Inspection on 05/05/05 for Forest Lodge

This inspection was carried out on 5th May 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 19/08/05

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 5th May 2005 at 10:25am 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 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 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 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 G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th November 2004 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 70s 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 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 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 Thursday, 5th of May 2005 between 10.25 a.m. and 2.40 p.m. The two carers on duty helped the inspector during the inspection. The inspector also had a telephone conversation with Mrs Taleb, one of the proprietor/managers. In addition, the inspector spoke to all six residents currently living in the home (one was in hospital) 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, such as care plans, activities book, 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 November 2004. The proprietor/managers had addressed many of these. However, some issues remained outstanding or could not be confirmed e.g. the manager was not on the premises to provide access to confidential staff records. These requirements and recommendations have been restated with new target dates. The inspector would like to thank staff and residents who contributed to the inspection. What the service does well: What has improved since the last inspection? The sitting and dining areas have been re-arranged to give more space for residents to walk and for side tables or walking frames beside their chairs. Work has started on building an office. This is the first stage in improvements to the premises, which will include a lift, and level access to the garden. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 6 Fire training and a range of other training has taken place for all staff, including oral hygiene, continence and diabetes. One staff member has an NVQ qualification and 2 others are on the way to achieving this. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 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 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 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 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: There are currently 2 vacancies in the home and prospective residents are being assessed and they or their relatives had been visiting the home. 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. The contract should indicate the amount of the fees, the method of payment and by whom payable. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 9 As no new resident had been admitted since the last inspection, it was not possible to check whether the requirement made from the last report, regarding the written assessment format, had been addressed. This is therefore been repeated with a new target date. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 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 standard(s) 7, 8, 9, 10 The manager and staff have a good knowledge and understanding of the needs of residents and there is a system for care planning in place to meet residents’ social and health 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 more records should be more detailed to evidence this. EVIDENCE: A system for care planning was in place with reviews of care plans taking place every few months. Most of the reviews indicated no change in the care plans. The care plans should identify objectives and goals and be updated to reflect changing needs. The reviews should take place at least once a month and be documented e.g. by monthly summaries of the events in the persons life and include an analysis of any progress/ difficulties/ ongoing issues. Daily logs were being completed by care staff but it was difficult to track action taken by the manager or others e.g. whether a referral to a physiotherapist had resulted in an appointment; the content or outcome of telephone calls to a GP; whether the GP had visited as requested etc. One of the residents was still on the medication risperidone and it was not clear whether the GP had undertaken a Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 11 review of medication in line with the recommendation of the Committee for the Safety of Medicines, and as recommended in the pharmacist inspectors report. The senior carer was asked to check with the GP about this. Staff have had training in continence control and oral hygiene. One of the residents had developed pressure sores while in hospital and these were being treated successfully by visiting district nurses. 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 is a policy and procedure for the administration of medication held in the policies and procedures file. It is suggested that the procedures should be kept with the medication administration records for easy access and the guidance of staff. Medicines are currently stored in a locked cupboard. A new medicines trolley, delivered to the home on the day of inspection, had not yet been seen by the manager. The trolley was very big with an institutional appearance, and the manager may wish to consider alternatives such as a carrying case, as recommended by the pharmacist Inspector in his report. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 12 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) 12,13,14,15 There was evidence of good ideas, intentions and commitment to provide a fulfilling environment for residents which was to a large extent achieved. 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, which was being used as a polling station on the day of the inspection. Two of the residents went out for a walk with a staff member during the inspection, another two were making conversation, on and off, and another was listening to music on headphones. The television was on but no one was watching this and less able residents were dozing in their chairs. A record was being kept of activities but this needed more detail to provide useful information and evidence how the activity linked with the care plans. Care plans should include individual interests, preferences etc particularly for those with memory loss, sensory loss or low motivation. Less able or less motivated rResidents may require more focused support, assistance and encouragement to join in 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. See standard 7 and its requirement, which is repeated. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 13 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 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 and snacks were being offered regularly and the lunchtime meal served was freshly cooked and attractively presented. Residents were encouraged to maintain their independence but assisted to eat in a sensitive way, when necessary. During the better weather bar-b-ques are held in the garden. Culturally appropriate meals have become a regular feature, built into the menu, as an option which is also offered to all residents. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 14 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 17 18 The inspector was satisfied that relationships in the home between staff and residents and the systems in place were sufficient to protect the safety and wellbeing of residents. EVIDENCE: There is the complaints procedure with timescales but this needs minor amendment. No complaints were recorded as having been received since last inspection. Residents felt that they could give their views to the proprietors and would be listened to. The day of the visit was general election day. Residents were on the electoral register and their wishes regarding casting their vote had been sought. The manager had reviewed the adult protection procedures for the home. The adult protection procedures for the London Borough of Waltham Forest were also available for guidance of staff. The arrangements regarding service users’ monies was not inspected on this occasion. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 15 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. Originally established in 1995, it therefore does not meet all the current standards e.g. the lack of level access to the garden, an office, a room for residents to meet visitors in private and a lift. After a long wait, the proprietors received planning permission for an office to be erected in the garden and building work has commenced. Once this is completed, the plan is to provide level access to the garden and install a lift. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 16 The double bedroom and 5 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 bath is fitted with a chair to enable residents to be assisted in and out. The garden area has a large table and chairs and a barbecue. 