Inspection on 22/05/06 for Forest Lodge

This inspection was carried out on 22nd May 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Forest Lodge 13/07/07

Forest Lodge 12/12/05

Forest Lodge 19/08/05

Forest Lodge 11/02/05

Forest Lodge 09/06/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

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

CARE HOMES FOR OLDER PEOPLE Forest Lodge Horney Common Nutley Uckfield East Sussex TN22 3EA Lead Inspector Rebecca Shewan Unannounced Inspection 22 May 2006 09:15 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 DS0000013987.V289099.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 DS0000013987.V289099.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Forest Lodge Address Horney Common Nutley Uckfield East Sussex TN22 3EA 01825-712514 01825-713653 forestlodge@sussexhealthcare.org www.sussexhealthcare.org Sussex Health Care 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) Ambowatee Seeruthun Care Home 68 Category(ies) of Dementia - over 65 years of age (68), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (68) Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The maximum number of service users to be accommodated is sixtyeight (68). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Service users with a mental disorder only to be accommodated. One named service user under the age of sixty-five (65) may be accommodated. 12th December 2005 Date of last inspection Brief Description of the Service: Forest Lodge is registered for 68 people aged over 65 years on admission who have dementia or a mental disorder. Nursing care is provided in the home. The home is owned by Sussex Health Care and is located one mile north of Nutley, East Sussex. Due to it’s rural location there are no local amenities within easy distance of the home. The home is divided into three units, Cedar, Beech and Ash, which are spread over two floors. Each unit has a Registered Nurse and Unit Leader. There are forty seven single occupancy bedrooms and seven double occupancy bedrooms (two of which are singly occupied) in the home. Twenty four bedrooms have en-suite facilities. There are additional toilets, shower rooms and bathrooms located throughout the home. There are four lounge areas, three of which are utilised as quiet and/or activity lounges. The home has a good sized dining area. The home has a number of specialist equipment in use such as mobility aids, specialist nursing beds and bath and moving/handling hoists. There is a shaft lift and ramps in the home to ensure that service users have access to all parts of the home. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £550 - £750 per week, with additional charges made for hairdressing and chiropody. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 22nd May 2006. Incident reports, Monthly unannounced monitoring visit reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took seven hours. A tour of the whole home was undertaken and the Registered Manager, three staff, three service users (known as Residents) and two relatives were spoken with. Records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were distributed of which six were returned (which were completed by a resident’s relative). The inspector also had contact with a Care Manager prior to the inspection. Resident’s views are included in this report where it was possible to gain them, with consideration given to the residents communication difficulties related to their diagnosis of dementia and/or a mental health disorder. Comments received included: • • • • • • ‘I think the standard of cleanliness of the home is very good’ ‘The staff are all friendly, pleasant and supportive’ ‘The home is always fresh and clean and is in course of redecoration to a very good standard. Very much improved of in recent times’ ‘The staff are very caring and patient to people who have severe mental disabilities’ ‘Residents could do with more stimulation as often they only have the TV or a film to watch’ ‘Sometimes there can be a language barrier between staff and residents but this is easily overcome’ The Registered Provider was requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. However, contact details for resident’s Care Managers, Social Workers and Placing Authorities had not been included in this documentation. These were also requested at the time of the inspection but were not received. Therefore, the views of these individuals/organisations have not been obtained for the purpose of this report. What the service does well: The home ensures that thorough pre- admission assessments are carried out on all new and potential residents with only those who needs can be met, being admitted to the home. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 6 The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. Menu choice can be given verbally by residents or by choosing from a pictoral menu format. There is an efficient complaints procedure in place and the homes procedures, processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. There is good maintenance of all staff recruitment files. The management and administration of the home is good, with evidence of consideration being given to resident’s and/or relatives opinion. What has improved since the last inspection? What they could do better: The home must ensure that urgent action is taken to ensure that all handwritten entries onto medication Administration Record (MAR) sheets, are explained, signed and dated by the person making the entry, that the use of medication omission codes are explained on the back of the MAR sheets, the Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 7 use of non-administration codes must be consistent with those detailed on the MAR sheet, that all medications administered are signed for by the person who administered them and that the use of ‘ticks’ on MAR sheets ceases and that where missed entries have been highlighted on MAR sheets these are investigated and action taken, in order to ensure that residents are receiving essential medication and that records are maintained accurately to reflect this. The home are also advised to ensure that residents and/or their representative and that sign care plans where this is not practical, in order to provide evidence that residents and/or their representatives are actively involved in the care planning and review processes. 