Inspection on 20/06/06 for Gledhow Lodge

This inspection was carried out on 20th June 2006.

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

Gledhow Lodge 04/06/07

Gledhow Lodge 21/10/05

Gledhow Lodge 10/06/05

Gledhow Lodge 13/10/04

Gledhow Lodge 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Gledhow Lodge 51/53 Gledhow Wood Road Leeds West Yorkshire LS8 4DG Lead Inspector Dawn Navesey Key Unannounced Inspection 20th June 2006 09:20 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 Gledhow Lodge DS0000001454.V298116.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. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gledhow Lodge Address 51/53 Gledhow Wood Road Leeds West Yorkshire LS8 4DG 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) 0113 266 7806 Yorkshire Residential Care Limited Mrs Andrea Atkinson Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2005 Brief Description of the Service: Gledhow Lodge is situated in Oakwood, a leafy suburb in the north of Leeds close to the amenities of Roundhay park and the canal gardens. It is only a short bus ride from the city centre. The home is well served by local shops, a library and numerous cafes. This establishment is Georgian grade 2 listed building. The home is registered to provide specialised dementia care to older people. Accommodation is provided mainly in single rooms with some double rooms for those who want to share. The home is on two floors and has a passenger lift. There are generous communal areas on the ground floor, offering a choice of lounges and a large dining room. The home has a large, well kept garden where residents can sit out or take a walk. The current scale of charges at the home is £403 per week. Additional charges are made for hairdressing, chiropody, cigarettes, newspapers, magazines, alcohol and hosiery. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced inspection was carried out by one inspector between 920am and 5-30pm. The purpose of this inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection, and to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term resident; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking to residents and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Comment cards were left at the home to provide service users and visitors with the opportunity to comment on the service. Those returned gave positive comments about Gledhow Lodge. Feedback was given to the management team at the end of the inspection. Requirements and recommendations made during the visit, and outstanding from previous visits can be found at the end of this report. What the service does well: The home has a relaxed atmosphere and there is a good rapport between residents and staff. One resident said “ It’s lovely here, staff are all so kind, Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 6 we are like one big happy family”. Staff were seen to be kind, caring and interested in spending time with residents. The home had received positive comments in letters from relatives. One had said “ Thank you to each and everyone of you for the excellent and kind care you give to my husband.” The home has a programme of training which has made sure that 80 of the staff have an NVQ (National Vocational Qualification) in care at level 2 or above. What has improved since the last inspection? The home has done some work on residents’ life history books, showing efforts to make care records more person centred. Work has continued in involving residents and their relatives in the development of care plans and their on-going review. Referrals are now made to other health professionals as needs arise. The home is now using a monitored dosage, pre-packed system for medication. Staff have received accredited medication training. Menus are designed after consultation with residents. Their likes and dislikes are made known to the cook. This information is updated as and when required. All staff have received training on the protection of vulnerable adults. One of the managers has also trained to be able to present this training to staff in the future. Staff have received training specific to the needs of people with dementia. Two of the managers are progressing with their accredited training in dementia care. A number of new carpets have been fitted. The manager has sought advice on odour control from a specialist consultant and is currently trying a new product to minimise odours in the home. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 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 contacting your local CSCI office. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have reasonably sufficient information available to make an informed choice about the home. Residents have a basic assessment prior to moving in to the home. EVIDENCE: There is an up to date statement of purpose and service user guide. The home have also produced an easier- read service user guide for residents with dementia. This could be further developed by including some picures/photographs or using large print, making it more accessible. The Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 10 statement of purpose does not state in detail how the specialist needs of people with dementia will be met. Not all residents had current fee levels noted on their contract with the home. Pre-admission assessments take place for residents before they move into the home. One of the homes managers does these. The level of detail could be improved on as only very basic information is gained. The manager will assess people at home or in hospital. Residents and their relatives are given opportunity to visit the home prior to moving in. One resident said she had been to look at other places but chose to come here as she liked it best and there was a sense of welcome. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Overall, residents health and personal care needs are met, however the absence of individualised detail in the care plans creates the opportunity for care needs to be missed. Residents are protected by safe systems for dealing with medicines. Residents’ privacy and dignity is respected. EVIDENCE: Work has been done on improving the care records. However, the format does not lend itself to recording a detailed plan of care. A good care plan should give clear and detailed information on how and when care should be delivered, Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 12 during day and night, and with particular reference to residents’ individual preferences and choices. Most residents have had life history books developed. These are person centred and have involved residents, their relatives and friends. Staff said they had found them really useful, one staff member said I enjoy getting to know residents, what they did in the past helps you to get to know residents as individuals. Risk assessments had been carried out for some identified risks to residents, however more detail is needed. Nutritional assessments had not been completed in full for some residents who were at risk from losing weight. Care plans were reviewed monthly by the manager. Relatives and residents were involved in this process if they wanted to be. Some relatives had signed care plans on behalf of residents. The manager said she is planning for all staff and keyworkers to be involved with adding information to the care plans and assessment process. Staff were aware of residents needs and said the care plans and their induction with other staff had helped them gain this information. A resident who was anxious was seen to be reassured of her safety and whereabouts by a number of staff. All staff used the same consistent approach. A GPs practice nurse visits the home on a fortnightly basis for any residents who wish to see her for matters that are non-urgent and medication reviews. The manager said this has been very helpful in promoting and identifying health care needs. She also said this encourages good communication between the health care staff and the home. A resident spoke of how she had been supported by the district nurse coming in to see her, praising the staff for arranging this. Staff said that a staff member would accompany any resident going to hospital unless the residents family wanted to go with them. This can also happen in emergencies. A recent complaint from a relative was about her mother going in an ambulance unaccompanied. The manager said this would only happen if the relative were meeting the resident at the hospital. It would be good practice, in these situations, to accompany residents, especially if they are confused, until they reach the hospital. Referrals are made to other health professionals as needs arise. One resident had recently been referred to a community psychiatric nurse when their mental health seemed to be deteriorating. A survey card received from a community nurse gave very positive comments about the standards of care in the home. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 13 Staff were seen to be patient and kind when interacting with residents. One staff member said she loved spending time talking with residents. She showed some understanding of the needs of people with dementia, saying you need to give them time and listen to them, even if that means looking at their body language for people who have problems communicating. Another staff member said it was important to keep residents independent in order to maintain their dignity. A resident said, there is a lovely atmosphere here, staff are pleasant and remember your name. They notice if ever you look a bit down and would come and ask you discreetly if you are alright. The home now uses a monitored dosage, pre-packed system for medication. All senior staff have been trained to use the system. A record is kept in the home of medication ordered. This is checked against medication delivered and recorded as correct before any medicines are dispensed. Photographs had been taken of all residents, which made sure they are clearly identified on the medication records. Good practice was seen during the visit in the administration of medication. Staff have completed accredited medication training with a local college. The manager said this would continue for new staff. One member of staff said the training had made her think more about why medication is used and the importance of looking out for any side effects. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities provided within the home and community do not always take into account the preferences and interests of the residents. However, the manager wants to make improvements to this by looking into more 1-1 activity. Residents have a well balanced and nutrititious diet, with their choices catered for as much as possible. The home encourages contact with relatives and friends. EVIDENCE: The provision of activity in the home is limited. Occasional group outings have taken place to local shopping centres and cafes. A gentleman comes in weekly to provide light entertainment and an exercise activity. Residents said they enjoyed this, especially the singing and piano playing. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 15 The home has a visitor who brings a dog who is part of the pat scheme. This visitor also does some reminiscence work with residents. Staff said this was a popular activity. Some residents said they get a little bored at the home and would like more magazines and books in the home. They were particularly interested in magazines such as gardening. The manager said a number of magazines are bought such as gossip and showbiz and home and garden,” type magazines. Other residents said they would like to go out on a more 1-1 basis rather than in a group. The manager said she would look into the feasibility of this. Residents meetings showed that more activity outside the home had been requested. Throughout the day, residents were seen to spend time talking with staff, enjoy a walk in the garden, watch TV or listen to music. Having the TV on seemed to be a choice. Some residents had chosen not to have the TV on as they were enjoying conversation between themselves and the staff. A Church of England vicar visits the home monthly. He makes sure that residents can celebrate significant religious events such as Christmas and Easter. The manager said that other denominations could be catered for as needs arise. Relatives and friends are regular visitors to the home. There is a room in the home where residents can have privacy with their visitors or enjoy a meal with them. Menus were varied and nutritionally balanced. The cook keeps a book in the kitchen with residents’ likes and dislikes in. This is added to as likes and dislikes become known. Menus are developed from this information. The main meal of the day is served at lunchtime. An alternative can always be provided. A resident who didnt want the lunchtime meal was given sandwiches as she requested. The cook had a good awareness of special diets and had received training on diabetes. The lunchtime meal was gammon, sauté potatoes, swede and stringless beans with gravy followed by bakewell tart and custard. Residents were supported with courtesy and dignity during their meal. Gledhow Lodge DS0000001454.V298116.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives concerns are listened to and acted upon. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure that is made available to relatives and residents. It is also referred to in the statement of purpose and service user guide. Complaints have been investigated and handled properly by the home. A complaint from a relative is currently being dealt with by the manager. A resident said, I would complain if I needed to, I could turn to anybody, staff are never short tempered. Staff were familiar with the adult protection procedures and have received training on abuse and the protection of vulnerable adults. Staff spoken to were aware of the different types of abuse and how to report any concerns. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 17 Some residents held keys for their rooms and kept them locked. Other residents chose not to do this. Some residents had their rooms locked when they were not using them to prevent other residents entering their room and destroying or taking their property. This had been agreed with service users and their relatives and was documented in a risk assessment. These residents had access to their room through staff assisting them when necessary. Gledhow Lodge DS0000001454.V298116.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and tidy home . EVIDENCE: The home was generally clean and tidy. Residents were satisfied with their rooms. One resident said I have a very comfortable bed, its like a first class hotel here. Residents are encourged to personalise their rooms and to bring familiar pieces of furniture in with them. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 19 Residents were particularly pleased with the wall mounted, large, plasma screen TV. Residents said it was like being at the cinema when watching it. Offensive odours have been a problem for the home. The manager is currently trying a new product on carpets and makes sure they are spot shampooed when any spillages or staining occurs. They are also routinely shampooed every six weeks. Some areas have had new carpets fitted. Odours were still present, however the home is trying to improve this by their management and control measures. The home does not currently have any domestic staff employed, despite their recent efforts at recruitment. Staff spoken to said they have time to do the cleaning, they work as a team and the managers also get involved. One of the managers was observed to be undertaking a cleaning task on the day of the visit. The kitchen was clean and hygienic. The cook takes responsibility for kitchen cleaning tasks. The bath in the downstairs bathroom has some of the enamel chipped off. This looks unsightly and could cause injury to residents. It needs to be repaired or replaced. An upstairs toilet did not have a seat. The manager was aware of this, a new one had been bought and was waiting to be put on. The room used for residents to spend time with their visitors is also used to store wheelchairs and zimmer frames. This could pose a potential hazard to residents and visitors. Alternative storage must be found for them. Infection control is well managed. Staff have recieved training and were seen to wear protective aprons and gloves when assisting residents to the toilet or bathroom. Some furniture in the home is looking worn. A few of the occasional tables had been covered with a patterned sticky back material to keep them looking attractive. Some consideration should be given to developing a programme of replacement and renewal for funiture. The home has substantial, attractive gardens. Risk assessments on use of the steps down to the garden need to be carried out to ensure residents safety. Gledhow Lodge DS0000001454.V298116.