Inspection on 12/12/05 for Fern Lodge

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fern Lodge 14/08/07

Fern Lodge 21/07/05

Fern Lodge 13/01/05

Fern Lodge 08/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Fern Lodge 24-26 Compton Road London N21 3NX Lead Inspector Susan Shamash Unannounced Inspection 12th December 2005 11:00 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 Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fern Lodge Address 24-26 Compton Road London N21 3NX 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) 020 8360 6219 020 8364 1240 Mrs Angela Hunt Mrs Angela Hunt Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: Fern lodge is a privately owned registered care home for 20 older people located in a residential area of Winchmore Hill, North London. It is situated within a few minutes walk of public transport services and close to a number of amenities such as shops, churches and GP surgery. The registered provider, Mrs Angela Hunt, is also the registered manager of the home. Accommodation is provided on the ground floor and the first floors in ten single and five shared bedrooms, all of which meet the minimum spatial standards. None of the bedrooms have en suite facilities, though they are all fitted with hand-wash basins. A lift facilitates access to the first floor. The home has a well-tended garden, with a patio accessible through French windows. The stated aim of the home is to ensure that the individuality of care to service users is emphasised; that staff provide this, pay attention to detail, and are highly experienced and professional in their care of older people. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately five and a half hours and was carried out as part of the routine inspection schedule for the home and to check on compliance with requirements made at the previous inspection. The inspector was able to speak with three members of staff and nine residents during the visit. A tour of the building was conducted and care records were inspected in addition to maintenance records for the home. A number of requirements made at the last inspection have not yet been met and have been restated in this report, with a new timescale for compliance. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. What the service does well: What has improved since the last inspection? Nine requirements were made at the previous inspection, four of which were met and one of which was partially met. There was an improvement in the general standard of cleanliness and hygiene procedures within the home. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 6 The required information was now stored within identified staff files to evidence that appropriate recruitment procedures were being followed. Current gas and electrical safety certificates were available for the home and a certificate evidencing current employer’s liability insurance was also available for the home. Finally the manager had contacted the local fire prevention authority for advice regarding self-closing doors for the home. What they could do better: Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 7 It is of concern that five requirements from the previous inspection remain unmet, without the manager having negotiated extended deadlines to meet these requirements. It remains required that a current photograph of each resident be available in the home. It is also required that more detailed care plans be produced and that evidence be available that residents (or their relatives/advocates if appropriate) have been consulted about their care plans. Relevant risk assessments must also be undertaken for each resident. There had been a recent decrease in activities available to residents since the ‘diversion therapist’ ceased working at the home. Action must be taken to ensure that residents have sufficient and varied activities available to them. It is recommended that separate daily notes, activities and health records be maintained, and that residents be encouraged to undertake an annual medical check with their GP. Adult protection training should be provided to all staff members to ensure the protection of residents. A number of minor repairs must be undertaken in the home, the carpet in one resident’s room must be cleaned and hot water temperature must be monitored to ensure that it does not exceed a safe temperature. Disposable hand drying facilities must be provided in bathrooms and toilets to protect residents from cross-infection. It remains required that fire safety training must be provided to all staff members and night staff should be involved in periodic fire drills on their shifts. It also remains required that regular staff meetings must be held. Consultation meetings must also be held with residents. It is recommended that informal staff and residents meetings be recorded. It remains required that a minor variation application must be submitted to the CSCI so that named residents who have developed dementia can remain living at the home. The manager must also ensure that the pre-inspection questionnaire for the home is completed and returned to the CSCI without delay. It remains required that a written fire risk assessment and emergency plan must be available for the home. Finally the faults specified in the gas safety certificate for the home must be addressed. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 8 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. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 9 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 Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 10 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. New service users can be assured that their needs will be assessed prior to being admitted and that these will be met effectively at the home. EVIDENCE: The referring authorities provide a comprehensive assessment of the service users’ needs, and a care plan that is the basis for planning the care of each service user. When possible potential service users or their representatives are encouraged to visit the home prior to admission. In general, service users spoken to advised that their needs were met appropriately within the home, and care plans inspected indicated that these were based on comprehensive assessments as appropriate. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Service users have care plans that are updated regularly to ensure that their health, personal and social care needs are being met appropriately. However their safety should be further ensured by detailed risk assessments and recent photographs of each service user being available within the home. Medication is stored, administered and recorded appropriately, thus protecting the welfare of all service users. Service users are treated with dignity, sensitivity and respect. EVIDENCE: Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 12 Care plans were available for all service users within the home. Four service user plans were inspected and were generally found to include sufficient detail to ensure that service users health care needs are provided for, including monthly care plan evaluations as appropriate. Risk assessments were not available for all service users, although a recommendation regarding a format for risk assessments was made at the previous inspection. Risk assessments should include risks relevant to each service user including the use of sensory pads for service users unable to call for assistance at night. A requirement is made accordingly. It remains required that a recent photograph be available of each service user in the home. It is also required that greater detail be included within each care plan including a short life history for service users and confirmation of their consultation regarding care plans. Details of health and personal care recorded, and feedback received from service users spoken to, indicated that the home generally provides a level of care that service users are satisfied with. It is recommended that separate formats be used to record daily notes, activities and health care appointments. It is also recommended that each service user be encouraged to see their GP at least annually for a general medical check and review of medication. Records of medication administration and storage were found to be satisfactory. A recommendation made at the previous inspection, regarding the recording of prescribed medicines needed only on an ‘as and when’ (PRN) basis had been followed. Service users spoken to advised that they were treated with respect and that their privacy and dignity were maintained. Observation of staff and service user interactions within the home confirmed that this was the case. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Provision is made to meet service users’ social, cultural, religious and leisure needs or preferences, and ensure that service users have choice and control over their own activities. However there is room for improvement in the provision of a varied selection of activities for service users. Contact with family members and friends is encouraged, so that service users are not isolated at the home. Varied, nutritious and appetising meals are served to service users. EVIDENCE: Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 14 A Christmas party for service users and their relatives had been held at the home over the weekend prior to the inspection, and service users advised that they had enjoyed it a great deal. Service users spoken to were positive about the care provided at Fern lodge. At the previous inspection the programme of activities inside and outside of the home was spoken of highly by service users. A number of service users continue to attend a local social club, however since the previous inspection the ‘diversion therapist’ employed by the home on a part-time basis had ceased to work at the home. Service users indicated that there had been a decrease in the number of activities available to them since the ‘diversion therapist’ had left. The manager advised that it was her intention to find a replacement worker as soon as possible. A requirement is made accordingly. Service users and the home manager advised that entertainers visited the home occasionally. A nun gives holy communion at the home regularly for those who are interested in participating, and one service user attends a local church. Some service users had been on a trip to Forty Hall to see a concert recently. Service users told the inspector that the food was of a good standard with sufficient choices and variety available. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home has appropriate procedures for addressing complaints and concerns raised, ensuring the protection of service users. Appropriate procedures are in place at the home to protect service users from the many forms of abuse. However training is required to ensure staff awareness of best practice in the protection of vulnerable adults. EVIDENCE: A format is available for the clear recording of complaints including actions and outcomes as appropriate. Copies of the complaints procedure are provided within the service users guide to the home. A suitable policy is available at the home regarding the protection of service users from the many forms of abuse. However staff have not undertaken training in this area and a requirement is made accordingly to ensure the protection of service users. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home is generally bright and open plan, furnished and decorated to a satisfactory standard, and meets the needs and tastes of service users. An improvement was noted in the standard of cleanliness and hygiene practices in the home. However a number of identified and housekeeping issues must be addressed to ensure the comfort and safety of service users in the home. EVIDENCE: Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 17 The building was generally found to be in a good state of repair and decorated appropriately. There was a homely atmosphere on entering the premises and service users spoken to indicated that they were satisfied with their accommodation. A pleasant garden area is also available to service users at the rear of the home. Bedrooms were personalised as appropriate, and within close access of lavatories and bathrooms, in addition to which commodes were available in most service users’ rooms. At the previous inspection it was required that cleaning procedures and the frequency of laundering flannels at the home be reviewed. An improvement was noted in these areas at the current inspection. However a broken glass pane was noted on the window in a toilet on the first floor, the carpet in room 15 and the whirlpool bath floor required cleaning. These issues must be addressed. The temperature of hot water from the whirlpool bath was found to exceed 43°C. The manager advised that this bath had not been in use for some time, however the temperature of water from all hot water outlets must be monitored on a regular basis to ensure that it does not exceed 43°C. It remains required that the bucket commode chair identified at the previous inspection must be repaired or replaced. The manager advised that a new chair was on order. There was a build up of dust behind the tumble driers in the laundry room, this must be addressed as it may present a fire hazard. Finally the use of cloth towels for hand-drying in the toilets and bathrooms within the home places service users at risk of cross-infection. It is required that paper towel dispensers be fitted in each bathroom and toilet and that these be kept stocked. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30. Adequate and experienced staff are available in the home to meet the needs of service users. However training in fire safety and adult protection is required for all staff members to ensure the safety of service users. There was an improvement in the information stored on each staff file to ensure that service users at the home are fully protected by rigorous recruitment practices. EVIDENCE: Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 19 An immediate requirement was restated at the previous inspection regarding the employment of new staff and the necessary checks to be undertaken. Since the previous inspection, the registered manager had provided evidence to the inspector that appropriate references and enhanced CRB disclosures were being obtained for new staff members. The manager was aware of her responsibility to ensure that up to date work permits are available for every staff member. Staff members spoken to indicated that they receive a range of relevant training and several have completed their NVQ level 2 in care. The manager advised that staff had also completed training in the administration of medication. It remains required (from the previous inspection) that fire safety training be provided to all staff and that the night staff be involved in regular and relevant fire drills for the night shifts in the home. It is also required that all staff receive training in adult protection as noted under Standard 18. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. The home is managed by an experienced individual with the best interests of service users in mind. The home does not take responsibility for the finances of any service users in the home. Staff receive regular formal and informal supervision, but would benefit from more regular meetings to ensure that they are able to meet service users’ needs to the best of their abilities. Informal service user meetings are also required to ensure that their wishes are taken into account. An application must be made to vary the registration of the home so that service users who have developed dementia since moving into the home may remain in the home. There is room for improvement in the fire safety procedures including a need for a detailed fire risk assessment and emergency plan. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 21 EVIDENCE: Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 22 The manager has been in post since the home was set up and is experienced and well respected within the home. Discussion with service users and staff indicated that the manager continues to be supported by her staff team. Service users advised that they felt that the registered person runs the home well and listens to their views. At the previous inspection it was required that staff meetings be held regularly and that records of these meetings be maintained at the home. However there were still insufficient records of staff meetings available for inspection during the current inspection. This requirement is therefore restated. It also remains recommended that the content of informal staff meetings be recorded. The manager advised that historically service user meetings have not been successful at the home. However it is required that service user meetings should be arranged (although these can be informal and involve small groups if necessary) to ensure that service users are involved in making decisions about the running of the home as far as possible. The outcome of these meetings should be documented. The manager advised that the home does not take responsibility for the finances of any service users in the home nor is the manager appointee for any service user, instead relatives or advocates undertake this role. At the previous inspection it was required that fire drills be undertaken with night staff to ensure that they are clear as to action to be taken during the night shift should there be a fire alert. However no records of fire drills or fire alarm testing were available during the current inspection. The manager advised that the individual responsible for these tests had the relevant logbook (away from the home). This requirement is restated and it is also required that all documentation relating to health and safety within the home must be kept on the premises. As required at the previous inspection current insurance, gas and electrical safety certificates were available at the home. Certificates were also available for portable appliances testing, water chlorination and lift servicing as appropriate. It is required, however, that the faults specified on the gas safety certificate must be addressed. At the previous inspection it was also required that a fire risk assessment and emergency plan be produced for the home and reviewed at least six-monthly. This requirement is also restated. The manager advised that she had sought advice from the local fire prevention office with regarding the absence of self-closing fire doors on the bedrooms of each service user. She advised that she planned to have the wiring installed for a number of self-closing doors in the home, over the coming year. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 23 It remains required that an application must be made to the CSCI to vary the registration conditions of the home so that service users who have developed dementia since moving into the home may remain in the home. The manager has been provided with the relevant forms to be completed. Failure to do this means that the home may be operating outside of its registered category and may result in enforcement action being taken by the CSCI. It is also required that the pre-inspection questionnaire for the home must be completed and returned to the local CSCI area office, as this had not yet been returned. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 24 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 25 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 1517(1a) Sch 3(2) Requirement The registered person must ensure that recent photographs of each service user are available within each service users plan. (Previous timescale of 02/09/05 not met). Further detail must be included within each care plan including a short life history for each service user and confirmation of their consultation (or their relatives/advocates’ if appropriate) regarding the care plan. The registered person must ensure that relevant risk assessments are available for each service user including the use of sensory pads for service users unable to use the call system at night. The registered person must ensure that a varied selection of activities are available to service users. The registered person must ensure that staff receive training in the protection of vulnerable DS0000010673.V265315.R01.S.doc Timescale for action 31/03/06 2 OP7 13(4bc) 14 10/03/06 3 OP12 16(2mn) 03/02/06 4 OP18OP30 13(6) 18(1ci) 31/03/06 Fern Lodge Version 5.0 Page 26 5 OP19 23(2b) adults. The registered person must ensure that the bucket chair comode in room 5 is repaired/replaced. (Previous timescale of 12/08/05 not met). A broken glass pane on the window in a toilet on the first floor must be repaired. The registered person must ensure that the carpet in room 15 and the whirlpool bath floor are cleaned. 03/02/06 6 OP26 23(2d) 13(4a) 20/01/06 7 OP19OP38 8 OP26 9 OP30OP38 10 OP36 The build up of dust behind the tumble driers in the laundry room must be addressed, as it may present a fire hazard. 13(4a) The registered person must ensure that the temperature of water from all hot water outlets (with action taken to adjust the hot water temperature from the whirlpool bath). Hot water temperature from all outlets (excluding the kitchen) must be monitored on a regular basis to ensure that it does not exceed 43°C and this must be recorded. 16(2j) The registered person must ensure that paper towel dispensers are fitted in each bathroom and toilet and that these are kept stocked. 13(4c)18 The registered person must (1ci)23(4e ensure that fire safety training is ) provided to all staff members, and fire drills are arranged for the night staff periodically. (Previous timescale of 02/09/05 not met). 18(2) The registered person must 21(2) ensure that staff meetings are held at least six times annually and that these are recorded. (Previous timescale of 30/09/05 not met). DS0000010673.V265315.R01.S.doc 20/01/06 24/02/06 31/03/06 10/02/06 Fern Lodge Version 5.0 Page 27 11 OP36 16(2mn) 24 12 OP37 Reg Regs 2001 13 OP37 CSA 2000 31(1) 14 OP38 13(4a) 23(4acv) 15 OP38 13(4a)17 (2) 4(14) The registered person must ensure that service user meetings are arranged (although these can be informal and involve small groups if necessary). The outcome of these meetings should be documented. The registered person must ensure that an application is made to the CSCI for a minor variation to the conditions of registration, so that named service users who have developed dementia since living at the home, may remain resident at the home. The application must be accompanied by social workers and medical recommendations that each named service user remain at the home. (Previous timescale of 30/09/05 not met). The registered person must ensure that the pre-inspection questionnaire for the home is completed and returned to the local CSCI area office. The registered person must ensure that a written fire risk assessment and emergency plan are available for the home and that these are reviewed sixmonthly. A copy must be sent to the local CSCI area office. (Previous timescale of 02/09/05 not met). The registered person must ensure that all documentation relating to health and safety within the home is kept on the premises. The faults specified on the current gas safety certificate must be addressed. 24/02/06 24/02/06 10/02/06 10/02/06 20/01/06 Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP8 OP36 Good Practice Recommendations It is recommended that separate formats be used to record daily notes, activities and health care appointments. It is also recommended that each service user be encouraged to see their GP at least annually for a general medical check and review of medication. It is recommended that the content of informal staff and service user meetings be recorded. Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Fern Lodge DS0000010673.V265315.R01.S.doc Version 5.0 Page 30 - 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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