Inspection on 18/02/08 for Groby Lodge

This inspection was carried out on 18th February 2008.

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

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

Other inspections for this house

Groby Lodge 08/10/08

Groby Lodge 17/10/06

Groby Lodge 26/10/05

Groby Lodge 09/08/05

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

CARE HOMES FOR OLDER PEOPLE Groby Lodge 452 Groby Road Leicester Leicestershire LE3 9QB Lead Inspector Thea Richards Unannounced Inspection 18th February 2008 10:00 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 Groby Lodge DS0000063629.V360080.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. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Groby Lodge Address 452 Groby Road Leicester Leicestershire LE3 9QB 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) 0116 2855868 0116 2547343 pineviewcarehomes@ntlworld.com Pine View Care Homes Ltd Mr Dinesh Raja Care Home 12 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (12) of places Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To be able to admit the named person in the category PD(E) subject of variation application V22846. Service User numbers: No one falling within category DE(E) may be admitted into Groby Lodge where there are 3 persons of category DE(E) already accommodated within Groby Lodge Service User Numbers No one falling within category OP may be admitted into Groby Lodge where there are 12 persons of category OP already accommodated within Groby Lodge Service User Numbers No person to be admitted to Groby Lodge in categories OP or DE(E) when 12 persons in total of these categories/combined categories are already accommodated in Groby Lodge. 17th October 2006 3. 4. Date of last inspection Brief Description of the Service: Groby Lodge is a converted property in a residential area situated on the A50 close to Glenfield Hospital. Access to Groby Lodge is via a slip road off the A50 It is easily accessible by car or public transport and there is parking at the front of the home. It is a care home providing personal care and accommodation for 12 older people with a physical frailty and/or mental health needs. Pine View Care Homes Ltd owns the home together with two other homes in the area. The Registered Provider Mr Dinesh Raja is registered as the manager. There is large lounge and dining room, which overlook the garden. There are double doors, which can be used to divide the room into two separate rooms. The bedrooms are on the first floor, most of which have en-suite facilities. The bedrooms can be accessed by the stairs or the passenger lift. In the garden there is a large paved seating area where the residents will be able to sit in the better weather when the new furniture is bought. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 5 The current registration certificate from the Commission for Social Care Inspection is displayed in the reception area. The latest report is available in the manager’s office. The home can be contacted by telephone or fax. The current level of fees is between £330:00 and £360:00 per week. There are extra charges for hairdressing, chiropody, newspapers and personal items. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 Star. This means that the people who use this service experience good quality outcomes. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection), spent five hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 17th October 2006. The visit took place on the 18th February 2008 and lasted six and a half hours. During the visit we checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that we looked at the care provided to two of the residents. To achieve this, the residents were spoken with. We spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission the residents’ bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit we spoke with the registered provider/manager, the area manager, the care manager, the staff, the residents and families. What the service does well: Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 7 There is a thorough admission process that makes sure that the resident can have all their needs met in the home. There are well -documented care plans that are regularly reviewed with the resident, family and key-worker. The staff are well trained to give the care to the residents that they would expect. A comment from a resident; ‘ The staff are excellent’ The care plans identify the past lives and interests of the residents, which helps the staff to continue those interests with them if they wish them too. What has improved since the last inspection? What they could do better: The results of the quality audit could be put into the Statement of Purpose to give prospective residents a better idea of what other residents and families think of the home. This will help them in making their choice of home. With their permission photographs of the residents could be put on the front of the medicine administration records (MAR). This will help the staff, particularly new or agency staff to identify the resident and avoid possible mistakes being made. There could be a signature sheet for the staff so that their signature on the MAR sheets can be easily identified when medicines have been given. The complaints record should always be completed, so that there is a complete record of how the complaint has been handled and resolved. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 8 The home should make sure that the home remains free from unpleasant odours, to give the residents a more pleasant environment to live in. The walls in the kitchen should be thoroughly cleaned to make sure that there is no risk when the residents’ food is prepared. The old and badly stained carpets should be replaced to provide a more pleasant environment for the residents. There should be an alternative storage area found for the carpet cleaner and wheelchairs to protect the residents and the staff from harm in the bathroom. The staff records should contain all the documents required by the Care Homes Regulations to make sure that the staff that are employed are suitable to work in a care home. The management structure in the home could be made clearer to the residents and their families so that they know who to go to discuss any issues that they might have. 