Inspection on 05/01/06 for Glenkindie Lodge

This inspection was carried out on 5th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glenkindie Lodge 19/11/07

Glenkindie Lodge 14/02/07

Glenkindie Lodge 10/04/06

Glenkindie Lodge 29/09/04

Glenkindie Lodge 26/04/04

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

CARE HOMES FOR OLDER PEOPLE Glenkindie Lodge 27 Harborough Road Desborough Northants NN14 2QX Lead Inspector Pat Harte Unannounced Inspection 5th January 2006 10:15 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 Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glenkindie Lodge Address 27 Harborough Road Desborough Northants NN14 2QX 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) 01536 762919 01536 762919 Premedic Limited Mr Graham Edward Weekes Care Home 33 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (11), of places Physical disability over 65 years of age (4) Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The Home will limit its services to the following service user categories: No person falling within the category Older Persons (OP) can be admitted where there are 33 persons of category OP already in the Home. No person falling within the category DE (E) can be admitted where there are 18 persons of category DE (E) already in the Home. No person falling within the category PD (E) can be admitted where there are 4 persons of category PD (E) already in the Home. The Home restricts its services in the Cottage to no more than 6 individuals within the category OP only. The total number of service users in the Home must not exceed 33. Date of last inspection 22/06/05 Brief Description of the Service: Glenkindie Lodge is a privately owned care home providing personal care and accommodation for up to 33 Older People. Within this total the home is registered to provide care for up to 18 People with Dementia and up to 4 Persons with a Physical Disability. The Home is owned by Premedic Limited and the Manager is Mr. Graham Weekes. The Home is situated in the outskirts of Desborough close to local shops and the town’s amenities. The premises consist of a two storey main house with a bungalow annex for 6 Residents separated from the main building across a driveway. Residents are provided with single bedrooms with en suite facilities throughout the accommodation. Currently extensive building work is on going in the main house to provide an extension and major alterations to the existing main building. The Work has been considerably delayed and remains uncompleted despite the Commission’s expectation that it would be finished by Autumn 2005. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for Service Users and their views of the service provided. Inspection planning took one and a half hours and consisted of a review of the last Inspection report, previous requirements and recommendations and the Home’s service history including notifications and events. The primary method of inspection used was ‘case tracking’ which involved selecting two Residents and tracking the care they receive through review of their records, talking with them and the care staff. In addition five staff and four Residents were spoken with to obtain their views. A partial tour of the premises took place, a selection of records was inspected and observations made on care practices. Discussions were held with the Manager. The Inspection took place during the morning and afternoon over a period of six and a half hours and was carried out on an unannounced basis What the service does well: The Home has a stable staff group who demonstrated their commitment to the well being of their Residents. Residents spoke very highly of the staff commenting that they were very caring and helpful. Relationships between Residents and staff were observed to be very good. The Home’s Medication system was safely managed. Routines were relaxed and flexible and Residents had choice in how and where they wished to spend their time. Staff took care to protect Residents’ dignity and privacy by ensuring personal care tasks were carried out in private Staff have worked very hard to ensure a good level of domestic and hygiene maintenance whilst the building work is ongoing. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 6 The systems for managing Residents’ moneys, where necessary, were well maintained. What has improved since the last inspection? What they could do better: The assessment process should be revised to ensure that all areas of need and risk are identified prior to admission with particular attention paid to the assessment of Dementia care needs. Care plans should be developed further to provide clear guidance and instruction for staff on how the care is to be carried through. Particular attention should be paid to the needs of Residents with Dementia to guide staff on how to support them effectively. The reviewing of care plans should be increased to monthly and care should be taken to ensure plans are updated when changes occur and new instructions are proved for staff. The activity programme should be reviewed to provide Residents with a good range of choice both on a group and individual basis. Training for staff should be undertaken in order that meaningful activities can be provide for Residents with Dementia. Further training for staff should be provided to broaden their understanding of the Protection of Vulnerable Adults procedures to ensure that any Resident-toResident abuse is recognised and appropriate action taken. Serious concern is expressed on the failure to progress and complete the building works, finish alteration work in existing Residents bedrooms and maintain the décor of the building appropriately. There is the potential for risk to the health and safety of Residents in the failure to complete the outstanding work to cover Radiators in the Cottage, secure the garden area to the front of the property and to ensure the fitting of a new alarm call bell system. Staff recruitment processes must include the required checking procedures in order to ensure the protection of Residents. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 7 Induction and Foundation training for staff should be revised in accordance with recommended guidelines. Attention should be paid to enabling staff to undertake National Vocational Training to reach the minimum expected standard of 50 qualified staff. Dementia training for staff is needed to enable them to develop their skills and understanding in order to be able to meet the needs of their Residents. The Manager should update his training in Dementia care to enhance his understanding and to update practice within the Home. 