CARE HOMES FOR OLDER PEOPLE
Foxley Lodge 24-26 Foxley Hill Road Purley Surrey CR8 2HB Lead Inspector
Claire Taylor Unannounced Inspection 20th January 2006 10:30 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 Foxley Lodge DS0000025783.V282008.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. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Foxley Lodge Address 24-26 Foxley Hill Road Purley Surrey CR8 2HB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8668 4135 020 8668 4135 yabhee@btinternet .com Mr Yogindrananth Abhee Mrs Devika Abhee Mr Yogindrananth Abhee Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow a maximum of three service users aged between 60 and 65 in the Dementia (DE) category to be admitted from time to time. 3rd August 2005 Date of last inspection Brief Description of the Service: Foxley Lodge is registered to provide care and accommodation to elderly residents with a diagnosis of dementia. With the exception of one double, each resident has their own bedroom, and access to spacious communal areas including two lounges, dining room and large garden with both paved and lawn areas. There are adequate toilet and bathroom facilities to meet the needs of the current resident group. The building was also extended to provide two single, en-suite bedrooms and two toilets. The house is situated in Purley, and well placed for road and rail links, and access to the local supermarket. It is also within reasonably easy reach of the centre of Croydon. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second of the statutory two inspections that the Commission for Social Care Inspection is required to carry out each year. This visit was unannounced, began at 10.30am and lasted five and a half hours. Inspection time was spent talking to the residents and staff, one visiting relative and the manager /owner Mr Abhee. A brief walk round the premises took place and some bedrooms viewed in relation to previous requirements. Prior to this inspection, a meeting was held under the auspices of adult protection to discuss an accident involving a female resident. Part of the inspection process therefore focused on some issues raised at the meeting as well as the home’s progress to meet requirements from the previous inspection and the core standards not assessed at that visit. For a complete overview of the home’s standard of operation between these dates, this report should be read in conjunction with the inspection report carried out in August 2005. What the service does well:
Care plans set out well the individual needs of each resident and how staff members should meet these needs. Healthcare needs are well monitored and the home liaises with a range of health care professionals to ensure that residents’ care needs are met. This includes maintaining close links with specialist services for people with dementia. The majority of staff have worked in the home for a number of years and the turnover of staff is low which helps retain some form of consistency of care for those residents with memory impairment. Likewise, the owner/manager has been running the home for several years and demonstrates a valuable knowledge of the residents and in meeting the needs of older people. Residents commented that they enjoy the meals in the home and find the staff to be helpful and attentive. The manager listens to and respects the views of those who live in, work in, and visit the home. Staff went about their duties in an efficient way and interacted with residents in a caring and respectful manner. Resident’s social skills are maintained with individual interests developed through the organised activities such as bingo, reminiscence, music, board games and skittles. Foxley Lodge provides a pleasant and homely environment for its residents, some of who have lived there for many years. The premises are maintained to a good standard; communal areas are spacious and facilities for residents are clean and accessible. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
Whilst it is acknowledged that a considerable amount of staff training had been updated in recent months some still needs to be completed. The home has a low number of care staff achieving the required NVQ training and the manager needs to address this. Due to the two recent adult protection meetings, it is recommended that staff receive further training on abuse awareness and adult protection. This will ensure a better understanding of the local authority guidelines for protecting vulnerable people. The home generally presents as clean, and pleasant although the carpet by the downstairs toilet is in need of attention. A programme of maintenance and refurbishment is still needed to demonstrate that repairs and upkeep of the premises are undertaken. Accidents and incidents are recorded appropriately although the home must ensure that the Commission is notified more promptly of any events that affect the service users well being. This includes the reporting of any deaths. The manager must ensure that all staff are familiar with the reporting of incidents under Regulation 37 of the Care Standards Act. Some bedroom doors are kept
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 7 locked and staff hold the keys. The kitchen is also kept locked for similar reasons. The manager must therefore complete individual risk assessments and a locked door policy as such restrictions could be construed that residents are not fully able to exercise their rights within the home. As good practice, and repeated from the last inspection, the manager should explore further ways in which the residents can access their local community as some indicated that they would like to go out of the home more often. One resident looks forward to his daily paper although the times he received it from staff were variable. The home might therefore consider arranging for newspapers to be delivered at a regular time to suit individual residents. Although residents and relatives are fully involved in the care planning process the manager should ensure that they sign in agreement with the plan wherever possible as some had not been completed. 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. Foxley Lodge DS0000025783.V282008.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 Foxley Lodge DS0000025783.V282008.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 and 4. Standard 6 is not applicable to this home as it does not provide intermediate care. Residents’ needs are assessed more fully prior to admission to ensure that the home can meet their needs and that staff are aware of how to support them. EVIDENCE: The needs assessment has been improved upon to ensure that an individual’s needs are more fully assessed at the point of admission. Before any visit is arranged the manager receives written information from the social worker and a psychiatric assessment regarding the mental health issues caused by dementia. Contact is also encouraged to ensure that relatives, who may view the home on behalf of prospective residents, are satisfied that their specific needs can be met. One relative gave positive feedback concerning the settling in period to the home. There have been three new residents admitted since the last inspection in August 2005. Their files were sampled and each contained a detailed pre-admission assessment that had been carried out by the manager/ owner. The assessment is usually completed with the resident, his/her relative or representative and with the relevant professionals that have been associated with the referral. Detailed information about the person, their
