Inspection on 17/10/06 for Godden Lodge

This inspection was carried out on 17th October 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

Godden Lodge 20/02/08

Godden Lodge 02/03/06

Godden Lodge 02/03/06

Godden Lodge 02/03/06

Godden Lodge 15/11/05

Godden Lodge 15/08/05

Godden Lodge 15/08/05

Godden Lodge 23/02/05

Godden Lodge 09/08/04

Godden Lodge 22/01/04

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

CARE HOMES FOR OLDER PEOPLE Godden Lodge 57 Hart Road Thundersley Benfleet Essex SS7 3GL Lead Inspector Carolyn Delaney Unannounced Inspection 08:00 17 & 18 October 2006 th th 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 Godden Lodge DS0000015536.V316601.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. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Godden Lodge Address 57 Hart Road Thundersley Benfleet Essex SS7 3GL 01268 792227 01268 565474 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) www.bupa.com BUPA Care Homes (CFHCare) Limited Mrs Sunita Warner Care Home 120 Category(ies) of Dementia (60), Dementia - over 65 years of age registration, with number (60), Old age, not falling within any other of places category (120), Physical disability (10), Terminally ill (10) Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. People who have a diagnosed physical disability to be nursed on Cedars House only. People who have a diagnosed Terminal Illness to be nursed on Cephas House only and be aged over 40 years. People who have a diagnosis of Dementia to be nursed on Boyce and Murelle House only. 2nd March 2006 Date of last inspection Brief Description of the Service: Cephas House is one of four houses, which make up Godden Lodge. Cephas House provides nursing care for up to a maximum of thirty older people, including up to a maximum of five people who have a diagnosed Terminal Illness. The house provides each resident with their own bedroom and access to clean, comfortable and well maintained communal areas including a combined lounge and dining area and garden space. Godden Lodge is situated close to bus routes to Southend and Rayleigh and local shops and amenities. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced Key inspection carried out on 17th & 18th October 2006. Lead inspector Carolyn Delaney carried out the inspection. As part of the inspection process a number of the Commissions ‘ Have your say about..’ service users questionnaires were posted to the home prior to the inspection visit and four residents responded. In addition a further ten residents living at the home were spoken with during the inspection visit. A number of resident’s relatives were contacted by post so as to offer them the opportunity to make comments about the services provided by the home. At the time of completing this report fourteen of these people had responded. A number of general practitioners and social professionals were also contacted for their views about the home. Two of the four responded. The comments and views of residents and those people who responded to questionnaires have been used in conjunction with the findings of the inspection visit so as to make a judgement about the level of services provided by the home and have been included throughout the report. Records including assessments, care plans, daily care notes, and medication records and risk assessment documents in respect of people living at the home were examined. Residents and relatives were spoken with during the inspection A number of staff and the homes manager were spoken with and a number of records including duty rota’s and staff recruitment files were examined. A tour of the premises was carried out. Key standards as identified in the intended outcomes sections of this report are inspected at each key inspection. Key standards are identified for each section of the report. Where other standards have not been assessed these will have been assessed at previous inspections. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? As each of the houses in the home were assessed separately and individual reports were written in respect of the findings of the inspection it is not possible at this time to complete this section of the report. Godden Lodge DS0000015536.V316601.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. The summary of this inspection report can be made available in other formats on request. Godden Lodge DS0000015536.V316601.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 Godden Lodge DS0000015536.V316601.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 3 & 4 were assessed for this outcome area. These standards were assessed on each of the four houses (Cephas, Cedars, Boyce & Murrelle). Persons are only offered a place at Godden Lodge once suitably qualified staff has carried out a detailed assessment of their nursing and general care needs. However, a number of persons were accommodated in houses within the home where their needs would not be best met. EVIDENCE: Each of the twenty-five residents or their representatives who completed ‘Have your say about…’ surveys said that they had received a contract and that they had received enough information about the home so that they could decide if it was the right place for them. