Inspection on 18/10/05 for Grosvenor Lodge

This inspection was carried out on 18th October 2005.

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

Grosvenor Lodge 28/09/07

Grosvenor Lodge 30/05/06

Grosvenor Lodge 23/05/05

Grosvenor Lodge 03/02/05

Grosvenor Lodge 28/09/04

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

CARE HOMES FOR OLDER PEOPLE Grosvenor Lodge 40 Old Shoreham Road Hove East Sussex BN3 6GA Lead Inspector Jane Jewell Unannounced Inspection 18th October 2005 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 Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 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. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grosvenor Lodge Address 40 Old Shoreham Road Hove East Sussex BN3 6GA 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) 01273 739739 01273 739739 Mrs M Holliday-Welch Mrs Kim Long Care Home 31 Category(ies) of Dementia (31) registration, with number of places Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtyone (31). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Date of last inspection 23rd May 2005 Brief Description of the Service: Grosvenor Lodge is a privately owned residential home for up to thirty-one older people who have dementia. The home’s provider also owns a further four registered homes for older people within the Sussex area with each home being a standalone business. The home is a large detached property situated in Hove on the main A270. It is located near to local amenities such as shops, cafes and bus routes into Brighton and Hove. The home is presented across four levels, basement, ground, first and second floor with access to the first floor and second floors via stairs or shaft lifts. Resident’s accommodation consists of twenty-seven single and two shared bedrooms, with all rooms providing en-suite facilities. Shared facilities include two lounges, dining room, hairdressing room, conservatory and rear garden. The front garden is mainly paved to provide off road parking. The homes literature states that the home is committed to offer a highly professional care service for the elderly with a personal touch. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which was undertaken between 10am and 2.30pm. The inspection was undertaken with Kim Long (Manager) and in part by Samantha Brown (Regional Manager). There were twenty-nine residents living at the home. The inspection involved a tour of the premises, examination of the homes records, consultation with six staff on duty and nineteen residents. As many residents were not able to verbally share with the inspectors their experiences of life at the home much of the inspection was spent observing residents in their daily routines and interactions with staff. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection reports. The Inspectors would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? A clearer sense of management leadership and direction is evident, this has resulted in residents receiving a more consistent quality of care and has improved residents safety. Changes in the assessments process has ensured that residents are only accommodated who’s needs are able to be met at the home. Greater choice is evident in the routines of daily living, with resident’s individual needs and preferences being taken into account. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 6 What they could do better: Not all medication was being administered in line with policies and procedures and must be addressed to ensure residents safety. Some parts of the environment need the standards of cleanliness addressed. The management of risks associated with exposed hot pipes, falls from windows and safe fire exit routes needs further work to ensure that residents are safeguarded. In response to the draft inspection report, the provided returned to the CSCI an action plan of how they intend to meet the requirements and recommendations made from this inspection. 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. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 The home provides both prospective and existing residents, with a good level of information about what services are provided and what to expect when living at the home. There is a process in place for residents to have a say whether they wish to remain at the home following a trial period. The way in which prospective residents are assessed ensures that the home admits only those residents who’s needs can be met by living at the home. EVIDENCE: A statement of purpose and service user guide sets out the homes aims, objectives, facilities and the terms and conditions of the home. Both these documents are made available to residents and other interested parties and is displayed within the home. Following a trial period at the home, residents are provided with a written statement of terms and conditions of residency. In the interim copies of the homes terms and conditions are included in the homes literature, this helps to inform residents as to the terms at the home prior to moving in. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 9 Records inspected showed that the home had obtained a copy of a care management assessment from the placing authority, and had also conducted its own needs assessment of a recent admission to the home. The manager confirmed an understanding of the categories of care that the home is registered for and interpreting assessment information. The level of information obtained about prospective residents enabled the manager to make an informed decision whether the home could meet their needs. It was evident that the manager is undertaking more stringent assessments of prospective residents. This has resulted in fewer admissions of residents who have high or complex needs. In addition residents whose needs were going beyond that which the home could safely manage have been supported to move to nursing accommodation. Staff stated that fewer residents with complex needs had had a large impact on being able to undertake their roles more effectively. Residents continue to appear relaxed and comfortable in their surroundings. Some residents described their experiences at the home as: “I like living here” “I can relax as I know that I am safe” and “I am happy here”. The home was able to evidence that it can meet most needs of residents who live at the home. Prospective residents and their relatives have an opportunity to visit and assess the quality, facilities and suitability of the home. However nearly all residents consulted said that their relative had visited the home on their behalf. The first six weeks of occupancy is looked upon as a trail period. Where placements are funded by social services this culminates in a review, to establish whether the home is meeting a residents needs. A formal process is also in place for privately funded residents to have a say whether they wish to remain at the home and become a permanent resident. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Care plans provided a good standard of recorded information about each resident. The health needs of residents are well met with evidence of regular input from health care professionals. Improvements are needed to medication management to ensure residents are receiving their required medication. EVIDENCE: Three care plans were examined and these were seen to have been reviewed on a weekly basis and updated monthly. Care plans identified the psychological and physical needs, and to a limited extent social needs of the resident. The personal care needs were set out with clarity and there was evidence of nutritional care plans, weight checks and health issues that could require input from Health Care professionals. Good practices continue to be noted in the use of personal histories, which enable staff to be aware of significant events and individual lifestyles prior to the onset of dementia. It was previously required that the plan of care must have the agreement of the resident or their representative, this was in the process of being obtained for all residents. Where this cannot be obtained, this must be stated. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 11 Risk assessments are in place for manual handling, challenging behaviour and the environment including any actions needed to manage or reduce risks. Records of medical intervention showed that the home works closely with health care professionals including GP’s, District and specialist nurses, chiropodists, opticians and dentists to ensure residents receive the necessary health care intervention. None of the residents accommodated are assessed as safe to administer their own medication. Medication is stored in a clinic room which was clean and well ordered. A shelving unit has been built to house the cases for the method of medication administration used. Drug fridge and clinic room temperatures have been recorded on a regular basis and a small air conditioning unit provided to keep the room at the correct temperature for drug storage. There was evidence of stock control of medication, and controlled drugs were signed for and stored correctly. It is recommended that the controlled drugs are counted at regular intervals, apart from when they are being dispensed. In order to facilitate this, it is recommended that the manager obtains a counter designed specifically for this, which would also prevent unnecessary handling of the drugs. Some members of staff have undertaken an accredited administration of medication course whilst others have received training from the supplying pharmacy. Some medications and prescribed creams had not been signed on administration. Therefore it was not possible to ascertain whether these medicines had been given. An immediate requirement has been made to ensure that the manager addresses this concern. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents are provided with a range of opportunities for occupation and stimulation. The daily routines are now being largely determined by the needs and preferences of residents. Residents generally spoke positively about meals provided. EVIDENCE: In line with previous requirements an activities programme has been displayed. It was discussed that this needs to be made more accessible to residents, namely bigger and easier to read. This is to enable residents, visitors and staff to be aware of planned activities. The home has a cat, and residents were observed enjoying talking about it and petting it. Staff said that they are responsible for undertaking most of the activities organised, which are undertaken during the afternoon. This involved bingo, board games, music and extend classes. In addition musical entertainers and art therapy is also undertaken. There has been a marked shift in the homes practices of promoting choices for residents. This includes some residents now opting to get up later and enabling residents to access their bedrooms during the day. The serving of morning coffee and afternoon teas has improved, with residents being offered a choice of which beverage they prefer along with biscuits and