Inspection on 14/05/08 for Elizabeth Lodge

This inspection was carried out on 14th May 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 Elizabeth Lodge 3 Bowley Road Hailsham East Sussex BN27 2DB Lead Inspector Caroline Johnson Unannounced Inspection 14th May 2008 09:50 Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Lodge Address 3 Bowley Road Hailsham East Sussex BN27 2DB 01323 846287 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) Elizabeth Care Limited Vacant post Care Home 9 Category(ies) of Learning disability (0) registration, with number of places Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 9. Date of last inspection N/A Brief Description of the Service: Elizabeth Lodge is registered to provide accommodation and care for nine (9) people with a Learning disability. The home is a detached house situated in a residential area of Hailsham and is located close to the town centre, although no public transport runs past the home. The Hailsham ponds and weekly market are within walking distance. There are (6) single bedrooms on the ground floor and three on the first floor, all have en-suite facilities. The ensuites are made up of a step in shower, toilet and sink. In addition there is a bathroom in use on the ground floor with a bath seat. The range of fees as of May 2008 was £814 to £1,084. Fees are negotiated with Social Services and are based on assessed individual needs. Day care fees are not included in this fee. Additional fees are charged for hairdressing, toiletries and magazines. A copy of the most recent inspection reports will be available at the home and from the owners upon request. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. For the purpose of this report the people living at Elizabeth Lodge will be referred to as ‘residents’. As part of the inspection process a site visit was carried out on 14/05/08 and it lasted from 9.50am until 2.50pm. The appointed manager facilitated the inspection. In addition one of the owners was working in the home at the time of inspection. Over the course of the inspection there was an opportunity to meet with both of the residents. In addition time was spent with one member of care staff in private. All areas of the home were seen during the inspection. A full examination was carried out of two care plans. In addition records seen included; staff recruitment and training, medication, menus, health and safety, quality assurance and leisure activities. Elizabeth Lodge was opened in December 2007. There was a registered manager in post at that time. The manager resigned from her position in January 2008 and a new manager was appointed in March. The new manager has yet to apply for registration. As there was a period of time where there was no manager, the owners decided not to admit any further new residents. However, now that a new manager has been appointed the home are actively looking for new residents. Following the inspection the owner contacted the Commission to discuss the requirements made and she advised that they have already addressed some of them and are working towards achieving the remainder. What the service does well: The building is well maintained and the standard of décor is very good. The building is very spacious and there are a number of communal areas for residents to choose where to spend their time. Residents have been encouraged to personalise their bedrooms and can choose a change of colour scheme. Residents advised that they are happy in their home and like their bedrooms. Staff spoken with felt well supported and felt that they were given clear information about the needs of the residents. The majority of the staff team were up to date with mandatory training and arrangements were being made to address any shortfalls. The manager is currently studying for NVQ (national vocational qualification) at level four and the intention is that all staff employed will have the opportunity to train to NVQ level 2 or an equivalent course. Quality of care planning to date is very good and when care plans are Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 6 fully completed they will assist greatly in ensuring that residents’ needs continue to be met. Residents participate in a range of interesting and stimulating activities throughout the week and at weekends. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of prospective residents are fully assessment prior to the home making a decision about whether to provide accommodation. EVIDENCE: There is a detailed statement of purpose in place, which needs to be amended to include the manager’s details. The service user guide also needs to be reviewed and if necessary adapted to make sure it is appropriate for the needs of the residents. Residents should also be given their own copy of this document. The manager advised that in future she would ensure that on completion of an assessment she will write to the referrer advising them of the outcome of the assessment. Preadmission documentation was seen in relation to one resident. The home had obtained detailed information from the resident’s previous placement and the home had also carried out their own assessment of needs and abilities. There was a signed terms and conditions of residence in each of the care plans. The weekly fees are currently not stated on this document but the manager confirmed that this would be practice in future. The manager advised Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 9 that transition plans for both the residents varied. The hope would be that all new residents would have the opportunity to visit on a regular basis prior to moving into the home and perhaps to have an over night stay. However, this was adapted for the most recent resident when it was agreed by all concerned that it would be better for them to move in quickly and avoid a build up of anxiety and tension. Residents spoken with stated that they are happy in their home and have settled in well. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good progress has been made to date. However the care of residents will be enhanced further when care plans are fully completed and staff are working consistently to achieve them. EVIDENCE: The new manager took over in March and since then she has been introducing a new format for care planning. Both care plans were seen during the inspection. One care plan had been completed and the second care plan included detailed advice and was being updated in the new format. The new format is very good and used to its full potential should provide excellent advice and guidance for staff. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 11 There was a hospital transfer form in each file seen. The format is good and a good level of information is provided. The exception to this is that there is no information detailing each resident’s level of communication. The care plans have yet to be signed by the residents. In relation to one care plan a detailed assessment had been carried out highlighting the individual’s abilities and needs. From the assessment nine goals had been identified. Some of the goals were generally information and guidelines that staff would need to be aware of rather than goals. Some of the goals were too broad and discussion was had about the need to clearly define which part of the goal is being worked on. Once this has been carried out it will be easier to complete the progress sheets. The format for keyworker reports is there but has yet to be implemented. A number of risk assessments, particularly in relation to epilepsy and behaviour, were identified as needing to be drawn up but it was noted that the manager had already identified that these were needed. In relation to the second resident, very detailed guidelines had been obtained form the previous placement about routines that are important for the resident and the home has tried to ensure that they are adhered to. Staff spoken with advised that the residents make a variety of choices and decisions throughout the week such as the clothes they wear, the food they eat and the activities that they want to take part in. The home needs find a way of demonstrating more clearly how choices are made and how agreement is reached if residents are making different choices in relation to activities. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to participate in interesting and stimulating activities. EVIDENCE: One resident attends a day centre three days a week. The manager advised that one of the residents used the local swimming pool for the first time recently. They also enjoy playing football and arts and crafts. On the morning of the inspection this resident helped with gardening and then went with one of the owners to do the weekly shopping. In the afternoon they were supported to take a walk to the local pond. Staff advised that they assist this Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 13 resident to maintain contact with their relatives. Visits are generally on a monthly basis and contact is made with another relative by telephone. The second resident attends college one morning a week. Staff advised that sometimes it is hard to find activities that suit this individual but they work hard to keep them motivated. If they refuse to participate in an activity this can mean that the other resident is then unable to go out. Efforts are being made to increase the range of activities provided and a meeting had been arranged with Social Services to discuss funding for day care. Residents are supported to maintain contact with their families and friends. One of the residents spends each weekend day with their parents and whilst there, they attend a church service weekly. Residents are encouraged to participate in daily living tasks on their one to one day in-house. On this day they attend to their laundry with support from staff, tidy their bedroom and help generally in tasks about the house. The home has a mini-bus, which is used to take residents to activities. Menus are drawn up one week in advance. Each of the residents cooks one evening each week and they choose the meal that they want to cook. Menus seen looked varied and well balanced. The manager advised that they would photograph each of the meals as they are prepared and then laminate the photograph. This will then be used to assist residents in making meal choices in the future. At the time of inspection there were some symbols in use but it was felt that a photo of the actual meal would be better. Residents join in and help with baking and occasionally with cleaning up after meals. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place ensure that residents’ healthcare needs are met. EVIDENCE: Within the care plan there is space to record all health care visits and appointments. Since moving to the home both residents have been registered with a new doctor. One resident has recently had an optician’s appointment. Records show that the home carried out a nutritional assessment for both residents on admission to the home and their weight is monitored monthly. It was noted that one resident has gained a stone in weight since moving to the home. The manager advised that they were monitoring this and ensuring that the resident received regular opportunities for exercise. Both male and female staff are employed to work in the home so residents have a choice of staff to provide personal care for them. Staff observed Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 15 working with residents were courteous and were seen to treat them with respect. Where residents have been diagnosed with a particular condition it was noted that there is detailed information contained with the care plans about the condition and how it can affect an individual. The arrangements for the storage and handling of medication were in order. There is a very detailed medication policy and procedure in place. The manager advised that she thought the owner had prepared a local policy but this could not be located. The home has taken a decision not to use homely remedies. All staff have received training on the administration of medication. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place ensure that any complaints, and any suspicion or allegation of abuse would be dealt with appropriately. EVIDENCE: There is a detailed complaint procedure in place and a more simplified version is available for residents. The manager advised that to date no complaints have been received. A decision needs to be made about the format for recording complaints. There is a detailed procedure in place on adult protection and prevention of abuse. A copy of East Sussex multi-agency guidelines was also available in the office and there was a flow chart on display explaining the process. A staff member spoken with had not yet received formal training on the subject but advised that they had covered the subject during induction. The majority of the staff team have received training in the protection of vulnerable adults. The manager completed a train the trainer course on the subject in 2005. The owner advised that she would like the manager to update this course so that she could then train all future staff employed on the subject. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is well maintained and decorated to a very good standard. EVIDENCE: A full tour of the building was undertaken. The house is very spacious. Communal areas consist of a large lounge, an activities room, a meeting/quiet room and a separate dining room. In the activities room there is a large notice board area for residents’ use. It is hoped to use the board to inform residents about which staff are on duty, the menu choices for the day and the activities on offer each day. Pictures and symbols are currently being laminated and although the board is partly in use it will enhance residents’ decision making when fully operational. Bedrooms are all ensuite. Both of the residents have personalised their bedrooms. The manager advised that one relative supported one of the Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 18 residents to personalise their room. As residents move into the home if they choose to have their room painted a different colour this can be accommodated. One of the residents showed the inspector their bedroom and they were very proud of their bedroom and all their possessions. They stated that this was the second room they had tried and they preferred the second choice. In addition to the ensuite facilities there is also a bathroom for general use with an assisted bath facility. The laundry room also has a sluice facility although this is not in use at the moment. The home is encouraging the practice of recycling and residents are participating in this process. All staff will receive training in infection control. It was noted that a hand towel was provided in the bathroom. In order to avoid cross infection it was recommended that disposable towels be used in this area. The garden to the rear of the property is on two levels and prospective residents would need to be fully mobile to enjoy this space. The owner advised that the intention is to have a summerhouse at the top of the garden and to have a vegetable patch. Both of the residents accommodated are fully mobile and do not require any specialist equipment. However, one resident has a specialist bed. Fire safety training is carried out by staff at induction and will then be undertaken on an annual basis. The home has yet to carry out a fire drill. Records showed that alarms have been tested weekly and emergency lights monthly. As part of the registration process a fire safety officer assessed the building. It was noted that some bedroom doors have a large gap at the bottom and a request was made to double check with fire officers that this meets requirements. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,45,35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Thorough recruitment procedures would support and protect residents. EVIDENCE: As there are only two residents the manager and the owners provide the majority of the care but another two part-time staff have been recruited in the past few months. Staffing levels will increase as the occupancy numbers increase. Both residents are funded for one to one hours each week but the manager was not sure how many. One to one hours are not clearly documented on the staff rota. One of the owners, the manager and one staff member are generally up to date with mandatory training. The manager advised that they have recently purchased training DVDs to cover staff training in manual handling, infection control, food hygiene, health and safety and fire safety. All staff will work through these DVDs in the coming weeks. There is also a DVD covering epilepsy and two of the staff have yet to view this. It was noted that all staff Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 20 would be expected to complete the LDAF (learning disabilities award framework) course on completion of induction training to the home. Three staff files were examined. In each case staff had provided a curriculum vitae but had not completed an application form. Written references were in place in relation to two of the three staff. An email had been received as a reference for one staff member but it was not clear when and for how long the referee had known the applicant. Criminal Records Bureau (CRB) checks had been obtained for all staff. There were no job descriptions in the files but the manager advised that the home are in the process of issuing job descriptions. The manager advised that she is clear about her role and responsibilities and that she has full responsibility for all managerial tasks. There were no supervision records in place for any of the staff employed in the home. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved systems for reviewing the quality of care provided could assist the home in ensuring that it is meeting the stated aims of the home and what it has been set up to achieve. EVIDENCE: The home was registered in December 2007. In January 2008 the registered manager resigned from her position as manager. A new manager was appointed and she commenced in post in March 2008. She has yet to submit her application for registration. The manager has completed NVQ level two. In addition she has completed a level three certificate in first line management Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 22 and commenced studying for the Registered Manager’s Award (RMA) in July 2007. A staff member spoken with described the manager as very supportive. As the service is new the home is continually reviewing how they are operating. They have yet to formalise a quality assurance system but have started the process. Satisfaction questionnaires are in place but need to be simplified so that the residents can complete them more easily. The manager advised that relatives’ satisfaction questionnaires would be sent out in the near future. As the numbers of residents increases the home will introduce a system for auditing areas like care plans, staff personnel files and medication. An annual development plan will also be drawn up. There is a very detailed policy and procedure manual in place. Some of the policies and procedures are generic to all care home and they will need to be reviewed and if necessary amended to ensure they are applicable to Elizabeth Lodge. The process of reviewing has been started. There are different arrangements in place to support residents with the management of their finances. One of the relatives is appointee for one resident and the owner is appointee for another. The manager was unsure what entitlements each resident was in receipt of. Where the home is responsible for supporting a resident with their finances the break down of what is received and how it is to be handled on the resident’s behalf must be clearly documented. Residents’ DLA (disability living allowance) is currently paid to the owners for petrol costs. Both residents are in receipt of a low level of DLA and they both have regular use of the home’s minibus. All records seen were in order. The manager advised that an Environmental Health Officer inspected the premises in March and no recommendations were made. The home has recently been assessed in relation to Legionella and they are awaiting a report. Records showed that the fire equipment had been serviced and there was an up to date gas certificate in place. Water temperatures are recorded regularly. Health and Safety checks are carried out monthly and an accommodation checks for those rooms currently occupied were carried out the day prior to the inspection. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 2 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 2 X 3 X Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 24 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Goals in care plans must be specific, measurable and appropriate to the needs and age of the residents. Residents must be encouraged to sign their care plans if they are in agreement with the content. Written risk assessments must be drawn up in relation to challenging behaviour and epilepsy to ensure that all safety arrangements that need to be in place have been taken. The home must ensure that all staff have regular opportunities to take part in fire drills. All staff including the manager and owners must have a written job description. Where residents receive one-toone support this must be clearly documented on the staff rota. In relation to staff recruitment, two references must be obtained in respect of each staff member and the authenticity of references must be established. All staff must receive regular supervision. A formal quality assurance DS0000071043.V363577.R01.S.doc Timescale for action 30/06/08 2. YA9 13(4a,c) 30/06/08 3. 4. 5. 6. YA24 YA31 YA33 YA34 23(4e) 18(1ci) 17(2) Schedule 4 para 7 19 Schedule 2, para 5 18(2) 24 30/06/08 15/07/08 30/06/08 30/06/08 7. 8. YA36 YA39 30/06/08 15/07/08 Page 25 Elizabeth Lodge Version 5.2 system must be set up including the drawing up of an annual development plan. 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. Refer to Standard YA1 YA6 YA7 YA23 YA30 YA34 YA40 Good Practice Recommendations The service user guide should be available in a format appropriate to the needs of the residents. The hospital transfer sheets should include information about each resident’s ability to communicate. The home should ensure that residents’ individual choices and decisions are more clearly documented. Where the home supports a resident with there finances a record should be kept of all money received and how it is to be managed on their behalf. In order to prevent the risk of cross infection the home should review their hand drying facilities. All prospective staff should be asked to complete an application form to work in the home. The home should ensure that the generic policies and procedures are reviewed and applicable to the home. Elizabeth Lodge DS0000071043.V363577.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elizabeth Lodge DS0000071043.V363577.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. 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. 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