Inspection on 21/05/08 for Forest Lodge Care Home

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Adequate service.

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 Care Home 12/12/07

Forest Lodge Care Home 21/05/07

Forest Lodge Care Home 02/05/06

Forest Lodge Care Home 28/11/05

Forest Lodge Care Home 28/07/05

Forest Lodge Care Home 10/01/05

Forest Lodge Care Home 30/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Forest Lodge Care Home 20 Forest Road East Nottingham NG1 4HH Lead Inspector Karmon Hawley Unannounced Inspection 21st May 2008 10:00 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 Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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 Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forest Lodge Care Home Address 20 Forest Road East Nottingham NG1 4HH 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) 0115 978 0617 0115 942 2582 Mr Riaz Khan Mr Riaz Khan Care Home 28 Category(ies) of Past or present alcohol dependence (1), registration, with number Dementia - over 65 years of age (6), Old age, of places not falling within any other category (28) Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr Riaz Khan is registered to provide personal care and accommodation for service users of both sexes whose primary needs fall within the following categories:- Old age, not falling in any other category (OP) up to 28 Dementia, over 65 years (DE(E)) up to 6. Within the maximum number of 28 service users Mr Khan may continue care of the following: one service user aged 55 years of age with Alcohol Dependency as identified in an application dated 22/8/03 and one service user aged 61 years as identifed in an application dated 19/3/05 12th December 2007 2. Date of last inspection Brief Description of the Service: Forest Lodge provides care for a maximum of 28 people. The service is registered to accept older people and up to six people who have Dementia. There are also two people whose needs are outside of the registration category who are also accommodated. The home is a large, detached house within one mile of the city centre and close to the tram route. It overlooks the Forest recreation ground and is also close to the Arboretum Park. The accommodation is arranged over two floors and includes some bedrooms with en-suite toilets. There is a vertical lift and a chair lift to provide access to the first floor. There are two lounges, a dining room and a conservatory offering a choice of communal space. There is an external patio area and ample car parking. A sloped entrance provides access for wheelchair users. Staff are multi-lingual and current service users are from various cultural backgrounds. The cost of the service is currently between £298.21 and £323.36 per week. This fee does not include hairdressing, chiropody, toiletries, magazines, external transport or holidays. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and included the lunchtime period. The main method of inspection used is called ‘case tracking’ which involved selecting four residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Three members of staff and one relative were spoken with as part of this inspection. In addition the views of six people using the service were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home from the provider and the general public since the last inspection was considered in planning this visit and this helped decide what areas were looked at. What the service does well: A warm and welcoming atmosphere is evident on entering the home. Staff were observed to converse in a caring and professional manner with people using the service. People using the service spoke highly of the care home and offered the following comments: ‘we get what we want when we want, we can make our own choices,’ ‘it is very nice and comfortable here, the staff are very good,’ ‘I have no complaints, it is a good atmosphere, I feel safe and I know who I can talk to if I need to.’ A range of activities are available for people to join in should they wish and the activities coordinator is currently working on personalised activity programmes which will meet the needs of people using the service. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 6 People using the service are supported and enabled to maintain contact with relevant others and be part of the local community should they wish. They are also supported in maintaining their religious and cultural needs with support from the staff. Complaints if received are listened to and taken seriously so that these can be investigated and resolved to the person’s satisfaction. People using the service expressed no complaints on the day of the visit and one person stated that the home was, ‘exceptional’. There are sufficient staff available to meet the needs of people living in the service. Staff are dedicated to keeping up to date in compulsory training to ensure that they are aware of the needs of people using the service so that they may support them as needed. What has improved since the last inspection? What they could do better: Plans of care are required to be in place for all complex needs such as diabetes mellitus and challenging behaviour to ensure that the needs of people using the service are met. Risk assessments are required to be in place for all identified risks such as diabetes mellitus, smoking and challenging behaviour to ensure risks are managed appropriately and people using the service are safe. Improvement in medication recording and management is required to ensure that people using the service are protected and receive their medication as prescribed. Consultation with the Fire Authority regarding keeping doors open is needed to ensure that people living at the service remain safe should a fire occur. Staff must only be employed with only a POVA 1st in place if supervised until a satisfactory criminal record bureau check is received to ensure that people using the service are protected from unsuitable people being employed. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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 Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may wish to use the service are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the care home. EVIDENCE: To ensure that staff are able to meet the needs of people before they make a decision to move into the home, the manager visits them in the community to carry out a preadmission assessment before any decisions are made. There was evidence of preadmission assessments taking place within case files examined. People may also visit the home and spend time there getting to know everyone should they wish. Staff spoken with were able to discuss the preadmission process and how they are made aware of people’s individual needs before they move into the home. One person using the service spoken with discussed the preadmission process that they had undertaken, they stated that they had not had chance to visit Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 10 the home before they moved in due to their circumstances, however they had settled in very well and were pleased with their care. The service does not offer intermediate care. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are not fully met due to the lack of care planning for complex needs. People are not fully protected due to the lack of risk assessments and management plans in place. People using the service are not fully protected by the service’s medication policies and procedures. EVIDENCE: Within plans of care examined there was evidence that people using the service had undergone a basic assessment in regard to their daily activities of living. Plans of care were then drawn up from this information that had been gathered. Plans of care in place were mainly task focused and did not concentrate on the likes, dislikes and preferences of the person using the service which may result in them not getting their care in their preferred way. Not all plans of care were up to date in regard to changing needs which may affect the continuity and effectiveness of care received. Progress records were not kept frequently, however there was evidence that when issues arose such as ill health that the doctor had been informed quickly. For those people with complex needs such as diabetes mellitus, mental health issues and behavioural Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 12 problems the plans of care did not cover in full the support that the person would need in regard to this, which may result in their needs not being fully met. There were no risk assessments in place for identified risks, resulting risks not being monitored effectively. Staff spoken with were able to discuss the needs of people using the service and how they manage risk such as fire and smoking. People using the service said, ‘the staff are very good, I am comfortable and my needs are met,’ the staff are good here, I can do as I please.’ To ensure that the health care needs of people using the service are met they are supported in accessing specialist services such as the general practitioner, district nurse, chiropodist and optician as needed. There was evidence of this occurring within case files examined and one person using the service discussed how the staff had assisted them in getting new glasses. Staff spoken with confirmed that people are able to see the doctor as required. To see if the people using the service are protected by the medication policies and practices the medication was examined. Medication charts demonstrated that there had been occasions when medication had been administered but not signed for as given, which could lead to people being given further medication causing ill health. When medication had been omitted there was no reason given as to why this had happened, which does not highlight if there are any concerns that need to be addressed. Hand written entries had not been signed for by two members of staff to show that these had been checked as correct, which may result in people using the service being given the wrong medication. There was one instance where boxed medication had been administered but not written up on the medication chart, which could result in the person being either over or under medicated. On examining plans of care each person using the service had undergone an assessment for selfmedication, there was no one able to do this at present. Therefore plans of care were in place for the arrangements that had been made for how staff were to supported people using the service in their medication administration. Staff spoken with were able to discuss how they ensure that the privacy and dignity of people using the service is maintained, they stated that they ensure that they knock on doors prior to entering people’s rooms and also ensure that they are supported in personal care in a dignified manner. There are curtains available within shared rooms to ensure that people are afforded privacy as needed when they are getting up and going to bed. Staff were observed to treat people using the service in a dignified and caring manner and respect their privacy when attending to their needs. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are enabled to participate in various activities both in the care home and the local community if they wish. People using the service are helped to exercise choice and control over their lives. EVIDENCE: An activities coordinator is employed on a full time basis to offer a range of activities such as arts and crafts, movies, memory exercises, gardening and games to people using the service. A Wii (a virtual games consol which offers people realistic games that they physically participate in) has recently been purchased and there were photographs available of people using the service playing with this console. The activities coordinator has also been trying out specialist activities from the Alzheimer’s Society activity book; they discussed how they had adapted games and tasks to suit the needs of the people using the service. Pupils from a local school also visit the service on a weekly basis and they spend time talking with people or playing games. To ensure that people are given opportunities to practice their faith or religion or simply acknowledge who they are and where they come from various sources have been accessed in the community and one Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 14 person using the service has just returned from spending a brief holiday in their country of birth. On talking with the activities coordinator they were very enthusiastic in regard to their job role and the future developments that they have in mind, such as personalised plans of care and social support plans. People using the service offered the following comments about life in the home and activities available: ‘ I can get up when I want and make my own choices,’ ‘I can get up and go to bed when I want, it is very nice and comfortable here, there is a good atmosphere,’ ‘I can go out in the garden and I enjoy the activities,’ and ‘we can ask for anything and we get it.’ One person using the service expressed their delight at being able to carry out gardening work, which they stated that they really enjoyed doing. Although there are no church services in house people using the service are supported to maintain their faith should they wish and one person attends a club that enables them to do this. To ensure that people using the service are enabled to maintain contact with people that are important to them there are no restrictions on visiting and visitors may be received in private. Several visitors were seen coming and going throughout the visit. One visitor spoken with said, ‘I am always made welcome when I come to see my friend, the staff are very good here.’ Two people using the service spoken with said, ‘my family come to see me and often take me out,’ and ‘my family are always made welcome when they come.’ Staff were observed to have comfortable relationships with people visiting and conversed freely with them. To ensure that people using the service receive a wholesome and appealing diet there are a variety of choices available at each meal time. Specialist diets and personal preferences are also catered for. An Asian alternative is available each day at the main meal. To enable people using the service to have full understanding of the meals on offer, the menu is available in a picture format. People using the service offered the following comments: ‘the food is nice, there are choices,’ and ‘the food is plentiful and alternatives are available if you want them.’ One member of staff spoken with was able to discuss the dietary needs of people who have diabetes mellitus to ensure that their health care needs are met. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are assured that any complaints will be taken seriously and acted upon. People using the service are protected from abuse. EVIDENCE: To ensure that people using the service are aware of how they may make a complaint known should they feel the need, they are given a copy of the complaints procedure within the service user guide. A copy of the service user guide was available within the rooms of people living in the home. The service has not received any complaints since the previous visit. Staff spoken with were able to discuss how they would deal with any concerns or complaints should they be received. People using the service offered the following comments: ‘the staff are very good, I have no complaints, I feel safe and I know who to talk with if I have any problems,’ and ‘ I usually find complaint with 4 and 5 star hotels, however I have nothing to complain about here, it is exceptional.’ To ensure that people living in the care home are protected from abuse there are policies and procedures in place in respect of safeguarding adults. This did not cover the alerting process that is needed should an issue occur, however the manager was aware of the processes that they should follow and who they needed to inform should they suspect that abuse was occurring. Staff spoken with were able to discuss what they felt constituted abuse and their roles and Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 16 responsibilities in ensuring that people using the service are protected. They confirmed that they would report bad practice if they suspected that this was occurring. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service live in a comfortable and homely environment. EVIDENCE: There was evidence of ongoing maintenance work taking place and all areas of the care home observed were satisfactorily maintained. The garden was well kept and provided a nice seating area for people using the service. A separate smoking area has also been provided to ensure that there are alternative areas for people to use, thus ensuring that people’s rights are protected. During the tour of the home, there were a number of bedroom, corridor and communal doors that had been propped open, which leaves people using the service at potential risk should a fire outbreak occur. (This is further discussed and quality rated in standard 38) The kitchen door was also propped open for large periods of the visit; staff have to pass this door to enter the laundry room. This was discussed with the Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 18 deputy manager who stated that all laundry is bagged and the kitchen door is kept shut when food is being prepared. The laundry room itself was clean and tidy as were all other areas of the care home. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are available to support people in meeting their needs. People using the service are not fully protected by the current recruitment polices and procedures in place. EVIDENCE: To ensure that sufficient staff are available to meet the needs of people using the service the duty rotas were examined. These showed that three care staff as well as the management are available throughout the day and two members of staff during the night. In addition to this there are domestic and kitchen staff. Staff spoken with stated that the staff team worked well together and that there was sufficient staff available to meet the needs of people living in the home. People using the service also confirmed that there was sufficient staff available when they needed them. To ensure that new staff are aware of their roles and responsibilities on commencing employment they undertake an induction. There was evidence of staff doing this within staff files examined. One member of staff spoken with confirmed that the induction process takes place. To ensure that staff have the necessary knowledge and skills to meet the needs of people using the service 67 of staff have now achieved the National Vocational Qualification in care level 2 (a nationally recognised work and theory based qualification). This information was confirmed in the Annual Quality Assurance Assessment Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 20 information that was sent to the Commission for Social Care Inspection prior to the visit. There was evidence of staff achieving these qualifications within staff files examined. To ensure that people using the service are protected from unsuitable people being employed four staff files were examined to see if they contained all the required documentation required by law. All files contained required documentation such as an application and references, however one file did not contain an up to date Criminal Record Bureau check (a police check to see if a person has a police caution or criminal record) as required. Due to this all staff files were checked to see if they contained a satisfactory criminal record bureau check; this demonstrated that in total there were three members of staff working in the home without satisfactory Criminal Record Bureau checks in place. The manager stated that they were not aware of the fact that new staff needed new checks between employers. An immediate requirement was set to ensure that this is remedied straight away to ensure that people using the service are protected from unsuitable people being employed. One member of staff spoken with confirmed that they had undertaken a criminal record bureau check when they commenced employment. Training records demonstrated that staff continue to undertake compulsory training such as fire, manual handling and dementia care to ensure that they have the necessary knowledge and skills to meet the needs of people using the service. Staff files observed confirmed that this training was taking place. Staff spoken with also stated that they felt supported by the management in their development and that they training was at a good standard. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a home are given opportunities to have a say in how the care home is run. People living in the home are not fully protected by the fire safety systems in place. EVIDENCE: The manager remains up to date with compulsory training and has completed the National Vocational Qualification level 4 in care, (a nationally recognised work and theory based qualification). Staff spoken with said, ‘the manager is very approachable and often works along side us on the floor,’ and ‘the manager is very good, he has time for us if needed.’ People using the service spoken with stated that they felt that the care home was well run and managed. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 22 To ensure that people using the service are able to have their views and opinions taken into consideration, annual surveys are carried out which cover staffing, the environment and the facilities on offer. The last survey that took place was in the spring of this year, twenty-three surveys were returned and all were of a positive nature. The deputy manager stated that informal meetings are held for people using the service, however there were no records available to confirm this. Within the plans of care of those people case tracked there was evidence of annual reviews taking place when they are asked if they are satisfied with all aspects of their care. The deputy manager and staff stated that staff meetings take place, however again there were no records available to confirm this. There were policies and procedures in place in regard to the annual development of the home to ensure that people continue to receive a quality service. There were several plaudits available which were examined, offering comments such as; ‘care is offered with the greatest tenderness,’ care is dignified and staff show kindness and real concern for people’s welfare.’ To ensure that the finances of people using the service are safe, the staff are not responsible for anyone’s personal finances. Should a cost be incurred then the relevant person responsible for finances are invoiced. There was reference to who was responsible for people’s finances within case files observed and how people are supported in accessing their money. The Annual Quality Assurance Assessment information told us that all equipment in the care home has been serviced as required. The hoist and lift certificate were observed to ensure that servicing and maintenance is carried out as required to ensure that people using the service are protected. Staff had received training in health and safety and they were able to discuss relevant issues such as fire prevention when spoken with. There are however concerns due to the amount of doors that had been propped open. The deputy manager stated that the fire authority are aware of this practice but there was no evidence of this available, therefore an urgent action letter was sent following the visit to ensure that the fire authority are liaised with in regard to this issue. There are two people using the service that smoke in their bedrooms, whilst it is acknowledged that staff stated that these people were quite capable, there were no risk assessments in place to identify potential risks and reduce these. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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 OP7 Regulation 15(1) Requirement Plans of care are required to be in place for all complex needs such as diabetes mellitus and challenging behaviour to ensure that the needs of people using the service are met. Risk assessments are required to be in place for all identified risks such as diabetes mellitus, smoking and challenging behaviour to ensure risks are managed appropriately and people using the service are safe. Medication that has been administered is required to be signed for to ensure that people using the service receive their medication as prescribed. A reason for when medication has been omitted is required to ensure that any concerns are identified and dealt with as soon as possible to ensure that the health and welfare of people using the service is maintained. It is required that the policies and procedures in regard to safeguarding adults is updated in DS0000002198.V364865.R01.S.doc Timescale for action 15/07/08 2 OP7 13(4,c) 10/07/08 3 OP9 13(2) 10/07/08 4 OP9 13(2) 10/07/08 5 OP18 13(6) 10/07/08 Forest Lodge Care Home Version 5.2 Page 25 6 OP19 OP38 23(4,a) 7 OP29 19(1,b) regard to the alerting process should an untoward incident occur to ensure that people using the service are fully protected from abuse. Consult with the Fire authority regarding keeping doors open, whilst complying with Fire safety regulations to keep people living at the service safe. Implement practice recommended by the Fire authority without delay. Staff must only be employed with only a POVA 1st in place if supervised until a satisfactory criminal record bureau check is received to ensure that people using the service are protected from unsuitable people being employed. 17/06/08 21/05/08 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 OP7 OP9 OP26 OP33 Good Practice Recommendations Staff complete more frequent entries within progress notes to reflect the continuity of care for people using the service. Handwritten entries on medication charts are signed by two members of staff to show that these have been checked as correct. Liaise with the Environmental Health Officer in regard to the practice of propping open the kitchen door in regards to infection control procedures. Keep records of staff meeting to demonstrate that these have taken place. Forest Lodge Care Home DS0000002198.V364865.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Care Home DS0000002198.V364865.R01.S.doc Version 5.2 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. 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