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. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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, 3, 4 & 5 Prospective Residents are provided with information to enable them to make informed choice regarding their placement. The pre-admission assessment is not fully effective in ensuring that the needs of Residents admitted to the Home can be met. EVIDENCE: Prospective Residents and their relatives are given information on the Home’s services and facilities and have opportunities to visit the Home before deciding whether they wish to take up a placement. The admission process ensures that all prospective Residents are visited and assessed by the Manager and/or Deputy Manager from the Home. The records relating to assessments showed an overall good approach to identifying physical care needs. However consideration should now be given to developing the use of recognised and specific assessment tools such as Pressure, Nutritional and Dementia assessments to identify risk areas and plan strategies for the management of any risks. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 10 The assessment of Residents with Dementia was less comprehensive. Records indicated that the dementia diagnosis was not necessarily established to assist staff in understanding the conditions or give them awareness of the likely progression of the dementia. Although some information had been gathered, at the point of assessment, on individual Life Histories the information was limited and had not been utilised to develop strategies for supporting individual Residents. Contracts are provided to all Residents with copies maintained on individual Residents files. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 & 10 Care Plans did not cover all areas of need nor provide detailed instructions for staff on how the care and support was to be carried through, particularly in respect of Residents with Dementia. EVIDENCE: It is acknowledged that the care planning formats have been reviewed to provide increased information for staff. However the inspection of two care plans showed a variance in the level of information, instruction and guidance for staff on how the care was to be provided. Physical needs were generally detailed although some elements of personal care were omitted for example Hair, Denture or foot care. The timings for routines were not always listed, for example rising times, to guide staff in Residents preferred lifestyle preferences. It was clear that Staff responded quickly to Residents health care needs and referred concerns to relevant Medical and ancillary Medical Professionals such as Opticians and Chiropodists. Records were maintained of visits. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 12 There were no references as to the emotional support to be given to assist new Residents to settle into their placements. There was no guidance for staff on the management of Residents finances, which is particularly important for Residents with Dementia, for example there was no guidance as to whether Residents could have access to their monies or to the support they required to manage their finances. Individual Dementia care plans have not been developed to guide staff on how to deal with memory loss, frustrations and behaviours. Records did not show that reviews of the care plans were carried out on a monthly basis. Discussions were held with the Manager on ensuring that any changes in need are fully recorded on the care plans with new instructions given to staff. It was clear from observations made and Residents’ comments that staff provide good basic care. However the lack of instructions on care plans has the potential for areas of care to be missed. Further development work is needed to ensure a holistic approach and to develop Dementia care plans. Observations confirmed that staff ensured the protection of Residents’ dignity and privacy by carrying through personal care tasks in private. The Home’s Medication system and records were in good order. Storage was safe and appropriate and included two medication trolleys and a medication fridge. The required incoming, administration and disposal records were well maintained and in good order. Instructions were in place for the use of PRN Medications. No controlled drug held, the Manager is aware of the required recording procedures should this become necessary. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The programme of activities is still limited particularly for Residents with Dementia. EVIDENCE: Residents confirmed that they had choice in where and how they wished to spend their time. They stated that routines were relaxed and flexible and took account of their personal preferences. Residents felt that the activity programme was could be improved. It is acknowledged that a senior member of staff has responsibility for the activity programme but this remains limited. This is an area in need of further development, in consultation with Residents, to ensure they are enabled and supported to pursue their hobbies and interests. Consideration should be given to developing 1 – 1 programmes and group activities taking account of appropriate sizes of groups. There is a need to provide training for staff in order to develop meaningful activity programmes for Residents with Dementia taking account of their interests, preferences and abilities. Reminiscence is used as the main activity but consideration should be given to individual as well as group activities and to providing 1 – 1 quality time. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 14 The Home has an open visiting policy and Residents confirmed that they are able to receive their visitors in private if they wish. Residents spoke very positively about the food provided. They felt that their likes and dislikes were respected, that they were given more than enough to eat and were provided with choice including additional alternatives to tempt their appetites. The quality of the food was said to be good. The evening meal of sandwiches and cakes was viewed as well presented and offered a good range of choices. The Kitchen was in good order and hygienically maintained. However the Manager stated that the Environmental Health Office had expressed concerns that the building works to the new Kitchen should now be completed and the transfer to the new location made as soon as possible. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 15 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 & 18 The Home’s Complaints Procedure ensures that any complaints are listened to, investigated and acted upon. Staff do not have sufficient training and understanding in the Protection of Vulnerable Adult procedures. EVIDENCE: The Home has a complaints procedure, which is made available to all Residents, their Relatives and Representatives. Residents spoken with felt they had confidence to raise any issues of concern with staff. A record of complaints is maintained. There have been three complaints since the last Inspection, two concerning inappropriate communication by staff and one on the décor of a Residents room. The record showed that 2 complaints had been investigated, resolution sought and action taken where necessary. The third complaint is currently in the process of being finalised. The Manager stated that training for staff in the Protection of Vulnerable Adults Procedures had been provided however discussions with staff did not confirm their full awareness and understanding of the procedures although they were clear that they would report allegations to the Manager. Whilst they were aware of the types of abuse that can occur they did not recognise that Resident-to-Resident abuse can occur. This is an ongoing area for development. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 16 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, 21,22, 23, 24, 25 & 26 The lack of progress in completing the building work continues to have an adverse effect on the running of the Home and it’s overall appearance is poor. The work should now be completed to provide Residents with a comfortable, pleasant and well-maintained environment. EVIDENCE: There is serious concern at the lack of progress in completing the building work to the Home. The works have been on going for three years and are still far from complete. The Commission discussed the urgency for the completion of this work with the Company’s Responsible Individual in the summer of 2005. Further discussions were held with the Responsible Individual on this Inspection. Access to the Home is severely restricted through the front door entrance only. There is no safe access from the side of the home, this area is temporarily ramped. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 17 The first floor extension is still in need of considerable work. The new Kitchen and Laundry has not been completed. It is acknowledged that some work has been carried out to provide a safe garden area for Residents. However the work has not been carried out in full by the agreed date of June 2005 and one fencing panel is yet to be erected to enclose and secure the area for Residents with Dementia. There has been a failure to fit radiator guards in the Cottage annex by the agreed date of 31st July 2005. The guards having been purchased and are available at the home but have not been fitted. Redecoration work to the Lounges, first and ground floor corridors and some bedrooms has been carried out with new carpeting provided. Night lighting has been fitted to the corridors. New easy chairs have been provided for Residents Bedrooms. Old and ripped dining chairs were found in some Residents’ rooms. The Manager took immediate action to have them removed and disposed of to ensure Residents were not at risk from skin abrasions. Many areas of the Home are still in need of redecoration. It is of concern that where alterations have been made in Residents rooms the work has not been finished off nor have the areas been redecorated. Pipe work in a number of en suites remains exposed; holes in walls have not been attended to, plasterwork has not been repaired and redecorated. Some vanity units are in need of replacement as the chipboard is exposed and crumbling. The entrance Hall is in poor decorative order. One of the double doors to the en-suite in Room 8 is badly warped and cannot be closed. The existing bathrooms are in need of redecoration. The en suite facilities do not have alarm calls. It is acknowledged that a new system is to be installed and the wiring has been fitted but the work still requires completion. There was no bolt or lock on the Hot Water Cistern cupboard with a potential risk that Residents could access excessively hot pipe work. This was rectified during the Inspection with a bolt fitted at high level. Thermo static controls valves are fitted to all hot water outlets used by Residents to prevent the risk of scalding. It is acknowledged that the Manager has taken precautions to monitor the premises to ensure general safety whilst the work is carried out. However the morale of Staff is affected by the ongoing difficulties of managing the situation. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 18 The staff are to be commended for the good levels of domestic and hygiene maintenance considering the difficult circumstances they are working in. Appropriate aids and specialist equipment are obtained where necessary. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Recruitment practices do not protect Residents and Staff training is inadequate to meet Residents needs. EVIDENCE: The Home has a stable staff group with sufficient numbers employed to maintain the rotas, there has been no need to employ any Agency staff. Staff rotas indicated that 4 care staff are on duty on day time shifts from 8am to 10pm, one of whom is deployed to the Cottage annex. 2 waking Night staff provide night care in the main building with a sleeping in carer providing cover at the cottage annex. The Manager and Deputy Manager are on duty during the day from Monday to Friday together with an additional Senior Carer who has responsibilities for the activities programme. In addition the Home employs catering and domestic staff and a Handyman. When the Manager, Deputy or Senior Carer is not on duty one care staff member is designated as Shift Leader. The Staff spoken with were viewed as dedicated, caring and committed to the well being of their Residents. Relationships and interaction between Residents and staff were observed to be very good. Residents stated staff were very supportive and responded quickly to their needs. One newer staff member’s records were inspected. The record showed that two references had been obtained. Whilst it is acknowledged that a Criminal Records Bureau Clearance had been sent for the Manager had accepted a CRB Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 20 from the employee’s last place of employment. He was unaware of current procedures and had not obtained a POVA 1st clearance prior