Inspection on 09/06/09 for Pine Tree Care Home

This inspection was carried out on 9th June 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pine Tree Care Home 14/04/10

Pine Tree Care Home 16/07/08

Pine Tree Care Home 09/08/06

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Gwendolen Lodge Residential Home 305 Gwendolen Road Leicester Leicestershire LE5 5FP     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Linda Clarke     Date: 0 9 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Gwendolen Lodge Residential Home 305 Gwendolen Road Leicester Leicestershire LE5 5FP 01162738381 01162738381 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sudera Care Associates Limited care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: No person under the age of 55 who falls within categories MD, DE or PD may be admitted into the home. To be able to admit the named person of Category A(E) identified in variation application number V17739 dated 17th February 2005. Date of last inspection Brief description of the care home Gwendolen Lodge Residential Home is owned by Sudera Care Associates and is registered to provide personal care and accommodation for up to twenty-three older Care Homes for Older People Page 4 of 34 Over 65 23 23 23 23 23 23 0 23 Brief description of the care home people who may have additional needs including Dementia. The home is located near to the centre of Leicester and is accessible by bus. There is limited off the road car parking to the front of the Home. Gwendolen Lodge has several communal rooms, which includes a conservatory overlooking the rear garden. The home has two floors and access is provided by a pasenger lift. The home has an enclosed courtyard to the side of the home and a garden to the rear. The Homes brochure provides information about the service to prospective and current service users and incudes the terms and conditons of their stay, this information is referred to as The Statement of Purpose and Service User Guide. There is information available in the reception area including the Certificate of Registration and the latest copy of the Inspection Report from the Care Quality Commission. The Registered Manager on the day of our site visit told us that fees range between £395.00 per week for a shared room to £400.00 a week for a single occupancy room. Additional expenditures may be incurred and information about these is detailed with the Statement of Purpose and Service User Guide. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We as it appears throughout the Inspection Report refers to the Care Quality Commission. The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is a selfassessment tool, which was completed by the Registered Manager of the service, reviewing previous inspection reports, and any information we have received. The unannounced site visit commenced on the 9th June 2009 and took place between 09:15 and 14:15. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was case tracking. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Care Homes for Older People Page 6 of 34 Gwendolen Lodge. Three people accessing services were chosen and discussions were held with two of them, along with other people living at the home and a visitor. Staff members were spoke with along with the Registered Manager. We sent surveys to people living at the home and their relatives, however none were returned. We also sent surveys to health and social care professionals, of which two were returned, and two staff surveys were returned. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 Care Homes for Older People Page 8 of 34 7535. Care Homes for Older People Page 9 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals considering using the service are provided with information about the home, which is not in parts a true reflection of the services provided, individual assessments are carried out before people move into the home to ensure that the home can meet a persons needs. Evidence: We wanted to look at the information provided to people who use the service to find out whether it was detailed and answered all their questions. We sent surveys to individuals who live at the home and their relatives which asked them about the information provided by the home and whether it was sufficient to enable them to make a decision as to whether Gwendolen Lodge was the right home for them, unfortunately no surveys from people living at the home or their relatives were returned to us. We looked at the information provided to people who are considering residential care Care Homes for Older People Page 11 of 34 Evidence: at Gwendolen Lodge, the information is in a document referred to as the Statement of Purpose and Service User Guide, by looking at the information we found that in some instances the information was not accurate, and examples of this are included within this inspection report. We spoke with people who lived at the home, some could not remember why they moved into the home, or whether they were provided with information. We looked at the records of three people living at the home, and found that their care was funded by Social Services, and that a comprehensive assessment of their needs had been carried out by a Social Worker, which enables the Registered Manager of the home to determine whether the home and the staff can meet that persons needs. The home does not provide intermediate care. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Gwendolen Lodge receive personal care and support and have access to health care services. Evidence: We wanted to find out how the health and personal care needs of people living at the home were met. We spoke with people living at the home along with visitors, and observed the care and support provided by staff, we also looked at the care plans and records of three people living at the home. We asked people about the care they received; one person said The care is okay as are the staff. A visitor told us that they were happy with the care their partner received, and found that staff were very kind and supportive, and looked after them well. We spoke with a carer about a person living in the home whose care plan we had read, they were able to tell us about the care of the person, and were well informed as to their needs. By reading the care plan we found that the person was cared for in bed, and that pressure relieving equipment and care was in place, so that the person was not at risk from developing pressure sores. The care plan also told us that the Care Homes for Older People Page 13 of 34 Evidence: person required a liquidised diet, and required full assistance with eating. In the self assessment tool completed by the Registered Manager it said that people at risk of malnutrition were screened, we found no evidence of this, and the Registered Manager told us that the person had not been referred to a dietician as they ate well, the care plan however did not provide guidance as to when a referral should be considered. The care plans we looked at focused on personal and physical health care needs but provided no guidance for staff in how to support and care for people who have Dementia, care plans did not focus on the outcomes for people, and did not include their wishes, preferences and expectations of care. Records told us that people have regular access to General Practitioners and District Nurses. We sent surveys to individuals who live at the home and their relatives which asked them about the care and support they receive, and whether they have access to health care, unfortunately no surveys from people living at the home or their relatives were returned to us. We also sent surveys to health and social care professionals, of which two were returned. Surveys indicated general satisfaction with the care provided, and both felt that the staff at the home sought their advice and acted upon it. A social care professional wrote that the service doesnt exclude service users with challenging behaviour, and that staff make every effort to get to know service users complex needs. The health care professional wrote that their is good communication and a caring attitude. We looked at daily records and found that they contained limited information about a person, information was restricted to sleep, elimination and eating. We found that care plans were reviewed monthly, and that monthly reviews over a period of twelve months always read no change. It is difficult to understand how staff at the home could review the changing needs of people based on the limited written information available. The Registered Manager said that staff were responsible for the development and reviewing of care plans, with guidance from senior staff and herself, however staff have received limited guidance and no training on this task. We observed staff supporting people with eating and drinking, and we found this was done sensitively, we did observe two staff using a hoist to move someone, this was managed well with regards to correct moving and handling procedures which promotes the safety of the person. However the dignity of the person was compromised, as the persons incontinence pad was clearly noticeable when she was moved within the dining room area. We looked at the medication and medication records of three people, and found them Care Homes for Older People Page 14 of 34 Evidence: to be in good order. No one at the home is currently being prescribed a Controlled Drug. Recent changes to legislation meat that the Registered Person needs to ensure that the current storage facilities comply, to ensure that Controlled Drugs when used are stored appropriately. Care Homes for Older People Page 15 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Gwendolen Lodge are provided with limited opportunities to engage in activities or be involved in community activities, and have little influence over their lifestyle and daily living. Evidence: We wanted to find out about how people spend their day, and how staff working at the home support people to make decisions and take part in activities and lead a meaningful life. We did this by looking at the information provided to us by the Registered Manager and by observing people throughout the day, talking with people living at the home and by looking at the care plans and records of three people. The Statement of Purpose we were given by the Registered Manager when we visited the home states:- The Homes Policy on Therapeutic Activities takes into account the Service Users interests, skills, experiences, personalities and medical condition. The home offers a wide range of activities designed to encourage the client to keep mobile, and most importantly take an interest in life. The information goes onto say that Service Users are encouraged to participate in the following, entertainment and music therapy, cards, scrabble, bingo, scrabble, dominoes, droughts, skittles, jigsaws, reading circle, taking books and pet therapy. The information also states Outings are Care Homes for Older People Page 16 of 34 Evidence: geared to our Service Users needs and capabilities and, due to this, a limited number of Service Users can go on any one outing. Examples of activities include, visiting local shops, places of interest, garden centres, pantomimes or plays and picnics. We found that care plans included a document entitled this is your life, this contains a range of information about a persons life, including school days, career, family and friends, hobbies and interests. We looked at the section detailing hobbies and interests for three people, and found they contained information such as playing the piano, reading, and an interest in animals etc. Care plans had not been developed to support people in engaging in activities, and included no information about external activities, such as outings, or visiting local clubs