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. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 9 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 Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using the available evidence. The residents’ needs are assessed and agreed with by the resident or their families before moving into the home, which they are able to visit before their admission. The staff are aware of the residents needs before they move into the home. EVIDENCE: The residents whose care plans were checked had all received a Statement of Purpose and a Service Users guide. The Statement of Purpose and Service Users’ Guide provide all of the required information about the services offered and the Terms and Conditions that apply, making sure that they can get the most suitable care. These can be made available in other formats such as large print to make sure that as many people as possible can understand them. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 11 Consideration should be given to including the results of the annual quality questionaire so that prospective residents can read the comments from the residents and their families. This will help them in making a decision about the home. Completed assessments were present in the files, identifying the residents’ care needs, before they were admitted to the home. Care plans showed that they contained the needs of the resident which had been identified in the original assessment. The staff spoken with said that they knew what the resident’s needs were before they were admitted to the home. All of the care plans seen had been agreed by the residents or their families. The residents and a family spoken with told us that they had a visit from a member of staff from the home before they were admitted. They confirmed that they were given the opportunity to visit the home before they came in. These practices make sure that that the staff in the home have the the right information before the resident and that they can meet their needs. It also makes sure that the resident meets someone from the home who they can recognise, which makes the move into care easier to manage for them. The current registration certificate from the Commission for Social Care Inspection (CSCI) and up to date details of insurance cover are displayed in the entrance of the home. The reports from the CSCI are available in the manager’s office. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The staff meet the care and medication needs of the residents as identified in the care plans with privacy, dignity and respect. EVIDENCE: The care plans for the ‘case tracked’ residents were found to contain good individual evidence of care, which reflects the care being given to the residents. The care plans include a regular assessment of the residents’ weight and their nutritional needs. There are records of the involvement of G.P.s, chiropodist, optician and dentist present, giving evidence of thorough health care being provided for the residents. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 13 The residents and the family spoken with said that they were happy with the medical care that was being given. The home has recently put a new system of care plans in place that has made the residents needs and the care to be given much clearer for the staff. This makes sure that the residents get the right care. There was documentary evidence in place that consideration had been given to The Mental Capacity Act, which considers the residents’ ability to make decisions and to protect their rights. The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. Medication records for the case tracked residents were in order. In this home medicines are only administered by the care manager or senior care staff who have had medicine training. Staff were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The manager completes monthly audits of the medication records to make sure that they are accurate. The above makes sure that the residents are protected with the correct medicine administration. The residents spoken with were happy that they got the right medicines at the right times. The controlled (dangerous) drugs records were checked and found to be correct. With their permission the manager should put photographs of the residents on the front of the medicine administration records. This would reduce any risk of mistakes being made, particularly if there was a new or agency member of staff on duty. The manager should put in place a signature record for the staff so that signatures can be identified easily when medicines have been given. There is a policy and risk assessment in place for the residents who look after their own medicines. There are no residents taking their own medicines at this time. The staff were seen to be sitting with the residents helping them with their lunch and sitting talking with them in the lounge area. When the staff were giving care and speaking with the residents they were seen to be doing so with dignity and respect. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 14 The residents spoken with were happy with the way staff treated them and said that they were very kind. A comment from a resident was: ‘The staff are excellent’ Families spoken with on the day of the visit were very happy with the level of care being given and confirmed that they had been involved in reviewing and agreeing their relatives care needs. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. Residents have their social, spiritual and nutritional needs met. EVIDENCE: There was evidence of activites being provided for the residents with games seen in the dining room, however there was no organised activity on the day of the visit. The television was on loudly throughout the visit. Some of the residents said that they were watching it, but most weren’t and some left the room to go to their bedrooms. This could result in some residents becoming isolated if the staff don’t offer alternatives to the television. We saw the staff spending some time talking with the residents and families. The residents are taken out, either individually or in small groups to local facilities such as the park, the local shops, café and pub, which makes sure that they remain part of the local community. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 16 The residents and the families spoken with felt that there were enough appropriate activities provided. The home has developed a profile of the residents past life and interests so that they can continue with their interest if they wish to. There is a choice of two main meals available every day and diabetic meals are provided. We spent time with the residents at lunchtime in the dining room and all of the residents said that they were enjoying their meal and that they could have a choice of meal. One resident had her pudding changed three times before she was happy with her choice. The dietary likes and dislikes are recorded in the careplans together with weight charts which makes sure that weight gain or loss can be checked. Visitors are made welcome in the home. This was confirmed by visitors spoken with who told us that they were made very welcome at any time. We saw the warm and friendly welcome given to visitors when coming into the home. The care manager sees each of the residents on a one to one basis every day. There are annual quality audits to get the views of the residents and their families. These practices make sure that the residents maintain contact with the community and their families and that views for improvements can be considered. There is a church service held in the home every month with special services for times such as Easter, Harvest and Christamas. The home will arrange for people of other faiths to have their religious needs met. There are currently no residents in the home with different cultural or ethnicity needs. The hairdresser visits the home every fortnight, which the residents enjoy. Groby Lodge DS0000063629.V360080.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): 16, 18. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to if they needed to. This can be made available in a large print , which makes sure that as many people as possible can read it. Every resident has a copy of the policy in their bedroom. There is thorough form for recording complaints, however it was not being fully completed. This means that there is no record of how the complaint was resolved or the date or a signature to say who had investigated it. The home has received two complaints since the last inspection on 17th October 2006, both of which had been resolved satisfactorily. The Commission for Social Care Inspection have not recived any complaints since the last inspection on 17th October 2006. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 18 The residents spoken with were happy that they would speak to the manager or a member of staff if they had a problem and that it would be dealt with. All the staff have had training in ‘Safeguarding Adults’. The staff spoken with were aware of the procedure to follow and would be prepared to ‘whistle blow’ if they thought there was a need to. They were aware of how to handle a complaint that was given to them. This makes sure that the residents are safe from any abuse and that any concerns are handled correctly. Groby Lodge DS0000063629.V360080.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): 19, 21, 23, 24, 25, 26. Quality in this outcome group is adequate This judgement has been made using available evidence including a visit to the service. The residents are protected by the policies and procedures in the home to provide a safe environment. There are areas in the home, which could be improved to provide a more pleasant environment for the residents to live in. EVIDENCE: Groby Lodge is a converted property in a residential area on the A50 close to Glenfield Hospital. The atmosphere in the home was welcoming when we went in and the home appeared to be clean. There was however an unpleasant odour in the reception area and in some of the bedrooms. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 20 There should be a dedicated cleaner in the home so that the care staff will no longer have to do the cleaning. The manager says that he is advertising for one. This will give the staff more time to spend with the residents and reduce the risk of any cross infection with the staff undertaking care and cleaning duties. There is a lounge/dining room, which can be divided with double doors. This room has been redecorated and provides a pleasant environment for the residents to sit in. The carpets in parts of the home were worn and in some areas badly stained, consideration should be given to replacing them to provide an improved environment for the residents. There was a new shower/wet room, but it was being used as storage for the carpet cleaner and for wheelchairs. Alternative storage space should be found as these items could present a hazard for the residents and the staff. Both the bathrooms seen contained some toiletries, which could be a hazard for the residents if someone who is confused drank them. They could cause cross infection if used for more than one resident. This was shown to the manager, who had the items removed before the end of the visit. With their permission, we looked at the case tracked residents bedrooms. The bedrooms were clean and well maintained and the residents had been able to bring their own belongings in to personalise them. Eleven out of the twelve bedrooms have en-suite facilities of a W.C. and washhand basin. There was evidence of equipment such as hoists and special mattresses having been provided to help in the care and comfort of the residents. The kitchen walls were yellowed and could have a deep clean and/or be redecorated. This would make sure that there was no risk to the residents food when it was being prepared. The last Environmental Health report found there to be no problems in the kitchen. The staff spoken with said that they had received health and safety training for the chemicals used in the home. There was a locked cupboard containing the cleaning products, which keeps them safe. There have been some concerns raised thriugh surveys about the laundry being given to the wrong residents. This has now been resolved with individual baskets having been provided to put it in. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 21 There were no further outstanding safety or maintenance issues seen on the tour of the premises. There is an accessible, pleasant garden outside with a large patio area where the residents will be able to enjoy the better weather. The manager told us that he would be buying some new garden furniture as the old plastic chairs could be unsafe. The group of homes employ a maintenance person and there is an ongoing programme of refurbishment in the home. The registration certificate from the Commission for Social Care Inspection was displayed in the reception area. The current inspection report is available in the managers’ office. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The residents’ needs are met and the recruitment policy and the training programme protect their safety. EVIDENCE: There is evidence of a good skill mix of staff, which makes sure that the residents have the right care. The duty rota reflected the number of staff on duty. The residents, staff and families spoken with felt that there were usually enough numbers of staff on duty to look after their needs. We looked at three staff files and the required information was complete in one of them. This included evidence of identification, adequately completed application forms, two written references and a Criminal Records Bureau (CRB) check. One had the application form missing and the other had the references missing. The manager told us that they had probably been mis-filed when they recently moved offices and that he would find them and send us a copy. These had not arrived at the time of writing the report. The current practice of the home is to make sure that all the required documentation is in place before an employee starts work. This was confirmed Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 23 by the staff spoken with who told us that they could not start until they had all the paperwprk in place. There was evidence of staff training including induction and the staff spoken with confirmed that they had received recent training in moving and handling. Training in the protection of vulnerable adults, basic food hygiene and health and safety had also been given. All of the staff either hold a National Vocational Qualification at level 2 or are in the process of completing it. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents live in a home, which provides for their needs, with safety systems in place and with suitable staff training. EVIDENCE: The care manager was available throughout the visit to the home and the manager arrived a little later. The care manager has worked at the home for some time and was appointed as care manager one month ago. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 25 The Registered Manager, who is the Responsible Person is also the Registered manager for one of the other homes in the group. There has been an area manager appointed who helps with supervision of the staff, paperwork in the homes, pre -admission assessments and helps with the care needs when she has time. The residents, families and the results of the Commission for Social Care Inspections’ surveys showed that the management structure was not always clear. The manager said that he would talk with the residents and their families and put up a ‘picture board’ showing who was who and the management lines. There was evidence seen that supervision for the staff was taking place within the required frequency. This was mainly based on how the member of staff performed a task, more time could be given to talking with staff to make it a two way discussion. The frequency of supervision was confirmed by the records seen and by the staff spoken with. This process should give the staff and their ‘line manager’ the opportunity to have individual discussions about work and training needs. The manager holds regular meetings with the staff and the residents as well as one to one discussions with the residents, both to pass information on and to listen to their views and opinions. There are annual quality questionaires sent out to residents and their families to gain their views about the home. This allows the manager/ responsible person to respond to the residents and the staff’s needs. There is currently only one resident using the residents account. This is handled by the manager and there are always two signatures to confirm any transactions, with receipts to support the expenditure. The residents are well protected by the financial policies in the home. Records for the maintenance of fire equipment and testing of water temperatures were found to be in place and up to date. There are records in place to show that fire drills and fire instruction have taken place. This was confirmed by the staff spoken with. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? 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 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP1 OP9 OP9 OP16 OP19 OP21 OP26 OP29 Good Practice Recommendations The Registered Person should consider putting the results of the quality audit into the Statement of Purpose. The registered manager should arrange to have photos of the residents on the front of the medication administration sheets. The registered manager should put a staff signature record in place. The complaints record should be completed correctly so that an audit trail can be shown. The registered provider should replace the old and badly stained carpets in the home. The registered person should find alternative storage facilities for the carpet cleaner and wheelchairs The registered manager should make sure that the home remains free from unpleasant odours. The registered person must ensure all staff files contain information as set out in schedule 2 of the care homes DS0000063629.V360080.R01.S.doc Version 5.2 Page 28 Groby Lodge regulations 2001. 9. OP31 The registered person should make sure that all the residents, families and any one else involved with the home are clear about the management structure in the home. Groby Lodge DS0000063629.V360080.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Groby Lodge DS0000063629.V360080.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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