Inspection on 15/12/05 for Eighton Lodge Residential Care Home

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Eighton Lodge Residential Care... 21/08/07

Eighton Lodge Residential Care... 10/08/06

Eighton Lodge Residential Care... 05/07/05

Eighton Lodge Residential Care... 01/02/05

Eighton Lodge Residential Care... 02/09/04

Eighton Lodge Residential Care... 25/02/04

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The Highlands

Turret Villa Retirement Home

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Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Eighton Lodge Residential Care Home Low Eighton Gateshead Tyne & Wear NE9 7UB Lead Inspector Miss Andrea Goodall Unannounced Inspection 15th December 2005 9:30am 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 Eighton Lodge Residential Care Home DS0000007380.V256357.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. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eighton Lodge Residential Care Home Address Low Eighton Gateshead Tyne & Wear NE9 7UB 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) 0191 410 3665 0191 410 3665 Wellburn Care Homes Limited Care Home 45 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (45), of places Physical disability over 65 years of age (5), Sensory Impairment over 65 years of age (2) Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Eighton Lodge is a large home in Low Eighton set back from the road in its own extensive grounds. It is a listed building of historical interest and is directly opposite the Angel of the North, which can be seen from many of the bedrooms. The home provides personal care for up to 45 older people, some of whom may have dementia care needs and a smaller number who may have physical needs. The home does not provide nursing care. There are bedrooms on both floors of accommodation, which are served by a central passenger lift. There is level access into the home from the driveway, and around the ground floor where the communal lounges and bathrooms are sited. The home is located on a main bus route, and it is a couple of miles to the nearest local facilities. The home is currently being extended, and building work is on-going at this time. The additional premises will allow for a slight increase in number of places, shared rooms will be reduced to single occupancy and a further bathing facility will be provided. The extension building is indistinguishable from the original house and most works are being carried out externally to minimise any disruption to the running of the home. Eighton Lodge Residential Care Home DS0000007380.V256357.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 over one day in December 2005. One Inspector spent the visit talking with around 15 residents, and their visitors, to get their views of the service. Time was also spent looking at how medication is given, and looking around the premises. One Inspector spent time talking with the Manager and staff about the progress of the service, looking at care records and health & safety records. What the service does well: What has improved since the last inspection? Care plans are more detailed now so that staff have clear guidance in how to help each person with their specific needs. Since the last inspection all staff, including housekeeping and catering staff, have started a 12-week course in Positive Dementia Care. This means that all staff will better able to support the people who live here who have dementia care needs. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 6 Refurbishment work to extend and improve one of the lounge areas is now complete and residents commented favourably on this area of the home. What they could do better: The home should have information about its service in a suitable format for people with a visual impairment, such as on cassette tape. The home writes to let people know if it can provide a service to them, but it should also write to let people know if it cannot meet their needs. All assessment documents should be fully completed so that staff know what each person needs support with, especially moving & assisting. Care plans should show whether residents or their relatives were involved in the plan. It would be helpful if the home kept a daily record of everyones well-being, and if the monthly evaluations gave details of what has actually been achieved. Residents should also be involved in risk assessments, for example where they have been assessed as able to manage their own medication. Unused medication must be returned to the pharmacist. There should be guidelines for staff to help them know when to give as and when required medications. Some bedrooms are kept locked by staff so residents cannot use their rooms whenever they want without asking staff to open them. At this time everyone is still using just one dining room and this makes it very cramped and difficult for staff to serve and help residents with their meals. The home now needs to start using the other lounge/dining area again, now that this has been extended and redecorated. The home does not have enough bathing facilities for the number of places it is registered for, but this will be improved as part of the extension works will provide 2 new shower rooms. The home should make sure that people with a hearing and/or a visual impairment have the right equipment to support their independence, such as listening devices for the television. There should be individual records for each of the residents that the home helps to look after small amounts of money. Advice still needs to be sought from the Environmental Health officers about the radiator guards used in the home, as it is possible that people could burn themselves. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 7 There are rusting screws in a chair hoist in one bathroom that need to be fixed. Also the temperature of water to one bath was very cold. These two matters were written on an immediate requirement form. (The Manager has since written to the CSCI confirming that both these matters have been fixed.) 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. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. (Standard 6 is not applicable.) Residents only move to this home following an assessment of their needs, and confirmation that their needs can be met. Most resident know that the home will meet their needs, but information about the service is not in a suitable format for those residents with a visual impairment. EVIDENCE: The needs of all potential new residents are assessed prior to them making a decision about moving to this home. Most residents have first been assessed by a Care Manager of the Social Services Department. The Manager of the home also carries out an assessment to ensure that a persons needs can be met at Eighton Lodge. The Manager uses an assessment document to check peoples care needs including emotional, physical and mental health. The potential resident is also invited to spend a full day at the home so that their support needs can be checked. If it is determined that the home can provide the necessary care, the Manager writes formally to the potential resident confirming this. At this time there is no such written decision for people whose needs cannot be met at the home. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 10 The home is registered to provide up to 14 places for older people with dementia care needs, 5 places for people with a physical disability and 2 places for people with a significant sensory impairment. At this time all those places are filled, so the home cannot admit any more people with those needs at this time. Since the last inspection all staff, including housekeeping and catering staff, have started a 12-week training course Positive Dementia Care. This means that all staff will be better equipped to support people with dementia care needs. There are 2 people who live at the home who have significant visual impairments. However at this time the home does not provide information (such as the Service Users Guide or Complaints Procedure) in a suitable format for these residents, nor any specialist equipment to support their orientation around the home. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9. Residents needs are set out in a care plan, but these are not fully completed. Residents health care needs are met by community health care services. Residents receive the treatments that they have been prescribed, but some medication administration procedures are unsafe. Those residents who are capable of managing their own medication are encouraged to do so, but assessment records do not support this. EVIDENCE: There has been a clear improvement to the care plans since the last inspection. Assessment records are used to identify the appropriate goals and needs of each resident and these are set out in an individual plan of care. The goals/needs are evaluated on a monthly basis, or sooner if there is a significant change. The care plans are well-ordered, easy for staff to follow, and much more descriptive than previously. However, in a sample of care files that was examined, some the assessment records are not fully completed which does not help staff to know the full support needs of each person. For one person who has a history of falls, the moving & assisting assessment had not been completed. Risk assessment records had not been filled in. Some evaluation records do not always describe Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 12 what the resident has managed to achieve over the past month. Care reports, which support the care plans, are not currently completed on a daily basis so there can be long gaps (up to 2 weeks) with no indication of a persons wellbeing. In one case the actual care practices carried out with a newer resident with anxieties were observed to be very supportive and appropriate. However there was no demonstration in the care plan of how best to support this person, so that all staff could support her in a consistent way. The Manager confirmed that the resident had only been living at the home a few weeks and that staff were still assessing her support needs. At this time care plans still do not demonstrate whether residents have been included in their own care planning. However, a form has been designed for this and the Manager confirmed that care plans would be discussed and signed by each resident or their representative at the next 6 monthly review. The care files also contain good records of the health care arrangement for each resident. There are records of visits and attendance at health care services, and it was evident that residents have access to all community health care services. Medication is stored in a secure location within the home and transported around the home in a medication trolley. A monitored dosage system is used, whereby the dispensing pharmacist supplies each residents medication within a “blister pack”. An examination of medication administration records showed that there was only one unexplained gap, indicating that medication is generally administered appropriately to the residents. Where possible and appropriate the residents are encouraged to look after their own medication. However, the self-medication assessment for one person did not include all the details of this arrangement and had not been signed as agreed by the resident, nor dated for future review. A resident had been prescribed a controlled medication to be used “as and when required”. However there is nor care plan to guide staff of the circumstances when this medication should be administered. Discussion with the staff confirmed that sometimes they need to “persuade” the resident to take it by telling them it is for their “pain”. This is not acceptable practise. In discussion with the Deputy Manager it became evident that medication declined by residents is disposed of in the waste water system. This means medication is not being returned to the pharmacist for proper disposal and is not being recorded in the medication returns book. Also eye drops containers did not have the date of opening recorded on them, so it was not possible to know if they were still in date. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 & 15. Residents are able to maintain contact with family and friends and the local community. However not all residents are helped to exercise control and choice over the use of their own bedrooms and therefore their right to independence may be compromised. Residents are offered a varied menu with wholesome food, which promotes their health and well-being. However, the current dining arrangements are very crowded. EVIDENCE: Residents spoken to said that their relatives could visit them at any time in the home and this was observed on the day of the inspection. Good contact is maintained with the local community and residents enjoy trips to local garden centres, shops and the neighbouring pub. Residents had many positive comments about the home, such the new lounge is lovely”; “I like it here”; staff always knock on my door before coming into my room”; and “the laundry is good”. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 14 Residents are able to choose what personal possessions to bring to the home, what to eat at mealtimes and one of the residents spoken to said that they retain control of their own finances. However, the majority of residents are not able to choose to spend time in their bedrooms. This is because the majority of residents do not hold a key to their bedroom and it has become standard practise in the home to keep all bedroom doors locked by the staff whilst these areas are not in use. This means that residents have to ask the staff to open their bedroom door if they want to use their rooms. For those residents who have a dementia type illness this is more problematic as there are is also no supportive signage to help them to find their own rooms. Everyone spoken to commented favourably on the quality of the meals provided in the home. Throughout the inspection, in between meals, residents were offered drinks and snacks, including fresh fruit as well as sweets and cakes. Currently, due to the extensions work in the home, only one dining area was not being used. This meant that all of the residents were served their lunch at the same time in the remaining dining room. However, the space available in this dining area is insufficient. This created a potential hazard and residents appeared uncomfortable. This was discussed with the Acting Manager during the inspection who agreed to carry out an immediate review of mealtime arrangements. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. The policies and protocols at the home protect residents from abuse. EVIDENCE: As with all adult service agencies in Gateshead, Eighton Lodge has adopted the local POVA (Protection of Vulnerable Adults) policy and procedures. These are robust procedures for dealing with suspected abuse. The Manager and senior staff have had training in the POVA procedures, but other staff have not. The home has an appropriate policy on restraint and physical intervention, but such intervention has never had to be used within the home. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 22. The accommodation provides residents with a homely, comfortable environment in which to live. However, there is no supportive signage to help people with dementia needs or a visual disability find their way around the home. There are not sufficient bathing facilities for the number of people living in the home, and the bathwater temperatures are very low. EVIDENCE: On the day of the inspection all communal areas were viewed and a small number of residents bedrooms. All areas were found to be clean and warm, and there are always fresh flowers around the home. Refurbishment work to extend and improve one of the lounge areas is now complete and residents commented favourably on this area of the home. Christmas decorations in both lounges were on display in preparation for the festive season. The home is also set in its own grounds and residents benefit from access to a wellmaintained spacious garden. There are three bathrooms within the home. However, as discussed during the last inspection, one of these areas is currently not used by the people living in Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 17 the home as it is not fitted with an assisted bath. As part of the refurbishment of the building the Acting Manager stated that this will be fitted with a new suite and appropriate lifting equipment. However, in the meantime only two assisted bathrooms are available for the 45 places at this home. The bathwater temperature was tested in the two bathrooms used by residents. In one the bath water was 35.4°C, which is too cold to bathe in. The home is registered to provide up to 5 places for older people with physical disabilities. To support those residents with physical and mobility needs the home provides 2 baths with chair hoists, plus a mobile hoist with slings to help people get up from a bed to a chair. The home also has a number of moving & assisting aids such as stands, glide sheets and moving belts. These help staff to assist residents in a safe way. In the dining room there are plate-guards and 2-handled cups to help people with dexterity needs. There are a number of people who have a hearing aid. However the home does not currently have an Induction Loop or other listening devices to help those people hear the television or music. There are 2 people who have a significant visual impairment, but there has been no input from specialist services (such as access, mobility or rehabilitation officers) to help those people get around the home as independently as possible. There are no supportive signs to help people with dementia needs to find their way around. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30. Residents are supported by the skill mix of staff. Staff receive training to support their competency to do their jobs. EVIDENCE: The care staff team includes a good balance of age and experience. There are currently no male care staff within the team. Staffing levels remain the same, that is 5 care staff on duty throughout the day and evening, and 3 care staff on waking duty. These staffing levels currently meet the needs of the 36 people who live here. However these will need to be reviewed in light of the proposed increase in number of places and potential increase in dependency levels on the completion of the extension. At this time, 10 out of the 25 care staff have attained either NVQ level 2 or 3. This falls slightly short of the minimum standard of 50 of staff with such a qualification. However a further 5 care staff are training towards NVQ level 2, so it is anticipated that this standard will be met in the near future. All new staff receive suitable Induction training in line with Skills for Care standards. Staff stated that they have good opportunities for training, and training records confirmed this. Records show that all staff have training in statutory health and safety matters, and all staff are currently engaged in training in Positive Dementia Care. All housekeeping staff have completed indepth training in Infection Control. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 19 In addition to formal training, the Manager also arranges frequent in-house training and role-play in using hoists, being supported whilst blindfolded, being supported with eating and walking. In this way staff can sample what it feels like to be a resident within the home, and how it feels to be supported by another person. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38. Residents benefit from a well-run home. Residents views are used to run the home in their best interests. Residents financial interests are safeguarded, but the record style cannot ensure confidentiality. The health & safety of residents is promoted but a small number of premises issues do not protect their safety. EVIDENCE: The former Deputy Manager has been acting as the Manager for the past 6 months, so has been responsible for the daily management and running of the home during that time. She has applied to be the Registered Manager. The Acting Manager has many years experience at a senior level within the home. She has attained a number of care and management qualifications, including NVQ 4 in Management. She is currently undertaking NVQ 4 in Care. In this way she demonstrates her capability and commitment to professional development. At this time her application for registration is being processed. Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 21 The Acting Manager is supported and supervised by an Area Manager, and there are clear lines of accountability within the organisation. The Area Manager carries out frequent visits to the home, including a monthly audit of the service. During those visits the views of residents and relatives are sought to ensure their satisfaction, or otherwise, with the service provided by this home. It is evident from those reports that suggestions and comments made by those residents who take part do influence the practices in the home. In this way, the home endeavours to run in the best interests of the people who live here. Residents, and their representatives, are invited to attend 6 monthly reviews to discuss their care needs and to ensure that these continue to be met. This provides another setting for residents to make their comments about the service. In the past there have been satisfaction questionnaires for residents, which some people might find useful if they wanted to make anonymous comments. However the questionnaires have not been used for 3 years. Residents are encouraged to continue to manage their own finances wherever they can, and currently around 7 people still look after their monies. The home helps around 29 people to securely store small amounts of personal allowance. The records of how this is managed were well detailed and up to date. However there is only one record book to record the transactions of monies for 29 people. This means that the records could not be viewed confidentially by individual residents if they wish to do so. There is maintenance staff to carry out routine maintenance checks and address any minor repairs. A health & safety audit is carried out to the premises each month to check that the home remains a safe environment for the people who live here. Radiators throughout the home have been fitted with guards. However, the bars of these are wide and it is possible for a person’s hand to fit through and touch the radiator, which could burn them. Also there are rusty screws protruding from the chair hoist in one bathroom that presents a risk of injury to residents and staff when using this equipment. Eighton Lodge Residential Care Home DS0000007380.V256357.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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X 2 2 X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Following an assessment of needs, the Provider must write to the prospective resident if the home is unable to meet their needs. The home must provide information in a suitable format for people with a visual impairment, and seek specialist advice about orientation and support for those residents. All relevant assessment records for care plans must be fully completed, including moving & assisting assessments. Care plans must demonstrate the involvement of residents and/or representative or record why this not possible. (Previous timescale of 01/11/05 not met.) A care plan must be developed instructing staff of the circumstances under which “as and when” controlled medications are to be administered. Timescale for action 01/03/06 2. OP4 12(4)b 22(6) 01/03/06 3. OP7 15 01/03/06 4. OP7 15 01/04/06 5 OP9 13(2) 01/02/06 Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 24 6 OP9 12(2) (3), and 13(2) 7 OP9 13(2) 8 OP9 13(2) 9 OP14 12(4)a 13(4)a 10 OP18 13(6) 11 OP21 23(2)j 12 OP21 23(2)j 13 OP22 23(2)n The practise of covertly administering medication to residents must cease, and advice must be sought from the GP about acceptable methods of supporting this person to take their medication. Unused or declined medication must be returned to the pharmacist for proper disposal, and the returned record must be completed. Eye drops containers must be dated to ensure the medication is only used within the 28-day period. Assessment records for selfadministration of medication must be signed by the resident to demonstrate their involvement and agreement, and be dated for future review. All residents must have access to their own bedrooms unless it can be demonstrated through a risk assessment of individual needs that it would be an unreasonable risk for them to do so. All staff who have not yet received training in POVA procedures must be nominated for such training. The home must provide sufficient bathing facilities to meet the needs and choices of the number of people who live here.(Previous timescale of 01/11/05 not met.) Hot water temperatures of baths must be tested on a weekly basis to ensure a safe temperature of 43°C is achieved. The needs of people with a sensory impairment must be met by the provision of specialist equipment, including Induction Loops, and any adaptations that will support the needs of people with a visual impairment. DS0000007380.V256357.R01.S.doc 01/03/06 01/02/06 01/02/06 01/03/06 01/03/06 01/05/06 01/02/06 01/04/06 Eighton Lodge Residential Care Home Version 5.0 Page 25 14 OP38 15 OP38 Advice must be sought from the Environmental Health Department in relation to the suitability of the current radiator guards.(Previous timescale of 01/09/05 not met.) 13(4)a,b,c The rusting screws protruding 23(2)c from the chair hoist in one bathroom must be made addressed. 13(4) 01/09/05 01/02/06 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. Refer to Standard OP7 OP7 OP15 Good Practice Recommendations Evaluation records should describe the residents achievements towards each of their goals. Consideration should be given to keeping daily reports in order to maintain a record of each residents well-being on a daily basis. A review of mealtime arrangements should continue to be carried out to ensure that staff have sufficient space and time to assist residents in a dignified and unhurried manner. Staff should continue to pursue NVQ training to ensure that at least 50 of the team achieves NVQ level 2 in care. Individual satisfaction questionnaires should be brought back into use to ensure that all residents and their representatives can give confidential comments about the service. There should be individual records in respect of monies held for each resident. 5. 6 OP28 OP33 7 OP35 Eighton Lodge Residential Care Home DS0000007380.V256357.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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