or events. There was a weekly activity programme on display, which did not reflect the wide range of activities as detailed within the Statement of Purpose and did not include outings. Two events have been planned, for July which included an hour Magic Show, and a Summer Fair, open to relatives and friends of people living at the home. We sat in one of the lounges for most of our visit, looking at records which enabled us to observe how people living at the home spend their day. We found that when we arrived a majority of people were sitting in one of the homes three lounges or the conservatory. The television was on in one lounge, but nobody was taking an interest in the programme. A delivery of copies of the local newspaper were distributed to some people living at the home, we observed nobody reading the paper. Until lunchtime people remained sitting in one of the lounges or the conservatory, a majority of people were then supported to the dining room for lunch, and after lunch returned to one of the communal rooms, we saw no evidence of activities taking place. We observed minimal interaction between people living at the home and staff, as staff were busy undertaking care duties. We spoke with people living at the home who said that their are very few activities, and that their are no outings, one person asked if they were allowed to go out. Staffing levels at the home are not sufficient to support people in engaging in activities within the home, and are not sufficient to take people out as a group. We found no evidence that people living at the home are consulted about any aspect of the care and support they receive, which includes their views about activities and outings. We noted that the menu for the lunchtime meal was displayed in the dining room; the menu for the day or our visit was Pork Chop of Pastie, Potatoes and Vegetables with Care Homes for Older People Page 17 of 34 Evidence: two choices for dessert. We noted that peoples meals arrived already plated, with their preferred choice, which doesnt enable people to serve themselves by having serving dishes placed on the dining table. The Assistant Cook told us that people are asked after breakfast what their choice is for the lunchtime and tea time meal. The Cook and Assistant Cook are employed and work in the home until 2pm, and care staff are therefore responsible for serving and clearing away the team time meal. Individuals who require support with their eating, were supported in a senstive manner. We found no evidence that people living at the home are consulted about the menu provided, and therefore have no opportunity to influence the choices available to them. Care Homes for Older People Page 18 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Gwendolen Lodge have limited opportunities to discuss the care and support they receive or to raise concerns. Evidence: We wanted to find out how the staff at Gwendolen Lodge promote the safety and welfare of people who use the service, written information supplied within the self assessment tool before our visit told us the home has a complaints procedure which is simple and accessible, when we visited the home we found that the complaints procedure was not displayed, and people we spoke with were unclear about how to raise concerns. Information supplied by the Registered Manager within the self assessment tool, states that the home has not received any complaints in the last twelve months, and our records show that we have also not received any complaints or concerns in the same period. We looked at the training records of three members of staff to find out about the training they receive, we wanted to find out if the training enables staff to understand their roles and responsibilities in reporting concerns and protecting people from abuse and neglect. Staff records, indicated that staff have received training in abuse awareness, and this training consisted of staff watching a DVD and completing a questionnaire. Staff said they would report concerns to the Registered Manager. We Care Homes for Older People Page 19 of 34 Evidence: sent surveys to some of the staff who work at the home, two were returned to us, and they told us that staff know what to do if someone expresses a concern about the home. We also sent surveys to people who live at the home and their relatives, which asks them about their understanding of how to make a complaint, and when complaints are made whether they are managed well, unfortunately no surveys were returned to us. Care Homes for Older People Page 20 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The accommodation provided to people at Gwendolen Lodge is adequate but could be improved for the benefit of people living at the home. Evidence: Gwendolen Lodge has two small lounges and a dining room to the front of the property, with a larger lounge leading into a conservatory at the rear of the garden, all lounges and dining rooms had sufficient natural light, and were decorated to a basic standard, with painted walls and carpet on the floors. Furnishings were individual seats, and some rooms had a television. The entrance foyer and ground floor corridor were in the process of being painted on our visit. We looked at several bedrooms which were at the time of our visit unoccupied, bedrooms were decorated to a basic standard with painted walls and carpet on the floors. Wardrobes and draws were in each bedroom, some of which were worn as were bed coverings and lampshades. One bedroom is a shared room and has an en-suite which comprises of a wash hand basin and sink, all other bedrooms in the home are single and do not have an en-suite facility. Gwendolen Lodge has a courtyard to the side, which is accessible to people living at the home and provides seating, the courtyard leads into the rear garden, which can also be viewed from the conservatory. The garden has a grass area, and plants and Care Homes for Older People Page 