Inspection on 14/02/07 for Eden Lodge Care Home

This inspection was carried out on 14th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eden Lodge Care Home 15/07/08

Eden Lodge Care Home 14/08/07

Eden Lodge Care Home 26/04/06

Eden Lodge Care Home 28/09/05

Eden Lodge Care Home 09/06/05

Eden Lodge Care Home 09/02/05

Eden Lodge Care Home 06/10/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Eden Lodge Care Home Park Road Bestwood Village Nottingham NG6 8TQ Lead Inspector Rob Cooper Key Unannounced Inspection 14th February 2007 09:15 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 Eden Lodge Care Home DS0000008666.V329257.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. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eden Lodge Care Home Address Park Road Bestwood Village Nottingham NG6 8TQ 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) 0115 977 0700 0115 9770786 Sai Om Limited Position Vacant Care Home 60 Category(ies) of Dementia (44), Old age, not falling within any registration, with number other category (60) of places Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following catgories: Old Age (OP) (60) Dementia (DE) (44) The category DE applies to service users aged 55 years and over, and included in the total number of registered users. The maximum number of service users to be accommodated is 60. Date of last inspection 3rd August 2006 Brief Description of the Service: Eden Lodge is situated in Bestwood Village from which there is access to public transport to the wider community and the city centre. The home is registered to cater for the needs of older people, aged 65 years and over as well as people with a diagnosis of dementia who are aged 55 years and over. The accommodation is on the ground floor. There is level access throughout. The bedrooms are single some of which have en-suite toilets. There are four lounges, one is a designated smoking area and residents do not use the other one. There is an activities room and two dining rooms. The grounds are expansive and mainly set to lawn. There is a large car park to the front of the home. The fees range from: £283 - £340 per week. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection – so that no one at Eden Lodge knew that the inspection was going to take place before hand. This was a joint inspection with Sharon Rosenfeldt an inspector from the Regional Registration team (CRCT) who was considering Eden Lodge’s application to vary their Registration and increase the numbers of people living at Eden Lodge who have dementia. The inspection took approximately six and a half hours through the middle of the day. The method used to carry out the inspection was to send out a questionnaire, which asked questions about the service, to gather statistics, such as how many service users there are, the numbers of staff etc. This was followed with a visit to Eden Lodge, where a method called case tracking was used; this involved identifying five residents and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was done by a partial tour of Eden Lodge, looking at the activities on offer, and talking to staff. On the day of the inspection there were fifty-four residents living at Eden Lodge. Joy Farrell who is the acting manager facilitated the inspection. What the service does well: What has improved since the last inspection? Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 6 There has been a definite improvement on many levels at Eden Lodge since the last inspection, and while there is still room for more improvement, the progress so far is to be applauded. Eight of the ten requirements set at the last inspection have been met: Care plans contain more detailed information about resident’s medical conditions for the use of the staff. Medication handling and recording procedures have improved. The cleanliness of Eden Lodge has improved. There is now a policy in place for the protection of residents and staff from blood borne viruses. The steps at the far end of the building have been risk assessed and warning signs have been put in place. The lighting in many areas has been replaced and upgraded. In addition since the last inspection the roof has been replaced, and there has also been some redecoration within the building. What they could do better: Six requirements have been set as a result of this inspection: * All staff must receive up-to-date training in safeguarding adults. * There is an odour in the corridor, which needs to be investigated and solved. * All staff must receive dementia training, so that they can meet the needs of the residents. * A review of all staff training needs to be undertaken to ensure that staff are appropriately trained. * The current acting manager must submit an application to the Commission for Social Care Inspection to become the Registered manager. * Eden Lodge must develop and introduce a system of quality assurance. In addition nine recommendations have been made at this inspection: * There should be an individualised approach to care plans. * The drug trolleys should be secured to the wall when not in use. * Contact should be made with local churches to ensure residents spiritual needs are being met. * Choice needs to be improved, possibly by the involvement of the speech & language department. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 7 * Efforts should be made to ensure the same quality of environment throughout the building. * Other professionals working within dementia care should be contacted for support and advice. * Consideration should be given to the grounds, and ways of making them more accessible to residents. * Two damaged picnic tables should be replaced. * Formal resident’s meetings should be started as soon as possible. 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. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 8 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 Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 9 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): 3&6 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. No resident moves into Eden Lodge without having had their needs assessed, and been assured that these will be met. Eden Lodge does not offer intermediate care. EVIDENCE: As part of the case tracking process three residents files were seen in respect of the assessments within them. Each file contained a completed assessment form, and the dates on the assessments showed that these had been completed before the residents moved into Eden Lodge. Among the different types of assessment tool seen were an Extended Community Care Assessment, completed by the resident’s social worker, and two Shared Nottinghamshire Assessment Process forms (SNAP’s) This is the latest assessment form for older people used within Nottinghamshire. There were also examples of in- Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 10 house assessments completed by Eden Lodge staff to follow on from the formal social worker assessments. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social needs are set out in an plan of care at Eden Lodge, although this should be more individualised. Resident’s health care needs are fully met. One resident at Eden Lodge self-medicates and all residents are protected by the policies and procedures in place for dealing with medicines, although storage facilities need to be reviewed. Residents at Eden Lodge feel they are treated with respect and their right to privacy is respected. EVIDENCE: As part of the case tracking process five resident’s files were seen. Each file had a clear plan of care, although there was evidence that some care plans are generic (the same care plan for many residents, with just the resident’s name having been changed) rather than written individually. A requirement was set at the last inspection relating to individualised plans of care, and while there has been some improvement, the evidence suggests that the care plans do require further development, and a fully individualised and ‘person centred’ approach to care would be in the best interests of the individual residents. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 12 Each of the five resident’s files that were seen contained specific information relating to the resident’s health care needs. Each file also contained information relating to visits to the Doctor and any other health care professional. A requirement was made at the last inspection in respect of the information available in resident’s files for staff relating to any medical conditions. There were two examples of this type of information seen in two separate files, and this is clear evidence of Eden Lodge attempting to address this issue. Boots (The Chemist) provide Eden Lodge with their medication. An inspection of the storage, and booking in and out procedures showed that medication is handled safely and there is a clear audit trail for medication from the point of ordering to administration and/or disposal. Administration records were inspected and found to be complete. One resident self medicates, and the procedure for this was seen, and found to be safe. The resident also has a care plan and risk assessment within their file relating to the selfadministration of their medication. When asked this resident said that they were very happy with the arrangements for their medication. One issue that does need to be addressed is that there are not enough anchor points to attach the drug trolleys to the wall. When not in use the trolleys should be fixed, and while it is stored in a locked room, the fixing to the wall will provide additional security. Two requirements were set at the last inspection relating to medication, the first related to medication being inappropriately stored, and no evidence that this practice was continuing was seen. The second was in relation to a policy being in place to prevent staff and residents being infected by blood borne viruses. Eden Lodge now has such a policy, and this policy was seen during the inspection. During the course of the inspection a number of staff to resident interactions were observed. These were seen to be polite and respectful, and staff were observed knocking on resident’s doors before entering. Three residents were spoken with during the inspection, and each one said that they thought the staff treated them well. One saying: “The staff are very kind, they look after us really well.” Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Residents find that the lifestyle experienced at Eden Lodge matches their expectations and preferences, and satisfies their social, cultural, and recreational interests and needs, although the residents religious needs are not currently being met. Residents at Eden Lodge maintain contact with family, friends and representatives and the local community as they wish. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times that are convenient to them. EVIDENCE: Eden Lodge has a very well equipped activity room, and employs an activity co-ordinator on a part-time basis, although on the day of the inspection the activity co-ordinator was not on duty, and no residents were using the activity room. Last summer a small vegetable plot was established, for residents to sow and grow produce, and there are plans to extend this project this year, with possible re-siting of the plot to a more productive area of the garden. Two residents were asked about activities and both said that they were quite Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 14 satisfied, one said that they: “Watched films on the big telly” which related to the large widescreen television and DVD player in the activity room. Currently no religious representatives visit Eden Lodge, which means that for the majority of residents assisted or guided religious observance is quite difficult. Eden Lodge has an open visiting policy, and a number of visitors were seen during the course of the inspection. One relative who was visiting was spoken with, and said that they were able to visit whenever they wanted, and that they were very happy with the care being provided to their relative. One resident wanted to go to the local shops to buy a newspaper and a bar of chocolate. The manager quickly identified a member of staff to go with this resident to make their purchase. When asked staff said that this was a common activity and this resident often went to the shop to make small purchases. Unfortunately the resident had communication difficulties, and was unable to answer my questions, although they were obviously delighted with the purchase they had made. A number of photographs of resident’s activities were on display, including a Christmas lunch at the local welfare hall in the village. Issues of choice at Eden Lodge have improved, and there is a good choice offered at mealtimes, which is recorded. However consideration should be given to ways of improving the choices offered, particularly through the use of photographs, which will be especially useful for those residents who have dementia. It would be beneficial to seek the advice of a speech & language therapist, who would be able to offer practical advice and suggestions. Two residents were asked about