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 DS0000013987.V289099.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 DS0000013987.V289099.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): 3&6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: The home’s Registered Manager carries out pre- admission assessments. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. It was noted that the documentation allows the assessor to gain a good overview of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority. Intermediate care is not offered by this home. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 10 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 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvement is required to ensure that medication records are maintained appropriately in order to prevent the risk residents not receiving essential medications. EVIDENCE: Five residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Relatives informed the inspector that care plans are devised with their involvement. However, from the care plans sampled it was evidenced that neither residents/relatives/representatives signatures were recorded. Additionally ‘palliative care plans’ that detail resident’s change of needs in the event of illness or dying are also in use. Following a recent dementia care workshop attended by staff of the home, a new pictorial needs questionnaire has been implemented by the home. This questionnaire is known as the CLIPPER (Cardiff Lifestyle and improvement Profile for People in Extended Residential Care) Questionnaire, which encourages staff to monitor residents needs and involves residents using pictures to describe how they manage their activities of daily Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 11 living i.e. washing, dressing, toileting. Staff spoken with were aware of residents needs and their current capabilities. Suitable risk assessments were in place for the complications associated with reduced mobility, trip/falls hazards and associated risks and whether residents have the capability to use a bedroom key and/or the nurse call bell. The Registered Manager said that residents have a choice of GP from a local surgery. Twice weekly GP visits are made to the home, in order that resident’s health needs can be appropriately reviewed and addressed. Records viewed showed that residents can retain contact with professionals such as dentists and opticians whom they had visited before coming to the home. Referrals to the Occupational Therapist, Physiotherapist and Audiologist are made via the GP or the hospital. The Registered Manager said that resident’s have open access to the Community Mental Health Team, Psychiatrists, Psychologists or any other health care professional that will assist with their care needs. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. However, the medication administration record (MAR) sheets were viewed and it was evidenced that some improvements are required, to address the manner in which staff record medications either administered or non- administered. It was evidenced that where medication had been omitted, the recording for the reason of this omission was not clearly recorded, with the code ‘F’ being recorded as ‘not required’ and the code ‘O’ being utilised, which is a code that is not detailed on the bottom of the MAR sheet for use in the event of the non administration of medication. There were also some missed entries noted, in particular a resident’s respiratory medication making it difficult to determine whether this medication had been administered or not. It was also evidenced that where medications such as creams/lotion/ointments have been prescribed, entries onto MAR sheets are ticked. All medications administered must be signed for by the person who has administered the treatment. Some handwritten entries and drug dosage changes were also noted and it was evidenced that these were unsigned, undated and that no explanation had been given on the back of the MAR sheet. Therefore Immediate Statutory Requirements were made. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Records for the daily monitoring of fridge temperatures were also viewed and these were noted to be well maintained. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Of the seven service user surveys received four stated that their relative always received the care and support that they needed, whilst two responded that their relative usually received the care and support that they needed. However, some survey responses highlighted that on occasion there can be communication problems due to staffs accents/use of language and resident’s hearing difficulties. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 12 Forest Lodge DS0000013987.V289099.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 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a balanced diet to residents, with residents choice and wishes being respected. EVIDENCE: The home has a team of activity co-ordinators who ensure that a wide range of social activities are conducted, with residents choosing what they would like to attend. Resident activities are arranged and can be altered according to resident’s requests. Residents are free to participate in activities, held by the home or within the local community, or not as they wish. Residents also benefit from one to one activities. Records are maintained of all activities attended by residents. One resident spoke of how much they enjoyed a recent trip to the seaside. Of the six service user surveys received two responded yes, two responded sometimes and two responded never to the question that asks ‘are there activities arranged by the home that you can take part in?’