Inspection on 22/11/05 for Fitzwilliam Lodge

This inspection was carried out on 22nd November 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fitzwilliam Lodge 25/02/09

Fitzwilliam Lodge 11/12/06

Fitzwilliam Lodge 14/12/04

Fitzwilliam Lodge 15/06/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOME ADULTS 18-65 Fitzwilliam Lodge Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY Lead Inspector Mike Hamstead Unannounced Inspection 22nd November 2005 07:55 Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 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 Fitzwilliam Lodge DS0000003094.V264511.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fitzwilliam Lodge Address Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY 01709 523400 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) Yorkshire Parkcare Company Limited Karen Blakeman Care Home 15 Category(ies) of Physical disability (15) registration, with number of places Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One specific service user over the age of 65, named on variation dated 7th January 2005, may reside at the home. The home can accommodate one named service user with an associated learning disability named on the application dated 1st June 2005 9th May 2005 Date of last inspection Brief Description of the Service: Fitzwilliam Lodge is a care home situated in Rawmarsh Rotherham, South Yorkshire providing care for up to 15 residents with a physical disability. Fitzwilliam Lodge is owned by Craegmoor Healthcare, and is one of 3 other residential care properties also owned by Craegmoor, which are situated in this quiet and secluded area. They include Westfield Mews (unregistered) a home providing supported living arrangements, and Westfield House, which is registered and providing care for people with a mental illness. Fitzwilliam Lodge provides accommodation in 15 single bedrooms, together with bathroom and toilet facilities, and has a range of disability equipment around the home for the benefit of residents. The home also has suitable communal facilities, and a popular patio area enjoyed by residents. A car park is provided, which is shared by all visitors and staff to the 3 properties mentioned above. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty and residents where possible, and an examination of the homes records. It also included a tour of the building to observe the accommodation and to see residents in different parts of the home. Additional information of the overall situation had been gained from previous inspection visits. The inspection was commenced at 07:55 and finished at 15:15 and included talking to 8 members of staff, and 6 residents. What the service does well: What has improved since the last inspection? Residents views of the home are now available, so that any prospective user can decide whether the home meets her/his needs. A plan of care is now contained within the residents individual contracts explaining exactly what the home will provide with regard to their care needs. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 6 An activities co –coordinator has been recruited to make sure that more activities are made available for residents. The recruitment and selection procedures have been improved when employing staff so that the home is confident that residents will be protected. An additional washing machine has been purchased so that residents clothes can be washed and returned as soon as possible. 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. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 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 the following standard(s): 1,2,3,4 &5. Potential residents/representatives would have all the information about the home available to them to enable them to understand and decide whether the services the home provides meets their needs. EVIDENCE: There is a Statement of Purpose and a Service User Guide available that enables potential residents to understand the services the home has to offer including what services are included in the basic contracted fee, and those services where there is an additional charge. The Service User Guide is available and residents views are available separately and will be placed in the reception area to be seen by prospective residents or their representatives. Extra charges are made for private chiropody and physiotherapy, aromatherapy, hairdressing, and special toiletries. The care manager has tried to obtain NHS services for chiropody and physiotherapy for residents without success, but has managed to negotiate a reduced fee for both services to the benefit of residents. Fitzwilliam Lodge uses the assessment of needs documentation provided via the Care Management (Health and Social Services) assessment, but also a comprehensive assessment tool developed by Craegmoor, an “Outcome Based Evaluation”, and all prospective residents are only admitted on the basis of this assessment that considers all their needs. The care manager has used both Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 9 documents to assess two residents admitted since the last inspection, one with an associated learning difficulty to ensure that the home can meet the residents needs. Plans of care are devised for each resident based on this assessment that are reviewed on a regular basis to update their changing needs and more frequently than the required six monthly intervals for the benefit of residents. All potential residents are invited to visit the home to see the accommodation, and meet other residents and staff, the arrangement being that they visit initially for a day, then a half day, and then for an overnight stay if possible, so that their night time needs can be assessed. One resident who was able to communicate said that he was well cared for and liked living at the home. There is a contract between the registered provider and each resident, that now contains a copy of the residents plan of care outlining the action/ activities to achieve their assessed needs and this provides the homes statement of intent with regard to the residents care package. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 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 the following standard(s): 6,7,8,9 &10. An accurate and ongoing assessment of all residents enables their individual needs and choices to be met. Residents are consulted with and enabled to pursue their lives within a framework of risk assessment and confidentiality of information. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 11 EVIDENCE: The resident’s plan of care is devised from the assessment of need documentation, and the plans of care checked were comprehensive and contained risk assessments and are reviewed regularly. Residents/representatives are encouraged to become involved in the drawing up of their plan of care and their review, but unfortunately this is not possible with all residents for a variety of reasons including limited communication and understanding, but two residents are able to understand and participate in the process. The care manager records those instances where residents/representative involvement has been requested, and where there has been no response. All residents are encouraged to make their own decisions where possible, and residents meetings are held where they are encouraged to become involved in the day- to- day running of the home. Some residents had requested the conversion of an existing but unused bath into a shower facility, and this work has been completed demonstrating the consultation and participation process within the home. The care manager is still pursuing the possibility of inviting some residents to be part of the selection process when recruiting new staff in order that they can be involved in the selection of staff who will look after them. Some resident’s monies are looked after by the home but are available upon request, and information on advocacy facilities is also available. One resident who had an advocate that was involved with her placement from out of area has lost this facility, and the care manager is pursuing another advocate for her via Rotherham Advocacy Service. There is a policy on unexplained absences that promotes the protection of all residents, and residents know that staff will respect information given to them in confidence unless that information may endanger them, when it will have to be passed on to the care manager. The inspector attended the morning handover that was held in private and was able to confirm that personal information is stored securely for the benefit of residents. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 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 the following standard(s): 11,12,13,14,15,16,&17 Most residents are able to maintain appropriate and fulfilling lifestyles both in and outside the home. There are some opportunities for personal development and, education, and community links are promoted. There has been an improvement in the availability of regular leisure activities, but not including the option of an annual minimum 7 - day holiday outside the home that must receive immediate attention. Contact with family and friends is encouraged and maintained. EVIDENCE: Residents have opportunities for community involvement, and there are organised activities on occasions organised by the new activities co-ordinator. There is an activities list detailing activity days including arts and crafts, baking, shopping, going to the cinema, and other indoor games such as horse racing to enable residents to have a wide and varied choice. The home now has its own driver for the mini-bus that has appropriate equipment to accommodate wheelchair users, and this enables more external Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 13 activities to be undertaken, and there have been trips to “The Deep” at Hull, the illuminations at Blackpool, shopping visits to Meadowhall, trips to the cinema, and the museum at Clifton Park. The care manager is hoping to implement a resident “diversional therapy plan” in every file to record the activities that residents participate in to provide a fuller picture of their interests. Residents are looking forward to Christmas, and staff have arranged a variety of trips to enable them to celebrate the festive season. Some residents attend day care and other support services and told the inspector that they looked forward to meeting other people there. Another resident attends a private day centre in Rotherham “ Pathways”, and although the care manager has tried to obtain a place for another resident, his placing authority will not fund it, and has asked the home to refer the resident to local authority provision in Rotherham that is scarce /nonexistent. The care manager should continue to pursue this matter with the placing authority. The care manager continues to encourage other residents to become involved in support services without success, but the severe physical disabilities of some other residents would restrict them participating in meaningful work placements/ employment. Residents are able to vote, and are all on the electoral register, and at the general election in May 2005,a few residents used postal votes demonstrating their inclusion in the local community. Although the home obtained funding for an annual 7 day holiday for each resident in 2004, it did not take place, and so far in 2005, one resident has been to another Craegmoor home in Southport for 5 days, and another resident has been to another local Craegmoor home in Rotherham for 2 nights. The home should be aware that this is not the general objective of the relevant National Minimum Standard 14.4 , that stipulates that “residents in long term placements have as part of the basic contract price, the option of a minimum seven day annual holiday outside the home which they help, choose, and plan.” The inspector and care manager discussed the fact that the home ought to be searching out a venue that provides disability equipment facilities, so that residents can enjoy a holiday in the proper sense of the word, rather than replacing one residential care venue for another. This is a long standing issue that must receive immediate attention so that residents can look forward to an annual holiday in the traditional sense. All of the residents are still dependent upon staff assistance, to enable them to both rise and retire and also for many other interventions throughout the day, including both assistance with eating and drinking, toileting and bathing. Staff Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 14 undertake these tasks with sensitivity and tact to preserve the residents dignity. The care manager has had a shower trolley installed instead of a shower chair for the extremely disabled residents to use, that has considerably improved the showering process for them. Residents get up at different times throughout the morning, and meal times are very flexible, and breakfast was being served throughout the morning, and staff were observed knocking on bedroom and bathroom doors before entering, respecting residents privacy, and this example is followed in that all mail is given to residents unopened. Dietary needs are well catered for, and staff are available to assist in providing support to residents at mealtimes. Residents were seen to enjoy a varied diet with good choices being available on the menus. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 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 the following standard(s): 18,19,20 &21. The promotion of personal healthcare and specialist support to residents continues to be taken seriously and acted upon to safeguard their interests at all times. EVIDENCE: The majority of the residents require personal support and guidance on a daily basis as their assessed needs reflect their primary assessment of physical disability. Personal support is provided in private, and wherever possible intimate care by a person of the same gender. Times for rising and retiring are flexible, and are dependent upon the wishes of the resident and the need to attend day care placements in some cases. The specialised services of both NHS and private physiotherapy are obtained, and the services of speech therapy and the community psychiatric nurse, are obtained as required to provide a comprehensive service to residents. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 16 The healthcare needs relating to all the residents particular physical disabilities are recorded in file notes, together with the likely health problems to be encountered associated with their condition. Risk assessments are in place, for issues such as moving and handling, and the degree of independence permissible whilst bathing. Most residents including the two most recent ones, are enrolled with the local GP practice, and a record is maintained of all GP, and other health care professional, visits which is good practice shows that the interests of residents are being maintained. A chiropodist and dentist should visit the home on a three monthly and six monthly basis respectively, but the care manager has had to utilise a private chiropodist because the NHS chiropodist has not visited this year. The home has a policy on medication, and a record is kept of all medicines received, administered and disposed of. The home has a contract with a company that collects the homes medication waste that has a Waste Management Licence as required by the NHS contract introduced from the 1st April 2005. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 22&23. Staff are aware and have knowledge and an understanding of Adult Protection issues that promotes the protection of residents, and are now recording residents complaints in the complaints book. EVIDENCE: There is a complaints procedure on display in the entrance area that is now in a format language/format for all residents in the home, as many have limited communication skills and poor levels of understanding. There is also a complaints book. There has been one complaint recorded since the last inspection that has been satisfactorily dealt with, and the inspector became aware of a further complaint being made on the day of the inspection. A particular issue discussed with the care manager on previous occasions has been the possibility that complaints were being made by residents, but that staff were failing to record them, possibly regarding some as general comments or trivia, from residents who can communicate, and also possibly failing to recognise anxieties or worries from other residents who have limited communication skills The care manager has raised the complaints issue informally with staff, and reminded them to be vigilant in recognising when complaints are being made, and to record all complaints according to the requirements of the standard and this action appears to be working to the benefit of residents. The home has an Adult Protection Policy, and also a Whistle Blowing Procedure. The staff approached at this inspection were aware of the Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 18 procedure, and of the action to be taken in the event of an incident occurring and the importance of referring any incident to the care manager or nurse in charge, however trivial it may appear at the time. The home now has its own official policy on residents money and financial affairs, and information stating that staff are not allowed to participate in residents wills is mentioned in the staff terms and conditions of employment, and they are aware of this fact. The money of one resident was checked at random by the inspector and found to be satisfactorily recorded, with accurate entries and receipts of expenditure maintained to safeguard the interests of residents. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 19 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 the following standard(s): 24,25,26,27,28,29 & 30. There is a continuing investment in the upkeep of the furnishings and fabric of the premises. Resident accommodation is personalised and homely, and the home is clean and odour free which contributes to the residents overall health and safety. Further attention needs to be paid to the regular testing of the fire bell, and to the wedged kitchen door found on this inspection. EVIDENCE: All residents have a single bedroom and all bedrooms meet the spatial requirements of this standard. All of the bedrooms seen were comfortable and well personalised, and are fitted with a suitable locking device. Two bedrooms have been redecorated since the last inspection and work has been started on the reception area, and in addition the care manager has purchased a new hoist to maintain the health and safety of all residents. The majority but not all of the furniture required in this standard has been supplied in residents bedrooms, and the care manager has asked all the Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 20 residents/representatives whether they would like the remaining items but none of them do, and this is recorded in the plans of care. Most bedrooms are already well stocked with the residents personal possessions, and additional furniture would restrict wheelchair access in many cases. One resident has his own computer, and most residents have televisions, and stereo equipment. The home has converted an existing bathroom into a shower room at the resident’s request, to enable them to have 2 shower rooms and one bathroom, but this facility was out of order at the time of the inspection because of a floor problem. The laundry facilities are adequate and a new washing machine has been purchased since the last inspection to provide an acceptable turn around of residents clothing. The fire records were checked and found to be in order with the exception that that there was no record of a fire test for the past 2 weeks, and in addition the door from the kitchen to the dining room was wedged at different times throughout the day. This is against Fire Service advice and both practices must receive immediate attention to safeguard residents and staff. A tour of the premises found that the home was hygienic, and the home has a policy on the control of infection. The home has also been assessed to ensure that its services and facilities comply with the relevant legislation to provide a safe and comfortable environment for residents. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 &36. Residents are protected by a competent staff team in sufficient numbers and suitably trained. Recruitment procedures are robust but further staff training in NVQ must enable residents to feel assured that that they are in safe hands at all times. EVIDENCE: All staff have job descriptions that are linked to achieving residents individual goals as identified in the residents plan of care, and staff were seen to have a good rapport with residents. A staff handbook is available, which outlines expectations in terms of behaviour for staff. The staff spoken to were aware of their own, and others roles within the home to provide an organised service to residents. The home has a relatively new registered care manager who continues to establish herself in the post, to the evident benefit of all residents. Two files relating to two members of staff employed since the last inspection were checked, both of them from Lithuania, who were working in this country under the EU Accession State Worker Registration Scheme approved by the Home Office. The home now has seven Lithuanian workers, and these workers are being supported by staff and some have enrolled on an English language course in order to improve their conversation skills with residents. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 22 All but one of the CRB’s are up to date, but the remaining person has had a POVA check and is working under supervision until this is received to ensure the protection of residents. There is a staff training and development plan in place, and all staff have received statutory training. A written induction and foundation programme is in place that enables staff to learn the skills necessary to meet the resident’s needs. Supervision and appraisal of staff is now being carried out and follows the subject areas covered in the standard that will ensure that staff performance can be measured against the level of care provided to residents. The care manager is due to attend further training this week on a new format for staff supervision in the protection of resident’s interests. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 &43. Residents continue to benefit from a home run well and in their best interests where their health and safety is generally promoted. The care manager must arrange for the gas boiler to be serviced as soon as possible to protect the residents safety. EVIDENCE: The registered care manager has been in post for 12 months having been recruited from another Craegmoor home in Glossop. She is a registered nurse and has over 4 years residential care experience with the group in a number of care homes, providing care for younger adults with a physical disability and older people with dementia that is useful experience to enable her to care for residents in the home. Staff felt that the care manager operated a “down to earth” management approach that was open and inclusive and was always available offering support and guidance when needed to make sure that residents received the best possible care. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 24 There is an effective quality assurance system, and the Clinical Governance Team from Craegmoor carry out an audit of the homes operations on a regular basis. There is also a continuous self-monitoring process as part of the QA system, via residents surveys, and feedback from families friends and other agencies, if residents are not capable of completing a questionairre. The care manager also carries out a monthly audit of care plans, pressure sores, medication, and accidents to maintain an up to date assessment of the quality of care being provided to residents. The question of residents views and their publication is a long standing issue that has hopefully now been resolved, leading to the residents views now being available to potential residents/representatives in an understandable format. There is a formalised annual development plan that the care manager contributes towards, and her plans for the coming year include a request for an additional member of staff on the afternoon shift, an increased food budget, together with an incresed activities budget and additional staff activity hours. Appropriate policies and procedures are in place, and staff have access to these policies to clarify issues that may affect the welfare of residents. There is also access to their files for any residents who wish to look at them, but to date no such request had been received. Other records to do with the efficient running of the home,are kept safe and secure because of their confidential nature. There is a policy on safe working practices, that was checked and was found to be all up to date with the exception of the gas boiler servicing that was overdue, and which must receive attention to protect residents. Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 25 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 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fitzwilliam Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 3 2 3 DS0000003094.V264511.R01.S.doc Version 5.0 Page 26 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. Standard 1 YA14 Regulation 16 Requirement Timescale for action 30/11/05 2 YA24 23 3 YA24 23 4 YA42 23 The registered person must provide the option of a minimum seven day holiday outside the home. The registered person must ensure 30/11/05 that residents live in a safe environment with regard to the absence of weekly fire tests in the home. The registered person must ensure 30/11/05 that residents live in a safe environment with regard to the wedged kitchen door found on this inspection. The registered person must ensure 30/11/05 that the gas boiler is serviced by a corgi registered person. 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 YA32 Good Practice Recommendations The registered person should ensure that a minimum ratio of 50 trained members of staff NVQ Level 2 or equivalent is achieved by 2005. DS0000003094.V264511.R01.S.doc Version 5.0 Page 27 Fitzwilliam Lodge Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Fitzwilliam Lodge DS0000003094.V264511.R01.S.doc Version 5.0 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!