Inspection on 25/05/05 for Fir Lodge

This inspection was carried out on 25th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fir Lodge 08/06/06

Fir Lodge 08/10/05

Fir Lodge 24/01/05

Fir Lodge 16/06/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Fir Lodge 91 Bloomfield Avenue Bath BaNES BS2 3AE Lead Inspector Angela Smith Draft - Unannounced 25th May 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fir Lodge Address 91 Bloomfield Avenue, Bath, BaNES, BA2 3AE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01225 421241 01225 421241 New Era Housing Association Ltd Miss Elizabeth Frampton CRH PC 5 Category(ies) of LD (3), PD (2) registration, with number of places Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Five bed home currently registered for 5 people with learning and/or physical disabilities Date of last inspection 24 January 2005 Brief Description of the Service: Fir Lodge is a care home operated by New Era, an independent voluntary organisation. Four of the five beds offered by Fir Lodge are block contracted by Bath & North East Somerset Local Authority. Fir Lodge is a spacious Victorian house situated in a quiet location, and provides easy access to local shops on Bear Flat and Moorland Road. The city centre is also no more than a mile away. Accommodation is provided on three floors. There are six single bedrooms in total, one on the ground floor, which has ensuite facilities, and four on the first floor, one with ensuite facilities and another with a through floor lift, which was installed specifically for the person who accommodates this bedroom. Staff members provide sleep-in cover and use the sixth bedroom, which is on the second floor. There is also an office and a kitchen on the second floor. A communal lounge area, a dining room, kitchen and laundry area are located on the ground floor. There are two bathrooms with toilets, one on the first floor and one on the second floor. There is also an additional communal toilet on the ground floor. The home is set in its own grounds and there is a garden with a patio area, which can be accessed by wheelchair down a path, which runs along the side of the house. The home has its own minibus, which is leased and service users contribute a proportion of their mobility allowance towards transport provision. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over one day. Evidence was gathered for this report through the examination of relevant records, from consultation with staff and residents, and from direct and indirect observation of practice and interactions between staff and residents. What the service does well: What has improved since the last inspection? The home now has a full compliment of staff. Some internal redecoration and recarpeting of communal areas has been carried out, which has greatly improved the environment. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 6 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. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, & 3 Residents are as clear as is possible due to their communication difficulties about the terms and conditions of their stay in the home. Residents have been assessed and their identified needs have been used to develop care plans, which inform staff members on how to support them. EVIDENCE: The home’s Statement of Purpose provides information on the services and facilities provided at the home. This is complemented by a service user guide, which is written with the use of pictures and symbols. This is a more accessible document that would enable any prospective new resident and/or their advocate to learn more about the home. The home’s philosophy of care is included in the statement of purpose and says that all residents will be treated with dignity and respect, as unique individuals, as valued members of society with a right to respect and a positive image, a right to live like others in the community, a right to make choices about their life and lifestyles and a right to the support their need in order to participate in community life. Five residents were accommodated and the home had no vacancies. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 9 All of the residents accommodated at Fir Lodge have a communication difficulty and are reliant on members of the home’s staff team to help understand and meet their needs. From reading residents’ records and from direct observation of interactions between staff and residents there was evidence to show that the staff on duty had a good level of understanding of the individual communication needs of each of the five residents. Due to the increasing needs of one of the residents, the service was receiving some additional funding so that 1:1 staffing could be provided for periods of the day. Support had been sought for this particular resident from their G.P., who had diagnosed dementia, and from a Consultant Psychiatrist, who was in the process of undertaking an assessment at the time of this inspection. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Care records are sensitively written and enable the home’s staff team to provide consistent support that is based on residents needs. Any restrictions on resident’s choice, freedom, services or facilities to safeguard their welfare are documented within their individual care files. EVIDENCE: Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 11 Care documentation maintained on two of the residents was reviewed during this inspection. Both residents had an individual file, which contained a photograph of them and all necessary care documentation that staff needed to refer to regularly e.g. individual daily routines and guidelines; the residents individual programme plan (IPP); all necessary risk assessments, and their individual activity timetables. Care documentation provided an overview of the residents’ ability and dependency, preferences and dislikes, and offered suggestions based on staff members knowledge and experience of caring for them. Correspondence between the home and various professionals involved in the care of the residents was also