. It is of note that those who responded sometimes or never stated that this is because their relatives are nursed in bed or that their illness means that they do not have the capacity to join in with certain activities. Family contact is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Resident’s Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 14 religious wishes are observed and arrangements are in place for residents to receive non-denominational Holy Communion. Discussions with the Registered Manager highlighted that although many of the current residents fall into a specific age group and have similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Due to the residents varying degrees of dementia and mental health, the home assists residents with maintaining independence in their daily living and daily routines, where able. Residents are treated with respect and it was observed that there is a good rapport between staff and residents. The home’s menus are devised on a four week rolling programme. The menus viewed showed that there is a variety of food and that the menus are varied. In order to assist residents with meal selection the home has devised picture menus so that residents can see the menu options. All meals are home cooked with an alternative option available for each mealtime. Medical, therapeutic or religious diets are provided as needed. Of the six service user surveys received one responded yes and five responded usually to the question that asks ‘Do you like the meals at the home?’. Relatives spoken with informed the Inspector that the food served for their relative is always attractively presented, although it is pureed, and that the home and staff are open to comments about food and changes that are required to ensure that the resident has food that they like. Forest Lodge DS0000013987.V289099.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 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. From the section in the service user surveys received relating to complaints, this showed that the four resident’s relative always felt listened to and that they always knew who to speak to in the event of a complaint/concern, whilst two responded that they usually know who to speak with. It was evidenced from the home’s PreInspection Questionnaire that the home has received five complaints within the past twelve months, all which have been recorded as addressed within the twenty-eight day response time as specified by the home’s policies and procedures. One of the five complaints received was initially made to the CSCI, this was subsequently referred to the Registered Provider to investigate and this matter has now been concluded. Each of the five complaints have now been resolved and appropriate action was taken. Verification of nursing staff’s registration to practice is obtained from the Nursing and Midwifery Council (NMC) prior to nursing staff commencing employment. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 16 staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. The home has an up to date copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 17 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 & 26 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a good quality of accommodation for residents that is safe, well maintained, hygienic and odour free. EVIDENCE: The home is well maintained and all areas of the home, including parts of the garden, are accessible to residents. Parts of the garden are at the present time inaccessible to residents due to the new service building works currently taking place. The current building works have not impacted on the daily routines of the existing home, staff and relatives spoken with confirmed this. The home has an ongoing plan of refurbishment in place. Of the six service user surveys received four responded yes and two responded usually to the question that asks ‘Is the home fresh and clean?’. From the tour of the premises it was evident that the home has ensured that the following requirements, made during the inspection in December 2005, have been met. The fire exit leading to the front of the building is now Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 18 monitored, ensuring that residents are in a secured environment. The fuse cupboard in the storage room is now kept locked and the potential risk to residents has been reduced. The window in the bathroom opposite room 35 has been restricted, which has eliminated any element of risk to residents. The bathroom and bath hoist situated opposite room 55 has been thoroughly cleaned and the clothes removed from beside the bath, resulting in a clean and well presented environment (in this area) for residents. The rooms identified as needing cleaning and /or redecoration has been completed. Where this has not been possible, due to the impact it would have on the resident’s mental well being, consideration has been given as to how this will be managed. The home was odour free throughout. The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records and by staff spoken with. Staff were observed practising good infection control procedures. It was evidenced that a clinical waste contract is in place. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 19 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 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the home’s pre-inspection questionnaire. Of the six service user surveys received four responded yes and two responded usually to the question that asks ‘Are the staff available when you need them?’