Inspection on 19/08/05 for Forest Lodge

This inspection was carried out on 19th August 2005.

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

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

Other inspections for this house

Forest Lodge 01/05/07

Forest Lodge 11/05/06

Forest Lodge 05/05/05

Forest Lodge 11/11/04

Forest Lodge 28/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Forest Lodge 1 Hartley Road Leytonstone London E11 3BL Lead Inspector Vivienne Patchett Unannounced Inspection 19 August 2005 at 2:25pm th 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 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 G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Forest Lodge Address 1 Hartley Road, Leytonstone, London, E11 3BL 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) 020 8530 2009 020 8530 1242 Mr Imteyaz Hussein Taleb Mrs Cliona Taleb Mr Imteyaz Hussein Taleb Mrs Cliona Taleb Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 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 G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The routine unannounced inspection of Forest Lodge took place on Friday, 19th of August 2005 between 2.25 p.m. and 6.00 p.m. The male proprietor/ manager was on duty at the beginning of the inspection and a female careworker came on duty at 3.20pm. The female proprietor/ manager was due to be on duty but had been unable to attend due to illness of one of her children. There was therefore only one member of staff for 9 residents and no female member of staff on duty from 1pm - 3pm to attend to personal care of female residents. The inspector spoke to most of the 9 residents currently living in the home who were happy with the care being provided. A full inspection of the premises was not undertaken at this time but the sitting room/diner, kitchen, garden and a bedroom were seen. The inspector looked at various documents, including care plans, medication records, fire records etc. The National Minimum Standards assessed had been met or mostly met and the overall quality of care was good. The main focus of the visit was to check on progress in the implementation of requirements and recommendations from the report of the last unannounced inspection in May 2005. The proprietor/managers had addressed many of these. However, some issues remained outstanding. These requirements and recommendations have been restated with new dates for compliance. The inspector would like to thank staff and residents who contributed to the inspection. What the service does well: This is a family style home with a warm and relaxed atmosphere. The proprietor/ managers have high standards in the running of the home and are keen to “give residents a life”. They encourage residents to go out and there are regular visits out e.g. to the shops or the local park or pub. A holiday is being planned for those who are interested. The staff group is a stable one so that there is consistency of care and residents and staff know each other well and have good relationships. Staff treat residents with respect and sensitivity. Food is freshly cooked and attractively presented. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 8 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 standard(s) 1,2,3, 5 Prospective residents and their relatives are welcome to visit the home, are provided with information on which to make a choice about the home and their needs are assessed prior to admission. However, the Statement of Purpose and service users guide would benefit from being more “user friendly”. Standard 6 is not applicable, as intermediate care is not offered in this home. EVIDENCE: Two residents had been admitted since the last inspection. The proprietor/ managers encourage prospective residents to visit at any time to talk to the proprietors and staff and get a feel of the home. Information is available to prospective residents through the Statement of Purpose, Service Users Guide and contract. The Service Users Guide might benefit from summarising the statement of purpose rather than duplicating it and should include views of current residents. The Statement of Purpose, Service Users Guide and contract should all be reviewed regularly and updated. A new written assessment format had been developed and is about to be implemented. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7, 8, 9, 10 Residents needs are set out in the care plans and the manager and staff have a good knowledge and understanding of these needs. However, the written documentation could be more detailed to reflect the individual care being given and guide the staff in how to implement the care plans. Staff treat residents with dignity and respect and personal care needs are met with the appropriate sensitivity and privacy. Health care needs are met appropriately but records should be more detailed to assist staff. EVIDENCE: A system for care planning was in place with reviews. A new written format for the assessment of needs and to document care planning had been developed and was about to be implemented. The inspector and proprietor/ manager discussed how to make this a helpful and effective tool for the manager and staff. One of the residents was still on the medication risperidone and it was not clear whether the GP had undertaken a review of medication in line with the recommendation of the Committee for the Safety of Medicines, and as recommended in the pharmacist inspectors report and the May 2005 report. A Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 10 copy of the relevant information from the Committee for the Safety of Medicines was given to the proprietor/manager to show the GP. None of the residents are currently assessed as being able to administer their own medication. Staff administer this using the Boots blister pack, measured dosage system. Staff have had training from Boots in the use of this system. There was a policy for the administration of medication held in the medication administration file but this was issued by The Pharmaceutical Society and gave overall guidance but did not give procedures for staff to follow. A copy of the homes procedures should be kept with the medication administration records for easy access and the guidance of staff. Medicines are currently stored in a new medicines trolley. There was a list of staff authorised to administer medication which had some staff crossed off but no date when they ceased to be authorised. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13, 14 There was evidence of good ideas, intentions and commitment to provide a fulfilling environment for residents, which was to a large extent achieved but could be further developed. EVIDENCE: Outings, entertainment and activities are offered for residents who wish this although some are reluctant to try new things. One resident regularly attends a local day centre, although was at home at the time of inspection. During the inspection, the television was on and the proprietor/manager also put on comedy videos. The Care plans should include individual residents interests, preferences etc - particularly for those with memory loss, sensory loss or low motivation - and indicate how residents will be assisted to participate 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. Appropriate training for staff may be available from Age Concern or the Alzheimers Society. A holiday is being planned for September for residents. A photograph album was available documenting Christmas celebrations etc. 