reviewed during this inspection. This correspondence demonstrated the home’s commitment to trying to ensure that residents receive the necessary support they require and is in their best interest e.g. referral for assessments/investigations relating to their health. Such correspondence was being kept securely in a filing cabinet in the home’s office. Daily records maintained on these two residents were also examined. A daily record proforma was being used to allow for an entry to be made by staff during their morning shift and during their afternoon/evening shift. These records enabled the two residents’ conduct and progress within the home to be case tracked. The opportunity was taken to speak to a member of staff who plays a central role in co-ordinating the service for one of the residents astheir key worker, and it was evident that this person had a clear understanding of their role and displayed a comprehensive knowledge of the resident’s needs. This person displayed a commitment to respecting and protecting residents’ rights. It was clear from the records examined and from the discussion held with the staff member that the home was providing a holistic service that took into account the emotional, social and physical needs of the resident. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, & 16 Residents receive support from staff to pursue activities that they enjoy, to enjoy holidays and keep in contact with their family. This means that residents are supported to enjoy interesting/fulfilling lifestyles. Activities undertaken are tailored to the individual preferences and needs of the residents. EVIDENCE: Each resident has their own timetable of activities, which have been specifically designed for them. Two residents timetables were seen within their care record files and included educational activities and leisure activities, which were being accessed through local day centres, day centre outreach services or colleges. One service user was attending drawing and painting, pottery, and relaxation and yoga classes at Trowbridge College and was being transported to College by members of the staff team in the home’s minibus. Residents’ daily records showed that residents do use community facilities. e.g. shops, the cinema, or pursue leisure/sporting activities they enjoy such as swimming. One resident enjoys going to cricket matches with a member of the staff team, weather permitting. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 13 Residents have also been supported by staff members to enjoy short breaks and holidays away from the home and to try out activities they have always wanted to do. One resident the Inspector spoke to with the support of staff told the Inspector that he had always wanted to go on an aeroplane and that the home had arranged for him to fly to Dublin with a staff member for the day, and since this proved to be successful and enjoyable had made further arrangements for him to fly to Dublin again, but on this occasion to stay for a weekend with the support of two staff members. This resident told the Inspector that he was now planning a holiday to Spain for October and had chosen the staff member he wanted to accompany him. The Deputy Manager told the Inspector that she was having discussions with travel agents and other home’s that have successfully organised holidays abroad in order to find a suitable destination in Spain for a wheelchair user. This particular resident went on to tell the Inspector that he would be going to London soon and would be travelling on the Orient Express to Southampton from Victoria Station spending the day in Southampton and then returning to London. Staff told the Inspector that two other residents had enjoyed a holiday in Devon in a cottage for a week in April with the support of two staff members. The home’s holiday budget is used to cover staff costs and to make a contribution towards the cost of the holiday for the resident. Some residents have regular contact with their families and friends. One resident told the Inspector that he had plans to go out with friends the evening of the inspection. Staff spoken with told the Inspector that they would transport residents to visit their relatives if necessary. Staff members try to keep families informed if there is a change in a resident’s health or care needs. This was witnessed during the inspection when one resident was unfortunately taken into hospital and a staff member telephoned the resident’s brother. The home does not operate a set menu plan. Staff members will plan the menu for residents each day, taking into account the individual preferences of residents, supplies held in the home, and activities for the day. Records of meals eaten by residents are maintained in their individual case files. The two residents case files examined during this inspection contained menu records, which showed that the residents had been provided with a reasonably balanced varied diet. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 14 Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Residents receive personal care support as needed. Residents health care needs are being regularly monitored and action is being taken promptly to address concerns so that residents can be assured that their physical and emotional health needs are being met. Medication administration was being managed effectively. EVIDENCE: Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 16 Residents receive personal and health care support as needed. Staff were observed encouraging and providing support to residents who needed assistance with their personal care. Personal care was carried out either in the resident’s own bedroom or in the home’s ground floor communal toilet. Arrangements have been made for all residents to be registered with a local G.P. practice and GPs have visited the home when requested, although the Inspector was told that staff would generally take residents to the surgery should they need to see their GP. All residents have received a degree of support from the range of professionals employed by the Local