. The home has three care staff who are trained to National Vocational Qualification (NVQ) level 2 or above in care. A further twenty care staff are employed by the home who are either Registered Nurse qualified in the UK and are employed as Senior Carers or have a nursing qualification from their native country. The Registered Manager said that a qualified NVQ assessor had verified this. Therefore the home has met the required target of 50 of care staff trained to NVQ level 2 or above. This was confirmed in the homes PreInspection Questionnaire and from staff training records viewed. Staff confirmed that the home is committed to staff achieving NVQ’s in care. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 20 employer. A number of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. There is a staff training matrix in place, which now identifies the training needs of staff and whom must attend training in certain subjects. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Medication Training, Fire Training, Health and Safety, Moving & Handling, Infection Control and First Aid. Other training related to the needs of the resident’s such as palliative care, Caring for People With Dementia and Diabetes has also been undertaken. Registered Nurses spoken with at the time of the inspection said that they felt the training provided was good and provided them with the opportunity to achieve their Post Registration Education and Practice (PREP) requirements, as governed by the NMC. The home has also recently been approved to provide Adaptation Nurse Training, whereby nurses who are qualified overseas can train to be the UK equivalent. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion with the health, safety and welfare of residents and staff being protected at all times. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people with mental health disorders and dementia. The Registered Manager is a qualified Registered Nurse Learning Disabilities, has a Dementia care Certificate (EN11) and a Certified Management Studies (CMS) Certificate. She has also recently completed the Registered Managers Award (RMA), which she states will be verified by June 2006. Relatives and staff spoken with said that the Registered Manager is friendly, approachable and actions any issues raised quickly and efficiently. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 22 There is a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Organisation. Quality Assurance questionnaires are distributed to residents, their representatives and other interested parties, by the Head Office of Sussex Health Care. The results of which are made available to all via the home’s annual report. Monthly unannounced (Regulation 26) visit reports are conducted and a copy of this report is sent to the CSCI Eastbourne Office. Staff meetings are held two monthly along with a weekly ‘Team Brief’, which is a meeting held between the Registered Manager and staff to discuss any issues that are relevant to current residents of the home. Minutes of Staff meeting were viewed and these were found to be detailed in content and included actions taken to address previous issues raised by staff. Staff spoken with stated that they felt it was appropriate to have regular ‘Team Briefs’ and staff meetings, as it allows them to constantly monitor the changes needs of residents. Residents and Relatives meetings are also held two monthly, this was confirmed by relatives spoken with and by the minutes that are maintained. Relatives said that they found these meetings ‘productive’ and that they ‘felt listened to’. The Registered Manager reported that the home does not take any responsibility for resident’s finances. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. During the inspection a fire alarm was activated and it was evident that the Registered Manager and staff were aware of the procedures to follow, to ensure that both residents and staff would be safeguarded in the event of a fire. Accidents are well documented in the home’s accident book. Fridge, freezer and food temperature probe readings are recorded on a daily basis. During the tour of the premises it was noted that two hoists, which were being charged, had trailing leads that presented a trip hazard. An immediate requirement was made that the home make these leads safe in order to reduce the risk to both residents and staff. This was actioned prior to the conclusion of the inspection. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 3 Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement That the use of medication omission codes are explained on the back of the MAR sheet. This is an immediate requirement. That the use of nonadministration codes are consistent with those detailed on the MAR sheet. This is an immediate requirement. That where missed entries have been highlighted on MAR sheets, these are investigated and action taken to ensure that all residents are receiving essential medication. This is an immediate requirement. All handwritten entries onto medication Administration Record (MAR) sheets, are explained, signed and dated by the person making the entry. This is an immediate requirement. That all medications administered are signed for by the person who administered them and that the use of ‘ticks’ on MAR sheets ceases. This is an immediate requirement. DS0000013987.V289099.R01.S.doc Timescale for action 22/05/06 2. OP9 13 (2) 22/05/06 3. OP9 13 (2) 22/05/06 4. OP9 13 (2) 22/05/06 4. OP9 13 (2) 22/05/06 Forest Lodge Version 5.1 Page 25 5. OP38 12 (1) (a) (b) & 13 (4) (a) (b) (c) That trailing leads to appliances being charged are made secure. This was an immediate requirement that was actioned prior to the conclusion of the inspection. 22/05/06 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 OP7 Good Practice Recommendations That residents and/or their representative sign care plans and that where this is not practical, care plans reflect this. Forest Lodge DS0000013987.V289099.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 DS0000013987.V289099.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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