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. Residents are able to bring small items of furniture for their rooms and have Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 12 their personal possessions around them. Residents are encouraged to make decisions are about their own financial affairs for as long as possible although most are assisted by relatives. Drinks were offered regularly. Residents were encouraged to maintain their independence in personal care but assisted in a sensitive way, when necessary. A residents visitor was welcomed. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 The inspector was satisfied that the quality of communication and relationships in the home between the managers, staff and residents and their relatives were sufficient to ensure that any complaints would be listened to, taken seriously and acted upon. However, the written complaints procedure needed some amendments to assist in this process. EVIDENCE: Residents were confident that their complaints would be heard. The complaints procedure did not include the process by which any complaint would be investigated, the stages involved or the address of CSCI. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24 The home was clean, comfortable, homely, well maintained and free from offensive odours. The premises meet the standards for a pre-existing home in 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. The proprietors are working, in a planned way, towards meeting areas such as this, where the home does not fully meet the standards. EVIDENCE: The home is situated in a residential area, blending in with the surroundings. The new office building has been completed although is not yet in use. This is the first stage in planned improvements to the premises, which will include a level ramped access to the garden (planned within the next 2 months) a lift (planned within the next 12 months), and, in the longer term, an extra sitting area/visitors room. 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 G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 15 The double bedroom and five of the single bedrooms are above the minimum sizes of 16 and 10 square metres. Two single bedrooms are below 10m2 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 ensuite seen had the call bell pull tied up out of reach and the shower did not appear to be working. 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 residents. The owners have also sought guidance from an OT regarding the design of any extension and ramp. The National Minimum Standards recommend that an OT or other suitable person be asked to assess the whole building and produce a written report as evidence that this standard has been met. The garden area has a large table and chairs and a barbecue. The bedroom seen was comfortable, well furnished and personalised but, together with some of the other bedrooms, did not contain all the furnishings recommended in this standard e.g. a chest of drawers, comfortable seating for 2 people and a table to sit at. When the residents do not wish to have all the recommended facilities or there are practical difficulties, such as the size of the room, this should be recorded in the care plans and regularly reviewed. The requirement from the last report had not reached the target date and is therefore repeated. The National Minimum Standards recommend that lockable facilities be provided in residents rooms and the proprietors are working to achieve this. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Insufficient staff were on duty at the beginning of the inspection to meet the needs of residents and offer same gender care. The staff group is a stable one offering consistency of care for residents. Staff are experienced and a range of in-house staff training is offered. There is a commitment to at least half of the staff obtaining NVQ level 2 qualification but a strategy needs to be implemented to ensure that this is achieved by the date for the compliance. EVIDENCE: Only one member of staff, the male proprietor/manager was on duty at the beginning of the inspection, responsible for the care of residents, cooking and cleaning etc. A female careworker had been on duty until 1 p.m. and had assisted residents with toileting before going off duty. The female proprietor/ manager was due to be on duty from 1 p.m. but had been unable to attend due to illness of one of her children. The proprietor had been unable to get cover until a female care worker came on duty at 3.20pm. There was therefore only one member of staff for 9 residents and no female member of staff on duty from 1pm - 3.20pm, to attend to personal care of female residents. One member of staff was on holiday and two others had left employment. The proprietor/managers were therefore working shifts as care workers when they would normally have been engaged on management tasks. The proprietors must have systems in place to ensure sufficient staff are available to cover vacancies, holidays and emergencies. The rota showed two care staff on duty between 8 a.m. and 9 p.m. each day and one staff awake at night and one sleeping in. It did not indicate who was in charge of each shift. On two days of the week, Tuesday and Saturday, a Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 17 third member of staff was rostered to be on duty from 6 p.m. to 50 and 9 p.m. The policy of the CSCI is that there should be no lowering in staffing levels from those agreed with L.B of Waltham Forest as the previous registration authority. For a home accommodating 9 residents the minimum staffing levels should be as follows: 2 care staff on duty at all times. In addition, there must be a third member of staff at peak periods for a minimum of 5 hours each day. Peak periods are normally considered to be early mornings and evenings. Ancillary staff must be available to cook meals and do cleaning. The registered persons must ensure that staffing levels are sufficient at all times to ensure the health and welfare of residents and meet their needs. Two members of staff have NVQ3 in care and one is doing NVQ 2. Four of the carers have done training in dementia care. Medication administration training had been held. Staff records were not available for inspection so the previous requirement has been repeated. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37, 38 The ethos of the home is open and positive. The management of the home is usually efficient, organised and effectively facilitates the smooth operation of the service. However, systems need to be in place to ensure adequate staff are available to cover holidays and in emergencies. Further development is also required in relation to the supervision of staff, record keeping and documentation. 