21 of 34 Evidence: shrubs. When we arrived at the home a Fox was seen lying in the grass of the rear garden, the Registered Manager told us that it often visits, and that people living at the home look out for it, and enjoy watching it. Bathing and toilet facilities are providing on the ground and first floor, and access to the first floor is provided by a passenger lift. Care Homes for Older People Page 22 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are sufficient to provide personal care and support, and people are cared for by staff who have received basic training. Evidence: We wanted to find out whether the number of staff working at the home at any one time could meet the individual needs of people living at Gwendolen Lodge, by looking at the staff rota and by observing staff working on the day of our visit we found that there were two care staff on duty during the day and two at night. By observation and discussion with the Registered Manager we found that the Registered Manager works along side staff delivering personal care and support. Staffing levels at the time of our visit were sufficient to meet peoples needs, as their were eleven people living at the home, staffing levels will need to be reviewed should the number of people at the home increase, or at such a time as when the Registered Manager is not involved in the delivery of personal care on a daily basis. Staffing levels are not sufficient to suppport people in engaging in activities or outings into the community. We sent surveys to staff which told us that in their view their are sufficient staff on duty to meet peoples needs, the surveys we sent to people who live at the home were not returned. Care Homes for Older People Page 23 of 34 Evidence: Throughout our visit the staff were continually engaged in personal care and assistance, which included getting people up, taking them to the toilet and assisting them with their meals, staff interacted well with people during this time, but there were limited opportunities for staff to spend time with people and engage them in conversation, occupy them in activities, take them into the garden or into the community, as detailed within the Statement of Purpose. Staff are responsible for updating care plans and our conclusion following our visit is that their is little if any time for staff to undertkae this task, as in addition to providing care and support; staff are also responsible for other duties. Information supplied within the self-assessment tool told us that 79 of staff have obtained a National Vocation Qualification (NVQ) in Care, and that staff have received training in topics related to health and safety, which includes fire awareness, moving and handling, infection control and food hygiene. We saw the certificates confirming the training staff have received, through discussion with the Registered Manager we found that training in these areas was attained by staff watching a DVD and answering a questionnaire. There was no evidence of staff attending external courses or training, provided by health care practitioners or colleges. Some staff had received training in Dementia, which consisted of watching a DVD and anwering a questionnaire. Information supplied by the Regsitered Manager in the self assessment tool stated that staff training has been provided and additional training courses attended which enables staff to have better knowledge in many areas, we found no evidence of training in addition to that already described, and training did not reflect the needs of everyone living at the home, which includes, mental disorder and supporting people who may be physically or verbally challenging. We wanted to find out how staff were recruited and whether the recruitment of staff promotes the health and well being of people who use the service. We looked at the records of three members of staff and found that they contained all the necessary information, which included a completed application form, two written references, and a Criminal Record Bureau (CRB) disclosure, which means that people who work at the home are considered by the Registered Person to be appropriate to support and care for vulnerable adults. Care Homes for Older People Page 24 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Gwendolen Lodge does not have a system which reviews the quality of care provided within the home, and does not consult with people about the care and support they receive. Evidence: The Registered Manager of Gwendolen Lodge, Janet Tailor, has worked at the home for sixteen years, and has attained the Registered Managers Award. We asked the Registered Manager about the training she had attended in the last twelve months, training was related to health and safety topics which comprised of watching a DVD and completing a questionnaire. Through discussion with the Registered Manager we found that they were not aware of how the Care Quality Commission determines the ratings for homes. We also found that the Registered Manager was not aware of how people who are at the end of their lives can be supported to stay within the home and not move into hospital if that is their wish. Care Homes for Older People Page 25 of 34 Evidence: We looked at the staff rota and noted that that the Registered Manager works six days a week at present, this was confirmed by her, and that she spends a majority of her time working alongside care staff and delivering personal care, she is also responsible for administrative duties. This therefore significantly reduces her ability to keep up to date with changes and access external training to improve the quality of care provided to people living at the home, and training relevant to her role. We wanted to look at how the quality of care and the service the home provides is reviewed, we did this by finding out about the opportunities for people living at the home to discuss things that were important to them. We found that