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 10 A sample of assessments in respect of the nursing needs of prospective residents were examined for people who have moved into each of the four houses since the last inspection. Documents were well written with each person’s nursing and general needs well documented. There was evidence in some instances that the resident or their family had been involved in the assessment process. However, on arrival at Cephas house on the first morning of the inspection a resident complained to the inspector that another resident has ‘been calling out all night and kept her awake’. On assessing the care documents for the ‘noisy’ resident it was noted that this residents needs would be better accommodated if they were living on one of the houses which provides care for people who have dementia. It was also noted that one of the residents living on Cedars House has also been diagnosed with dementia and should have been offered a place on either Boyce or Murrelle house. However it was clear that following a review of this persons care carried out with their social worker and family that Cedars House was meeting this person’s needs ands that their family were happy with the care provided by Cedars house. Following this inspection visit a resident’s relative contacted the Commission because the homes manager wanted to move the resident from one of the houses, which provide care for people who have dementia to another house where a better range of activities could be provided. The relative informed the Commission that the resident had been diagnosed with dementia. In accordance with the conditions of registration for the home people with dementia must be accommodated on either Boyce or Murrelle house only. Godden Lodge DS0000015536.V316601.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 7, 8, 9 & 10 were assessed for this outcome group. These standards were assessed on each of the four houses (Cephas, Cedars, Boyce & Murrelle). Information about residents needs was generally found to be well written and kept under review. However staff do not always act in accordance with the planned care and some staff could pay more attention to the personal care and hygiene needs of residents who are not capable of maintaining these needs independently. Godden Lodge has detailed policies and procedures in respect of the receipt, storage, administration and disposal of medicines. However some serious failings in respect of nursing staff practices were observed on one of the two houses where this standard was assessed. EVIDENCE: Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 12 Of the twenty-six residents or their relatives who completed ‘Have your say about…’ surveys nineteen said that they always received the care and support that they need, three said that they usually did and four said that they sometimes did. Each of the fourteen relatives who completed comment cards said that they were kept informed of important matters and that if the resident was not capable of making decisions about their care and treatment that relatives were consulted about the care and treatment provided. One healthcare professional and two general practitioners completed and returned comment cards. One of the general practitioners who commented said staff at the home do not always communicate clearly and work in partnership with him and that there was not always a senior member of staff to confer with. He also said that on occasions when staff contacted the surgery to request a visit that they were very vague when describing the condition of residents and used phrases such ‘resident doesn’t look well’ or that they ‘are leaning backwards’ which didn’t give an accurate indication as to the problem being experienced by the resident. The one healthcare professional who completed a comment card also indicated that there was not always a senior member of staff to confer with. However that generally staff are ‘helpful’. Care plans and risk assessments for two people living on Cephas & Cedars house were assessed. These were very well written and detailed in respect of the nursing and general needs of each resident. Where risks had been identified in particular risks to residents of developing pressure sores there was clear and detailed information recorded as to how these risks might be minimised so as to safeguard the welfare and safety of the person. It was noted that some of the residents on Cedars house had dirty nails and teeth. It was also noted that for one resident who received oxygen therapy via a mask that the mask was very dirty. Three residents and two relatives were spoken with on Cedars house. Each person who was spoken with indicated that they were happy with the care provided by staff. Care plans and risk assessments for two residents who were living on Boyce house were assessed. In general these were very well written and reviewed on a regular basis. However where it was identified for one resident that they could become agitated and that he had difficulty in communicating there was very little information recorded as to any situations which may trigger agitation or how his need were to be met by staff. Three relatives who were visiting Boyce house during the inspection were spoken with and each said that they were generally happy with the care provided by staff. However two relatives commented that care ‘was not as good’ when the senior nurse for the house was not on duty. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 13 Care plans for three residents living on Murrelle house were assessed. These were well written with detailed information about the persons physical and mental health needs. Care plans and risk assessments were reviewed on a regular basis. Two residents on Murrelle house were noted to have dirty nails and were wearing stained clothing and a number of residents did not have footwear. Two relatives who were visiting Murrelle house during the inspection were spoken with. Both said that they were satisfied with the care and treatment provided by staff. Medication was assessed on two houses, Cedars and Murrelle. It was noted that on both houses that medicines were administered to residents at the appropriate time. Records including Medication Administration Records (MAR) were sampled and assessed on both houses. There were no errors or omissions noted in the records assessed on Murrelle house. However, some serious errors were noted on Cedars house. It was noted that for a period of nine days that staff had administered a morphine based medication to a resident three times per day instead of twice daily as prescribed. The home has a policy and procedure for auditing records in respect of medication, however, staff on Cedars house had on numerous occasions failed to act in accordance with these procedures. A letter detailing the serious concerns raised at this inspection was sent to the registered provider and a response had been received at the time of writing this report. A further visit may be made to the home so as to ensure that staff working at the home administer medicines in a safe manner in accordance with the homes policies and procedures. Godden Lodge DS0000015536.V316601.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each of the above standards were assessed for this outcome group. These standards were assessed on each of the four houses (Cephas, Cedars, Boyce & Murrelle). Activities are not provided by the home which meet the needs and wishes of the people living at the home. Some staff working at the home do not interact with residents in a positive and effective way. Residents relatives and friends can visit and maintain regular contact with residents. The home provides a range of meals which meet the needs and wishes of the majority of people living at the home, however, more could be done on some of the houses to improve the dining experience for residents. EVIDENCE: Of the twenty-five residents or their representatives who completed ‘Have your say about…’ surveys fourteen said that staff always listened and acted on what Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 15 they said, seven said that staff usually did and four said that staff sometimes did. During the two days of the inspection there was very little in the way of social, recreational or occupational activities provided for the residents living at the home. Two of the relatives who were visiting residents on Boyce House commented that there had not been activities provided in the house for some time. The senior nurse on Murrelle house said that there was an activities coordinator allocated to the home for three days per week, however, recently the activities coordinator had been spending one of the three days allocated providing support to Boyce house. Staff on Cedars house were observed to spend time interacting with residents and supporting those who are capable to participate in occupational activities. However, on each of the other three houses residents were left for long periods without any form of stimulation. Since the inspection a person who has a relative living on Boyce house contacted the Commission. The homes manager wished to move the resident to another house where there were more activities provided. In the past the inspector has been informed that residents are supported to participate in activities organised and held in other houses. However, there was no evidence that this occurs in practice and the person who contacted the Commission was informed by staff that they could not facilitate this due to lack of available staff. Of the fourteen residents relatives who completed comment cards one commented that there was not enough suitable stimulation for those residents who are mentally alert. Each of the fourteen residents relatives who completed comment cards said that they were welcomed into the home and that they could visit their relatives / friends in private if they wished. The majority of the residents who were spoken with during the two days of the inspection commented positively about the food provided by the home. Some residents felt that there could be more choice and said that there were a lot of ‘casseroles and stews’. On the days of the inspection residents were offered a choice of meals and there were alternatives to the menu such as jacket potatoes and salads available. Residents were offered regular hot and cold drinks throughout the day. Meals were observed on Cephas, Cedars and Boyce houses. Staff on Cedars house were noted to assist residents in a positive manner, promoting independence in the more able residents and offering support for those who are less capable. The meal was served in an ambient setting and tables were laid nicely which made for a more homely athmosphere. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 16 It was noted that residents on Boyce house were not offered a starter course as per the homes menu. The experience for people living on Cephas house could be enhanced if tables were laid more nicely so as to provide a more homely and ambient setting. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 16 & 18 were assessed for this outcome group. These standards were assessed on each of the four houses (Cedars, Cephas, Boyce & Murrelle). Godden Lodge has a detailed policy and procedure for dealing with and responding to complaints. At the time of this inspection there was evidence that complaints were being dealt with in an appropriate manner in accordance with the policy and that staff practices did not generate an undue number of complaints. Staff are provided with training and information in respect of the protection of vulnerable people who live at the home. Both residents and their relatives indicated that they were happy with the care provide by staff. EVIDENCE: All but one of the residents who completed the ‘Have your say about…’ survey said that they were aware of how to make a complaint and many indicated that they had never had cause to make a complaint. Of the fourteen residents relatives who completed comment cards eight said that they were not aware of the home’s complaints procedure. Of this eight one said that they had cause to complain. Of the remaining six people who completed comment cards and who said that they were aware of the Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 18 complaints procedure one said that they had cause to complain. Both general practitioners who completed comment cards said that they had not received complaints about the home. The healthcare professional who responded indicated that on occasions there had been a need to raise issues of some concern, however, these were ‘easily rectified after discussion with management’. There has been a reduction in the number of concerns and complaints made in respect of the home. One complaint was made to the Commission since the last inspection. A member of medical staff at Southend General Hospital Accident and Emergency department made this complaint. The complainant was concerned that a terminally ill resident was sent to hospital when in their opinion the person should have been cared for by staff working at the home. It was also alleged that the member of staff who accompanied the resident was unaware of the resident’s condition and reason for transfer to hospital. The complaint was referred to BUPA’s operations manager to investigate and to respond to the complainant. The complaint was investigated promptly and it was found that it was the resident’s family wish that the resident be sent to hospital. It was found that while detailed information was sent with the resident that the nurse accompanying the resident did not know the resident well and therefore may not have been able to answer any specific questions in respect of the residents health etc. There is a running programme to provide training and regular updates for staff in respect of the protection of vulnerable people from harm and abuse. There have been no allegations of abuse of vulnerable people who live at the home and a number of residents and their relatives who spoke with the inspector or who completed comment cards and surveys were complimentary in respect of the care provided by staff and how residents were treated. Three relatives commented about the level of care provided by staff. One said ‘we are very happy with the care my grandmother receives. She seems very ‘at home’ and `comfortable’. Another commented ‘we are very happy with the care Mum receives and the sister in charge is excellent’. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 19 & 26 were assessed for this outcome area. These standards were assessed on each of the four houses. More could be done in some areas so as to provide a more homely environment for residents who live at the home. There has been an ongoing issue about odours on Murrelle House and this has not been addressed satisfactorily. EVIDENCE: Godden Lodge is a purpose built home which provides accommodation in four houses. The premises are homely in nature and communal space is provided in the form of lounge / dining room. There is a programme for renewal and redecoration. Stained carpets were noted in some communal areas and residents bedrooms and more could be done in terms of decoration to make Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 20 the communal areas more homely particularly on Cephas and Murrelle House. In particular Murrelle House does not look homely or inviting. Of the twenty-five residents or their representatives who completed ‘Have your say about…’ surveys sixteen said that the home was always fresh and clean, six said that it usually was and three said that it sometimes was. There were stale and unpleasant odours detected in areas of Murrelle House. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All of the key standards were assessed. Staffing levels while in accordance with the agreed minimum levels are not always sufficient for meeting the needs of the people who live at the home. Staff are recruited and trained so as to ensure that residents living at the home are cared for by suitable and skilled staff. EVIDENCE: The duty rotas assessed on each of the four houses indicated that the agreed minimum staffing levels were employed in the home. However a number of residents, their relatives and healthcare professionals indicated in their responses that staffing levels are not always sufficient for the needs of the people living at the home. Of the twenty-five residents or their representatives who completed ‘Have your say about…’ surveys ten said that staff were always available when needed, six said that staff were usually available and three said that staff were sometimes available and one said that staff were never available. Of those who said that staff were not always available some indicated that they had to wait for staff to assist them to the toilet etc because staff were too busy. One resident said that ‘ at times staff are very busy but they get to you as soon as they can’. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 22 Healthcare professionals who completed surveys indicated that there was not always senior staff available to confer with when they needed to. Of the fourteen residents relatives who completed comment cards eleven said that in their opinion there were always enough staff and the other three said that there were not. Some resident’s relatives commented that staff turnover was an issue and that some staff were difficult to understand as English was not their first language. Staff recruitment files were assessed for three members of staff who had been recruited to work at the home since the last inspection. There was evidence that staff are recruited according to a consistent and robust process, with all of the checks including references, Criminal Records Bureau disclosures being obtained prior to a person commencing work at the home. Interviews were carried out for all candidates so as to determine their suitability to work at the home. The home has a detailed induction process, which all staff undergo once they commence employment at the home. The home has a detailed training programme covering both mandatory training such as safe moving and handling, fire safety, and the protection of vulnerable people as well as more specialised training. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35 & 38 were assessed for this outcome group. Godden Lodge is well managed and resident’s interests are safeguarded. EVIDENCE: Godden Lodge is generally well managed. The registered manager is supported by heads of home for each of the four houses who manage the daily running of the houses and report to the homes manager. The majority of residents and their relatives said that they are satisfied with the care provided by the home and many made very positive comments about the home and the staff who work there. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 24 Residents living at the home may retain their monies and valuables; alternatively the home will hold monies on behalf of residents. The home employs maintenance personnel so as to ensure that the repairs and maintenance including decorating are carried out as needed. Records are maintained which evidence that electrical, gas, fire and mechanical systems and equipment are kept in good order. Throughout the inspection there were no health and safety issues in respect of premises or equipment noted. Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 26 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. OP4 OP3 Standard Regulation 14 Requirement The registered persons must ensure that people are accommodated in the houses, which will best meet their individual needs and that all admissions are in accordance with the conditions of registration for the home. Timescale for action 15/02/07 2 OP7 OP8 12 13 15 3. OP9 13(2) The previous timescales for this requirement of 15/03/06 & 15/12/06 have not been met. The registered person must 15/03/07 ensure that staff record sufficient information about each persons nursing and care needs and that staff act in accordance with this information so as ensure that residents receive proper care and attention. The registered persons must 15/02/07 ensure that all staff adhere to the homes policies and procedures in respect of the administration of medicines so as to ensure that residents receive the medicines, which have been prescribed for them in the correct dosage and at the correct DS0000015536.V316601.R01.S.doc Version 5.2 Page 27 Godden Lodge frequency. Elements of this Requirement are outstanding and have not been met since the last inspection. The previous timescale for action 15/03/06 has not been met. 6. OP10 OP14 7. OP12 16(m) (n) 12 The registered person must ensure that all staff act so as to ensure that resident’s personal care needs are met. The registered persons must ensure that a range of stimulating and occupational activities are provided at such times as meets the wishes of the people living at the home. Elements of this Requirement are outstanding from the last two inspections and the previous timescale of 30/04/06 has not been met. 8. OP26 16(2) (k) The registered persons must ensure that appropriate action is taken so as to dispel odours within the home. The registered persons must ensure that staffing levels are appropriate to the needs of the needs of the people living at the home and that staff act in accordance with the homes policies and procedures. 30/03/07 28/02/07 28/02/07 9. OP27 18 30/03/07 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 Good Practice Recommendations DS0000015536.V316601.R01.S.doc Version 5.2 Page 28 Godden Lodge 1. Standard OP15 The provision of condiments and sauces at mealtimes would improve the experiences for the people living on Cedars House. More could be done so as to make some parts of the home more homely and comfortable particularly on Cephas and Murrelle house. 2 OP19 Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Godden Lodge DS0000015536.V316601.R01.S.doc Version 5.2 Page 30 - 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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