CARE HOMES FOR OLDER PEOPLE
Forest Lodge, 1 Hartley Road Leytonstone London E11 3BL Lead Inspector
Robert Sobotka Unannounced Inspection 11th May 2006 09:10 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 Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Forest Lodge, Address 1 Hartley Road Leytonstone London E11 3BL 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 8530 2009 020 8530 1242 Mr Imteyaz Hussein Taleb Mrs Cliona Taleb Mr Imteyaz Hussein Taleb Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th August 2005 Brief Description of the Service: Forest Lodge was first registered as a care home in 1995 but was bought by the present owners in April 2001 as a going concern. Many of the current residents and staff therefore transferred with the new registration. The proprietor/managers, Mr and Mrs Taleb, are both qualified nurses but nursing care is not offered by staff in the home. Mr and Mrs Taleb aim to offer a family style environment. The home has comfortable accommodation for nine elderly people, currently aged from their late 60s to their early 90s. Some suffer from a degree of memory loss or mild dementia, although the home is not registered to accept people diagnosed with dementia at the time of admission. The house is decorated in a homely and attractive manner. There is a through lounge/dining area downstairs and two bedrooms on the ground floor including one double with an ensuite shower. Two of the single rooms have ensuite toilet facilities, one with a shower. There is no lift and so the residents using the first floor bedrooms need to be able to negotiate stairs. The paved rear garden is accessed via steps, although a ramp is planned. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day and was unannounced and included speaking with some of the service users living in the home and staff working there, as well as both of the registered managers/providers. The inspector also conducted tour of the premises and viewed various records. The aim of this visit was to carry out an unannounced inspection and to check the home’s progress towards full compliance with legislation. The inspector would like to thank all residents and staff who contributed to the inspection. What the service does well: What has improved since the last inspection?
The home’s statement of purpose has now been updated as required during previous inspections. The statement of terms and conditions/contract of residence has been amended to include the amount of fees, the method of payment and by whom payable i.e. by the service user, local authority, relative or another. Some work has been done to ensure that the new written assessments and care planning format is implemented, however further work is required to ensure that record keeping is brought up-to-date and maintained so. The home has clarified an issue in relation to one of the service user’s medication with their General Practitioner, as previously required. The home’s medication policy has been rewritten and amended, and so has the home’s complaints policy. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 6 There appeared to be appropriate staffing levels at the time of the inspection and duty rosters were now being maintained. The recommendation that the names of staff involved in fire training and fire drills to be included in the record has also now been met. What they could do better:
At the time of this inspection some of the service users had a clinical diagnosis of dementia and were accommodated in the home, even though the home is not registered to provide care for those with dementia. It is therefore required that an application is submitted to the Commission to seek exemption to accommodate those service users who are already accommodated in the home. Care plans and risk assessments required further development and must be reviewed on a monthly basis. One of the service user did not have a care plan devised by the home. Photos of service users must also be attached to care plans. Recording of medication administered to service users required improvement. One of the rooms viewed had a strong odour of urine. This needs to be eliminated. Another room was in need of redecoration as some of the wallpaper started peeling from the wall. The registered managers must ensure that all food is appropriately labelled once opened, to prevent food poisoning. The home’s electrical wiring certificate was out of date and new test must be arranged. The recommendation that the format of resident’s files to be reviewed to ensure information is readily accessible remains outstanding. The present written policy and procedures for staff recruitment, including POVA checks, to be revised to ensure that Standard 29, Regulation 19 and Schedule 2 of the Regulations are met. Staff personnel files required updating. Staff must receive planned, regular supervision at least 6 times a year, to cover all aspects of practice, the philosophy of care in the home and career development needs, including training needs. The dates, contents and decisions made to me recorded. It is a good practice to develop supervision contracts with staff to determine the frequency and length of session and the content. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 7 The recommendation from the previous inspection for an Occupational Therapist to assess the building and facilities and provide a report remains unmet. The recommendation for lockable facilities to be provided in the resident’s bedrooms also remains outstanding. In additional the following requirements were made during this inspection visit: - The registered managers must ensure that each care plan includes a photo of a service user. - The registered managers must ensure that all medication administered to service users in appropriately recorded. - The registered managers must ensure that all perishable food products are labelled once opened, to avoid food poisoning. - The registered managers must ensure that offensive odour in one of the service user’s bedroom in eliminated. - The registered managers must ensure that all parts of the home are reasonably decorated. - The registered managers must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations. This includes satisfactory evidence of entitlement to work in the United Kingdom. - Evidence in a form of training certificates must also be obtained to demonstrate that staff have received all mandatory training and any other training required for the job. - The registered managers must ensure that fire drills are carried out on regular basis. - The registered managers must ensure that the electrical wiring certificate is obtained. 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. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4. Prospective service users have the information they need to make an informed choice about where to live. Application for variation to the registration category in respect of service users with dementia must be submitted to the Commission. EVIDENCE: The home’s statement of purpose and the service user’s guide has been revised/updated since last inspection, as previously required. Each service user has a costed contract/statement of terms and conditions in place. There have been no new admissions to the home since the last inspection. Standards relating to the home’s admission systems were therefore not assessed during this inspection and will be reassessed during next visit. At the time of this inspection, the home accommodated at least three service users with dementia, even though the home was not registered to provide care
Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 10 for those with diagnosis of dementia. In order to comply with the law, it is required that an application for variation to the registration is submitted to the Commission in respect of the service users with a diagnosis of dementia. As care plans kept in the home were not comprehensive, the inspector was unable to ascertain whether the assessed needs of those living in the home were being fully met. Standard 6 is not applicable, as intermediate care is not offered in the home. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Staff working in the home were aware of the service user’s needs, however care plans required improvement. Staff treat service users with dignity and respect and personal care needs are met with sensitivity and privacy. Health care needs are met appropriately, but records should be more detailed to assist staff. EVIDENCE: As part of this visit, the inspector checked care plans of four service users accommodated in the home. One of the service users did not have a care plan devised by the home management. The quality of other care plans varied. The registered manager stated that she was in the process of updating all care plans. The requirement in relation to care planning remains outstanding and has been repeated. It must be met without any further delay. The registered managers must also ensure that each care plan includes a photo of a service user. The registered manager was able to evidence that the medication review has been undertaken for one of the service users who was on the medication
Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 12 “Risperidone”, as required during the last inspection visit and following the CSCI pharmacist inspection. None of the service users were assessed as being able to administer their own medication at the time of this inspection visit. Staff administer medication using the Boots blister pack, measured dosage system. Staff have received medication training. Medication was stored in a medicines trolley. There was a list of staff authorised to administer medication. Medication systems were generally satisfactory, however staff did not always sign for the medication administered to the service users. The registered managers must ensure that all medication administered to service users in appropriately recorded. Staff employed in the home were observed to work with service users in a courteous and professional manner. Service users who spoke to the inspector said that they were treated with dignity and respect. Their right to privacy was upheld. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. There was evidence of good intentions and commitment to provide a fulfilling environment for residents, which was to a large extent achieved, but could be further developed. Service users enjoyed food offered to them, however storage of food required improvement. EVIDENCE: Following discussions with the service users, staff working in the home and review of the documentation, the inspector was satisfied that the proprietors and staff encourage and support service users to take part in outings and activities. The registered manager stated that outings offered to the service users included: shopping trips, bingo and trips out (weather permitting). Entertainment is also brought into the home. One of the service users enjoyed gardening and was seen doing it on the day of inspection. As mentioned in the previous inspection report, care plans should include individual resident’s interests, preferences etc – particularly for those with memory loss, sensory loss or low motivation – and indicate how residents will be assisted in appropriate activities. Less able or less motivated residents may require more focused support, assistance and encouragement to join in or undertake activities and staff may benefit from specific training in offering structured activities. The registered manager stated that two extra staff are employed in during summer period to support service users in taking part in activities.
Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 14 The home is commended for promoting sexual diversity of service users accommodated in the home. Visitors are welcome to the home. During this visit, the inspector spoke to one of the visiting relative, who said that the quality of care offered by the home was “top class”. Visitors book was maintained. Staff working in the home encouraged and supported service users to maintain contact with family and friends. Residents are encouraged to be as independent as possible and make choices about times to get up or go to bed, colour schemes in their rooms etc. They are able to bring small items of furniture for their rooms and have their personal possessions around them. Residents are encouraged to make decisions about their own financial affairs for as long as possible, although most are assisted by relatives. Residents were encouraged to maintain their independence in personal care, but assisted in sensitive way, when necessary. The inspector was invited to have lunch with the service users. It was attractively presented and nutritionally balanced. Mealtimes were unhurried and service users were given sufficient time to eat. Those who spoke to the inspector said that they liked the food served in the home. Record of food served was maintained. There were sufficient quantities of food in the home, however not all products were being labelled once opened. The registered managers must ensure that all perishable food products are labelled once opened, to avoid food poisoning. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Appropriate complaints systems were in place. Service users’ legal rights are protected. The inspector was satisfied that relationships in the home between the staff and the service users were sufficient to protect the safety and wellbeing of those accommodated at Forest Lodge. EVIDENCE: The home’s complaints policy has been updated since the last inspection, as required. Those who spoke to the inspector were confident that their complaints would be heard and promptly resolved. Service users are registered and enabled to vote in elections by post. Appropriate adult protection policies and procedures were in place. Staff working in the home were aware of adult protection issues. The adult protection procedure for the London Borough of Waltham Forest was also available for guidance to staff. Records of accidents/incidents were maintained. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 26 The home was clean, comfortable, homely, generally well maintained. The premises meet the standards for a pre-existing home is relation to the washing and bathing facilities and the number and size of bedrooms. The lack of a lift and steps to the garden limits the type of residents who can be accommodated in the home. The proprietors are working, is a planned way, towards meeting areas such as this, where the home does not fully meet the standards. Offensive odour in one of the bedrooms needs to be eliminated. EVIDENCE: The home is situated in a residential area, blending in with the surroundings. The new office building has been completed and was in use at the time of this inspection visit. Further improvements to the premises included provision of a level access to the garden and installation of a lift enabling service users who use wheelchair and/or have mobility needs to be able to access the upstairs part of the building. These changes should allow the home to extend the range of residents’ needs that can be accommodated and meet all the current standards.
Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 17 The double bedroom and five of the single bedrooms are above the minimum sizes of 16 and 10 square meters. Two single bedrooms are below 10m2m, but meet the standard. The home has toilets on the ground and first floor, accessible to bedrooms and communal rooms. Some bedrooms have ensuite facilities. The bathroom is fitted with a chair to enable residents to be assisted in and out of the bath. In the past occupational therapists and physiotherapists have assessed and made recommendations to meet the needs of specific service users. The owners have also sought guidance from an OT regarding the design of any extension and ramp, however no written report was available for inspection. The garden area has a large table and chairs and a barbeque. Some of the service users were seen using the garden area on the day of this inspection. As part of the inspection, all bedrooms were viewed, with permission from the service users. They appeared to be personalised and reflected individual tastes and interests of the service users. One of the bedrooms had an offensive odour. This must be eliminated. Another bedroom had a wallpaper, which has started peeling and required redecoration. The registered managers must ensure that all parts of the home are reasonably decorated. The recommendation that lockable facilities be provided in residents’ rooms remains outstanding and has therefore been repeated. The premises were found to be clean and hygienic and free from offensive odours, with exception of one of the bedrooms, as stated above. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Staffing levels were sufficient to meet the needs of the current service users group. Further work is required to ensure that at least 50 of staff have NVQ Level 2 or above qualification. Staff recruitment procedures required improvement. Further evidence was needed to demonstrate that staff have received appropriate training. EVIDENCE: The inspector was satisfied that there were sufficient numbers of staff on duty to meet the needs of the current service user group. The duty rosters showed that there were two care staff on duty between 8 am and 9 pm each day and one staff awake at night and one person sleeping in. In addition at least one of the managers works during the daytime. There were 8 staff employed in the home at the time of this inspection. Two members of staff had NVQ in Care qualifications and another person was in the process of obtaining one. This falls short of the required percentage (50 ). The requirement in relation of NVQ qualification has therefore been repeated. As part of this inspection staff personnel files were checked. They did not contain all information required by law. This required improvement. It was noted, however that all staff have received the Criminal Records Bureau checks. The registered managers must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations. This includes satisfactory evidence of entitlement to work in the United Kingdom.
Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 19 Evidence in a form of training certificates must also be obtained to demonstrate that staff have received all mandatory training and any other training required for the job. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. The ethos of the home is open and positive. Both managers must ensure that they obtain the relevant qualification in management, as required by law. Further work is required to implement quality assurance systems in the home, as well as in relation to supervision of staff, record keeping and other documentation. Health and safety checks were generally satisfactory, however the registered managers must ensure that fire drills are carried out on regular basis and that the electrical wiring certificate is obtained. EVIDENCE: The proprietors are involved in the day-to-day running of the home and both are registered as proprietor/manager. They share the role and tasks usually undertaken by the manager and proprietor e.g Mr Taleb: invoicing, finances, GP/hospital visits, pharmacy, maintenance, staff rota; Mrs Taleb: staff supervision/appraisal, policies and procedures, recording and documentation.
Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 21 Both of the proprietors/managers demonstrated that they are sufficiently competent and experienced to run the home and to meet it’s stated purpose, aims and objectives. Both Mr and Mrs Taleb are registered nurses, however they must obtain relevant qualification in management, as required by law. Frequency of staff supervision requires improvement, as staff were being supervised on an informal basis and a system of formal supervision needs to be established covering the areas recommended in Standard 36 on the National Minimum Standards. This is a repeated requirement. The requirement in relation to the quality assurance systems also remains unmet. Ways of impletementing quality assurance systems were discussed in more detail with the proprietors during this inspection visit. The home’s policies and procedures have been updated since the last inspection. Health and safety checks were generally satisfactory, however the registered managers must ensure that fire drills are carried out on regular basis and that the electrical wiring certificate is obtained. Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 x 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 3 2 x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 3 2 2 Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 14, 15 Requirement Timescale for action 15/07/06 2. OP28 18 3. OP31 10 The new written assessment and care planning format to be implemented. This is to include cultural needs, fulfilling activities and arrangements for the handling of residents’ monies. The care plans to be more detailed, identify objectives and goals and be updated to reflect changing needs. The record of monthly reviews to document and analyse progress/difficulties/ongoing issues. A system of recording to be set up to document action taken by the manager or others e.g. phonecalls to, or visits by health professionals or advice given by them. (Previous timescale of 01/11/05 was not met.) Care staff to have NVQ 2 or 3 in 01/09/06 care or be working to obtain one by an agreed date. A minimum level of 50 of care staff to have NVQ Level 2 qualification. (Previous timescale of 01/01/06 was not met.) The proprietors/managers to 01/09/06 ensure that their qualifications
DS0000007232.V293471.R01.S.doc Version 5.1 Forest Lodge, Page 24 4. OP29 19 5. OP33 24 6. OP36 18 7. OP3 12 8. OP7 17(1)(a) Sch 3.2 13(2) 9. OP9 are equivalent to level 4 in management and care. (Previous timescale of 01/01/06 was not met.) The present written policy and procedures for staff recruitment, including POVA checks, to be revised to ensure that Standard 29, Regulation 19 and Schedule 2 of the Regulations are met. (Previous target dates of 01/03/05, 01/06/05 and 01/12/06 not met.) A written annual development plan for quality assurance to be available based on a cycle of planning, action and review and involving residents and staff. (Previous timescale of 01/05/05 and 01/12/06 was not met.) Staff to receive planned, regular supervision at least 6 times a year to cover all aspects of practice, the philosophy of care in the home and career development needs, including training needs. The dates, contents and decisions made to be recorded. It is a good practice to develop supervision contracts with staff to determine the frequency and length of sessions and the content. (Previous timescales of 01/02/05, 01/07/05 and 01/11/05 were not met.) It is required that an application for variation to the registration is submitted to the Commission in respect of the service users with a diagnosis of dementia. The registered managers must ensure that each care plan includes a photo of a service user. The registered managers must ensure that all medication administered to service users in
DS0000007232.V293471.R01.S.doc 15/07/06 01/08/06 01/08/06 01/07/06 01/07/06 15/06/06 Forest Lodge, Version 5.1 Page 25 10. OP15 16(2)(i) 11. OP26 16(2)(k) 12. 13. OP19 OP29 23(2)(d) 7, 9, 19 Sch 2 14. OP30 7, 9, 19 Sch 2 15. 16, OP38 OP38 23(4)(e) 23(2)(c) appropriately recorded. The registered managers must ensure that all perishable food products are labelled once opened, to avoid food poisoning. The registered managers must ensure that offensive odours in one of the service user’s bedroom in eliminated. The registered managers must ensure that all parts of the home are reasonably decorated. The registered managers must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations. This includes satisfactory evidence of entitlement to work in the United Kingdom. Evidence in a form of training certificates must also be obtained to demonstrate that staff have received all mandatory training and any other training required for the job. The registered managers must ensure that fire drills are carried out on regular basis. The registered managers must ensure that the electrical wiring certificate is obtained. 15/06/06 01/07/06 15/07/06 01/07/06 15/07/06 01/07/06 15/07/06 Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 26 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 OP22 OP24 OP37 Good Practice Recommendations An Occupational Therapist to assess the building and facilities and provide a report. (This is a repeated recommendation.) Lockable facilities should be provided in residents rooms. (This is a repeated recommendation.) The format of residents files to be reviewed to ensure the information is readily accessible. (This is a repeated recommendation.) Forest Lodge, DS0000007232.V293471.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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