Inspection on 17/01/08 for Gibsons Lodge

This inspection was carried out on 17th January 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gibsons Lodge 29/05/07

Gibsons Lodge 17/05/06

Gibsons Lodge 19/12/05

Gibsons Lodge 04/07/05

Gibsons Lodge 22/11/04

Gibsons Lodge 27/05/04

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

CARE HOMES FOR OLDER PEOPLE Gibsons Lodge Gibson`s Lodge Nursing Home Gibson`s Hill London SW16 3ES Lead Inspector Janet Pitt Key Unannounced Inspection 17th January 2008 10:50 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 Gibsons Lodge DS0000019026.V356555.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. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gibsons Lodge Address Gibson`s Lodge Nursing Home Gibson`s Hill London SW16 3ES 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 8670 4098 020 8670 4261 Gibson`s Lodge Limited Acting manager in post. Care Home 46 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (24) Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 14 service users in the DE(E) category. Six specified service users in the Dementia - over 65 (DE(E)) category who are in excess of the 14 DE(E) service users that the home is registered for may reside at the home. As and when any of these service users are no longer in receipt of services from this home, the places will revert back to the Old age (OP) category. Six specified service users in the Dementia - over 65 (DE(E)) category who are in excess of the 14 DE(E) service users that the home is registered for OP service users, including the six specified service users referred to in condition no. 2. In order to cater for the needs of the service users, staffing levels must be maintained at the following levels: One of the qualified staff on each shift must be RMN qualified. The number of carers on each shift must be increased by one, thereby giving seven carers on each day shift and four on duty overnight. 29th May 2007 3. 4. Date of last inspection Brief Description of the Service: Gibson Lodge is a 46-bed care home with nursing set in a quiet residential area, yet well placed for access to local transport links. The home caters for up to 14 elderly residents with dementia, and 32 elderly infirm clients. Accommodation is provided in a mix of single and double rooms. There are several communal areas, and a very attractive, large garden. The stated aim of the home is to provide the residents with a secure, relaxed and homely environment in which their care, well-being and comfort are of prime importance. Information about services are detailed in a Service User Guide, which is made available to current and potential Service Users. Additional information can be found in the Statement of Purpose. The current weekly fees (as provided at the time of this inspection) range from £524 - £625. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. Two inspectors undertook this unannounced inspection. During the course of the site visit people who live in the home, visitors, staff and the manager were spoken with. The home completed an Annual Quality Assurance Assessment (AQAA) and information from this was also used to inform the inspection. The revised Statement of Purpose and Service Users Guide were examined. Records relating staff and people who live in the home were examined. A tour of the premises was undertaken and lunchtime was observed. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to detail the social needs of people who use the service and be more person centred. There needs to be a procedure for staff to follow in the event of terminal illness or death of a person with no relatives or representatives Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 6 A clear audit trail of medications is needed. Activities need to be developed in line with people’s preferences and all staff should participate in the provision of activities. Staff recruitment must include seeking a full employment history of all new staff, exploring any gaps in employment. 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. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home understands the importance of having sufficient information when choosing a care home. The Statement of Purpose clearly sets out the philosophy and aims of the home. The service user guide details what people who chose to live in the home can expect. People are assessed prior to moving in and work is continuing to make sure that people are involved in this process. EVIDENCE: People are able to make an informed choice about moving into Gibson’s Lodge. People’s assessments were examined and it was noted that pre-admission information was obtained prior to them moving in. One relative said that they were ‘happy with the moving in process’ and thought their relative was ‘settling’ Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 9 One person said ‘I chose to come here as it is close to my relatives’ The home’s AQAA detailed the service provision and what is provided in the fee. An updated copy of the Statement of Purpose and Service User Guide were forwarded for inspection. Both the documents cover privacy and dignity, and the right to develop or maintain relationships. It is recommended that both documents are grammar and spell checked for inaccuracies. The Statement of Purpose and Service User Guide contained the information required in the Regulations. Assessments of peoples needs are undertaken on admission. When inspected it was seen that there were good details on the differing needs a person had. Only one file did not have a recent photograph of the person. There was some involvement of the person or their representative, but this needs to be consistent, i.e. one relative had completed section on preferred clothing. People’s assessments were noted to be reviewed on a three monthly basis. The home’s AQAA stated on the subject of Sexual Orientation – ‘In depth preadmission life history may include this but may not be disclosed, so staff are educated not to make sexual assumptions about Service Users.’ Moving and handling, dependency and nutritional risk assessments are completed on admission. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People receiving services are happy with the way that most staff deliver their care and respect their dignity and rights. However, decisions on how personal care is delivered are not being consistently recorded. Medications are kept safely within the home, but there needs to be a clear record of medications that are received, to make sure there is an auditable trail. The wishes of the individuals about terminal care and arrangements after death are not always recorded. EVIDENCE: Care plans examined were person centred; the person’s preferred name was detailed. There was also evidence of personal preferences, e.g. night time routine, where to have meals and details such as tea without sugar, how food is to be presented and whether the person chose to stay in their room or participate in activities. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 11 Care plans were organised in fourteen sections that covered safety, personal care, eating, continence, social, mobility, breathing, temperature, mental health, pain, sleeping, sexuality, family involvement and mental health needs. The information in the section on sexuality needs to be expanded, once staff are confident and skilled with discussing the subject. Care plans are in the process of being reviewed and updated, it was clear that this work is ongoing, as not all plans inspected had been completed fully. One care plan gave information on the support required with personal care and specific details about dietary requirements and making sure that the person is able to reach their meal. Plans on nutrition can be improved further by including information on how to avoid dehydration and weight loss. Each file had a ‘biography’ sheet with space for details of personal history e.g. childhood, work, war experience, hobbies, likes and dislikes and significant events. This included good information for staff to use to speak with people about their life. However, this section needs to be a ‘living’ document and updated when new information is gathered. Fears for the future and death and dying are only discussed with the person’s consent, it was recorded when a person chose not to discuss this. The sections on dying on one plan noted that the person didn’t wish to discuss and the section on funeral was blank. This is obviously the persons choice, however, when no family members or next of kin are noted, there must be clear guidance on actions for staff to take. On another plan there was good information for the persons wishes regarding terminal care and their chosen place of burial. Details on dealing with aggressive or abusive behaviour were not consistently available. One plan’s mental health section noted ‘can be aggressive and abusive’ there were no details of what the behaviour is and how staff should respond. It was noted on other files that there were good details on steps staff should take and whether when an incident occurred, the interventions were appropriate. There was evidence within the daily records of people being able to continue to practice their religion. Daily records generally indicated what care had been given and whether needs had been met. Care must be taken with language used in daily recordings: Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 12 [the person] refused to get out from bed. This does not evidence personal choice. It was clear from the home’s AQAA, Statement of Purpose and Service Users guide that visitors are welcome in the home. Examination of daily records showed that one person brings their dog in to visit and some people go out into the community with their families. The home must make sure that reviews of care plans take place regularly and involve the person or their representative. One plan had not been reviewed for some time and the majority of plans did not evidence involvement of the person or their representative. Medications are generally handled safely at the home. Seventeen medication administration sheets were examined. It was noted that there were only four gaps in recording of medicines administered. Checks of the amount in stock indicated that the medicines had been given, but not signed for. Care needs to be taken when receiving medications into the home as records of amounts received had significant gaps. All Administration records examined had photographs of the person, but did not have details of any known allergies. One medication had a variable dose of one or two tablets, but the amount given was not recorded. The home must make sure that there is an auditable trail of medications into the home. Since the previous inspection the new manager has designated a room on the first floor as the clinical room. This enables all medications to be stored securely. The room was noted to be clean and tidy. Staff are monitoring the temperature of the room and thought needs to be given to air cooling when the weather is hot, as the records indicated that the temperature of the room was 22°C which is just below safe limits. People who live in the home looked clean and smart, wearing co-ordinated clothing, people were dressed warmly with clean hair and nails. One person said ‘they look after me properly, very good’ Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Generally staff are aware of the need to support people to develop and maintain their skills, including social, emotional, communication and independent living skills. Some people are consulted or listened to regarding daily activity, but this process could be improved. Not all people are consulted on how the home can work to provide them with a flexible lifestyle, the home recognises this and plans to make some changes. Mealtimes are now more of a social occasion and person centred, with choice evident. EVIDENCE: Significant improvements were noted in mealtimes. On the day of the site visit, lunch was observed in two areas of the home. Lunch in both areas was seen to be a social occasion in pleasant surroundings. People who use the service were offered choices and supported with the meal in an appropriate manner; this improves people’s quality of life. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 14 The dining room in the extension was set with six dining tables. Each table was attractively laid and had fresh linen tablecloths. Each person had a large linen napkin to use. Staff were either in uniform or wearing name badges, so it was easy to identify them. The food served matched the published menu and portion size was noted to be adequate. There was easy listening music playing, some people were seen to be enjoying singing along. There was a choice of water or cranberry juice on the table. Staff assisted where needed. One person had fish said it was ‘excellent’. One person, who did not want a cooked lunch, offered a sandwich. In the other area of the home lunch was served from a trolley with meals on covered plates on a tray, these were given to each person either at the dining table or on a table in front of their armchair. Three staff were helping three people with eating, although one staff left to answer the phone on two occasions. Care should be taken to make sure that meal times are protected. The television remained on throughout the meal in one part of the lounge, but it was not clear whether this was the people’s choice. People were seen to be offered the choice of soft drinks to have with and after their meal. People were offered a cup of tea when the meal had finished. The whole mealtime was unhurried in both areas. One person said they visit daily at lunchtime to help and said that the food usually looks and smells appetising. We were informed that the activities co-ordinator was off sick, but activities were continuing. There was an activities list displayed in the hallway, with selection of morning and afternoon activities six days a week On the day of the site visit there should have been a film showing in the morning and art and craft in the afternoon, but there was no obvious activity in the morning and Bingo or Hoopla was offered after lunch. The home notes in its AQAA that further improvements are needed to make sure that activities reflect peoples interests, making sure that this information is gathered, in order to develop the activities programme. Care staff will also be involved more in the provision of activities. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 15 Visitors were seen to be made welcome and offered refreshment. Visitors said staff are always ‘nice’ and ‘they give us drinks’ and ‘they offer the right support to the person we are visiting’ Gibsons Lodge DS0000019026.V356555.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): People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. A record is kept of any complaints; this includes details of investigation and actions taken. Training is provided in Safeguarding Adults and staff are expected to put this training into practice. EVIDENCE: People who live in the home are given information on how to make a complaint on admission. The complaints policy is displayed in bedrooms and in the Welcome Pack given to people. The home’s AQAA indicated that there had been five complaints of which two were upheld. CSCI received an anonymous complaint regarding people’s finances, staff working hours and food choices. There was no evidence on the day of the site visit and from other information held on the home that these complaints were valid. One issue regarding monies being taken from a deceased person bank account. The Responsible Individual has written to CSCI to affirm that the matter has been sorted out and any monies overpaid returned to the person’s estate. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 17 The homes AQAA indicates that staff receive training in Safeguarding Adults and the related policies have been reviewed to make sure that the information in them is current. The training is ongoing and staff are instructed to record any unexplained injuries and report them to the relevant authorities if necessary. People who live in the home and their relatives are encouraged at regular meetings to express any concerns they have and make suggestions for improvement. The AQAA states that staff have been given training in dealing with concerns and are requested to record any concerns received, in order that action can be taken if necessary. Gibsons Lodge DS0000019026.V356555.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 and 26 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who live in the home are able to personalise their rooms and only share a room if this is their own choice. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. EVIDENCE: The home’s AQAA stated that there was ongoing redecoration and refurbishment. On the site visit it was noted that fifteen bedrooms had been redecorated and three lounges. There is still work to do on the environment but the manager stated that it was going to schedule. The AQAA acknowledges that carpeting and curtains need replacing in many areas of the home, this has been planned to be done. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 19 The home is registered for forty-six people but at present some shared rooms are used as single occupancy to promote peoples privacy and dignity. On the tour of the premises one shower room had personal items of toiletries in an unlocked cupboard, which might indicate communal use of toiletries. The shower tray had been cleaned but not sufficiently and the extractor fan was covered in fluff. A number of extractor fans in toilets and bathrooms were covered in fluff and a cleaning programme must be in place to ensure all fans are cleaned on a regular basis to reduce the risk of fire and to maintain good standards of hygiene. There was a strong, unpleasant odour in the shower room. A bath list was displayed, in one bathroom and shower room, these were removed during the visit. In general the home provides a clean, tidy and maintained place for people to live in. People who live in the home are able to bring in small items of furniture and personal possessions. It was noted that many people had personalised their rooms. Gibsons Lodge DS0000019026.V356555.