Inspection on 29/05/07 for Gibsons Lodge

This inspection was carried out on 29th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Gibsons Lodge 17/01/08

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 29th May and 4th June 2007 10:25 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.V337677.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.V337677.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 Alan Anand Khusul 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.V337677.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. 17th May 2006 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 £505 - £625. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector and one regulation manager undertook this unannounced inspection. Two site visits were carried out which lasted a total of five hours. Three residents surveys and one relative’s surveys were received. Staff files, care documentation and a tour of the premises were inspected. Observation was made of staff interactions during a mealtime. Members of staff and relatives were spoken with. What the service does well: What has improved since the last inspection? What they could do better: Comments from surveys included: ‘Something to occupy the residents in the late afternoon, early evening after the meal.’ ‘The people at the home always appear to be doing their best. They came across as very tired. However, my overall impression is that the home would benefit from better management and better communications with relatives.’ ‘More staff, more training and awareness of changes in persons character, which indicates something is not right.’ Other areas, which need input, are care documentation, availability of information and making sure that residents are treated as individuals. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 6 More information can be found in the body of this report regarding areas to be improved. 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.V337677.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.V337677.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, 2, and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not consistently provide a statement of terms and conditions. Residents and their representatives do not think that they are provided with sufficient information. Assessments undertaken are not completed fully. This could lead to needs not being identified. EVIDENCE: Surveys indicated that some people had not received enough information prior to moving into the home. Contracts detailing terms and conditions were not always present. One survey respondent stated: ‘I would appreciate receiving a contract which states their values for looking after [the resident].’ Assessment of residents must include relevant information and fully identify fully. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 9 Assessments of potential residents were undertaken prior to and on admission. Both of these documents contained scant information e.g. ‘all aspects of care and support except feeding.’ This does not enable staff to identify areas of strengths and weaknesses. Preferred form of address was noted, but there was limited evidence of choice in other areas, i.e. preferred food and drink choices. Residents and their representatives not fully involved in the admission process. One comment from a survey stated: ‘I think the should be a far more professional approach to involving relatives in decision and giving more information so that the relative understands what is happening to the person being cared for.’ Assessments did not consistently note residents’ social interests or hobbies. Assessments detailed information such as ‘regular toileting’ however there was no indication of how often this intervention was required. Gibsons Lodge DS0000019026.V337677.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Health care is reactive rather than proactive, ongoing monitoring of health is poor. The home does not facilitate independent choice. There is a lack of awareness that poor practice could potentially be viewed as neglectful. Staff do not deliver person centred care. EVIDENCE: A significant amount of input is required to make sure care plans enable needs to be met consistently. Care plans lead from assessments on those needs that were identified. Generally the plans were reviewed monthly, but there was limited involvement of the resident or their representative. Language in care plans was sometimes inappropriate and did not protect the privacy and dignity of residents. E.g. ‘fussy with food’, ‘refusing to use [their] hearing aid.’ ‘refuses to elevate feet.’ Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 11 Information such as: ‘verbally and physically aggressive.’ Does not explain how the person exhibits this type of behaviour and why. Guidance on how staff can diffuse potential difficult situations is needed. There were bland entries in the daily records e.g. ’washed and dressed’, ‘had a quiet night’. This does not indicate whether interventions had been appropriate and whether needs had been met. Survey comments on care received in the home were: ‘More attention needed here.’ ‘I have asked for [the resident] to see a doctor on two occasions. It would have been better if I had received feedback on what had happened.’ ‘have found [the residents] hands smell because they are always clenched need to be washed more and [their] feet.’ Care plans need to demonstrate choice. e.g. weekly baths/showers offered. This does not indicate whether it is the resident’s preference to have a weekly bath or shower. Residents risk assessments need to be individualised and completed fully to make sure that they are protected from harm. Residents are weighed monthly, but there was no evidence of interventions when weight loss was apparent. It was also observed that residents’ wishes on end of life care were not recorded. Bruising and injuries were not consistently followed through; also there was delay in seeking medical attention. Medications were inspected. Written policies and procedures were seen to be satisfactory. The stock balance and receipt of medications was not recorded. One medication administration record (MAR) sheet did not have a photograph of the resident. Topical creams were signed for when given, but an indication of where the creams are to be applied needs to be detailed. The amount of variable medications are given, such as Co-codamol, was not noted. It is concerning that the majority of resident are prescribed aperients or laxatives. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 12 Amounts of stock did not tally with the amount signed for as given. There needs to be a clear audit trail of medications into and out of the home. Wishes for end of life care and death and dying were not consistently noted. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Routines in the home are rigid and task orientated. There has been some promising improvement with activities provided. However, all staff must support residents’ individuality and social preferences. EVIDENCE: Comments from survey respondents included: ‘we find that they spend most of their time just sitting if the activity person is not in.’ ‘[the person] who organises games etc for the patients is excellent at this. ‘I think [the resident] is treated like everybody else. [They] are quite physically active and likes going outside. I think this should be catered for.’ The range of activities offered is starting to reflect residents’ interests. The current activities organiser spends time with residents on an individual basis to discover what their hobbies and interests are. More consideration needs to be given to outings and community visits. CSCI are concerned that there are plans to reduce the hours of the activities organiser. This would be extremely Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 14 detrimental to residents and halt the promising progress that has already been made. Residents need to be sure they are able to communicate with their family and friends. One survey comment was ‘It is very difficult to get through on the telephone and the process of setting up a telephone is [their] bedroom is very difficult.’ Residents’ mealtimes should be a social event. Residents’ privacy and dignity must be respected. Observation was made of an evening meal. The process was tasked orientated and did not allow choice. The noise volume in the small lounge was not conducive to a pleasant atmosphere. On entering the room the television was blaring, this was then switched off and the radio put on, to a popular music channel. None of the residents were asked whether this was their choice. The volume level of the radio did not allow for spoken interaction. Soup was given to each resident at the same time; there was no account of who might need assistance. Therefore, some residents had cold soup, when a member of staff was able to assist them. Staff interactions with residents need to improve. One resident was expressing the wish to die and a member of staff persisted in trying to change the topic of conversation, rather than address concerns raised: ‘Want me to feed you’, the resident stated they wanted to die, to which the response was: ‘Don’t say that.’ Residents were seated around the edges of the rooms and no attempt had been made to utilise the dining table that was in the room. All residents had hospital tables placed in front of them and paper bibs on; the use of bibs does not ensure a person’s dignity. Staff were seen to be attempting to assist with more than one resident at a time and did not sit down when helping. One resident did not want soup, but staff kept insisting that they tried some. The soup was taken away, but then another member of staff retrieved a cup of soup from the trolley and tried to get this particular resident to drink it. It was not clear whether this was the original cup that the resident had. The choice of evening meal did not enable those people with problems chewing to eat a satisfactory meal. The meal consisted of sandwiches, with fishcake and salad. The salad had some dressing, but the fishcakes were dry. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 15 One survey respondent commented; ‘I think from what I’ve seen there should be more choice and more attention to healthy potions, e.g. fruit and vegetables.’ One resident was unsettled and wished to see their family. The inspector made a request that the family were contacted in order that the resident would be able to speak with them on the telephone. It was not clear whether this action was subsequently taken. Residents were not asked what beverage they wished to have with or after their meal. Gibsons Lodge DS0000019026.V337677.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 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaint procedure is not widely available within the home. Staff have not received updates on protection of vulnerable adults. The policies and procedures for Safeguarding Adults do not give clear guidance about what should happen if an alert is received. EVIDENCE: Information on how to make a complaint needs to be readily accessible. Survey respondents indicated that they would go to the manager if they had any concerns. Two respondents were unaware of how to make a complaint. Changes in staff have also affected whether people know who to complain to. One respondent stated ‘not really because of changes in staff.’ The policy relating to the protection of vulnerable adults needs to be reviewed to make sure that current procedures are followed. There needs to be reference to the current Regulatory authority and links with the local boroughs policy. Staff must be aware of current procedures, evidence of training in protection of vulnerable adults must be evidenced. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shared rooms do not have adequate screening to maintain privacy. The home is not clean and tidy and infection control procedures are poor. There is no planned on going maintenance programme in place. Communal areas do not promote interaction between residents. EVIDENCE: Residents should be able to live in a well maintained and pleasant environment. Cleanliness must be of a suitable standard to prevent infection. It is important that high dusting is carried out routinely, to prevent infection, there was a large spiders web in one room. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 18 Doors had chipped paintwork and carpets were worn and stained. Gibson’s Lodge has a large garden, which needs to be tidy, and made accessible for residents. A bar of soap was found in a shared bathroom, this indicates that there is communal use of toiletries. One shared room did not have adequate screening; therefore residents’ privacy could not be respected. Lounge chairs were arranged around edges of room and hospital tables were placed in residents. In one toilet the shower cubicle base was filthy and extractor fan needed cleaning. The bath in the extension had damage from use of the bath hoist chair. Respondents to surveys stated that the home was generally clean and fresh. However, one respondent raised concerns about a towel being old and worn and lack of soap being available in a resident’s bathroom. The main waste bins for the home are outside a resident’s room; an alternative place needs to be found. The manager has written to the council regarding this. A planned programme of redecoration and refurbishment, including the purchasing of profiling beds, is needed. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not support the development of a competent staff team. There are no reliable records of staff training that has been undertaken. The home has a poor recruitment procedure with shortfalls in recording and process being evident. EVIDENCE: One survey respondent commented: ‘There have been a number of changes of staff. This makes relationship building very difficult.’ The duty rota indicated that there were adequate numbers of staff available, but residents and their representatives are not always confident that they will receive support in a timely manner. As evidenced by comments on surveys, included in the summary section of the report, as well as this section. Staff files were examined, these need to contain the information required in the Regulations and Schedules. Work permit checks and Personal Identification Number checks had been done. Staff contracts did not routinely state which home was the main place of employment. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 20 One Criminal Records Bureau check (CRB) had not done by the home on commencement of employment. One person’s employment application form had date of application changed and the CRB form had been completed but not sent. Application forms need to be revamped to comply with current Employment Law and equal opportunities. Previous cautions were not asked for on the application form. The manager stated that staff supervision has recommenced. A plan of supervision was seen. The home must make sure that relevant training is planned and carried out. A structure induction programme is required for new staff. One member of staff had not received any training since commencing employment in the home. The manager said that he has accessed training on Dementia for staff and is planning further training for staff. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The new manager is qualified and experienced in care of older people. They need to be supported by the company to make sure requirements and standards are achieved. EVIDENCE: Gibson’s Lodge has a new manager in post. He has gained experience in hospital settings, but needs to develop expertise in a care home setting. At the time of inspection there was some confusion over who the responsible individual is. CSCI must be informed to make sure that correct details are available. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 22 Residents’ personal allowances records could not be inspected, as the records and monies are not kept in the home. This is an outstanding requirement from the previous inspection and needs to be addressed promptly. A Quality assurance programme must be developed, to make sure that residents and their representatives can be involved in the running of the home. Residents blood glucose monitoring was not being carried out in a safe way. An immediate requirement was made to make sure that there was a supply of single use disposable lancets within the home. A letter was received from the manager to indicate that this had been done. Staff who carry out blood glucose monitoring must attend refresher courses, to make sure residents are not put at risk of harm. Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 1 1 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X X 1 Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4&5 Requirement The registered person must ensure that residents have sufficient information on the home prior to moving in. The registered person must ensure that residents receive a copy of their contract detailing the service provided and terms and condition. The registered person must ensure that assessments of residents are completed fully and identify all needs. The registered person must ensure that care plans contain detail on how needs are to be met. The registered person must ensure that language used in care plans and daily records protects the dignity of residents. Service user plans must include reference to social care needs. Previous timescale of 30/06/06 not met. Timescale for action 15/10/07 2 OP2 5A 15/10/07 3 OP3 12 (1) (a) 15/10/07 4 OP7 12 (1) (b) 15/10/07 5 OP7 12 (4) 15/10/07 6 OP7 15 30/09/07 7 OP7 17 (1) (a) & Sch 3 The registered person must 15/10/07 ensure that daily records accurately detail how needs have DS0000019026.V337677.R01.S.doc Version 5.2 Page 25 Gibsons Lodge 8 9 10 OP8 OP8 OP9 12 (1) (b) 12 (1) (b) 13 (2) been met. The registered person must ensure that residents’ personal hygiene is maintained. The registered person must ensure that towels and other linen are suitable for use. The registered person must ensure that there is a clear auditable trail of medications. Staff must ascertain and record the wishes of each service user in the event of their serious illness/death. A resuscitation policy & procedure also need to be established. Previous timescale of 30/06/06 not met. The registered person must ensure that staff interact with residents in a manner, which is respectful. The registered person must demonstrate that residents are able to have choice and their dignity is respected. The registered person must ensure that mealtimes are a social event. Service users must be provided with a varied menu, which is in accordance to their established preferences. Previous timescale of 17/06/06 not met. The registered person must ensure that residents and their representatives are made aware of the complaint procedure. The registered person must ensure that the POVA policy is reviewed and updated to include current guidance. The registered person must ensure that all staff are familiar with the correct procedure to DS0000019026.V337677.R01.S.doc 15/10/07 15/10/07 15/10/07 11 OP11 12 30/09/07 12 OP14 12 (4) (a) 15/10/07 13 OP14 12 (4) (a) 15/10/07 14 15 OP15 OP15 12 (4) (a) 16 15/10/07 17/09/07 16 OP16 22 (5) 15/10/07 17 OP18 13 (6) 15/10/07 18 OP18 13 30/09/07 Gibsons Lodge Version 5.2 Page 26 follow in the event of suspected abuse. Previous timescale of 30/05/06 not met. 19 OP19 23 (2) (b) The registered person must ensure that there is a planned programme of redecoration and refurbishment. The registered person must ensure that there are effective infection control procedures in place. The registered person must ensure that all staff provide the required documentation before commencing work. Previous timescale of 17/06/06 not met. The registered person must ensure that there is a staff training and development plan in place and that training can be evidenced. Previous timescale of 30/06/06 not met. The registered person must ensure that there are clear lines of accountability and CSCI is aware of the Responsible Individual. The registered person must ensure that there are satisfactory quality assurance systems in the home. Previous timescale of 30/06/06 not met. The registered person must ensure that a copy of all financial transactions made on behalf of service users is kept in the home, so that there is a clear audit trail should one be required. Previous timescale of 30/05/06 not met. The registered person must ensure that blood glucose monitoring is carried out safely DS0000019026.V337677.R01.S.doc 15/10/07 20 OP26 13 (3) 15/10/07 21 OP29 19 17/09/07 22 OP30 18 30/09/07 23 OP31 2 (c) (i) 30/09/07 24 OP33 24 30/09/07 25 OP35 17 30/09/07 26 OP38 13 (4) (c) 15/10/07 Gibsons Lodge Version 5.2 Page 27 and competently. 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 Gibsons Lodge DS0000019026.V337677.R01.S.doc Version 5.2 Page 28 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.V337677.R01.S.doc Version 5.2 Page 29 - 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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