to the staff member starting her induction. The appropriate clearances are now to be undertaken to ensure good employment practice and the protection of Residents. Core training in relation to movement and handling, food hygiene and first aid is updated. An induction programme is in place but the Manager acknowledged that the programme had not been revised in accordance with the Sector Skills Council guidelines. Both induction and foundation training should be revised to ensure the programmes reflect guidelines and timescales. This is an area for on going development. Currently none of the staff have received training in Dementia Care despite previous assurances that this was being arranged. It was evident from discussions with the Manager that his own training is also in need of updating to ensure modern, accepted good practice. Attention also needs to be paid to securing National Vocational Training for staff. Currently only 5 staff hold a qualification, this is well below the expected ratio of 50 . Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The effective management of the Home is affected and compromised by the lack of progress to complete the building work. EVIDENCE: The Manager has a number of years experience in running a care home. He has recently commenced a National Vocational Training Course at level 4 which will update his skills and meet the minimum requirement for registered managers. It was identified and agreed with the Manager that he needs to update his training in Dementia care as soon as possible in order to fully provide for the needs of his Residents, to guide staff and ensure that accepted modern practice is achieved. Whilst it is clear that the Manager strives to run the Home in the best interests of the Residents the ongoing building work means that he has to constantly Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 22 monitor the premises for safety. This detracts from his other responsibilities and duties and has resulted in a lack of development in areas such as training, staff supervision, activity and care plan development. The Company must address the site management of the building work to allow the Manager to concentrate on his responsibilities. Residents stated that the Manager was readily available to them on a daily basis and they felt that they could discuss any worries or concerns and would be assured of his attention. Staff confirmed that the Manager provided them with informal supervision and good support on an on going basis. However they stated, and the Manager acknowledged, that formal supervision was not being carried through regularly. This is an area for further development. The systems for the management of Residents finances were inspected and found to be in good order. There is an audit system for moneys deposited for safekeeping and receipts were maintained for items or services purchased on behalf of Residents by staff. Considering the difficulties encountered by the on going building work the Manager has taken a proactive approach in ensuring the health and safety of his Residents and staff during this process. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 2 3 3 3 2 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 2 Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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. Standard Regulation Requirement Timescale for action 31/03/06 1 OP7 15 (1) & (2) 2 OP12 16 (m) 3 OP18 13 (6) 4 OP19 23 5 OP19 23 (2) (b) & (d) Residents care plans must be developed further to ensure all needs including Dementia care needs are fully recorded with detailed instructions for staff on how the care is to be carried through. The Activities programme is to be developed to include meaningful activities for Residents with Dementia. Further training must be provided for all staff on the Protection of Vulnerable Adults procedures. Written confirmation that this has been completed must be forwarded to the Commission. The Provider must submit a written plan of action with timescales for the completion of the building work. A written plan of action must be submitted outlining timescales for the completion of the redecoration and repair work to existing Residents Bedrooms, bathrooms and hallway. DS0000012786.V274025.R01.S.doc 31/03/06 28/02/06 30/01/06 31/01/06 Glenkindie Lodge Version 5.1 Page 25 6 Op 19 23 (2) (b) 7 Op25 13 (4) (a) 8 19 23 (2) (n) 13 (4) © 9 10 19 29 23 (2) (b) 19 11 12 30 30 18 (1) © (i) 18 (1) © 13 36 18 (2) The missing fence panel must be fitted to the garden area. Written confirmation that this has been completed must be forwarded to the Commission Radiator covers must be fitted to all radiators in rooms used by the Residents in the Cottage annex. Written confirmation that this has been completed must be forwarded to the Commission. This is an outstanding requirement from the Inspection report of 22nd June 2005. Expired Timescale: 31/07/05 The Alarm call system must be fully fitted and operational. Written confirmation that this has been completed must be forwarded to the Commission. The warped door to the en-suite in Room 8 must be replaced. POVA 1st clearance must be obtained prior to any new staff commencing induction and full CRB clearance must be obtained prior to staff working unsupervised or providing personal care to Residents. A copy of the training plan covering the year 2006 must be submitted to the Commission. Dementia Care training must be provided for all Managerial and Care staff working with Residents with Dementia. A plan of action is to be submitted to the Commission showing the stages in which this is to be achieved and confirming the booking of the initial course with names of participating staff. Staff supervision must be increased to 6 times a year. 31/01/06 28/02/06 28/02/06 31/01/06 15/01/06 28/02/06 28/02/06 31/03/06 Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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 Refer to Standard OP3 OP3 Good Practice Recommendations The assessment process should reviewed to ensure an holistic approach to identifying needs with specific attention given to the assessment of Dementia care needs. The use of recognised risk assessment tools should be introduced as part of the Assessment and ongoing care plan reviews to identify and monitor areas such as Nutritional, Skin and Dementia care Risks. Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenkindie Lodge DS0000012786.V274025.R01.S.doc Version 5.1 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. 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