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 10 medical and social history background and details of specific care areas such as nutrition, skin care, medication and mobility are included. In addition, the home completes a questionnaire to establish any personal preferences of the new resident. Such information gathered about a resident’s family history is particularly useful to staff when engaging with residents, particularly those with dementia. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11 The residents’ care and health needs are identified and reviewed regularly so that they continue to be met and they are able to access care from additional healthcare services. Residents and their families have been consulted about ageing, illness and death in order that their beliefs would be observed and choices respected. Staff treat people who live in the home with respect and maintain privacy and dignity for individuals. Standard 9 was assessed as met at the August 2005 inspection. EVIDENCE: Since the last inspection, records related to the residents’ plans of care have been improved upon with requirements and recommendations addressed. Eight files were sampled and contained comprehensive documentation relating to each resident. Records required by the care homes regulations are now in place. Plans were being reviewed on a monthly basis with care records directly related to the assessed needs identified in the care plan. Any necessary changes were clearly documented and the action to be taken in order to address those needs. Examples included care plan changes for one resident’s deterioration in mobility and for another to receive further support when eating. This demonstrates that agreed plans of care and actions were being followed. Both the resident and relatives are involved in the care planning
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 12 process although the manager should ensure that residents or their representatives sign in agreement with the plan wherever possible as some had not been completed. Risk assessments covering key areas such as fall prevention and nutrition are in place and had been reviewed in November 2005. Staff were observed to ensure residents’ privacy and dignity is maintained and residents spoken to confirmed that staff treated them with respect. One resident spoke fondly of the staff and said they were kind and helpful. Residents are in regular contact with General Practitioners, District Nurses and other health care professionals as required. I.e. hospital clinics, chiropody and optician. In addition, a visiting CPN or Consultant Psychiatrist monitors the care and mental health needs to ensure that residents continue receiving the correct treatment or medication. The home keeps records of all healthcare appointments, in addition to individual progress notes and an accident book. Nutritional records were in place such as monthly weight charts for residents and dietary guidelines for two individuals who have diabetes. Individual wishes concerning illness or arrangements after death are discussed with residents’ and/ or their families. Any action agreed is recorded in their respective care plan. Standards relating to the handling of medication were checked at the last inspection and the manager had addressed the previous recommendation. I.e. a folder is now available for staff that contains useful information regarding medicines prescribed for the residents e.g. possible side effects and reasons for their use. Foxley Lodge DS0000025783.V282008.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 and 15 Residents are provided with a range of opportunities for recreational and social activity that balances with their social, cultural and religious needs. Residents are offered a varied and wholesome choice of meals and nutritional needs are monitored closely. Standard 14 was assessed as met at the August 2005 inspection. EVIDENCE: From the point of admission to the home, each resident has a familiarisation profile which is a good way for staff to get to know each individual’s preferences. A life history profile is also developed. This information helps staff to gain a better understanding of the resident’s past life and interests especially when planning activities or reminiscence and is seen as good practice when caring for those with dementia and memory impairment. Residents preferred social and leisure interests are recorded in their care plans and records kept to show what activities are undertaken. There is an activity folder available to residents that include photos of activities available in the home. Each morning an organised activity is arranged within the lounge for those who enjoy group meetings, for residents who do not wish to participate, staff arrange other types of activities. Examples include bingo, skittles, music/ dance, “scrabble” and gentle exercise sessions. The manager/ owner advised that music entertainers visit the home on an occasional basis. Residents’
