Inspection on 02/05/06 for Fairdene Lodge

This inspection was carried out on 2nd May 2006.

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

Fairdene Lodge 26/09/07

Fairdene Lodge 19/12/05

Fairdene Lodge 28/06/05

Fairdene Lodge 01/02/05

Fairdene Lodge 21/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Fairdene Lodge 14 & 16 Walsingham Road Hove East Sussex BN3 4FF Lead Inspector Melanie Freeman Key Unannounced Inspection 2nd May 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fairdene Lodge Address 14 & 16 Walsingham Road Hove East Sussex BN3 4FF 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) 01273 735221 Mrs Maria Holliday-Welch Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32) of places Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtytwo (32). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Date of last inspection 19th December 2005 Brief Description of the Service: Fairdene Lodge is a privately owned residential home for up to thirty-two older people who have dementia. Prior to September 2005 the homes registration category was for older people only, following a successful application to the CSCI this was changed to now cater for dementia care. The home’s provider also own a further three registered homes for older people within the East Sussex area. The home is located within level walking distance of Hove seafront, close to local amenities and bus routes into Brighton and Worthing. The home consists of two detached Victorian houses organised into House 14 & 16, which are interlinked by a ground floor corridor. All residents have access to both houses. It is presented on two levels, ground and first floor with access to the first floor via stairs or a stair lift. The second floor is a selfcontained flat, which is currently not in use. Resident’s accommodation consists of twenty-two single and five shared bedrooms, with eleven rooms having their own en-suite facilities. Shared facilities include a large lounge, combined lounge dining room and a conservatory overlooking the rear garden. The homes literature states that their aims are to provide residents with a secure, relaxed and homely environment in which their care, well-being and comfort are of prime importance. The fees vary from £409 for a shared room to £441 a week for a single room. These fees include all services and facilities apart from hairdressing, chiropody and newspapers, which are itemised separately on the monthly invoices. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Fairdene Lodge Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit included a meeting with the registered provider and the regional manager who received the inspector’s feedback at the end of the inspection. On the day of the home visit the inspector spent most of her time meeting with residents and their visitors, speaking with staff and observing practice in the home. During the inspection visit 3 residents care documentation was reviewed in depth. A further selection of documentation was reviewed as part of the inspection process and this included the statement of purpose and service users guide, staff duty rotas, training records, 2 recruitment files, records relating to health and safety and a number of policies and procedures. Three staff members were also interviewed in private. In addition service users surveys were given to 10 residents or their representatives and 10 staff surveys were left in the home for staff to return. The information contained in the returned surveys has been incorporated into this report. What the service does well: Fairdene Lodge provides a good standard of individualised care within a friendly and homely environment. Residents and visitors expressed a high satisfaction with the care provided and their comments included ‘the home should be commended for its care’, ‘I am very happy and content here’ ‘ I am so well looked after’. The care staff have a good understanding of the residents needs and preferences and respond in a considerate manner to these. Links with resident’s family and friends are actively encouraged along with any community link that a residents wishes to maintain. Residents receive a varied diet with meals being of good quality and plentiful. Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in he home. The Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 6 staff group on the whole is stable both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. What has improved since the last inspection? What they could do better: The care plans still need to be improved to ensure all the care needs of residents are recorded along with clear guidance to staff on how to meet these needs. The infection control measures in the home need to be improved to ensure appropriate cleaning and hand washing facilities throughout the home. The home is still without a registered manager and a competent manager needs to be recruited and retained to ensure appropriate consistent management of the home. Quality assurance measures that respond to resident’s views need to be established and reported on. Robust Health and safety systems need to be adopted and recorded to ensure staff and resident safety. Please contact the provider for advice of actions taken in response to this Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. Copies of these are available in the front entrance area. A social care professional who had recently visited the home confirmed that relevant information was provided to a prospective resident. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 10 Everyone spoken to confirmed that the contract arrangements were clear and understood. A review of the care documentation confirmed that pre-admission assessments are always completed, and are currently completed by the regional manager with the support of the care supervisor. These assessments were found to be full and were used to ensure any new admissions to the home is suitable and that the home have the staff and environment to meet the care needs of any new resident. The information contained in these assessments is now being transferred over to provide the basis of the care documentation in the home. The homes transition to a home that cares for older people with a dementia type illness continues to be well managed. The assessment procedure ensures that only residents with low to medium mental health needs are admitted to the home. Residents that have been in the home prior to the change of registration continue to be consulted and one of these residents commented that the ‘transition has been nearly painless’. Intermediate or rehabilitative care is not provided at Fairdene Lodge Care Home. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of residents. The home was found to be meeting resident’s health and general needs with accessed additional community support when needed. Procedures and practice in the home allow for the safe administration of medicines and on the whole the privacy of residents to be promoted. EVIDENCE: The care documentation pertaining to 3 residents was reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, personal histories and risk assessments. On the whole the care documentation was full and demonstrated that the care was reviewed and evaluated, however it was noted that the plans of care did not always cover all the care needs of residents. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 12 need, another resident has been wandering at night and coping strategies had not been recorded. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main office area. They felt that their views were taken into account when planning resident’s care. Discussion with a visiting nurse and social workers confirmed that the home communicates well with other professionals as necessary with regard to the care of residents. Relatives spoken to were very satisfied with the care provided at the home one saying that the home ‘should be commended for its care’. Residents spoken to were also very satisfied comments included’ I am very happy and content here’ ‘ I am so well looked after’. The medicine administration procedures have been reviewed since the last inspection and were found to be satisfactory at the time of this visit. The medicine storage area was seen, and the systems for recording and checking controlled drugs were found to be thorough. Staff were seen to be respectful and considerate to all residents and visitors. Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. During the inspection it was noted that residents rooms were respected and linen is no longer being stored in a residents room. Contact with a visiting chiropodist however identified that an occupied resident’s room has been used for him to complete his treatments. This issue was raised with the regional manager for her to ensure this practice is not repeated. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Social activities and meals continue to be creative and provide daily variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The inspector observed residents being able to spend time where and how they wanted moving around the home freely. Set routines are avoided as far as possible and residents are able to determine when they would like to go to bed and what time they would like to get up in the morning. Residents are able to choose whether they wanted to join in the activities provided which are mainly available in the afternoons, and include bingo, darts singing and movement to music. Residents their representatives and a visiting social worker felt the activities and entertainment provided was appropriate Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 14 and fulfilling. Residents able to complete meaningful activities are encouraged to do so and one resident cares for all the plants in the home. On speaking to residents and visitors it was clear that visiting is very positively encouraged with no restrictions being imposed. One visitor expressed a satisfaction that staff made an effort to be aware of who she was even though she does not visit the home on a regular basis. The meal eaten by the inspector was found to be well presented and to have a very good taste with an emphasis on home cooking and fresh ingredients. Residents were able to have their meals where they wanted to and to have extra portions if they desired. All residents and visitors praised the food very highly and the vegetarians in the home were well catered for. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. There have however been no complaints received recently to be processed using this system. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and have initiated this procedure appropriately in the past. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in an attractive home that is well maintained and clean in most areas. Infection control practice in some areas is poor. EVIDENCE: The home is located within walking distance of Hove sea front and close to local amenities including shops, pubs and bus routes. There is a door entry system in operation, to enable staff to be aware when people are entering or leaving the building for security reasons. The standard of décor is good with minor redecoration works needed to some communal areas to ensure consistent standards throughout. A programme of routine maintenance and renewal is not maintained and the need for this was Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 17 discussed with the regional manager. The home was found to be warm and comfortable, with good levels of light and ventilation. The home is not designated to provide a service to people with physical disabilities as the stairs and other access arrangements would make it unsuitable for residents with a permanent restricted mobility. Access to the first floor is via stairs or a chair lift with some additional small flights of stairs both on the ground and first floors. The inspector was advised that one resident has been moved recently to a ground floor with her agreement to promote her independence and safety. There are a variety of aids and adaptations around the building to promote residents independence. These include walking aids, raised toilet seats and grab bars. Resident’s bedrooms are decorated and furnished to a good standard with appropriate furniture and fixtures. Individual rooms were found to be personalised and clean. It was however noted that carpets had been replaced with vinyl in a number of rooms. This can give an institutional feel to a home and should not be used routinely. One room was also found to be malodorous and when this was identified to the regional manager she confirmed that this would be addressed by the contract carpet cleaner who is called to the home often to manage any odours in the home. During the inspection it was noted that some commodes were rusty and some individual tables were not clean. This was identified and discussed with the management team. The laundry room is rather cramped and the inspector was advised that this area is to be re-organised with new machinery. Following the last inspection an alcohol rub was provided as a hand washing facility in this area. The suitability of this arrangement was discussed with the Health Protection Agency nurse who recommended that the hand washing facilities were improved, ideally with the provision of a hand basin, liquid soap and paper towels if this was not feasible detergent wipes would need to be provided. A sluicing facility has been provided since the last inspection providing an area where commode pots can be disinfected. This area was found to be rather cramped and hand-washing facilities had not been provided. These will need to be provided as described above for the laundry room in line with advice provided from the Health Protection Agency. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing level at inspection was for four-care staff and a person in charge to be on duty throughout the waking day. This is in addition to domestic and kitchen staff although it was noted that some kitchen duties are completed by care staff. This staffing level was sufficient to meet the needs of residents currently but must be kept under constant review to reflect any increased activity level in the home or dependency of residents. The staff group on the whole is stable both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. The recruitment records for 2 staff members were reviewed in depth and were found to be full and contain the required information and demonstrated the appropriate induction training had been completed in respect of the job they were to undertake in the home. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 19 Staff interviewed confirmed a high satisfaction with the training provided and stated that recent dementia training being completed in conjunction with a college was most useful and interesting. Staff and records seen confirmed that they had undertaken compulsory training such as manual handling, adult protection, first aid, food hygiene and fire safety. In addition specialist training in dementia care was being completed. NVQ training is available and staff are encouraged to complete this. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 and 38 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Fairdene Lodge does not have a stable consistent manager to provide leadership and to ensure health and safety and quality monitoring systems are fully used. EVIDENCE: The home has been without a registered manager since 2002. Since the last inspection another acting manager was recruited but this appointment was not a success and she left after being only 2 weeks in post. The registered provider and regional manager are clearly keen to appoint a manager and continue to recruit. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 21 In the interim the regional manager and care manager undertake the day-today management responsibilities of the home with the provider visiting several times a week. The care manager has worked at the home for a significant number of years and provides a stable and consistent lead on care matters and demonstrates good care practices. Staff, residents and relatives continue to speak positively about them with particular reference to their approachability and relaxed nature. All staff felt that they receive the necessary support from the management team to undertake their duties, including formal supervision. Some quality monitoring has been established and resident questionnaires were completed this year however there has been no audit of these or concluding report. The regional manager confirmed that the home has no dealings with resident’s monies and that any extras costs incurred are paid by the home and then individually invoiced on a monthly basis. During the inspection a number of areas of concern were noted and reported to the regional manager, these included; A) That bedroom doors were being wedged open, and that new cigarette burns were noted on a bedroom floor. B) That a new sluice room has been created in a landing area without any fire precautions being implemented. C) That 2 bathrooms were found to have unguarded radiators. (these areas had been risk assessed) D) Footrests were not being used when transporting residents in wheelchairs. E) An environmental risk assessment had not been completed on the garden areas. The inspector left an immediate feedback for with the regional manager to ensure immediate action was taken in respect of the fire risk analysis in the home. Accident reports are being completed and records confirmed that a recent accident had been responded to appropriately. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 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 OP7 Regulation 15(1) Requirement That care plans detail the actions needed to ensure that all aspects of the health and social care needs of service users are identified and which make explicit the actions needed to meet these needs. (Made at inspection of 28/6/05 with timescales of 30/08/05 not met). That all rusty commodes are repaired or replaced to ensure effective cleaning can be completed. That all areas of the home are kept clean and hygienic and checks are completed to ensure this is maintained. That appropriate hand washing facilities are provided in all areas where infected material is being handled. That a registered manager is in post. (First made at inspection of 22/01/03). That a full quality assurance system is established and used DS0000014199.V290348.R01.S.doc Timescale for action 01/08/06 2. OP26 13(3) 01/08/06 3. OP26 13(3) 01/07/06 4. OP26 13(3) 01/08/06 5. OP31 8 01/09/06 6. OP33 24(1) 01/08/06 Fairdene Lodge Version 5.1 Page 24 to maintain and improve the provision of care and services in the home. 7. OP38 13(4) That a full fire risk assessment is completed by a competent person and responded to, to ensure resident and staff safety. That robust health and safety practice is adopted to include thorough environmental risk assessments and guarding of all radiators. 17/05/06 8. OP38 13(4) 01/07/06 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. Refer to Standard OP10 OP19 OP26 OP33 Good Practice Recommendations That staff in the home ensure that the privacy of residents is promoted at all times. That the routine maintenance programme is developed further with time-scales for the completion of works. That any malodour in the home is identified quickly and responded to with a contract carpet cleaner as necessary. That a newsletter is used to advise residents and other interested parties of the quality monitoring audit and its result. Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairdene Lodge DS0000014199.V290348.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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