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 bedroom seen was comfortable, well furnished and personalised but some of the bedrooms do not contain all the furnishings recommended in this standard e.g. 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 is therefore repeated with a new target date. The National Minimum Standards recommend that lockable facilities be provided in residents rooms. Staff have had infection control training and food safety and hygiene training. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 17 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, 30 Sufficient staff were on duty to meet the needs of residents at the time of the inspection. 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. EVIDENCE: Two members of care staff, including a senior carer were on duty at the time of the inspection, responsible for the care of residents, cooking and cleaning etc. Only six residents were being accommodated so staffing levels met minimum levels set by the previous registration authority. The proprietors were both rostered to be on duty from 9.30 a.m. to 2.30 p.m. although neither were on the premises during the inspection. One of the members of staff who was on duty was shown on the rota as being off duty. The rota must be an accurate reflection of who is working in the home. The rota for the week of the inspection showed that the proprietors had been altering their usual pattern of working within the home to include covering shifts. This was because a member of staff had left unexpectedly and another was on annual leave. The rota should differentiate when the proprietors are present in their management role or doing care tasks. Night staff regularly work 14 hour waking shifts plus there is a member of staff sleeping in. One member of staff is shown on the rota as working seven nights a week, either on nightshift or sleeping-in. The manager must take into account the Working Time Regulations and ensure that the health and safety of staff and residents is safeguarded at all times. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 18 One staff member has an NVQ qualification and two others are undertaking the training. Eight members of staff are employed and the National Minimum Standards recommend that at least half of these be trained to NVQ level 2. The proprietors therefore need to establish a strategy to ensure this standard is met. Recent training for staff has included health and safety, infection control, food hygiene, manual handling, continence, oral health, diabetes. Further training in the administration of medication has been booked. Neither of the owner/managers was available during the inspection so access to the staffing records and the recruitment policies and procedures was not possible. Standard 29 was therefore not tested on this occasion and the requirement from the last report is therefore repeated with a new target date. The senior carer was not sure whether the home had a copy of the POVA guidelines, which came into force July 2004 and can be downloaded from the Internet. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 19 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 management of the home is efficient, organised and effectively facilitates the smooth operation of the service. The ethos of the home is open and positive. Further general development is required, however, in relation to the system of supervision, record keeping and documentation. Presently records do not demonstrate fully how practice is informed, supported or evidenced. EVIDENCE: Both the registered 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 involved in the running the home 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 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 20 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 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. Information is also available on the care standards website. 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 as 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 senior carer alternatives e.g. ring binders with dividers. Policies and procedures were in place but most were not dated and some of these needed review, especially those inherited from the old owners. As the managers were not in the home, the recruitment policy and procedures were not available for inspection. Requirements from the last inspection have therefore been repeated with new target dates. Fire training and fire drills had taken place although it was suggested that the names of staff involved be included for future reference. Checks were being carried out on the Fire alarm, door guards and emergency lighting system. Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 COMPLAINTS AND PROTECTION 2 2 3 2 3 2 x x STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 2 3 2 x x 2 2 2 Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 22 In 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 registered persons to update the Statement of Purpose, the Service Users Guide and the residents contract and amend them 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. (Target date of 1/3/and 2005 not met) The assessment by the home of residents needs to be documented more fully. It was suggested that the written format use the headings listed in standard 3 to ensure that all areas are covered and can then be incorporated into the care plan. (Previous Target date of 1/ 2/ 2005) The format and content of Care plans to be reviewed to ensure these cover all the areas described in the Standards and Schedule 3 to the Regulations, (including leisure activities, cultural and dietary needs, arrangements for the handling of Timescale for action 1 July 2005 2. 3 14 1 August 2005 3. 7, 8 15 1 August 2005 Forest Lodge G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 23 4. 9 13 5. 16 22 6. 19, 20, 22 23 7. 24 residents personal monies) and describe how the residents needs in respect of health and welfare are to be met. The care plans to be reviewed monthly. (Target date of 1. 3.2005 not met) The care plans to be more detailed, identify objectives and goals and be updated to reflect changing needs. The record of 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. The procedures for the administration of medication to be kept with the medication administration records for easy access and the guidance of staff. The manager may wish to consider alternatives to a medicines trolley such as a carrying case. The manager to ask the GP to review the use of medications risperidone and cocodamol. The complaints procedure to be updated to reflect the change to the CSCI and the move to Stratford. The proprietors to produce a written plan and programme for achieving compliance for those areas where the home does not meet current standards i.e. the current lack of level access to the garden, a room for residents to meet visitors in private and a lift. (Target date of 1.3.2005 not met) If any furniture in and or facilities recommended in this standard e.g. comfortable G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc 1 June 2005 1 August 2005 1 October 2005 1 October 2005 Page 24 Forest Lodge Version 1.20 8. 27 37 17 9. 28 13 10. 11. 28 29 18 19 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 the care plans with a note of who made the decision and regularly reviewed. (Target date of 1.3.2005 not met) A detailed and accurate rota to be kept: showing who is on duty, during which hours and in what capacity; clearly differentiating when staff are employed in care or management duties and cooking and cleaning tasks. The managers to take account of the Working Time Regulations to ensure the health and safety of residents at all times. At least half of the staff to have an 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 date of 1.3.2005) The proprietor/managers to ensure that their qualifications are equivalent to level 4 NVQ in management and care or that they are working towards this by a set date. 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 G56 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc 1 June 2005 1 June 2005 1 September 2005 1 June 2005 12. 31 10 1 October 2005 13. 33 24 1 December 2005 14. 36 18 1 July 2005 Forest Lodge Version 1.20 Page 25 15. 37 12 development needs, including training needs. The dates, contents and decisions made to be recorded. It is good practice to develop supervision contracts with staff to determine the frequency and length of sessions and the content. (Target date of 1.2.05 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 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection 4th Floor, 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 © 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 G06 S7232 Forest Lodge V225318 050505 Stage 4.doc Version 1.20 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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