Inspection on 28/09/07 for Friars Lodge

This inspection was carried out on 28th September 2007.

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

Friars Lodge 04/08/09

Friars Lodge 22/09/08

Friars Lodge 15/11/06

Friars Lodge 01/12/05

Friars Lodge 09/08/05

Friars Lodge 09/03/05

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

CARE HOMES FOR OLDER PEOPLE Friars Lodge 18 Priory Road Dunstable Bedfordshire LU5 4HR Lead Inspector Ansuya Chudasama Unannounced Inspection 28th September 2007 11:30 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 Friars Lodge DS0000062259.V350368.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. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friars Lodge Address 18 Priory Road Dunstable Bedfordshire LU5 4HR 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) 01582 668494 F/P 01582 668494 no email as at 28.6.7 Friars Lodge Ltd vacant post Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide accommodation for twenty people over the age of 65, four of whom may be accommodated in two rooms for double occupancy where it can be shown that the decision to share was a positive choice. 15th November 2006 Date of last inspection Brief Description of the Service: Friars Lodge is a private residential care home and is registered to provide care for twenty older people. The home is located in a pleasant residential area of Dunstable and is within close proximity to the Priory and the towns amenities. The bedrooms are on three floors that are accessible by a staircase and a newly installed shaft lift. Toilets and adapted bathing facilities are located for convenient access throughout the home. A large lounge with dinning area and a small visitors/quiet lounge are situated on the ground floor. The lounge area overlooks an established and well-maintained garden to the rear of the home. Parking is available for a few vehicles at the front of the building. However there is also some road parking close to the home. Fees for the home are between £425 and £530 a week depending on the room provided. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection, took place at 11.30am on the 28th of September 2007. The manager was off on the day of the inspection and therefore was assisted by the operations manager of the company. During the inspection, the inspector spoke to the people living in the home, and the staff on duty. She also looked at some of the records kept about the home and the people living in the home. A tour of the premises was undertaken. Some of the people living in the home could not communicate verbally, so the inspector spent time observing the support the people received from the staff. The information from the ‘service users’ and the completed Annual Quality Assurance Assessment (AQAA) form sent to the CSCI by the home have been used in this report. Some visitors were spoken to and positive feedback about the home was received from them. The inspector would like to thank the staff, the visitors and the people living in the home for the support and time they gave to this inspection. This inspection report should be read alongside the National Minimum Standards for Older People What the service does well: The home has a happy atmosphere and people using the service and their families say ‘the staff are very caring, nothing is too much trouble’. It was also said that ‘staff always seem genuinely interested in the residents, always friendly, helpful and happy’. It was also said “this home is warm and friendly not only to residents but also to visitors’. The inspector was informed on the day of the inspection that the meals were very nice. The people living in the home or their representative knew how to make a complaint. One comment stated that their family member ‘will talk to some one in uniform if he is not happy’. It was also stated that the ‘staff listened to them’. This was observed on the day of the inspection. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 6 The staff spoken to say that they enjoy working at the home. They attend training to help them meet the needs of the people they look after. They get support from management and discuss how they are getting on at work. They like working with each other and with the people living in the home. What has improved since the last inspection? What they could do better: Although offering a caring service to the people using the service, a number of areas requiring improvement were noted. This included, developing the care plans further to ensure that all the information is recorded. The risk assessments need to be developed further and fully completed. The home needs to develop their activities to ensure that all the people living in the home have their needs met. The home needs to have a robust monitoring system in place to ensure people using the service have their money safeguarded from any abuse. These are highlighted at the end of this report as requirements, and must be addressed within the timescales quoted. Friars Lodge DS0000062259.V350368.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. Friars Lodge DS0000062259.V350368.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 Friars Lodge DS0000062259.V350368.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): 1,2,3,4,5,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Perspective service users have the information they need to make an informed choice to move into the home and know that their needs will be met. EVIDENCE: A copy of the statement of purpose was not available in the home. The inspector was informed that this was being updated and a copy would be sent to the CSCI. A copy of this was not received at the time of writing this report. Visitors spoken to stated that they were given a copy of a statement of purpose about the home. They had also visited the home with their family before accepting the placement. Assessments of new people were being undertaken but the information needed expanding further to explain how their needs were being met prior to being admitted to the home. One of the Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 10 overview assessments seen did not state who had completed the form and this consisted of a tick box. Visitors spoken to stated that they had contracts with the home. This was also confirmed by the questionnaires received from the people using the service. The home does not provide intermediate care. Friars Lodge DS0000062259.V350368.