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets residents needs. Residents are protected by the homes recruitment procedures. Staff are trained and competent to do their job. EVIDENCE: The staff rota showed there were sufficient staff on duty at all times. All staff spoken to said they never feel rushed in their work and there is always time to sit down and spend time with residents. One of the residents said our needs are always met, everything flows, we are like one big happy family. There is a new induction programme based on the Skills for Care induction. Staff said they were enjoying this way of learning and could see how this benefits residents and themselves. The manager is using this training in group Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 21 sessions to encourage participation and discussion. External training is arranged for training such as moving and handling, first aid, food hygiene, infection control and fire. Training specific to the needs of people with dementia is provided to all staff. This is awareness training from a pack produced by The Alzeimers Society. Staff said it had made them realise the importance of providing person centred, individualised care. 80 of the staff have achieved an NVQ (National Vocational Qualification) level 2 or above in care. Recruitment records were inspected. All the necessary checks had been obtained for staff prior to their employment. The manager said that the home has recently employed the services of a consultant on employment law to make sure they keep up to date. Staff were aware of their roles and felt supported by their managers. Gledhow Lodge DS0000001454.V298116.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements now seem to be meeting the needs of the service. Residents’ financial interests are safeguarded. Overall, health, safety and welfare are promoted. EVIDENCE: The home has three managers. The registered manager who oversees the home, an administration manager and a manager who is responsible for care Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 23 management. This manager is currently in the process of her application with CSCI (Commission for Social Care Inspection) to also be a registered manager. Staff spoken to said the new management situation was now clear and they felt there was good teamwork and the managers are all approachable and fair. Two of the managers are currently undertaking their Registered Managers Award and the certificate in Dementia Awareness. Supervision is given on a regular basis, staff meetings take place about twice per year. The home is currently introducing a new quality assurance system, using questionnares and testimonials for feedback from service users, relatives and visiting professionals. Residents finance records are well maintained. All transactions are checked on a monthly basis by two managers. Property records are kept with photographs taken of valuable items such as jewellery. The home has employed the services of a health and safety consultant to make sure their record keeping and checks are in place. Recently completed environmental risk assessments were not available as they had gone to the consultant to be checked. All necessary fire records were in place and drills are carried out on a regular basis. Accident records are completed and the CSCI notified of the accidents. The accident forms do not have a section for follow up after accidents or a section on action to be taken to prevent re-occurrence of the accident. Maintainence records and certificates were up to date. On the day of the visit, the home recruited a handy man to undertake odd jobs and work on a programme for redecoration in the home. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The statement of purpose must state in detail how the specialist needs of people with dementia will be met. All residents must have an up to date contract with their current fee levels detailed. Detailed pre-admission assessments must be carried out to demonstrate how the home can meet assessed need. Care plans and risk assessments must show in detail the individual and specific care and support needs of residents to make sure staff provide person centred care. The previous timescales of 31/07/05 and 31/01/06 have not been met in full. Nutritional assessments of all residents who are at risk from weight loss must be completed. The registered manager must consult further with residents or their representatives regarding activity choices. Timescale for action 31/08/06 2. 3. OP2 OP3 5 14 31/08/06 31/08/06 4. OP7 15 30/09/06 5. 6. OP8 OP12 12 16 31/07/06 31/08/06 Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 26 7. 8. OP19 OP38 16 12 9. OP38 12 The previous timescale of 28/02/06 has not been met in full. The bath with chipped enamel must be repaired or replaced. Wheelchairs and zimmer frames must be stored in a safe place to ensure the health and safety of residents. Risk assessments on the use of the steps down to the garden must be completed to ensure the health and safety of residents and staff. 31/08/06 31/07/06 31/07/06 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. Refer to Standard OP1 OP8 OP19 OP38 Good Practice Recommendations The manager should consider producing the statement of purpose and service user guide in a format that would be more accessible to residents. The manager should make sure a staff member is available to accompany residents on journeys to hospital by ambulance. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced. Accident reports should have details of when residents were last seen and by whom. There should be a section for any follow up or outcome of the accident. Gledhow Lodge DS0000001454.V298116.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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