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 14 religious needs and beliefs are catered for and some individuals participate in a weekly communion service at the home. Monthly meetings are also held for residents to discuss issues. One resident looks forward to his daily paper and explained that the staff buy one for him although the times he received it were variable. The home might therefore consider arranging for newspapers to be delivered at a regular time to suit individual residents. A previous recommendation was that the manager should explore ways that the home could facilitate more community-based activities. This is repeated as again, some individuals commented that they would like to get out more often. During this inspection, some care staff were covering the catering arrangements due to the cook being on sick leave. Those staff designated for cooking duties had received up to date food hygiene training. Menus had been reviewed as suggested at the last inspection. They were available in larger print and offered a choice of meal. Residents were complimentary about the food provided in the home. The meals are generally organised over two sittings. The lunch appeared appetising with a choice of dishes and staff served and assisted residents appropriately and sensitively on the day of inspection. Levels of support required by residents were clearly documented within their care plans. Foxley Lodge DS0000025783.V282008.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 and 18 The home has a satisfactory complaints system in place to ensure that residents’ and relatives’ views are listened to and acted upon. There are procedures and systems in place regarding the protection of vulnerable adults and prevention of abuse although some extra staff training is needed to maximise protection for the residents. EVIDENCE: A detailed and accessible complaints procedure was in place and displayed in the home, which included details of how complainants could contact the CSCI if desired. Residents spoken to and one relative felt comfortable and confident enough to raise a complaint if they felt it necessary to do so. The CSCI office has received no complaints within the last twelve months. As recommended, the manager had written to all the residents’ relatives and representatives and provided them with a copy of the home’s revised complaints procedure. Foxley Lodge operates systems to safeguard residents from abuse including vetting staff correctly and providing training through induction for staff members. As previously required, the home’s policy has been amended to cover the local authority guidelines for protecting vulnerable adults. There have been two separate strategy meetings held under the auspices of Adult Protection; one on the 19 July 2005 and the second on the 16 January 2006. Both were organised by the care management team from the placing authority. Outcomes from both meetings have yet to be finalised and any significant findings will be included in the next inspection report. Due to the two recent adult protection meetings, staff need to receive further training on abuse awareness and adult protection. This will ensure a better understanding of the local authority guidelines for protecting vulnerable people.
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Improvements have been made to the fabric of the premises since the last inspection meaning that residents are provided with a more welcoming, homely and pleasing environment in which to live. Appropriate aids and adaptations are in place to promote a safe environment for residents that is in meeting with their needs. The home generally presents as clean, and pleasant although the carpet by the downstairs toilet is in need of attention. EVIDENCE: The registered provider has worked hard to address previous requirements concerning the premises. I.e. Carpets had been replaced in the identified residents bedrooms and exposed pipe work under one hand washbasin covered. The radiator control valve had been replaced in one bedroom so that the resident can adjust the heating as he so chooses. Fly screens had been installed in the kitchen as required by the Environmental Health Department. The premises had recently been inspected by the local fire authority (9-1-06) and overall found to be satisfactory with three recommendations made. The manager was taking steps to address these and progress will be checked at the
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 17 next inspection. One hygiene issue was identified concerning the carpet in the hall by the downstairs toilet. Due to an unpleasant odour, the manager must therefore arrange for the carpet area to be cleaned or replaced. Aside from this, the home appeared clean, tidy and in a good state of repair with appropriate systems in place to control the spread of infection. The care staff were undertaking domestic duties due to the home having a vacancy for a cleaner. A written plan for the home’s overall maintenance and redecoration programme still needs be put in place and the former requirement is therefore repeated. This should identify how the home maintains the upkeep of the building and show any planned improvements for the fabric of the premises. As required at the last inspection, a risk assessment of the premises has been carried out by an occupational therapist (September 2005). The findings from the report confirmed that the home provides a sufficient range of equipment and adaptations appropriate to meeting the needs of the current residents. No recommendations were made within the OT report. Residents were observed to be mobilising using specialist aids such as walking frames. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 There is a well-established staff team who understand the needs of the elderly people living there. Training for staff has much improved resulting in a more skilled workforce to meet the residents’ needs although more staff need to achieve the NVQ level 2 qualification. Robust recruitment procedures are in place to ensure that residents are cared for and protected. EVIDENCE: The rota provided indicated that there were usually 3 care staff on duty, plus the manager or deputy manager during the day, with two carers on at night. These levels are at present satisfactory. The staff team remain largely unchanged resulting in stability and consistency of care for the residents. The manager reported that the home had one vacancy for a cleaner and had appointed two new care staff since the last inspection. Four staff files were sampled including those for the two new employees. Records confirmed that the home’s recruitment practices had been adhered to and that staff were asked to provide the necessary documentation and undergo the appropriate checks before commencing work. This included the completion of a police CRB and POVA check. As previously required, staff have completed a health questionnaire to further evidence their fitness to work. Staff training required at the last inspection has taken place. Certificates showed that training has been achieved in first aid, diabetes, dementia, depression and MRSA. Night staff had also attended the required training identified at the last visit. The home is low in the numbers of care staff achieving the NVQ level 2 training in care and this must be addressed in order to meet the required National Minimum Standard.
