant that there were only six service users resident in the home. The inspector spoke with the manager and proprietor, interviewed one care worker, one service user and a visiting relative, spoke to several other service users briefly, toured the premises and looked at documentation and records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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 Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 No service user moves into the home without having their needs assessed and having been assured that these will be met. Prospective service users and their relatives/friends have an opportunity to visit and assess the suitability of the home. The home does not admit service users solely for intermediate care. EVIDENCE: Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 9 There have been no admissions since the last inspection, however the home’s admission procedure has not been changed. This involves the home obtaining the community care assessment from the placing authority and the registered manager visiting the prospective service user. At this visit the manager conducts her own assessment which includes all areas required by this Standard. The initial care plan is written from the placing authority’s and the home’s assessments, and any other professional assessments obtained. Community care assessment of needs forms were seen on care plans, along with letters/reports from other professionals such as speech and language therapist, South London & Maudsley Hospital and physiotherapy. The home has never taken an unplanned admission, and the service user is always visited first, even if they are in hospital. Wherever possible the potential service user and their relatives/carers are invited to visit the home prior to admission, and there is always a trial period of 6 weeks. Examples were given of trial visits by the current service users: one had visited with her family for tea, met all the service users and looked at the room she would occupy, another had visited for lunch, met the service users and staff, and looked at her room. The home does not admit service users solely for intermediate care and so Standard 6 is not applicable to the home. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Care plans set out individual’s health, personal and social care needs and service users’ health care needs are fully met. Medication procedures are thorough and service users self-medicate if appropriate. Service users are treated with respect and their right to privacy is upheld. At the time of death, service users and their families are treated with care, sensitivity and respect. EVIDENCE: Care plans were assessed at the previous inspection and at this inspection it was found that they continued to be well laid out and detailed. They contain thorough assessments of the resident’s self-care ability and lifestyle choices and preferences. Care plans are based on these assessments and set out needs, actions, goals and evaluations. These are regularly reviewed, monthly/bi-monthly/six-monthly, according to need and to any changes in circumstances. Reviews are dated and signed and monitoring sheets record any changes to the service users’ needs or wishes, thereby giving a thorough picture of the service user’s general progress and outlook. At the previous inspection it was found that one of the placing boroughs had not carried out its statutory obligation of conducting an annual placement review. A recommendation was made for the home to contact the borough to request that the statutory annual reviews be carried out. The home had implemented Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 11 the recommendation but at the time of this inspection had not yet received a response. There was evidence from care plans and from speaking with the manager and proprietor that service users have their health care needs provided for by a full range of healthcare professionals, according to individual need. This includes the general practitioner, district nurse, community psychiatric nurse, psychogeriatrician, chiropodist, speech and language therapist and physiotherapist. Storage, administration and recording of medication was checked and found to be in good order. One service user has been encouraged and supported by the home and the district nurse to undertake self-administration of insulin. Staff check the service user’s self-administration process and the district nurse visits weekly to undertake blood sugar and blood pressure tests. Since the previous inspection the requirement that all staff are trained in medication administration has been implemented. One member of staff had undertaken this by distance learning from a college, and the others by tutor-based training at the home. All staff had passed the course. Observation and verbal evidence from the manager, proprietor, staff and service users indicated that service users are treated with respect and dignity and that their rights, choices and privacy are encouraged and supported. A relative spoken with gave examples of the manager handling sensitive situations between the service user and her family with tact and understanding, and with the outcome that the service user’s wishes were respected and upheld. All service users in the home were observed to be well groomed and dressed and to be spoken to with respect. Screening is provided in the shared bedrooms, which are arranged to give the maximum privacy according to individual service users’ choices. One service user had died on the weekend previous to the inspection. The service user had been treated at the home by the GP but was taken to hospital when his condition deteriorated. The manager accompanied the service user to the home, spoke with the consultant, contacted the family and stayed with the service user until his relative arrived. She had already discussed death and dying issues with the service user and his family and so knew of the wishes in regard to resuscitation etc. After the service user died, the manager stayed at the hospital with his relative to console and support him. The manager has spoken to all service users, or their families as appropriate, to ascertain their wishes in regard to funeral arrangements. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents’ lifestyles reflect their social, cultural, religious and recreational interests and choices. Contact with family, friends and representatives is encouraged and facilitated. Residents are encouraged and supported to exercise choice and control in their daily lives. Residents are given a nutritious and balanced diet in pleasant surroundings. EVIDENCE: The home offers residents the choice to partake in a range of activities both inside and outside the home. Television, radio, large print books, knitting, cards, dominoes and puzzles are provided in the home, as well as a landscaped garden with patio facilities. Minutes of residents’ meetings show that the home offers and encourages residents to choose to participate in day trips to the cinema, museums, parks, shops and places of interest, but that the majority of residents prefer to stay at home. Since the previous inspection the manager arranged for the Pump House to visit the home over an eight week period to conduct reminiscence groups, which several service users enjoyed. One service user has her own favourite singer whom she regularly listens to by cassette tape, and one service user likes to read the Bible and listen to tapes of hymns. The home arranges for the mobile library service to visit, and one service user regularly goes out with the manager on shopping trips. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 13 Routines in regard to getting up and going to bed, when and where to eat meals, bathing and other routines of daily living are flexible according to individual choice. This was confirmed by one service user spoken with who has a very set routine that she likes to follow. This service user likes to be in control of her own environment – the bedroom – and this is respected by the proprietor and manager, who will make sure she has advanced information if staff are going to hoover her room, wash windows etc. Cultural needs in regard to food, interests and skin care are understood and provided for and service users are assisted and encouraged to fulfil spiritual needs at choice – for example, one service user requested and was escorted to Church on Christmas Eve, but another service user, who likes to pray every day and listen to hymns, has said she does not wish to go to church. Verbal and documentary evidence showed that the home encourages and supports service users to keep in regular contact with family, friends and representatives, according to their individual choices and preferences. The regularity of relatives’ visits varies from daily to once in a while but all visitors are made welcome and shown hospitality by the home. This was confirmed by the relative spoken with on the day of inspection. Service users are encouraged to keep in contact with the local community via trips to shops, parks and cafes according to their choice. Service users exercise choice throughout the day, for example, choosing when to go to their rooms or out into the garden, when to bathe, what to eat and what activities to undertake. Service users are encouraged and supported to keep personal possessions in the home and their rooms, and the manager has made special arrangements so that two service users can have some dailyused possessions kept near to them every day so that they can continue with their individual interests whilst enjoying the company of the others in the lounge. There had been some changes to the menus since the previous inspection, reflecting the choices of service users. Service users have a choice of breakfast each morning, a hot meal at lunch time and sandwiches and soup in the evening. A bowl of fresh fruit was available in the lounge. One service user will not eat eggs or milk, another controls her own diet very fastidiously, liking to eat large amounts of vegetables, and a third is on a GP approved complan diet. The meal given on the day of inspection was nutritious, well balanced and attractively presented. Residents chose where to eat their meal, in the separate dining room, the lounge or their own rooms, all of which are pleasant places to eat. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents and interested parties views and complaints are listened to, taken seriously and acted upon. Service users’ legal rights are protected and they are protected from abuse. EVIDENCE: No complaints have been made to the home since the previous two inspections. The home has a complaints procedure and a complaints book and also keeps a comments and suggestions book in case residents or visitors would prefer to use this approach. Any comments, suggestions or dissatisfactions are dealt with on a daily basis, and both the service user and the visiting relative spoken with said that they could approach the manager with anything they wanted to know or discuss. The relative said that he is always kept informed of anything that affects his wife or her care and that the home phones immediately if there is any news or a problem. Examples were given of how service users’ legal rights are protected, including the use of solicitors to draw up wills and to advise service users, and the use of external professionals, such as the GP, to sign or witness legal documentation. A member of care staff spoken with was familiar with the different forms that abuse can take and was clear about how these should be reported and dealt with. The home has a clear and well written abuse policy but needs to incorporate the newly published local borough’s adult protection policy. A recommendation has been made that this is done and that the borough’s policy and the implications of the POVA list are formally discussed with staff. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Residents live in a safe, well-maintained, comfortable and homely environment. Service users have access to safe and comfortable communal facilities and there are sufficient and suitable lavatories, washing facilities and specialist equipment. Bedrooms are safe and comfortable with individual possessions. The home is clean, pleasant and hygienic throughout. EVIDENCE: The home is accessible, safe and well maintained, and is comfortable and homely throughout. It is situated in a quiet residential street, a short walking distance from a park/common and within a short walk or car ride from a busy shopping centre with full transport and community facilities. It has a front rose garden and a large landscaped back garden that is attractive and well kept with a peaceful atmosphere and seating for service users. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 16 There is a spacious lounge/diner on the ground floor, and a separate dining room off the kitchen which can be used for meals or activities or visitors. The lounge is very attractively decorated, fitted and furnished and an awning has been provided so that residents are shaded in the summer when the French doors are opened. Toilets and bathrooms are suitably located for accessibility. The ground floor toilet and shower are close to the lounge and dining areas, and the separate bathroom and toilet on the first floor is to the bedrooms. The bathroom on the first floor has been refitted to a very high standard. Bedrooms have good décor, furniture and fittings and had all been personalised according to residents’ individual preferences and choice. A service user spoken with said that she was very happy with her room, didn’t want a television in there but enjoyed playing her music. There are three shared bedrooms, which are all above minimum space standards and which all have room dividers for privacy. The inspector was told that the occupants had made a positive choice to remain in shared rooms. One of the three single bedrooms that is marginally below minimum space standards is now being kept vacant and converted for use as an office. There are appropriate aids and adaptations throughout the home, including grab rails and bath seats in toilets and bathrooms and a chair lift for the stairway. The stairway was adapted to be unusually wide, making the use of the chair lift particularly easy. Service users are therefore able to maintain independence by operating the chair lift themselves, and the space taken up does not in anyway restrict other service users from using the stairs. Thermostatic valves have been fitted to all bedrooms and bathroom taps, and to radiators throughout the house. The proprietor has fitted radiator covers throughout the home, with the exception of one service user’s bedroom. This service user is resisting having the cover fitted but the proprietor and manager are patiently coaxing her to accept it. The inspector checked her room and is satisfied that there is no danger to the service user from the current uncovered radiator. The home is well ventilated, lit and heated throughout. On the day of inspection the home was found to be clean and hygienic throughout and free from offensive odours. The domestic washing and drying machines are located in a cupboard on the first floor, well away from the kitchen downstairs. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents’ needs are met by the numbers and skill mix of staff. The home is progressing towards the 2005 training target and has almost achieved it. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Since the previous inspection the number of service users has reduced from eight to six and the proprietor is considering keeping the service user numbers at this level. Currently in regard to staff cover, the manager and proprietor reside at the home and are always available, and in addition there are two care assistants on duty between hours of 8 am to 8 pm, in morning and afternoon shifts. However, with six service users only, it is intended that the staffing cover will be reduced so that there are still 2 carers on each shift, but one of these will be the manager. The manager and proprietor will continue to provide the late evening and night cover, and at weekends, either the manager or proprietor, or both, will be on duty. When this is implemented, the manager and proprietor should monitor the situation on an on-going basis to ensure that the new staffing cover continues to meet the assessed needs of service users. Of the eight current care assistants employed by the home, two have achieved NVQ Level 2, a third has will complete it by August 2006 and a fourth has begun the course. Therefore the home has not met the recommended 2005 NVQ Level 2 training target but is progressing towards achieving it. Meanwhile, all staff have undertaken first aid, food hygiene, infection control Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 18 and manual handling training, and in addition one member of staff spoken has undertaken vulnerable adults and risk assessment training. There have been no new members of staff since the home’s recruitment practice was fully assessed at the previous year’s inspection, and so this Standard continues to be met. Since the previous inspection the home has prepared individual staff training records and three were seen. These showed that all staff undergo in-house induction training, which includes fire safety, care of service users, personal care and health and safety. All staff have also received external training in medication and some have attended the Pumphouse course in developing skills in reminiscence. The home does not currently provide a minimum of 3 days paid training per year for each care assistant, as recommended by the National Minimum Standards, but is working towards this. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 The Manager is fit to be in charge, of good character and able to discharge her responsibilities fully and service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users and service users finances are safeguarded by the financial procedures at the home. Staff are supervised on a day-to-day basis but are not given formal, recorded supervision. The home’s record keeping, polices and procedures safeguard service users’ rights and the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager and proprietors have extensive knowledge of and many years experience of working with elderly people and of managing a care home for this client group. They give clear leadership and direction to staff in an open, approachable and supportive manner. Staff, service users and relatives spoken with said that they found both the manager and proprietor very approachable, friendly and supportive and there is a clear commitment to equal opportunities. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 20 The Proprietor has a two year development plan for the home and has already implemented new carpets, the building of a summer house, a new awning for the exterior of the lounge, new electrical wiring, radiator covers throughout the home, a completely refurbished first floor bathroom and the fitting of thermostats throughout the home. He is hoping to expand and renew the kitchen in the near future. In regard to service quality monitoring, this is achieved by monitoring the health of service users, verbal feedback from them on their satisfaction at the home, and feedback from family and relatives. For example, one service user’s daughter told the district nurse that her mother was very happy at the home and was looking well and brighter since she had been at the home, another service user’s son told the manager that his mother had changed since she’d been at the home and looked happy and relaxed, and the son of the service user who has just deceased said that he “couldn’t have wished for better care for my Dad”. The home had not undertaken a written service user survey for this financial year but intends to do this in March and publish the results. All service users’ monies are managed by themselves or their families but the home is appointee for two service users. This involves the physical collection of their pensions and suitable records of this are kept. As the manager and proprietor are constantly on the premises they are able to train and supervise staff on a daily one to one basis but at previous inspections it was found that formal documented supervision is not carried out. At the last inspection the manager said that systems of formal supervision and appraisal would be in place by the end of March 2006. At this inspection it was found that the appraisal system had been instituted but not the regular documented formal supervision. As this is a small home and the manager oversees and supervises staff informally on a daily basis, the inspector is of the opinion that formal supervision need only be undertaken 3-4 times per year (unless circumstances arise that dictate otherwise). The requirement in regard to formal supervision therefore remains. A range of documentation and records were seen at this inspection and were found to be well kept, accurate, up to date and secure. This included care plans, medication records, health and safety documentation, financial records, complaints records and staff files. Evidence from documentation and speaking with management and staff demonstrated that the health, safety and welfare of residents is promoted and protected. Staff have received training in fire safety, first aid, food hygiene, infection control and manual handling. Hazardous material is stored safely in a locked cupboard, windows have suitable locks and restrictors and thorough risk assessments for each service user and for general risks such as electrical appliances, wet floors, hot water, lifting and the stairway have been undertaken and reviewed as appropriate. Environmental Health food hygiene reports and Fire Officer inspection reports were seen, and no problems had Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 21 been found. The fire book showed that regular fire drills and fire procedure training is carried out and documented and that call points are regularly tested as required. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 4 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18(1)(c) (i)18(2) Requirement The Registered Manager must ensure that documented formal supervision sessions take place for all staff covering all aspects of practice, the philosophy of care and career development needs. Previous timescales of 31/05/05 and 31/10/05 not met. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP18 OP27 Good Practice Recommendations The Manager should incorporate the local borough’s adult protection policy into the home’s abuse policy and discuss it and the POVA list formally with all care staff. If a new staffing cover arrangement is adopted, the manager and proprietor should monitor the situation on an on-going basis to ensure that it continues to meet the assessed needs of service users. The Registered Person should provide a minimum of 3 DS0000022725.V273467.R01.S.doc Version 5.0 Page 24 3 OP30 Drewstead Lodge days paid training per carer per year. Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Drewstead Lodge DS0000022725.V273467.R01.S.doc Version 5.0 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!