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The care planning documents needed developing further but the people living in the home had access to health care services, which meet their assessed needs. EVIDENCE: The files of the people living in the home that were case tracked had care plans. One relative spoken to stated that they had seen a care plan and they had signed this. However there were others, which had not been signed by the person living in the home or their family. The care plans seen for a few people living in the home stated that the person is at risk of being abused due to the person’s age and health. However there was no information to explain the reasons why they were at a risk. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 12 One of the relatives spoken to stated that their family member had poor skin and staff put cream on them to help them. This information was not recorded in the care plan. Information recorded in other sections of the file was not always in the care plan. For example it was stated that dietary intake was being monitored and the person was on a low fat diet but this was not recorded in the care plan. A monitoring form for continence was seen but there was no information recorded in the care plan to state why this was being monitored. Also there was information recorded stating that the person living in the home had regular checks but there was no information to explain what the checks were about. Information read in one file stated that the person was allergic to one of the fruits. But this was not recorded in their care plan. One care plan had no date of when it was started. Information read in the review notes said that the person can become very aggressive but the care plan did not have any information recorded to state how this behaviour was being managed by the home. A risk assessment seen for July 07 said to be assisted with feeding when required but this was not recorded in the care plan. The risk assessment also stated that the person was falling out of bed and equipment was put in place. This information was not recorded in the plan. The water low skin condition assessment stated that the person had poor appetite but this was not recorded in the care plan. Information recorded on weight, stated that the person takes enlive drinks but this was not recorded in the plan. One care plan did not have any information about their family, or what activities the person enjoyed doing. There was also no information on falls, and getting out of chair but it stated that the person needed the support of one carer for walking. The care plans were being reviewed on a regular basis. The funding authority was also carrying out annual reviews. The operations manager stated that they were going to replace the care planning format. It was stated that this format had been approved by the CSCI at one of their sister homes. The medication information for the people living in the home that were case tracked was looked at. The information was well organised and the medication sheets were being completed properly by staff. The temperature of medication was also being monitored. The staff that gave out the medication had received in house training from the organisation. The staff were also observed giving out medication to the people living in the home in a satisfactory manner. They were also observed listening and being kind to them. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 13 Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home are provided with healthy meals that meets their needs. EVIDENCE: The inspector spoke to some visitors who visited the home on a regular basis. One visitor stated that this home was better than the other home that their family member had been living at. It was stated that some of the staff were superb and they had ‘seen such good care’ from the staff. On the day of the inspection the deputy manager on duty was cooking the meal. This was because the cook was on holiday. One of the visitors had lunch on Fridays with their family member at the home. It was also stated that the food was ‘very good’. The inspector was informed that the staff spoke to each individual person living in the home regarding what choice they wanted for lunch. It would be good to have a menu displayed in a format that all the Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 15 people living in the home could see. This also helps the relatives know what meals have been offered to the people living in the home. The people living in the home were observed having their lunch and two choices were offered at meal times. The meal was eaten in a relaxed manner. The staff were observed being helpful and kind to the people living in the home. The home should ask the people living in the home if they want soft music playing in the back ground whilst eating their lunch. This helps break the silence. The deputy manager spoken to was going to look into displaying pictures of meals that were offered to the people living in the home. She was also going to replace the smaller clock in the lounge area with a larger one. This was to help the people living in the home who did not have very good eyesight to see the clock better. Relatives spoken to and feedback received from service users survey stated that more stimulation was required. It was stated that not much activities were being undertaken and that the people living in the home get bored and some times irritable. It was also stated that some visitors/relatives were willing to help out with doing activities. The inspector was informed that the home did not have