choice, and both said they thought it was alright, however neither of these residents had dementia, and both were quite able to make choices unaided. An inspection of the kitchens at Eden Lodge showed that they are well organised, and that there is a good supply of fresh vegetables. On the day of the inspection there was a choice between sausage casserole and jacket potato with cheese or tuna. The food looked very appetising, and three residents who were asked said that they enjoyed the food very much. A range of records relating to the storage and ordering of food were seen, and found to be complete and correct. Eden Lodge has two dining rooms, and there was a marked difference between the two. One dining room for residential residents had flowers and pretty tablecloths on the tables, and was a very pleasant environment in which to eat lunch, while the second dining room primarily for residents who have dementia was much more sparse, and lacked the homely touches of the other dining room. While appreciating that working with people who have dementia presents a number of challenges, efforts could and should be made to create an equally pleasant dining experience for all residents. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Residents and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon at Eden Lodge. Residents at Eden Lodge are potentially at risk from abuse. EVIDENCE: Since the last key inspection Eden Lodge have received one formal complaint. A requirement had been set at the last key inspection that all complaints are dealt with inside a 28-day window, and that the complainant is sent a formal response. Evidence in the complaints record show that the one complaint received was dealt with in this manner. Copies of the complaints procedure were on display, and two residents when asked said that they knew how to complain, and who to complain to, although neither had ever felt the need to complain. A review of staff training records showed that the majority of staff have not received training in safeguarding adults, or that the training is in need of updating. This training is a crucial tool in protecting residents from abuse, as it raises awareness, and informs staff of the action to take if they suspect that abusive behaviour is occurring. This lack of up-to-date training for all staff leaves residents potentially at risk. Eden Lodge Care Home DS0000008666.V329257.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 20 25 & 26 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Residents at Eden Lodge live in a safe, well-maintained environment. Residents have access to safe and comfortable indoor and outdoor communal facilities, although currently the grounds are limited, and there is an odour problem indoors. Residents live in safe, comfortable surroundings. Eden Lodge is clean, pleasant and hygienic. EVIDENCE: There has been an improvement in the environment at Eden Lodge since the last inspection, with a new roof; some new lighting and some redecoration having taken place. Generally the front of the building is bright and welcoming, with good quality fixtures and fittings, although there is a marked difference between the front of the building, and the back, which is where the residents who have dementia live. There is an absence of ‘homely touches’ and this part of the building is bare in comparison to other parts. Staff at Eden Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 17 Lodge should take advice from other professionals working with people who have dementia, to look at ways of improving the environment. Contact details for identified professionals were left with Eden Lodge staff. At the last inspection the steps at the end of the corridor, were identified as being a risk to residents. The steps have now been risk assessed, and warning signs have been put up. This meets the requirement set, although the advice of other professionals could potentially improve resident’s safety even further. A partial tour of Eden Lodge both inside and out showed that the building sits in extensive grounds, much of which is either laid to grass or has been covered in tarmac. The grounds are secure, although with a little work they could be made more ‘user friendly,’ and residents could get more from the outdoor environment. Two picnic benches were seen on the tarmac, and both were in a very poor state of repair, and should be replaced as soon as possible. There is a definite change in odour halfway down the main corridor. This needs to be investigated, and the source treated. A requirement was set at the last inspection in relation to improving the lighting, some work has already been carried out, and further changes to improve the lighting were being carried out during the inspection, which means that this requirement has now been met. The cleanliness of the building has noticeably improved since the last inspection. The dining room chairs and tables in the bottom dining room were found to be dirty at the last inspection, and a requirement was set. A visual inspection of the tables and chairs at this inspection found them to be clean to an acceptable standard. There was clear evidence of staff cleaning, and no obvious problems related to the cleanliness of the building were found. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff at Eden Lodge meets the residents’ needs. Residents at Eden Lodge are in safe hands at all times. Residents are supported and protected by Eden Lodge’s recruitment policy and practices. Staff training at Eden Lodge is not currently good enough to ensure that staff are competent to do their job. EVIDENCE: The staffing rota was seen which showed that there were sufficient numbers of staff allocated to each shift through the day to be able to meet the resident’s needs. Two residents were asked about staffing levels, both said they thought there were enough staff to meet their needs. Two members of staff were asked about staffing levels, and one said that they thought there were enough staff, while the other said that they felt: “It’s OK, although sometimes we are a bit short, especially down the other (dementia residents) end.” A review of the staff training records showed that currently 13 staff have a National Vocational Qualification (NVQ) to level II or higher in care – which is the industry standard, and a further 8 members of staff are currently studying for their NVQ level II. It is recommended that 50 of the staff team should have an NVQ qualification to level II, and the evidence showed that Eden Lodge were working towards that figure. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 19 The personal files for three members of staff were seen which included all of the necessary employment checks – references, criminal records bureau checks etc. This demonstrates that Eden Lodge are taking care over their staff recruitment and are carrying out the necessary checks to ensure that the residents are safe. Two members of staff were asked about their recruitment, both said they had had a formal interview, and that they had not started work until the necessary checks had cleared. The staff training records at Eden Lodge show some serious gaps, as already identified not all members of staff have received up-to-date training in safeguarding adults, neither have they received training in caring for people with dementia. It was set as a requirement at the last key inspection, and stated again at a random inspection in August that staff should receive this training. The records also showed that there were gaps, and that some staff had also not received other key training such as moving and handling training and health & safety training. Eden Lodge Care Home DS0000008666.V329257.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 36 & 38 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Residents at Eden Lodge live in a home, which is currently managed by a person who has not been registered with the Commission for Social Care Inspection. Eden Lodge is not currently run in the best interests of its residents. Resident’s financial interests are safeguarded. Staff at Eden Lodge are appropriately supervised. The health, safety and welfare of residents and staff at Eden Lodge are promoted and protected. EVIDENCE: The current manager at Eden Lodge has not been registered with the Commission for Social Care Inspection, and must submit an application to become the registered manager as soon as possible. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 21 Currently a quality assurance system based around resident and visitors questionnaires is being developed, and this was seen, and it is close to completion. It was set as a requirement at the last inspection that Eden Lodge develop a quality assurance system, and while this has almost been achieved, it is not yet in place, so the requirement will remain. Currently Eden Lodge are not holding resident’s meetings, and these should be started as soon as possible, as they are an excellent way of gathering resident’s views formally, and enabling residents to comment on the service they are receiving. Eden Lodge operates a ‘small cash needs’ system for resident’s personal finances. The records for four residents were checked at random, and were found to be correct, and with receipts in place to evidence expenditure. Two residents when asked said that they could get their money when they wanted it, and that they were quite happy for the staff to look after their money. Four staff files were checked in relation to formal staff supervision. Each one had records, which showed that staff were being appropriately supervised. Two staff members were asked about supervision, and both said that they felt well supported, and were having supervision approximately once every 6 – 8 weeks. A range of health & safety records were seen, and all found to be correct and up-to-date. These included the fire safety records, the Control of Substances Hazardous to Health (COSHH) records, and the water testing records for Legionella. Eden Lodge Care Home DS0000008666.V329257.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 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 OP18 Regulation Requirement Timescale for action 31/10/07 2. OP20 3. OP30 4. OP30 5. OP31 Regulation The Registered person must 18 (c) ensure that staff receive training appropriate to the work they perform: All staff must receive up-to-date training in safeguarding adults. Regulation The Registered person must 16 (k) investigate the source of the odour in the corridor, and solve the problem. Regulation The registered manager should 18 ensure dementia training is sufficient in order that staff are able to understand and meet the needs of the service users at the home. This requirement remains unmet from the last inspection dated 26/04/06. Regulation The registered person must 18 review staff training records for ALL staff and ensure that every member of staff receives ‘training appropriate to the work they are to perform’. Regulation The registered person must ensure that the current manager at Eden Lodge applies to the Commission for Social Care Inspection to become the DS0000008666.V329257.R01.S.doc 31/05/07 30/08/07 30/08/07 31/03/07 Eden Lodge Care Home Version 5.2 Page 24 6. OP33 registered manager without delay. Regulation The registered provider should 31/08/07 24 (1 2 & establish and maintain a system 3) for reviewing and improving the quality of care provided at the care home. The service users must be consulted as part of the quality review. A copy of the report of any review must be supplied to the CSCI. This requirement remains unmet from the last inspection dated 26/04/06. 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 3 4 5 6 7 8 Refer to Standard OP7 OP9 OP12 OP14 OP15 OP19 OP20 OP20 Good Practice Recommendations The registered person should ensure that there is an individual approach to care planning rather than generic care plans. The registered person should ensure that all drug trolleys are able to be immobilised by fixing to the wall. The registered person should make contact with representatives from local churches to help residents meet their religious needs The registered person should consider ways of improving choice through the use of pictures and the involvement of speech & language. The registered person should make every effort to make both dining rooms equally pleasant. The registered person should contact other professionals working in the field of dementia care for advice and support with regard to improving the environment. The registered person should consider making the grounds of Eden Lodge could be more stimulating and userfriendly. The registered person should replace the two picnic benches in the grounds as soon as possible, as they are in DS0000008666.V329257.R01.S.doc Version 5.2 Page 25 Eden Lodge Care Home 9 OP33 an unsafe condition. The registered person should start holding formal residents meetings as soon as possible, and ensure that resident’s views are recorded. Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Eden Lodge Care Home DS0000008666.V329257.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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