cakes. It has been noted Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 13 over several inspections that the homes hairdresser promotes resident’s individuality. This is evident in residents many different hairstyles. The majority of residents consulted stated that the food was fairly good on the whole but ‘some days are better than others’ and that it was plentiful. One resident said “ I can’t manage to eat everything they put in front of us, there is just too much’. The meal presented at inspection looked appetising and plentiful. The monthly menus were examined and a well balanced diet is provided with a late night snack of cheese on toast or soup also provided. On the day of inspection the menu board did not display the alternative choices available. The cook said that this is not usually recorded. Most residents stated that they were not aware of the facility to choose something different from the main menu and one recently admitted resident could not recall having being asked about her dietary preferences. Another resident said that if she did not like something “ I would just eat it anyway as I don’t expect they have anything else”. It has been recommended that the list of menu alternatives be displayed in order to inform residents. No vegetarian option was evident and the cook said if they had a vegetarian she would ‘ just give them the vegetables’. This was discussed with the manager in order to address. The cook is now keeping records of those residents who are having pureed meals and is aware that she must keep records if anyone has an alternative meal that is not offered on the menu. Neither of the cooks have their food hygiene course, but this was booked for the day following the inspection. It was previously recommended that the cook undertake specialist training on catering for people with dementia and Alzheimer’s disease. This has not yet been actioned and has now been made a requirement. The kitchen was reasonably clean and fridge, freezer and hot food temperatures were being recorded on a regular basis, although this had been overlooked on the last weekend. Issues found in the kitchen will be addressed in the environment section of this report. The majority of residents eat their meals in the dinning room, which is pleasantly decorated. The mealtime was observed to be relaxed and unrushed. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 There is a formal complaints procedure in place. There are procedures and practices in place that supports the protection of vulnerable adults. EVIDENCE: There is a complaints procedure in place for residents, their representative and staff to follow should they be unhappy with any aspect of the service. This is displayed around the home. Complainants are invited to log concerns either verbally with the manager or through the completion of a complaint log. There were no complaints reported or recorded in the home’s documentation. Several residents said that if they were unhappy about anything at the home they would speak to their relative. Others said that they would tell the staff. In view of the high level of support needs of residents efforts are made to protect them from leaving the home unescorted, including a keypad entry and exit system to the home. There are clear procedures in place for staff to follow to report suspected abuse. Staff have also received formal training in adult protection and prevention of abuse and showed a good understanding of their roles and responsibilities under adult protection. The practices noted during previous inspection at the home, which did not safeguard residents, have now been fully addressed. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 15 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, 24 and 26 Refurbishment of the home has been undertaken over the last two years, which continues to improve the environment making the home a comfortable place in which to live. EVIDENCE: The home is located in a residential area in Hove with access to transport links to Brighton, and consists of three floors. The ground floor consists of two lounges, dining area, panelled hallway, hairdressing room and large conservatory. All of which are decorated to a good standard. The conservatory overlooks a small, well-maintained, secure garden. The home has undergone a major refurbishment over the last two years, which has significantly improved the environment throughout. This refurbishment has involved the redecoration and refurbishment of most bedrooms and the purchase of new bedroom furniture, which is of modern design. It was reported that the refurbishment of ensuite facilities is the only outstanding area of the refurbishment programme. Minor redecoration/maintenance issues were noted and this was discussed with the area manager who agreed to include these Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 16 items on the maintenance schedule. This includes the kitchen wash hand basin and some of the hand basins in residents rooms requires sealant being renewed, and the kitchen requires the spaces between the stainless steel facing and the walls to have a washable sealant inserted. Bedrooms were individualised with resident’s personal effects and were provided with domestic style furniture and fittings, together with bedding flooring, curtains and decorated to a high standard. Individual rooms are large and airy and the floor coverings are linoleum to aid cleaning and odour management. Some rooms did not have a lockable facility and this was discussed with the manager. The rooms and bathrooms at the top of the building are not in use at present due to refurbishment and could not be accessed during this visit. All rooms have en-suite facilities consisting of a washbasin and toilet, although some have baths, which are currently not used. The home has assisted bathrooms and communal toilets on each floor. A suitable lock must be fitted to the ground floor bathroom to ensure resident’s privacy is promoted. The home is not registered to admit residents with physical disabilities and the stairs and other access arrangements would make it unsuitable for people with significantly restricted mobility. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, hoist, ramps and grab rails Cleanliness within the home is much improved and the domestic staff are to be commended on this. The kitchen floor, which is cleaned by catering staff, requires the cleanliness of the edging and corners to be addressed. The majority of the home apart from two rooms, are free from odours and it is accepted that some rooms will have slight odours due to the circumstances of residents. Some high dusting around the pipes and shelves on the stairwells is required. It was discussed that the entrance floor should have a sealant polish applied to ensure that it can be adequately cleaned. It was discussed that attention needed to be paid to ensuring that toothbrush holders in empty rooms are kept clean and soap dishes do not become encrusted with soap, as this is an infection control hazard. Residents must be deterred from putting pads in waste paper baskets and it is recommended that a suitable receptacle replace certain waste paper baskets. Likewise clinical waste receptacles must only be used for clinical waste. Residents clothes were laundered to a good standard however, the standard of ironing of bed linen was variable. Some staff said that the purchase of a roller iron would help improve the standard of ironing. This was feedback to the area manager. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 There continues to be sufficient numbers of staff on duty to meet needs of resident’s. Staff are provided with suitable training and development opportunities. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: On the day of inspection there was sufficient care staff on duty to meet the needs of residents. In addition there were domestic staff and a cook. Rotas indicated that staffing levels were being consistently maintained. One resident said that there was always enough staff on duty to get the help they needed. Staff said that they had sufficient time to be able to carry out their duties effectively. Residents positively commented on staff variously describing them as: “All very nice people” “Lovely” and “the people are all very nice”. One resident stated that staff from abroad speak in their own language when in the home, “I don’t know what they are saying about me”. This was feedback to the manager and regional manager who were already addressing this issue through the homes disciplinary procedures. In the absence of the manager senior carers/supervisors undertake the responsibility for the home. It was previously required that persons in charge are suitably qualified. It was reported that there has been many delays in accessing suitable courses for them. In the meantime the manager reported Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 18 that they are undertaking regular supervision and spot checks of senior carers/supervisors. The recruitment records reviewed confirmed that appropriate procedures for the safe recruitment of staff are being followed. This includes CRB checks and references being obtained prior to employment commencing. The organisation continues to show commitment towards obtaining NVQ training for staff. An NVQ training plan has been developed to ensure that the vast majority of staff have an opportunity to undertake this training. A yearly training and development plan is in operation, which identifies what training is available. This includes core-training topics of manual handling, first aid, adult protection and fire safety. In addition specialist training is also offered in Alzheimer’s and dementia care. It was previously required that staff receive training in infection control and COSHH. Training had been provided on COSHH related subjects and infection control training was planned in the near future. It was reported that there has been little staff turnover since the last inspection with a core group of staff now having worked at the home for a number of years. It remains clear that their experiences, together with training indicates that they have a suitable level of competence and make a positive contribution to the quality of life of residents. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36, 37 and 38 A clearer sense of management leadership and direction is evident, this has resulted in improved practices at the home and residents safety. EVIDENCE: The manager has been in post since 2001, prior to this they worked at the home for many years in a senior position. They are currently undertaking an NVQ level 4, which they report remains their main training focus. The managers working knowledge of their role and responsibilities continues to improve. Since the last inspection there is a much clearer sense of leadership and direction by the manager. This has resulted in residents receiving a more consistent quality of care and improved practices at the home. Staff spoke of regular staff meetings where they had an opportunity to put forward their ideas and suggestions of new ways of working. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 20 Where the home acts as corporate appointee regarding resident’s personal monies, clear records were maintained of any expenditure, with receipts. Formal supervision and appraisals of staff is now being undertaken. This covers aspects of practice, philosophy of care, and career development needs. Staff said that they felt supported by the manager to undertake their roles and felt able to approach her with any concerns they had. Records required by law and to safeguard residents were well organised and supportive to the effective and efficient running of the home. All records were stored securely. Practices that promote the health and safety of resident’s, staff and visitors include: • A record of accidents is maintained, with no specific patterns identified. • Regular servicing and testing of fire safety equipment is undertaken. • Hot water mixer valves are fitted to outlets accessible to residents and all those checked delivered hot water within the required safe temperature range. • Radiators have been fitted with guards to prevent accidental scolding. All certificates relating to the servicing of utilities and equipment are in place other than the Landlord’s Gas Certificate. This must be kept in the home and available for inspection. Window restrictors were fitted to those windows checked by the inspectors. One restrictor, in a room specified to the manager, permitting the window to open too wide and must be addressed to prevent the risk of falls. During the refurbishment of the ground floor toilets, some hot pipe work had been left exposed. In order to eliminate the risk of accidental scolding it is required that this be boxed in. A resident was observed trying to access the laundry area independently. It was discussed that further controls should be implemented to prevent any residents being able to enter the laundry area unsupervised. This is recommended in order to manage the level of risk that independent access would pose. It was previously discussed that the fire escape leading from the top floor onto a flat roof should be risk assessed to ensure that it provides a safe fire exit route. This had not been undertaken and is now made a requirement. In line with previous requirements fire doors were not being propped open with none automatic fire door closure mechanisms. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 21 Feedback was given on the risk assessments of portable fans, which need to record greater detail of any risks associated with their use and of the controls needed to manage identified risks. Staff must wear full protective clothing, including eye protection when disposing of human waste. This is in line with infection control procedures Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 22 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 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 3 3 3 2 Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2)(c) Requirement That evidence is provided that service users or their representative have seen and agreed the contents of their care plan. (First made at inspection of 23/5/05 with timescales of 30-9-05 not met) That all medications be signed following administration by a member of staff. That the cook undergo specialist food training on catering for people with dementia and Alzheimer’s. (First made at inspection of 23/5/05 as a recommendation) That suitable locks are fitted to all toilet/bathroom doors, which provide privacy and allow staff access in an emergency. That attention be paid to cleaning the edges and corners of the kitchen floor, and the resealing of washbasins, and steel fascias in the kitchen. That bed linen be ironed to an acceptable standard. That persons in charge in the DS0000014201.V250135.R01.S.doc Timescale for action 30/01/06 2 3 OP9 OP15 13(2) 18(1)(c) (i) 18/11/05 30/01/06 4 OP21 12(4)(a) 30/01/06 5 OP26 13(3) 30/11/05 6 7 OP26 OP28 16(2)(e) 18(1)(c) 18/11/05 30/01/06 Page 24 Grosvenor Lodge Version 5.0 (i) 8 9 10 11 OP38 OP38 OP38 OP38 3(4) 13(4)(a) 13(4)(a) 23(4)(b) 12 OP38 13(3) absence of the manager are suitably qualified. (First made at inspection of 19/1/04 with timescales of 30-9-05 not met). That an up to date Landlord’s Gas Certificate be kept in the home. That the specified window restrictor be realigned. That hot pipe work is guarded or have guaranteed low temperature surfaces. That the suitability of the top floor fire escape, leading from the top floor onto a flat roof be risk assessed to ensure that it provides a safe fire exit route. That staff wear full protective clothing including eye protection when disposing of human waste. 18/11/05 18/11/05 30/01/06 30/01/06 18/11/05 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 Refer to Standard OP9 OP9 OP15 OP26 OP38 Good Practice Recommendations That balance of controlled drugs be checked on a regular basis by a senior carer and records maintained. That a drug counter is obtained in order to facilitate the stock checking of controlled drugs and to prevent the handling of drugs. That the list of menu alternatives to the main meal be displayed. That suitable receptacles replace waste paper baskets in bedrooms where residents use them to depose of continence aids. That the laundry area is able to be locked when not in use. Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Grosvenor Lodge DS0000014201.V250135.R01.S.doc Version 5.0 Page 26 - 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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