an activity list displayed. It was stated that the activities that the people using the service did was recorded in their daily notes. The staff were observed watching staff do activities such as dominoes with people using the service but they were watched leaving the game when called to help out with another chore. This did not provide continuity to the people using the service. It was stated to the inspector that the activities were limited and staff worked hard to do activities with the people using the service when they had the time. The staff welcomed the idea of having an activity organiser. This was discussed with the operations manager and they going to look into this. The home has meetings with the people who use the service and it was requested that they go out in the community more often. The deputy manager stated that she had organised a day trip out and the people using the service enjoyed this. The relatives spoken to on the day of the inspection knew how to get into the home by using the code. This information was recorded in the homes newsletter that was sent to the families of the people using the service. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 16 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): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did not have robust policies and procedures in place to ensure that the finances of people using the service are satisfactorily audited; as a result the people using the service were placed at risk. EVIDENCE: The home had a complaints policy. The homes relative’s satisfaction survey stated that all the people who responded knew how to make a complaint to the home. The relatives spoken to stated that if they had a problem they would speak to the staff. This was also confirmed by the CSCI questionnaires that were completed by the people using the service. One of the comments received from one of the people using the service stated that they had asked their representative to pass on a complaint to a senior member of staff. It was stated that the person was unaware that the complaint should have been made in writing. The representative was not informed of the complaints procedures for two to three weeks. It was stated by this time it was felt too late to pursue the matter further. This was discussed with the operations manager who stated that any concerns or Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 17 complaints could be communicated to the home either verbally or in written form. It was stated that the information on how to complain was also recorded in the statement of purpose The staff spoken to had received training on protecting vulnerable adults. They understood the procedures to follow if they suspected any kind of abuse practices being carried out. The staff were able to give examples of how they would be able to tell if any of the people using the service was unhappy. The home had made two safeguarding adults referrals to social services. One of these referrals was investigated. The operations manager stated that each person living in the home had a safe in their bedrooms to secure their valuables. It was stated that the people using the service were risk assessed for looking after their key to the safe. The home needs to record in each persons care plan to state how their money is being managed by the home. This information is not recorded at present in their plans. It was stated that the home was trying to get the people living in the home to have a say in how their money was being spent. On the day of the inspection, one of the people living in the home’s money was looked at in their bedroom safe. The last entry made was on the 4/9/07. This was signed by staff to state the amount of money that was kept in the safe. The money checked by the inspector showed that that the money was incorrect and there was some missing. The operations manager stated that she would check with the person to find out if they had this money in their bag. However the operations manager was unable to do this because the person concerned was not happy for any one to look into their bag. The operations manager was going to let the inspector know after the inspection. This was so the staff could check and discuss the money with the person that the money belonged to. Information was received from the home on the 8th of October 07 to state that seventy pounds was missing from a ‘service users’ safe on the day of the inspection. It was also stated that the service user was able to access the safe independently as they hold the key. The information also stated that the person concerned has a history of confusion, depression, and short term memory loss. And the next of kin did not inform the home when they gave money to the person using the service. The home had not undertaken a risk assessment to find out if the person using the service was able to look after their money safely. There were also no auditing procedures put in place to ensure that the person using the service were protected from risk. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 18 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people in the home live in a homely environment that is clean and tidy. EVIDENCE: The home was clean and tidy on the day of the inspection. This was also confirmed by the questionnaires completed by the people living in the home. The rooms of some of the people seen were clean and individualised to meet their needs. The observation of the lounge showed that most of the people living in the home were happy sitting in the positions that they sat in. However one person Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 19 sitting in the armchair was observed to be blocking the view of another person sitting behind the person. Another person’s chair was position near the fish tank and there fore would not have been able to see the television. The home needs to find out if the sitting position of all the people using the service meet their needs. The home had new patio doors replaced on the day of the inspection. It was stated that these doors had been difficult to open for over 20 years. A new ramp had also been put in at the front of the home. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people using the service are supported and protected by the home’s recruitment procedures. EVIDENCE: Discussion with the staff showed that they had experience and knowledge working with the people living in the home. One of the staff spoken to had induction for a week and had shadowed an experienced member of staff. All the staff that were spoken to enjoyed working at the home. It was also stated that the staffing levels were adequate. The home had four staff on per shift and two night staff at night shift. The home had 18 permanent staff and 4 agency bank staff. 5 staff had completed their NVQ level 2 or above training, and 6 staff were working towards this training. A training list for Friars Lodge staff and a training list for January to June 2007 was also seen. Evidence recorded in the form showed that nearly all staff had completed the dementia training. Some staff still Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 21 needed to complete the care planning training, nutrition and diet, challenging behaviour, death and bereavement and incontinence training. The operations manager stated that training was on going and this was being offered by the organisation. The staff files looked at showed that the company were following the recruitment procedures to safe guard the people living in the home. However one staff who had transferred from another sister home only had one reference. The operations manager was going to ring the sister home to send this information. All the staff now wear new identifying badges so people in the home and the visitors know who the staff are in the home. It was also stated that a board with staff photos was going to be displayed in the front entrance of the home. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although procedures are in place, but inadequate monitoring systems for managing the money of people using the service, and risk assessments place users at risk. EVIDENCE: The home had a new manager. The last manager resigned in July 2007. It was stated that the new manager was a qualified nurse and had lots of experience and knowledge of working with older people. It was also stated Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 23 that the new manager was registered to take her RMA award when they were settled in their job. The operations manager visits the home regularly and provides support to the manager and staff of the home. One staff spoken to had not received supervision since May 07. One staff had supervision recently. It was stated that supervision had lapsed due to the previous manager leaving and the home being short of staff. But it was stated that the manager was sorting this. (See complaints and protection standard regarding managing the money of people using the service). The home had sent out questionnaires to families of people who used the service. It was stated that a questionnaire for staff to complete was also being developed to get their views. The information read from the outcome of the questionnaires was very positive, with some areas that needed improving. It was stated that the organisation was going to undertake an annual audit of the home soon. The home carried out regulation 26 visits on a monthly basis. The home had also started a monthly newsletter to keep families informed of what was happening in the home. It was stated by the operations manager that they would hold a meeting with families and representatives of the people living in the home in the near future to listen to their views. Two different risk assessment formats were inspected. One risk assessment form was not completed fully. Another risk assessment form seen did not contain sufficient information for the risks identified on the form. The inspector observed near the lounge entrance that there were wheelchairs and zimmer frames stored near this area. This area also has a desk near the door. This was observed to be a health hazard. A risk assessment needs to be undertaken around this area. However the staff did remove the wheelchairs and zimmer frames during the inspection. A risk assessment also needs to be undertaken when the people living in the home are having their meal. It was observed that nine people were eating at the table and six people were eating in their chair. The space for people to get through at this time was greatly reduced. The relative’s satisfaction survey completed by the home also stated that the space was tight when visitors are in the lounge. This needs to be risk assessed by the home. Fire alarm and emergency lighting testing was being carried out regularly. The last Fire drill was carried out on the 12/1/07. Another drill was said to be taking place soon. Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 X X X X X X 3 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 3 X 2 2 X 2 Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 (2) (b) Requirement The service user’s care plans must contain all the information to state how their care needs are being met. The home must ensure that service users are provided with opportunities for stimulation through activities to suit their needs. The home must ensure that robust systems are in place to monitor the service users finances. All staff must receive a minimum of six supervision sessions a year. This requirement of 01/01/07 was not met from the inspection. The home must ensure that risk assessments are completed properly and covers the five steps to assessing risk in detail. The home must undertake risk assessments for the areas mentioned in the lounge areas. Timescale for action 30/12/07 2 OP12 16 20/01/08 3 OP18 16 30/11/07 4. OP36 18(2) 01/12/07 5 OP38 13,23 29/12/07 6 OP38 13,23 20/12/07 Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Friars Lodge DS0000062259.V350368.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!