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 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 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, 37 and 38 The manager has good experience, relevant professional qualifications and demonstrates good management practice. Based on residents’ views, the home still needs to develop its quality monitoring systems further to show how they intend to make positive changes and monitor quality of care. The home’s financial procedures are thorough and protect the interests of the residents. Record keeping is generally well managed to ensure that residents’ rights and best interests are safeguarded although reportable events must be notified to the Commission more promptly. EVIDENCE: Mr Abhee continues to own and run the home and advised that he is still trying to recruit a manager. Discussions and observation revealed that Mr Abhee is clearly familiar with the needs of the residents and continues to demonstrate good management practice. Certificates showed that he has attended training with the staff to keep his knowledge and skills up to date.
Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 20 Improvements are still needed with the home’s quality assurance process. The manager has obtained some resources to achieve this and now needs to develop the quality monitoring systems. The manager explained that surveys were due to be offered and an annual quality assurance development plan was still to be drawn up and implemented for the home. This requirement has therefore been repeated. The servicing and maintenance records for the home were checked at the last inspection and up to date. Fire drills are appropriately organised and fire alarms and equipment checked at regular intervals. The fire policy has been amended and some of the key health and safety training for staff has been achieved as previously required. A planned training programme is in place for others to attend relevant courses throughout the forthcoming year. Accidents and incidents are recorded appropriately although the home must ensure that the Commission is notified more promptly of any events that affect the service users well being e.g. concerning falls and/ or admissions to hospital. This includes the reporting of any deaths. The manager must ensure that all staff are familiar with the reporting of incidents under Regulation 37 of the Care Standards Act. Some residents are provided with keys to their bedrooms but for safety reasons and to minimise the risk of residents entering other people’s rooms, some bedroom doors are kept locked and staff hold the keys. The kitchen is also kept locked for similar reasons. The manager must therefore complete individual risk assessments and a locked door policy as such restrictions could be construed that residents are not fully able to exercise their rights within the home. Information within the needs assessments and care plans must detail why they are unable to have keys. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 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. 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes- 2 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 OP33 Regulation 24 Requirement Quality Assurance systems must be in place to assess whether the aims and objectives of the home have been met. (Outstanding from inspection April 2004 although it is acknowledged that the manager has started to obtain resources for implementing a QA system) A programme of maintenance and refurbishment should be put in place to demonstrate that repairs and upkeep of the building are undertaken. (Timescale of 31/10/05 not met) Timescale for action 31/03/06 2. OP19 23(2 b, d) 28/02/06 3. OP18 13(6) 4. OP26 16(2 k) Due to the two recent adult 31/05/06 protection meetings, staff need to receive further training on abuse awareness and adult protection. I.e. as organised by the local Croydon authority. Due to an unpleasant odour, the 31/03/06 manager must arrange for the hall carpet area by the downstairs toilet to be cleaned or replaced.
DS0000025783.V282008.R01.S.doc Version 5.1 Page 23 Foxley Lodge 5. OP28 19(5 b) 6. OP37 17(2) 7. OP38 13(4) More care staff need to obtain 30/06/06 the NVQ2 qualification to meet the required standard of 50 of care staff trained in the home. The Commission must be notified 28/02/06 more promptly of all significant events that affect residents well being. The manager must ensure that all staff are familiar with the reporting of incidents and accidents under Regulation 37 of the Care Standards Act. The manager must write a risk 28/02/06 assessment and develop a policy for locking the kitchen door and bedroom doors. Each resident must have a risk assessment concerning the provision of keys to their bedroom doors. Information within the needs assessments and care plans must detail why they are unable to have keys. 28/02/06 8. OP38 12(3) 13(4) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP13 OP7 OP12 Good Practice Recommendations The manager should explore ways that the home could facilitate more community-based activities. (Repeated from August 2005 inspection) The manager should ensure that the resident, wherever capable, and/or relative/ representative signs their care plan. The home should consider arranging for newspapers to be delivered at a regular time to suit individual residents. Foxley Lodge DS0000025783.V282008.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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