meetings are not held involving people living at the home or their relatives, and found their to be no active measures for seeking their views. The Statement of Purpose which we were given by the Registered Manager on the day of our visits states:- an important part of our quality programme is to involve the Service Users and their relatives. We regularly ask for comments on the Home, the staff and the services we provide and we also have a Residents Forum. In addition, we circulate a Service Users Questionnaire bi-annually, which assists us in assuring that we continue to provide a quality service. The Registered Manager advised that questionnaires were not sent out last year, and their isnt a Residents Forum. The registered person is required to visit the home unannounced on a monthly basis to speak with people who live at the home, and their relatives. Speak with staff and inspect the premises and records within the home, the information is then used to prepare a written report as to the conduct of the home. The Registered Manager was able to give a record of these monthly visits, we read these reports and noted that the registered person made no comments about the lack of meetings which people living at the home attend, or that questionnaires had not been circulated to people living at the home. Their are opportunities for staff and the Registered Manager to discuss their day to day roles within the home and care practices, by attending staff meetings which are regularly held and by staff receiving regular supervisions (one to one) meetings with the Registered Manager. Information the Registered Manager supplied to us prior to the site visit details the regular maintenance of equipment and systems in the home, including central heating Care Homes for Older People Page 26 of 34 Evidence: and electrical systems. Care Homes for Older People Page 27 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 The registered person to 07/08/2009 provide a service user guide to the Commission which is also made available to people who live at or are considering accessing services at Gwendolen Lodge, which is accurate and provides information about the home, and services. To enable people to make an informed decision as to whether the home is appropriate for their needs. 2 1 4 The registered person to 07/08/2009 provide a Statement of Purpose to the Commission which is made available to people who live at or are considering accessing services as Gwendolen Lodge, which is accurate and provides information about the home, and services offered. Care Homes for Older People Page 29 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To enable people to make an informed decision as to whether the home is appropriate for their needs. 3 7 15 The registered person in 11/09/2009 consultation with service users and/or their representatives, ensure that care plans are regularly reviewed and comprehensive, reflecting all aspects of care, including care and support to people with Dementia, and provide information as to how the person wishes their care to be carried out including their preferred daily routine. To provide people with an opportunity to influence and receive the care and support they require in a manner which they expect and wish. 4 9 13 The registered person to establish and have written information to confirm that the cabinet which stores Controlled Drugs at Gwendolen Lodge complies with the Misuse of Drugs (Safe Custody) Regulation 1973. If facilities do not meet the regulations then a storage system, which does comply with the Misuse of 11/08/2009 Care Homes for Older People Page 30 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Drugs (Safe Custody) Regulation 1973 to be purchased and installed. To ensure the safe storage of Controlled Drugs. 5 12 16 The registered person to consult with service users and/or their representatives about their social interests and activities, which are then to be provided, as detailed within the Statement of Purpose. This would promote and enable individuals to live a lifestyle of their choosing, and reflect their individual interests and wishes. 6 30 18 The registered person to 11/08/2009 review the training provided to staff, and establish a training plan which enables staff to meet the needs of people living at the home, and enables staff to understand and promote the rights of people. Training to include:1) safeguarding adults from abuse. 2) Dementia Awareness. 3)Mental Capacity Act training to include deprivation of liverty 11/08/2009 Care Homes for Older People Page 31 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action safeguards. 4) Mental Disorder To ensure that the needs and rights of people are being met and supported by staff who are trained and are competent to do so. 7 33 24 The registered person to establish a system which reviews and improves the quality of care people who live at the home receive, that includes consultation with people who live at the home, and their relatives. To enable people who receive care and support to influence the day to day management of the home and improve the service they receive. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 11/08/2009 1 2 15 16 People have the opportunity to serve themselves at meal times, by serving dishes being place on dining tables. The complaints procedure be prominently displayed within the home, and people who live at Gwendolen Lodge be advised of their right to complain. Training is reviewed, to include college courses and other external practitioners, and is based on staff competence and not attendance. 3 30 Care Homes for Older People Page 32 of 34 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 4 31 The Registered Manager to access external training which enables them to keep up to date with good practice and changes in legislation. Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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