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 and 30 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service recognises the importance of training, and tries to deliver a programme that meets any statutory requirements and the National Minimum Standards. The manager is aware that there are some gaps in the training programme and plans to deal with this. The recruitment procedure is followed in practice, but this needs to be consistent to safeguard people who live in the home. EVIDENCE: The duty rota indicates that there are adequate numbers of staff available to meet need. The manager reported that they have three vacancies for RMNs. Care must be taken to make sure that staff have adequate rest days between shifts. It was noted that some staff had one day off before and after undertaking seven days shifts in a row. Peoples comments about the staff included:’ staff are very good’, ‘staff help’ ‘staff compassionate’, ‘they are always short staffed and very busy’, ‘staff look after me ok, very good’ Staff were seen to be respectful to people when entering their bedrooms (knocking and announcing themselves). Good positive relationships were seen, staff were seen listening to and talking with people who use the service and their visitors. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 21 Generally staff files contained the required information and checks on employees. The application form needs reviewing as it only requests the previous ten years employment history, not the full employment history of the person. The home needs to make sure that references are written to the previous employer as well as one other person. Requests for references must be addressed to the name of a person. References received did not always evidence the person or company the reference was received from i.e. a company stamp, or headed paper. Appropriate work permits were in place for those who needed them. One person was scheduled to work over their contract hours, but there was no copy of a form opting out of the working time directive. It is important that when these forms are used they are reviewed regularly; one examined had not been reviewed for over a year. Gibsons Lodge DS0000019026.V356555.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 and 38 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager has a clear understanding of the key principles and focus of the service and works to improve services. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. The health safety and welfare of people who live in the home is maintained. EVIDENCE: At the time of the site visit the manager had been in post since September 2007 and was in the process of applying for registration with CSCI. She is a qualified nurse and social worker. The manager reported that staff complete a daily quality assurance check of the premises and care plans. Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 23 The manager also completes a daily audit of the premises and the care being provided and reported that these checks will be used in staff meetings, supervision sessions and to request maintenance and equipment from the company directors. The AQAA states that there is a quality assurance system in place at the home. ‘The company provides questionnaires which are given out by the home twice a year. One is a Service User satisfaction and choice of home and the second looks at general issues within Gibson’s Lodge Nursing Home. The results of these surveys are returned along with an action plan. The Service Users comments are detailed.’ We have set up a Service Users’ forum and we hold Service Users’ meetings, 2 monthly. The Home Manager or Deputy chairs these meetings and minutes are taken. The Service User’s forum is made up of resident from each unit who put forward their views on what they see as important issues to them.’ Generally people who live in the home are encouraged to manage their personal finances, if this is not possible then a relative or advocate is sought. The home will only act on behalf of a person if all other avenues have been exhausted. Lack of high dusting being carried out, blocked ventilator fans and some minor damage to areas in the home that are being addressed wither in the redecoration programme, or at the time of the site visit. A requirement relating to waste bins being outside a person’s room have now been moved to a more appropriate area. Gibsons Lodge DS0000019026.V356555.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 3 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 (4) (a) Requirement Details on people’s life history need to be reviewed and updated to make sure that they are treated and respected as individuals. Care plans detailing how to intervene when a person’s behaviour is challenging, must include specific interventions for staff to use, and whether these interventions have been appropriate. Care plans must evidence the involvement of the person or their representative and are reviewed regularly. This will make sure that all needs are identified. There must be a clear record of medications received into the home. This will make sure that medicines are easily audited. Timescale for action 30/08/08 2 OP7 12 (1) (a) 30/08/08 3 OP7 15 (1) 30/08/08 4 OP9 13 (2) 30/08/08 Gibsons Lodge DS0000019026.V356555.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. 1 2 3 4 5 Refer to Standard OP1 OP7 OP7 OP7 OP26 Good Practice Recommendations It is recommended that the Statement of Purpose and Service User Guide are spell and grammar checked. It is recommended that staff ascertain what is to be done in the event of a person’s death if there is no next of kin. It is recommended that information on a person’s sexuality is incorporated into the care plan when staff have receive training on how to approach this subject. It is recommended that care plans and daily records use appropriate language, so as to protect the dignity of people who live in the home. It is recommended that ventilator fans are cleaned on a routine basis and high dusting is undertaken routinely. To make sure there are effective infection control procedures in place. It is recommended that toiletries are kept for individual use and returned to the person’s room after use. 6 OP26 Gibsons Lodge DS0000019026.V356555.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Gibsons Lodge DS0000019026.V356555.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!