Authority Community Learning Disability Team (CLDT). These include the Speech Therapist, Physiotherapist, Psychologist, Behavioural Specialist, and Occupational Therapist. The Speech Therapist had recently been involved in assessing one resident’s level of understanding with regards to relationships with other people. A staff member spoken with told the Inspector that the resident’s level of understanding had not as yet been determined. This particular resident was awaiting an appointment to see the Hearing Specialist employed by the CLDT. An epilepsy protocol was seen for one resident, which was signed by a Registrar from the Royal United Hospital. The Inspector was informed that staff members were awaiting training with regards to the administration of prescribed medication for this resident. The home was maintaining a seizure record chart for the resident. This resident unfortunately had two seizures during the inspection, which necessitated an ambulance to be called and the resident taken to hospital. The home manager went with the resident to the hospital in the ambulance, as there was due to be a changeover of staff. The manager stayed with the resident until he was made comfortable on a ward and it was safe for her to leave him. The Inspector witnessed arrangements being made for other staff members to support the resident in hospital later that day and the following day. Family members were kept informed by the home. Medication is administered through the Boots Monitored Dosage System. The monitored dosage blister packaging, which had been provided to the home, was seen to include a description of medication e.g. the colour, shape and distinctive markings of the tablets. Boots provide the home with an advisory service and carry out a quarterly inspection generating an independent report. Boots carried out the last inspection on the 23 February 2005 and no problems were identified within the report seen. Administration records were up to date and in good order. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 17 Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Staff members need to advocate on behalf of residents due to their communication difficulties. Complaints and protection of vulnerable adult procedures are available in the home for staff to follow should the need arise. EVIDENCE: New Era has a complaints and compliments procedure dated 5 July 2004. This complaints and compliments procedure includes a flowchart, which sets out the various stages and timescales for dealing with and responding to any complaint. The procedure on its own would not meet the requirements of legislation, as it does not include the name, address and contact number of the Commission for Social Care Inspection. The home did, however, have a complaints leaflet and a pictorial complaints pamphlet both of which did include the contact details for the Commission for Social Care Inspection and these documents are included in the service users guide. There have been no complaints received by CSCI regarding Fir Lodge. Members of staff spoken with said they had received training on protecting vulnerable adults and the home had a vulnerable adults policy and procedure and a whistle blowing policy and procedure. The vulnerable adult policy and procedure was clear and included a flow chart for staff to follow. The policy and procedure clearly set out the role that social services play in convening a strategy meeting/discussion to determine who will lead any vulnerable adult investigation. There were policies and procedures in place relating to residents financial affairs and dealing with service users’ money. Records relating to monies held Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 19 and transactions made on behalf of two residents’ were examined during this inspection and found to be satisfactory. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 & 30 Improvements have been made to the décor throughout the communal areas of the home and this means that residents do benefit from a homely and comfortable environment. Residents are able personalise their bedrooms with the support of staff and/or their relatives, which demonstrates that their individuality and right to make choices is being respected. Residents needs with regard to specialist equipment have been acted upon or are being acted upon. The house was clean and tidy. EVIDENCE: Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 21 The opportunity was taken to inspect all communal areas of the home and three of the residents’ bedrooms. All communal areas, including toilets and bathrooms and the hall, stairs and landing, had all recently been repainted, and the kitchen had been refurbished. New floor coverings had also been provided in communal areas, up the stairs and on the first floor landing. This redecoration and new floor coverings has resulted in significant improvements to the environment. It was, however, disappointing to see that the stair carpet had not been replaced right up to, and including, the second floor landing. The new carpet stops on the first floor landing and this does detract from the overall appearance. Also the home’s office area would have benefited from being repainted and recarpeted. It is currently very dark and is showing signs of wear and tear. It is therefore recommended that consideration be given to carrying out some redecoration in this area and recarpeting up the stairs to the second floor on the landing and in the office. The home’s deputy manager said that she would be purchasing some pictures and plants etc. in the near future to add some homely touches to communal areas. One of the residents told the Inspector that they had been involved in selecting the new floor coverings for the home. The three residents’ bedrooms seen had been personalised and reflected the individual tastes of the residents – indicating that their choice and independence had been promoted. One resident had a cupboard door missing from a unit in their bedroom that needs to be replaced. A through floor lift is available in one of the residents bedrooms. The lift was, however, out of action at the time of the inspection and the Inspector was told that an engineer was expected. The Inspector was also told that an ensuite shower facility is to be installed in this particular resident’s bedroom in the very near future. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, & 36 There were sufficient staff on duty to provide support to residents on the day of this inspection. Staff were responsive to the needs of the residents and residents were relaxed and happy in the company of staff. The outcome of staff CRB clearances need to be available for inspection on the premises. EVIDENCE: Three new staff members have been employed to work at Fir Lodge since the last inspection. The home therefore had its full staff complement, which consists of 8 full-time staff members and one part-time staff member. Policies and procedures to support recruitment practice were available within the New Era Personnel Policy Manual. The home’s employment process is facilitated and supported by staff employed within New Era’s Head office in Bath. Copies of the application forms and references for two of the three new staff members were seen. The third person’s application form and references were not seen as they were still being held at New Era’s Head office. Home managers are expected to collect these items from the head office. It is required that a quicker method for getting these documents to the home is explored by New Era. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 23 Applications have been appropriately made to the Criminal Record Bureau (CRB) for clearances for members of the home’s staff team. CRB clearance outcomes were not available for inspection on the premises. This requires attention. A record log identifying whether or not staff members CRB clearance was satisfactory or whether a risk assessment had been necessary should be available on the premises. If a risk assessment is necessary this must be available for inspection on the premises within the staff member’s personnel file and must clearly support New Era’s decision to employ. The opportunity was taken to talk two of the new staff members who spoke enthusiastically about their new jobs and displayed a good understanding of their roles and responsibilities. Both new staff members said that they were due to attend a New Era Induction Training Course and would be provided with mandatory training in first aid, manual handling, food hygiene and protection of vulnerable adults. There was a good team spirit detectable in the home and it was evident from examination of staff records that a formal supervision system is in place, which from discussion with staff is seen as valuable in enabling them to develop their skills Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 42 The home is generally well run and progress has been made to improve maintenance record keeping systems. There are appropriate procedures in place to maintain good standards of health and safety in the home, which do help to minimise any potential risks to residents. However, staff members do need to receive fire safety training as a matter of urgency. EVIDENCE: The home manager, Ms. Frampton, holds a City & Guilds 325.2 Introductory Management Certificate, a NEBS Supervisory Management certificate and is working towards an NVQ Level 4 award. Staff members spoken with during this inspection stated that they felt the home was well managed and said that they felt supported and listened to by their manager. All residents care records seen at the time of this inspection were up to date, sensitively written and meaningful. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 25 Recording systems were in place to show that regular in-house checks had been carried out on such things as the home’s fire alarm system, fire fighting equipment, window restrictors, water temperatures and fridge and freezer temperatures. At the January 2004 inspection the Inspector had been informed that the home manager and deputy manager had been trained to deliver fire safety training to staff using a fire safety training package. Following the January 2004 inspection the Inspector questioned the appropriateness of this arrangement. CSCI asked to be provided with written confirmation that the level of training provided to the home manager and the deputy manager in order to equip them to provide fire safety training to other staff members was equivalent to fire warden training. This has still not been received and this requirement will therefore be repeated. Further non-compliance will result in enforcement action being considered. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Version 1.30 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fir Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x Version 1.30 D56_08180_FirLodge_232981_250505_Stage4.doc Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA24 YA34 YA34 Regulation 23 17(2) 17(2), Sch 4.6 Requirement Repair cupboard door in residents bedroom. CRB clearance outcomes to be available for inspection on the premises. Implement a system which ensures that staff members application forms and references are available in the home before they commence employment in the home. All staff to be provided with fire safety training. CSCI to receive written confirmation that the home manager and deputy manager were trained to fire warden level to enable them to deliver fire safety training to staff. Timescale for action 31/07/05 31/08/05 31/08/05 4. 5. YA42 YA42 18 12, 13 31/08/05 31/08/05 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. Fir Lodge D56_08180_FirLodge_232981_250505_Stage4.doc Refer to Standard YA24 Good Practice Recommendations Renew the stair carpet up to the second floor landing, on the landing and in the homes office. Version 1.30 Page 28 2. 3. YA24 YA34 Redecorate the homes office. Introduce and maintain a CRB record log on the premises, which identifies whether staff members CRB clearances were satisfactory or whether a risk assessment was necessary. 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