Inspection on 06/03/07 for Feltwell Lodge

This inspection was carried out on 6th March 2007.

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

Feltwell Lodge 09/02/09

Feltwell Lodge 16/02/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Feltwell Lodge Lodge Road Feltwell Thetford Norfolk IP26 4DR Lead Inspector Jenny Rose Unannounced Inspection 6th March 2007 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 Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Feltwell Lodge Address Lodge Road Feltwell Thetford Norfolk IP26 4DR 01366 728282 01366 727361 feltwelllodge@aol.com 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) Mr Thomas Paul Hanley Mrs Sandra Elizabeth Hanley Mr Thomas Paul Hanley Care Home 23 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (15) of places Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Feltwell Lodge is a care home providing personal care and accommodation to twenty-three Older people, eight of whom may have dementia. The Victorian house is set in five acres of landscaped gardens, surrounded by woodlands and provides a peaceful location in which to live. The home is situated on the edge of Thetford forest and is two miles from the village of Feltwell. It consists of a two-storey building, with accommodation on the ground and first floor. There are four shared rooms, fifteen single, seven with en-suite. There is a passenger lift and stairway for access to the first floor. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group This was the first unannounced key inspection since the change of ownership. It lasted 8 and a half hours. A pre-inspection questionnaire had been completed by the proprietor/manager and returned to the Commission with all relevant details. Ten comment cards had been received from residents and five from relatives. All comment cards were positive and stated that they were satisfied with the overall care in the home. The proprietor/manager was available throughout the inspection and was helpful in facilitating the process. There were 23 residents living in the home on the day of the inspection. During the inspection a tour of the building was carried out and records relating to staff and residents were inspected. Four members of staff were spoken to in private as well as two visitors. Several residents were spoken to in passing and four in private. The information from the comment cards and from the people spoken to has been incorporated in the report. Overall, the information received prior to the inspection and the evidence observed and inspected on the day of inspection suggested that Feltwell Lodge, offers a good service, with some excellent aspects, and examples of good practice for those who live there. As this is the first key inspection following the change of ownership, there is a lack of track record over time, which means that it cannot be judged excellent overall at this point. What the service does well: • The building and surrounding gardens are the subject of a 5 year improvement and refurbishment plan, much of which has already been implemented and is appreciated by residents. The woodland setting of the home offers beautiful views of naturalised flowers and also wildlife. There is a stable, well trained and enthusiastic staff team and residents speak highly of their kindness and care. • Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 6 • All residents spoken to expressed satisfaction with the meals in the Home, the choice available and the surroundings in which they are eaten. Relatives and friends are welcome into the home at any time and are involved with decisions regarding care, if appropriate. One relative’s comment was “The home is outstanding”. If appropriate, residents are enabled to bring their pets to the home. There is an example of best practice in the home’s monitoring of residents’ falls and reducing the risk of reoccurrence. The management are experienced in running a care home for older people and have introduced systems, which promote good care practice. There is management commitment to staff training and development which promotes the knowledge and skill of the staff team and hence the quality of the service. There are excellent management systems and commitment to quality monitoring and continuous improvement guided by the residents’ best interests. There is a ‘hotel-type’ telephone system installed, for residents to have phones in their room, if they wish, and to be able to make internal as well as external phone calls. There is a monthly newsletter informing residents, relatives and staff of new developments and improvements. • • • • • • • • What has improved since the last inspection? Two recommendations from the last inspection have been completed: • • Residents have lockable facilities within their rooms The fuse box on the first floor is covered to reduce risk to residents. One requirement for regulators to be fitted to hot taps to maintain water at a safe temperature is in progress. One recommendation that residents are offered the option of have a lock on their bedroom doors is in progress. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 7 Continuous improvement, as a result of the home’s development plan and quality assurance system has resulted in: • • Redecoration, refurbishments of carpets and curtains in communal areas and residents’ rooms. Electric locks on outside doors, alarms and metal landings on fire escapes and security lights to and from the visitors’ entrance have been installed, as well as the long driveway being renewed. The Laundry has been improved with addition of second washing machine, LPG cylinder with gas pipeline for tumble dryer installed. New water system, accumulator and thermostatic valves to all radiators has been installed and the central heating system renovated. All water, hot and cold, is now potable. Kitchen staff have new uniforms Ceilings replaced in two areas. Numerous outside improvements, including gutters, pipes, outbuildings and cutting back shrubs and trees and new planting. Patio renovated and enclosed with small, planted wall and gate. • • • • • • 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. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are made prior to a resident’s admission and care plans formulated from these. The home does not offer intermediate care. EVIDENCE: The care plan for the most recent resident showed an assessment by the manager, a medical report and also one from a relative. This resident had moved from another home and there was also information from this home. In speaking to the resident, she said, “They look after you – we’re always eating and drinking”. This resident used to live locally, she also has relatives locally and her husband had visited the home in the past for day care. All ten residents’ comment cards said they had had sufficient information before moving to the home. One remark was “I knew it was the right place for me”. Three other care plans examined and all had evidence of assessments by the manager before admission together with reports from healthcare professionals. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are set out in individual care plans and there are effective systems in place to show that these are met. The home has good medication management systems in place. Residents felt they were treated with respect and that their privacy was upheld. EVIDENCE: Three care plans were seen and each contained a comprehensive resident’s plan, detailing the overall needs of each individual. All care plans were up to date, had been audited, contained a photograph and relevant details in case of emergency. Two contained nutritional charts. GP visits were recorded separately, as well as visits from other healthcare professionals such as District Nurses and Community Psychiatric Nurses. One Healthcare Professional was visiting on the day of the inspection. Activities and Social Needs are recorded, as well as, where appropriate, the resident’s wishes for their funeral arrangements. Residents and visitors spoken to, together with the comment cards from both residents and relatives confirmed that residents’ healthcare needs are being met and changing needs monitored with regular Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 11 reviews, involving the residents’ relatives if appropriate. The home’s quality audit shows that 100 of the residents are very satisfied with the arrangements for their personal care. The management are committed to the holistic care of the residents. There is a good example of best practice in the home’s monitoring of falls. They have consulted with the Falls Awareness Team, who then held a course in the home. For one resident a study of the falls pattern resulted in a change of routine, which has decreased the risk of falls. There are medication policies and procedures in place. The medication round was observed and on the day an experienced member of staff was dispensing it. She was observed following correct procedures. The Care Manager has the responsibility for the ordering of medication. The medication administration has recently been changed and the member of staff concerned said that the method now employed, in her opinion, is much quicker and safer. Reordering is much more efficient and the home can ring the pharmacy at any time for advice. All staff administering medication have received training. There is a Controlled Drugs cabinet and the records for this and the MAR sheets were seen to be completed satisfactorily. There are no residents who are entirely self-medicating, but one partially administers her own pills; the home dispenses it and there is a risk assessment for this. All residents spoken to and evidence from observation confirmed that residents were treated with respect and their privacy was protected. One resident chooses to lock her bedroom door and carries the key with her. The manager is implementing a rolling programme of fitting locks to all bedroom doors (see Environment). The relatives of another wrote in a letter, “…she was treated at all times with dignity and respect”. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The routines, activities and plans in the Home are resident focussed, regularly reviewed and can be quickly changed to meet individual resident’s needs. There is a choice of wholesome and nutritious food provided and it is served in a comfortable environment, according to residents’ needs. EVIDENCE: The home has developed a programme of activities and a member of staff is now the designated Activities Organiser, who is undertaking her NVQ4 in care. It is intended that another member of staff will be attending an Extend training course in September. There are activities every afternoon, seven days a week, as well as music and games on two mornings and these are planned on a weekly basis. Activities are recorded and undergo regular assessment and will be linked through the quality assurance system to residents’ particular interests and hobbies. Eight residents’ comment cards said that there were always activities in the home and they could choose whether they participated. Three said “Yes, it is up to you”…another “Sometimes I participate if I wish but I am quite happy to be on my own in my room.” The home’s quality audit report also showed that Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 13 70 per cent of residents were very satisfied with the social activities provided or arranged. There is evidence from comment cards and visitors spoken to that many enjoyed the Christmas Party in the home. One resident spoken to was very pleased to have been able to bring her cat to the home and the staff support her in caring for it. The home encourages contact with family and friends. On the day, the spouse of one of the residents was visiting, which happens several times a week, and another resident’s family were also visiting. Care plans also showed evidence of relatives’ involvement in care plans and reviews. In the home’s quality audit 75 of relatives rated the home’s response to their phone calls as excellent and 25 as good. One visitor spoken to said she was very satisfied with her relative’s care and that her relative’s key worker always makes herself known when she visits and keeps in contact by phone. Another said she was always involved in her husband’s review. There is evidence that relatives’ comments are listened to and acted upon. The cook was spoken to, who confirmed she has a Food Hygiene qualification and would like to do further catering qualifications. The menu has been refined following consultation with the management, the cook and feedback from the residents. The menu provides two choices and the cook meets each new resident and asks for food preferences. There are four residents’ with special diets and this is recorded on menu plans every week and the Malnutrition Universal Screening Tool is used for all residents and care staff are trained in its use. The kitchen staff have recently received new uniforms. Two residents spoken to said, the “food is excellent”. The Quality Audit Report in January showed all the residents were satisfied with the meal times and the amount of food provided and the majority were very satisfied with the food and how it is presented. The tables in the dining room are pleasantly set out and contain the menu for the day in ‘café style’ holders. The dining room is a large, pleasant room overlooking the garden, where most of the residents choose to take their meals. For those who need assistance, there is a table in the sitting room and if they wish residents may have their meals in their rooms. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 using available evidence including a visit to this service. All residents and visitors spoken to on the day of the inspection were aware of the procedure, should they wish to make a complaint and that these will be acted upon. The home has a policy and procedures to ensure that residents are protected from abuse, and those staff spoken to were aware of this. EVIDENCE: Seven comment cards from residents said they knew how to make a complaint and one said “I’ve got no reason to complain” and three said they usually knew how to make a complaint. All the relatives’ comment cards demonstrated that they were aware of how to make a complaint and this was the case with all the residents and two relatives spoken to on the day. The procedure is included in the service user’s guide, which each resident has in their room. The Pre Inspection Questionnaire stated that there had been a complaint, of which the manager had informed the Commission at the time, which the home had dealt with appropriately. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 15 The home has a policy and procedures with regard to safeguarding vulnerable adults and all the staff spoken to on the day gave a good account of the home’s whistle blowing policy. The proprietors/manager are well informed about the issues of protection, the home which they co-own, one of the proprietors is the representative for the National Association of Care Homes on the Vulnerable Adults Protection Committee and is well informed about the issues of adult protection. The staff training profiles confirmed that all staff have received training in the Protection of Vulnerable Adults. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, homely and comfortable environment, which meets residents’ needs. Considerable refurbishment has taken place inside and out, but the rolling programme to install hot water regulators on all wash hand basins is still to be completed. EVIDENCE: The home is surrounded by woodland with naturalised flowers on the outskirts of the village of Feltwell, with access via a long drive. This drive has been renewed with luminous signs at the entrance and two security lights on arrival and departure at the visitors’ entrance have been installed. The home’s extensive grounds are in the peaceful countryside and attract a variety of wildlife, which can be seen from the many windows overlooking the gardens. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 17 There has been considerable work on the gardens, and particularly on some of the trees, which were overgrown. One comment card said “Since we have been visiting the home considerable improvements to the grounds and the environment have been made by the proprietors”. The outside patio has been repaired and a small retaining wall with wall planting and gate has been constructed, which also makes it a secure area with garden furniture for the summer months. The proprietors are considering designing a larger, secure garden area, which is part of the development plan. There have been structural improvements to the building and several outbuildings put to use as storage. The home employs a part time gardener and also a handyman. There is a small conservatory area on entering the home, which serves as a quiet area, and a large communal lounge overlooking the garden, as does a large dining room. All these areas have been refurbished with new curtains, as have all the corridors with new blinds, redecoration and recarpeting. Electronic locks have been fitted to outside doors, as well as alarms on fire escapes, which have also been refurbished. From the decorating and maintenance record, new carpets and new furniture has been fitted in the majority of bedrooms and the dining room. The laundry room has been renovated and new equipment installed. There is a new water system, accumulator and all water, both hot and cold is now potable. Work has begun on fitting regulators to taps and completed in the bathrooms and water temperatures recorded. Regulators on basin taps are in the process of being fitted, but there is a requirement for this work to continue to be carried out on all wash hand basins to ensure a safe water temperature. Work to cover the fuse board on the first floor has been completed. All residents’ rooms seen were pleasantly and comfortably furnished and personalised. One resident spoken to was very pleased with her room and its new redecoration. Bedrooms, which have not yet been refurbished, are included in the development programme. All bedrooms have lockable facilities within them and some locks have been replaced on residents’ bedrooms doors, so that residents may have a key if they wish. There is a recommendation that this work should continue. The home has a ‘hotel’ type telephone system installed, so that residents may also phone internally, if they wish, as well as externally. A resident’s and a relative’s comment card mentioned that it would be preferable that all bedrooms were ensuite, and the manager confirmed that this was also mentioned in the home’s Quality Audit and necessarily had to be Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 18 part of the development programme. However, he confirmed that residents were always offered rooms with ensuite facilities when one became available. All areas seen whilst touring the building were seen to be clean and tidy. The home has doubled the domestic staff to ensure that good standards of cleanliness are maintained. Residents spoken to and the comment cards confirmed that the home is kept fresh and clean. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents in the Home are cared for by an experienced, well-trained, motivated and stable care team with a clear structure of responsibilities. EVIDENCE: One resident spoken to said “The girls are so kind. They have good training”. This was reiterated by another resident spoken to and endorsed by residents’ comment cards – “They always come when I’ve wanted them – even in the night”. In the home’s quality audit 100 of residents were very satisfied with the care given by the staff. The staff rota for the week of the inspection showed that there were four members of staff on duty in the morning, three in the afternoon, two in the evening and two night staff. The cleaning staff has been doubled. The staff team is a stable one and no member of staff has left during the change of ownership. The staff exhibit commitment to the care of the residents. The Care Manager, who has worked in the home 15 years, said that she has an office day when she does staff supervision and appraisals. She has achieved an NVQ3 in care and is now undertaking her NVQ4, level 4 Registered Manager Award. She reported that staff turnover is very low and that last summer was last time there had been a new member of staff. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 20 The Pre-Inspection Questionnaire shows that 55 of staff have an NVQ2 or above, four members of staff are studying for NVQ2 and this will bring the percentage up to 78 to NVQ2. When others complete their level 3, this will equate to a 55 NVQ3 Care trained workforce. There is a good, individualised training programme and the management are committed to training for all members of staff. All staff members have completed an Induction programme in addition to national qualifications, other training, such as Challenging Behaviour, Infection Control, Dementia Care, Bereavement Training and Validation Therapy is offered. Three members of staff were spoken to in private and three staff files examined, as well as training folders. They all described the staff team as very friendly. Staff meetings were held every month; the agenda for this would go up and could be added to by staff. The Care Manager holds senior meetings on a regular basis and seniors also undertake a key working role. The management are committed to a management structure within the home, which delegates responsibilities and empowers staff to fulfil these. The file for the most recent member of staff was seen and all the necessary checks and documents were found to be in place. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is run in the best interests of the people in it, with good examples of best practice, well monitored by a highly qualified manager who has developed flexible structures to ensure the continuing quality of the service EVIDENCE: The proprietor/manager is a qualified nurse and has much experience of managing care services. He has completed his NVQ4 qualification in Management and is committed to keeping abreast of new developments. He is highly competent in the development and implementation of the service’s policies and procedures and demonstrates strong leadership of the staff team, who are empowered to fulfil their individual responsibilities within a clear line management structure. It was evident from observation and in speaking to staff and visitors that there is an open and inclusive management style in the home. The home have appointed a Care Manager (see Staffing) who is Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 22 undertaking her NVQ4 Registered Manager’s Award and is now undertaking the supervision of staff. Two comments from residents’ relatives in comment cards are: “I am very pleased with the care given to my relative by the staff of Feltwell Lodge.” …”the home is outstanding”. The home’s quality audit regarding the Management of Daily Living shows that 100 of participants are very satisfied with how the management involve residents and families in the home’s affairs and 90 are very satisfied with the management’s efforts to create a good atmosphere. The results of the home’s client questionnaire summary, which is part of the quality audit, are now available as well as the management responses, one example being the visitors’ book (see Daily Living). The management own another home, where they have developed an excellent quality assurance system over several years. This has been implemented at Feltwell Lodge and the analysis shows that there have been many areas of improvement in the home in its first year and that the manager is also monitoring his own work within the home. The management is committed to good communication at all levels and there is a monthly newsletter in the home informing staff, residents and relatives of new developments and improvements. The Pre-Inspection Questionnaire and the manager confirmed that the home does not handle residents’ finances. These are either managed by the residents themselves, their families or advocates. There are two residents in the home who manage their own finances. Residents are billed monthly for personal expenditure such as hairdressing and newspapers and records kept. There is a comprehensive, professionally produced Health and Safety Risk Assessment for the house and the records for the Fire Service, Electrical Maintenance, Lift, and Electrical Installation, were up to date. The training records for staff also showed that their training in health and safety areas was kept up to date. Feltwell Lodge DS0000065148.V332592.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 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 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 24 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 OP25 Regulation 13(4) Requirement The registered person must ensure that regulators continue to be fitted to hot taps to maintain the water at a safe temperature. Timescale for action 01/07/07 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. Refer to Standard OP24 Good Practice Recommendations It is recommended that residents continue to be offered the option of having a lock fitted to the door of their room. Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Feltwell Lodge DS0000065148.V332592.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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