Inspection on 19/01/06 for Gate Lodge

This inspection was carried out on 19th January 2006.

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

Gate Lodge 27/04/07

Gate Lodge 21/04/06

Gate Lodge 16/06/05

Gate Lodge 12/04/05

Gate Lodge 04/01/05

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

CARE HOMES FOR OLDER PEOPLE Gate Lodge 1 Upper Woodcote Village Purley Surrey CR8 3HE Lead Inspector Peter Stanley Unannounced Inspection 19th January 2006 9:30am 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 Gate Lodge DS0000025784.V276151.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. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gate Lodge Address 1 Upper Woodcote Village Purley Surrey CR8 3HE 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 7286 020 8668 7286 Mr Paramaseeven Chellun Mrs Georgia Chellun Ms Christina Thambirajah Care Home 16 Category(ies) of Dementia - over 65 years of age (16) registration, with number of places Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. For people with dementia who are over 65 Date of last inspection 16th June 2005 Brief Description of the Service: Gate Lodge provides residential care for up to 16 service users (65 and over) who have dementia. The home is an attractive detached property located on the green of Upper Woodcote Village within a pleasant residential area; it is within walking distance of a small village shop and is surrounded by several larger houses. The home has 12 single rooms and two double rooms located on two floors, ground and first floor. Gate Lodge has two adjoining lounge areas and a separate dining room. The home does not have a lift and thus access between the ground and first floor is by stairs.There is parking for three cars to the front, and parking is also available on the road outside the home. There is a well-kept garden available for the use of service users. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over half a day and involved discussion with the registered manager, Mrs Christina Thambirajah, and the registered provider’s son, Mr Jason Chellun, who is assisting with the management of the home. The inspector spoke with a number of service users, and with staff on duty. The inspector case-tracked two recent admissions to the home, and looked at a sample of service users’ files. Relevant documentation including staff files, policies and procedures, staff rotas and logs relating to incidents, accidents and complaints, were also examined. The inspector carried out a brief inspection of the premises and observed staff’s interactions with service users. The inspector noted that of the 12 requirements identified in the previous inspection report, 8 have now been fully met. There are 4 requirements which remain to be met, together with 13 new requirements from this inspection, making 17 in total. There are also 3 recommendations from this inspection. What the service does well: Each service user is being provided with a copy of their contract or terms and conditions at the point of moving into the home. Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. However, given the complexity of needs presented by service users, personcentred care plans should be developed which provide a more comprehensive breakdown of abilities and needs. Service users are being treated with respect and their privacy is being maintained. Service users are being provided with opportunities for recreational and social activities sufficient to meet their existing needs. Service users expressed their satisfaction with the range of activities provided. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 6 Service users are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The meals provided are wholesome and appealing and are served at times, and in places, which are convenient to them. Generally, service users have access to safe and comfortable facilities. However, carpeting in the lounge and dining areas is becoming worn and ingrained with dirt, and needs to be replaced. Generally, service users are living in a clean and hygienic environment. However, carpeting in the main lounge is not being maintained to a sufficiently hygienic standard, and needs to be replaced. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. The home is now on track for meeting the target of 50 of staff trained to NVQ Level 2. What has improved since the last inspection? A copy of the home’s terms and conditions is now being included alongside the local authority three way contract on the service users’ files. All but 2 care staff have now completed accredited medication training. Most care staff have now completed statutory adult protection training; this needs, however to be extended to all remaining staff who work in the home. Liquid soap and paper towel dispensers have been installed in the homes toilets and bathrooms. A workforce development training plan has been put in place. The home is beginning to develop the necessary tools for quality assurance purposes. The home is on track for meeting the 50 target of staff trained to NVQ Level 2. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 7 What they could do better: 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 Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 8 contacting your local CSCI office. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 9 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 Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 10 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): Each service user is being provided with a copy of their contract or terms and conditions at the point of moving into the home. While the home has been able to demonstrate that a service user’s needs have been properly assessed for a recent admission, some previous admissions have not evidenced the receipt of care management assessments. Whilst the home has undertaken its own assessments, it has failed to ensure that care management assessments and care plans, relating to the care needs of two recently admitted service users, have been obtained prior to admission. In the absence of full information concerning health and care needs, both service users and care staff are being placed at potential risk. While service users are periodically having their care needs reviewed, recently admitted service users have not, as yet, had an initial care review to assess the suitability of the placement in meeting their needs. EVIDENCE: Standards 2, 3 and 4 assessed. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 11 The home has revised its service user agreement so that it is appears in a user-friendlier format, in large print. All service users are being provided with a statement of their contract, or terms and conditions, a copy of which is now being included on the service user’s file. The home has admitted four service users since the last inspection. The files were examined, and it was found that pre-admission assessments and dependency profiles had been completed by the home. Care management assessments and care plans had not, however, been obtained for two admissions following their referral from hospital care managers. The Registered Provider and Registered Manager are reminded that any care management referral from health or social services must include full information concerning the care management assessment of the individual’s care needs and care plan, and that no admission should take place until this information has been provided. This is an issue that has been identified on previous inspections, and must be complied with for all future care managed referrals. All care managers’ assessments, or those of the home in respect of self-funding service users, must contain all elements of standard 3.3. Generally, the home is demonstrating the capacity to meet the assessed needs of individuals admitted to the home. Individual needs, and specific social and cultural needs, are identified in care plans, and these are being addressed. Care plans are being reviewed on a monthly basis. However, while the home is completing periodic review meetings with residents, recently admitted service users (including two referred through hospital care management arrangements) have not, as yet, had an initial care review (after 6 to 8 weeks) following their admission. This is essential in enabling discussion with the service user, and his/her relatives/representatives, as to whether the placement is suitable in meeting his/her needs. Reviews, involving the respective relatives/representatives (and care managers, if applicable) must be arranged without any further delay. All future admissions must evidence an initial review meeting. A requirement applies. Service users spoken to by the inspector indicated that the home is meeting their needs and that staff are both supportive and caring. A key worker system is in place. An ongoing programme of induction and training is enabling staff to develop the skills with which to deliver the service to a satisfactory standard. 9 of the 14 care staff have recently completed dementia awareness training, and this is being extended to the other staff. The GP visits the home and other medical professionals attend as and when needed. From service users’ care notes, there is evidence of good communication with the home’s pharmacist and other care professionals. The Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 12 home responds to the changing care needs of the service users with care plans being monitored on a monthly basis. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 13 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): Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. However, given the complexity of needs presented by service users, personcentred care plans should be developed which provide a more comprehensive breakdown of abilities and needs. While service users are being safeguarded by the home’s medication policy and procedures, and the recent provision of accredited medication training, their protection requires that this training is extended to all remaining care staff. Service users are being treated with respect and their privacy is being maintained. EVIDENCE: Standards 7, 9 and 10 assessed. The inspector examined a number of service users’ care plans. These are compiled on the basis of the initial assessment, and review following admission. Care plans all have a photograph of the service user on the front of Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 14 the file. These are reviewed on a monthly basis and are drawn up by the home, service user and/or relatives. Risk assessments are carried out by senior staff and are reviewed on a regular basis. These cover manual handling and other areas of risk. The inspector identified a need for the service user’s care plan to be developed so as to evidence a more person-centred approach and provide a more detailed breakdown of the service user’s needs. This should include physical/mental health, personal care, self-care/independent abilities, and emotional/social needs. The service user plan should evidence the full involvement of the service user and his/her representative. A requirement applies. There is a requirement from the last inspection for all staff to receive accredited medication training. This has been partly, but not fully met. The inspector was advised that 9 (out of 14) care staff have now completed this training with Bromley College. This needs to be evidenced with certificates, and all remaining staff provided with the relevant training. The inspector discussed a medication issue relating to a recently admitted service user. The manager advised that following her admission the service user had initially presented as anxious, and exhibited a pattern of getting up several times throughout the night. Following consultation with the GP a tranquiliser had been prescribed, but following signs of drowsiness and representations from a friend, this had, with the GP’s agreement, been discontinued. The manager was advised to monitor the situation and to assist staff to work with the service user in a responsive and reassuring way. The inspector spoke to the service user who presented as alert and well cared for. She indicated that she was feeling reassured by the support provided by staff, and had begun to settle in since her move from another care home. Staff were observed to be interacting with service users in a respectful and professional manner. The inspector spoke to a number of service users and received feedback indicating that there is respect for residents’ privacy and dignity in the home. The home does not have a separate room for visitors, but service users are able to see visitors in their own rooms if they wish. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 15 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): Service users are being provided with opportunities for recreational and social activities sufficient to meet their existing needs. Service users expressed their satisfaction with the range of activities provided. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The meals provided are wholesome and appealing and are served at times, and in places, which are convenient to them. EVIDENCE: Standards 12 to 15. Service users expressed their satisfaction with the range of activities provided. The home was evidenced to provide a wide range of activities, with a group activity such as aerobics, bingo, a quiz or film being scheduled each afternoon. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 16 Other activities such as drawing, skittles, puzzles, ball games, listening to music and sing a longs are available together with participation in gardening, flower arranging or with baking cakes if there is a wish or interest. The inspector was informed that there are monthly visits from entertainers and there was a nativity play performed at the home, at Christmas, by a local children’s drama group, which had proved particularly popular. Occasional trips out have included a day trip to Brighton in the summer and trips to the local park or shops. Friends and relatives are encouraged to visit and to take residents out for lunch or tea if they wish. Cultural and religious needs are evidenced as being met. There is a monthly Church of England service at the home that is apparently well attended, and a Roman Catholic priest visits fortnightly. There are not currently any service users from other religious faiths or backgrounds. Service users are evidenced to be able to exercise choice and control in their daily activities, with flexibility in daily routines, and respect for individual choice from staff being evidenced. Service users are able to raise any issues they wish with the manager and provider, and there is regular contact between each service users and their key worker. Service user meetings provide the opportunity for issues to be raised and addressed. The inspector examined the minutes of service users’ meetings and noted that these are only currently happening every 3 to 4 months; these are too irregular and should be held on at least a two-monthly basis. The inspector examined four-weekly menus and evidenced a varied range of food choices. The kitchen area presented as well stocked with fresh and frozen food, with appropriate hygiene standards being maintained. Service users were observed taking lunch and the food was noted to include fresh vegetables and a choice of main course. Service users indicated their satisfaction with the food provided, and individual tastes seem to be well catered for. The dining room presents as a pleasant area in which to take meals. Two service users were observed to be taking their meals in the lounge, in accordance with their wishes. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 17 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): For service users to be appropriately protected, the awareness of all staff must be raised through attending local multi-agency adult protection training. EVIDENCE: Standard 18 assessed. There has been one complaint since the last inspection. The inspector was satisfied that this has been appropriately addressed. A requirement from the previous inspection, for all staff to attend Croydon’s multi-agency vulnerable adult protection training, remains to be fully met. A number of staff have still to complete this training. This must be a high priority. No adult protection concerns have been identified. Service users spoken to by the inspector indicated that they feel safe in the home. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Generally, service users have access to safe and comfortable facilities. However, carpeting in the lounge and dining areas is becoming worn and ingrained with dirt, and needs to be replaced. Generally, service users are living in a clean and hygienic environment. However, carpeting in the main lounge is not being maintained to a sufficiently hygienic standard, and needs to be replaced. EVIDENCE: Standards 20 and 26 assessed. Standards 19, and 21 to 25 were met at the last inspection. Two requirements (standards 24 and 26) from the last inspection have been met. Liquid soap and paper towel dispensers have been installed in all of the home’s toilets and bathrooms, and a fire safety assessment of soft furnishings has been completed and evidenced. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 19 The inspector noticed unpleasant odours (associated with urine impregnation of the carpet) when entering the service users’ lounge. A requirement for regular shampooing of the carpet (on at least a 4-weekly basis) applies. The inspector also observed that the carpeting in the lounge and dining areas is becoming worn, and is in need of replacement; a requirement applies. The inspector was informed that all but 2 staff have completed infection control training (on 4/3/05). Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): For service users to be sufficiently safeguarded, and their needs adequately met, the home must ensure that there are three members of staff on duty at all times throughout the day. Through not fully completing all necessary criminal records and recruitment checks, the home is placing service users at potential risk. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. The home is now on track for meeting the target of 50 of staff trained to NVQ Level 2. EVIDENCE: Standards 27 to 30 assessed. The inspector examined the staff rota. This evidenced that there were two staff on duty during the day (reduced from 3 at the last inspection), with two waking staff on at night. Given the complex needs presented by service users at the home, the inspector was concerned that insufficient staff are on duty during the day. He is, therefore, making it a requirement that 3 staff must be on duty at all times, apart from overnight. The home currently has 11 care staff and four ancillary staff, which is sufficient for the number of service users. Two new staff members have started since the last inspection. The inspector examined the staff files. One file did not contain a copy of the person’s birth Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 21 certificate, whilst another did not contain a copy of the person’s passport; as required in Schedule 2 of the Care Homes Regulations. A requirement applies. The inspector discussed with Mr Chellun, the need for the home to be more vigilant in ensuring that all recruitment and employment checks are completed. To this end, the inspector recommends that the home’s providers ensure that a checklist of all the documentation and checks required (as required by Schedule 2) be maintained on the front of each staff file. The inspector was concerned to find that the home had not obtained a CRB (Criminal Records Bureau) certificate for one staff member and informed Mr Jason Chellun that this is in contravention of the regulations. It was evidenced that a POVA First check had been completed (Protection of Vulnerable Adults). The inspector advised that there must, in future, be prior (written) notification to the CSCI of any person for whom a CRB has not been obtained, and for whom there is a request for discretion to be exercised in commencing the employment of the individual. The following criteria must be met: a POVA First check must be completed; an assurance must be provided that there will be no one to one contact with any service user, (including taking out any service user from the home), that the person will not assist with any personal care; and that the person will be supervised at all times by an experienced (named) staff member(s). Discretion (by the inspector) will be exercised on a case-by-case basis, and where agreement to start is provided, the staff appointment can only be confirmed once the CRB certificate has been received. The inspector is making it a requirement for no further employment of any person at the home without a CRB, unless there has been a written request to the CSCI and agreement given (in writing) by the inspector. The home has now met a requirement for putting in place a staff training plan. There has been a programme of ongoing training which has recently involved staff in studying for their NVQs (National Vocational Qualifications), and attending dementia awareness and challenging behaviour, first aid, food hygiene, infection control, manual handling, accredited medication and adult abuse training. Mr Chellun advised that, since 5/12/05 all staff have been undertaking their NVQ 2 training; two of whom have completed this. And that both deputy managers are presently studying for their NVQ 3. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is developing its quality assurance processes, with view to evidencing that it is meeting its aims and objectives, and is being run in the best interests of service users. This needs to be consolidated, and a Development Plan put in place. While the home is now providing regular supervision for staff, this is not sufficiently regular, and must be provided at least two-monthly. The supervision format should be developed so as to reflect more fully the discussion and decisions taken in supervision. EVIDENCE: Standards 33 and 36 assessed. Standards 31, 32, 34, 37 and 38 met at the last inspection. Since the last inspection the home has been developing its quality assurance processes. An annual audit has been completed, the results of which are presented in a report. There is an unmet requirement for a development plan Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 23 to be put into place. A questionnaire has been devised and completed with the home’s service users, and a questionnaire has now been developed for the relatives and friends of service users. However, for the home to evidence consultation with all parties, a questionnaire still needs to be developed for visiting professionals and care managers. A requirement applies. The inspector examined staff supervision notes and found that staff have been receiving supervision on a 3-monthly basis. Whilst this represents an improvement, supervision is still not sufficiently regular and must be held at least once every 2 months with all staff. Hence the requirement from the last inspection remains to be fully met. The inspector feels that the level of supervision required for a home with 11 care staff and 4 ancillary staff is too great a burden for one person and should be divided between the manager, and the two deputy managers. The inspector was informed that one of the deputy managers has undertaken supervision training and is in a position to take on some supervision. The inspector recommends that the other deputy manager also receives supervision training and that there is thought given to delegation of the supervisory workload to both deputy managers. The inspector also identified a need for a more detailed supervision format to be developed so as to provide a more structured and detailed record of supervision. This should include an agenda of issues identified for discussion (including issues b/f from the previous supervision), and then (in separate columns) detail each issue discussed, the discussion points covered, and the actions/decisions agreed. Supervision notes should be signed and dated by both the supervisor and supervisee. Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 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 X 2 1 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X 2 X X X 3 x 2 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X x Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 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 OP2 Regulation 5(1)(b) & (c) Requirement The registered provider must ensure that the home’s service user agreement is signed and dated by the service user and by his/her next of kin or representative, and a signed copy kept on the service user’s file. The registered provider must ensure that, for any person referred (and funded) by health or social services, a full care management assessment and care plan is obtained prior to any admission taking place. For any individual transferring from another home, full information regarding the person’s assessed care needs and care plan must be obtained from that home prior to admission. The registered manager must ensure that care reviews are held for all service users, following their admission to the home. Where the admission has followed a care management DS0000025784.V276151.R01.S.doc Timescale for action 31/01/06 2. OP3 14(1)(a), (b) & (c) 31/01/06 3. OP3 14(1)(a), (b) & (c) 31/01/06 4 OP3 14(2)(a) & (b) 31/03/06 Gate Lodge Version 5.1 Page 26 5 OP7 15(1) & (2) referral, the the review must involve the respective health or social services representative. Reviews for four recent admissions must be arranged without any further delay. These must be evidenced at the next inspection. The home must develop a more detailed, person-centred, service user plan. This must evidence the full involvement of the service user and his/her representative, and provide a detailed breakdown of the person’s physical and mental health care needs, personal care needs, self-caring and independent abilities, and their social and emotional needs. This must evidence the agreement of the service user and his/her representative, and be signed and dated. The registered person must ensure that the accredited medication training, which has been accessed, is completed by all care staff who administer medication. This training must be evidenced with the relevant certification. Previous time-scale not met. The registered provider must ensure that service user meetings are held on a regular basis, at least once every 2 months. The registered provider must ensure that there is regular shampooing of the carpet (on at least a 4-weekly basis) in the lounge areas. The registered provider must ensure that the carpeting in the lounge and dining areas (which DS0000025784.V276151.R01.S.doc 30/04/06 6 OP9 13(2), 18(1)(a) 31/03/06 7 OP14 12(5)(a) & (b) 31/01/06 8 OP20 13(4)(c), 23(2)(d) 31/01/06 9 OP26 13(4)(a) & (c) 31/12/06 Gate Lodge Version 5.1 Page 27 10 OP27 11 OP28 12 OP29 13 OP29 14 OP29 is becoming worn and unhygienic) is replaced with new carpeting. This must then be maintained to a satisfactory standard. 18(1)(a) The registered provider must ensure that there are 3 staff on duty at all times throughout the day. 18(1)c The registered person must ensure that he implements the homes action plan for meeting the minimum ratio of 50 members of staff trained to NVQ level 2. (The home is on track for meeting this requirement). Previous time-scale not met. 19(1)(b) The registered person must (ii),Sch2 ensure that all recruitment and identity checks (including a copy of the birth certificate and passport) are completed. 19(1)(bii), The registered person must Sch2,No7 obtain a CRB check for a recently recruited staff member, and forward a copy of this to the CSCI, Croydon office. 19(1)(bii), The responsible person must Sch2,No7 ensure that a new CRB (Criminal Records Bureau) check is obtained prior to the recruitment of any new care staff. Where there is delay in receiving the CRB, and there is an urgent need for the home to commence the person’s employment, permission must be sought from the inspector, and a request placed in writing. The following criteria must be addressed: a POVA First check must be completed and evidenced. An assurance must be given that, until the CRB certificate has been received: 1. The employee will have no 31/01/06 30/04/06 31/01/06 28/02/06 31/01/06 Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 28 one to one contact with any service user (including taking out any service user from the home. 2. The employee will not assist any service user with their personal care. 3. The employee will be supervised at all times by an experienced staff member. At least two staff member(s) who will be supervising, must be identified. Agreement to start an employee prior to the receipt of the CRB must be received in writing from the inspector. Once the CRB certificate has been received, a copy must be forwarded to the inspector. 15 OP33 24(1)(2)( 3) An annual development plan 30/04/06 must be put in place to assess whether the aims and objectives of the home have been met. Previous time-scale not met. The home must develop surveys 31/03/06 with the relatives/friends of service users, and with visiting care managers and professionals, as part of the quality assurance process. (The home is on track for meeting this requirement). The registered person must 31/01/06 ensure that all staff receive regular supervision, at least once every two-months (36.2). Supervision must cover all aspects of practice, philosophy of care in the home and career development needs of the staff as a minimum. 16 OP33 24(1)(2)( 3) 17 OP36 18(2) Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations The inspector recommends that the home’s providers ensure that a checklist of all the documentation and checks required (as required by Schedule 2) be maintained on the front of each staff file. The inspector recommends that both deputy managers receive supervision and appraisal training, and that there is some delegation of the supervisory workload to both deputy managers. The inspector recommends that a more detailed supervision format is developed so as to provide a more structured and detailed record of supervision. This should include an agenda of issues identified for discussion (including issues b/f from the previous supervision), and then (in separate columns) details of each issue discussed, the discussion points covered, and the actions/decisions agreed. Supervision notes should be signed and dated by both the supervisor and supervisee. 2 OP36 3 OP36 Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 30 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 © 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 Gate Lodge DS0000025784.V276151.R01.S.doc Version 5.1 Page 31 - 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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