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, assessments, care plans and reviews, contact with families, policies and procedures, recording and documentation. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 19 The Inspector was satisfied that, overall, the proprietor/managers are sufficiently competent and experienced to run the home and meet its stated purpose, aims and objectives. However, registered managers should have a qualification at level 4 NVQ in both management and care. Mrs Taleb has nursing experience with older people and has undertaken management training. Both proprietor/managers must get confirmation from Skills for Care (TOPSS England) as to whether their existing nursing qualifications (both) and management courses (Mrs Taleb) are considered equivalent to level 4 NVQ in management and care. Additional training will need to be taken to gain any necessary additional qualification/s by January 2006. Staff meetings are held three-monthly. Staff were being supervised but this was on an informal basis and a system of formal supervision needs to be established covering the areas recommended in standard 36. The format of residents files (held in envelope folders) made it difficult to find important information. The inspector discussed with the Proprietor alternatives e.g. ring binders with dividers. Presently records do not demonstrate fully how practice is informed, supported or evidenced. Policies and procedures were in place but most were not dated and some of these needed review, especially those inherited from the old owners. The recruitment policy and procedures have not been revised and the requirement from the last inspection has therefore been repeated with a new date for compliance. The fire all alarm checks were taking place weekly. Fire training and a fire drill last took place on 15.12.04. The fire safety officer from the London Fire Brigade visited on 25th July 2005. Staff have had training in infection control, food safety and hygiene and moving and handling. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 x 3 x 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 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 2 3 2 3 2 x x STAFFING Standard No Score 27 2 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 2 3 2 x x 2 2 2 Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 21 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. Standard 1 Regulation 4,5 Requirement The Statement of Purpose, the Service Users Guide and the residents contract to be amended to include information described in Regulations 4 and 5 and detailed in Schedule 1 to the Regulations. These documents to be dated and reviewed regularly. A copy must be supplied to the Commission and all residents. (Dates for compliance of 1/3/2005 and 1.7.05 not met) The statement of terms and conditions/ contract of residence to include the amount of the fees, the method of payment and by whom payable i.e. by the service user, local authority, relative or another. The new written assessment and care planning format to be implemented. This 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 Timescale for action 1 November 2005 2. 2 5 1 November 2005 3. 3, 7, 8,12 14, 15 1 November 2005 Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 22 4. 9 13 5. 9 13 6. 16 22 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. The GP to be asked to undertake a review of medication for the resident prescribed Respiridone, in line with the recommendation of the Committee for the Safety of Medicines, and as recommended in the pharmacist inspectors report. (Outstanding since May 2005. Date for compliance of 1 June 2005 not met ) Writen procedures for the administration of medication within the home to be available and kept with the medication administration records for easy access and the guidance of staff. The list of staff authorised to administer medication to include the date they were authorised and ceased to be so authorised. The complaint procedure to be amended to clarify the stages of the complaint investigation process, to whom the complaint should be made and how the complaint would be investigated. Also to include the address of CSCI. If any furniture in and or facilities recommended in this standard e.g. comfortable seating for two people and a table to sit at, are not available either because the residents do not wish to have these or there are practical/room- size difficulties, this to be recorded in G56 S7232 Forest Lodge V245679 190805 Stage 4.doc 1 October 2005 1 October 2005 1 October 2005 7. 8. 24 16 1 October 2005 Forest Lodge Version 1.40 Page 23 9. 27 18 10. 27 37 17 11. 28 18 12. 29 19 13. 31 10 14. 33 24 15. 36 18 the care plans with a note of who made the decision and regularly reviewed. (Target date of 1.3.2005 not met) Staffing levels to be sufficient at all times to ensure the health and welfare of residents and meet their needs. Systems to be in place to ensure cover is available in emergencies. A detailed rota to be kept: showing who is in charge of each shift; clearly differentiating when staff are employed in care or management duties and cooking and cleaning tasks. Care staff to have NVQ 2 or 3 in 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. 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. (Target dates of 1.3.2005 & 1 June 2005 not met) The proprietor/managers to ensure that their qualifications are equivalent to level 4 NVQ in management and care. 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. (Target date of 1.5.05 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 good practice G56 S7232 Forest Lodge V245679 190805 Stage 4.doc 1 September 2005 1 September 2005 1 January 2006 1 December 2005 1 January 2006 1 December 2005 1 November 2005 Forest Lodge Version 1.40 Page 24 16. 37 12 to develop supervision contracts with staff to determine the frequency and length of sessions and the content. (Target date of 1.2.05 & 1 July 2005 not met) The owners to review and revise all policies and procedures on a regular basis, to ensure that they are up to date and meet standards and regulations. Some of them require to be more detailed and should be dated. (Target date of 1.4.2005 not met) 1 December 2005 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. 4. Refer to Standard 22 24 37 38 Good Practice Recommendations An Occupational Therapist to assess the building and facilities and provide a report. Lockable facilities should be provided in residents’ rooms. The format of residents files to be reviewed to ensure the information is readily accessible. The names of staff involved in fire training and fire drills to be included in the record. Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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 Forest Lodge G56 S7232 Forest Lodge V245679 190805 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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