Inspection on 11/07/06 for Hampton Court

This inspection was carried out on 11th July 2006.

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

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

Other inspections for this house

Hampton Court 27/11/08

Hampton Court 07/05/08

Hampton Court 15/05/07

Hampton Court 14/03/06

Hampton Court 08/11/05

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

CARE HOMES FOR OLDER PEOPLE Extwistle Lodge 34 Scarisbrick New Road Southport Merseyside PR8 6QE Lead Inspector Mrs Trish Thomas Unannounced Inspection 11th July 2006 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 Extwistle Lodge DS0000065950.V295377.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. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Extwistle Lodge Address 34 Scarisbrick New Road Southport Merseyside PR8 6QE 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) 01704 532173 01704 532172 Ramos Healthcare Limited Ms Janet Marshall Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to a maximum of 20 DE(E). The Service should employ a suitably qualified and experienced manager who is registered with the Commission For Social Care Inspection. 8th November 2005. Date of last inspection Brief Description of the Service: Extwistle Lodge is a large detached building, which has undergone conversion to provide residential care for up to 20 older people who have a degree of mental health need. The home was originally a Victorian dwelling house set in it’s own grounds, situated on a regular bus route, about half a mile from the town centre of Southport. The accommodation is divided over three floors with the day facilities on the ground floor and bedrooms above. There is office accommodation on the lower ground floor as well as laundry and kitchen facilities. Externally the grounds are secure with seating provided for residents. Ramos Healthcare Ltd own the home and the responsible person is Mr Roland Mangahas Ramos. Janet Marshall is the registered manager. Application has been made to CSCI by Ramos Healthcare, to change the home name to Hampton Court. As the process is not yet completed, the home will be referred to in this report as Extwistle Lodge. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and the methods used were direct observation, discussion with residents, a visitor and the registered manager. Records compiled in the home were read, including care plans, health & safety certificates, staff files and quality questionnaires. A tour of the premises was and grounds was carried out. Three regular visitors to the home were later contacted by phone and gave their comments on the care provided and environment. What the service does well: What has improved since the last inspection? A number of requirements made in the last inspection have been met, including improved access to health care following delegation of decisionmaking in this to senior staff when the manager is not on duty. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 6 What they could do better: Comments received on the quality of care were mixed, one relative describing the care as “excellent”, two other comments in agreement that more attention could be paid to residents’ personal grooming. Out of respect for residents’ dignity and diversity, residents’ clothing should be kept in good order. The lift must be repaired to ensure that those who are accommodated on the top floor, are not disturbed by the unacceptable noise levels, experienced during the inspection when the lift was in motion. To ensure that recording and storage of medication is accurate and safe, handwritten MAR sheets (in use for respite service users), must be signed by the writer and checked and signed by a colleague and the medication cupboard must be thoroughly cleaned and maintained to the highest standards. To avoid cross contamination, the kitchen and laundry must be thoroughly cleaned and food stocks regularly rotated and checked to avoid out of date substances being served to residents. Two regular visitors who have been present when meals are served and who commented, said they thought the food looks appetising. To ensure that all residents’ diet and weight is monitored, it is advised that diabetic diets be recorded on the relevant resident’s care plan and arrangements are made for residents who cannot use stand-on scales are regularly weighed. To ensure the building is maintained in good order, the leak from an upper floor at the exterior must be repaired. A requirement is also given that the windows be checked to ensure that they have suitable opening restrictors to protect residents from falls. Comments made by visitors were that sometimes there appears not to be enough staff on duty. One visitor said, “Residents are always supervised in the lounge.” One comment was that long-term staff appear competent, others aren’t so good.” To ensure that staff have the skills to meet residents’ needs, further training requirements and recommendations are made. Staff files were difficult to follow and not well organised and it was difficult to check the training undertaken by staff. To ensure that information is easily accessible, a training schedule is advised and re-organisation of staffing records to a standard format. The staff roster did not provide the full names of staff or their designation and it was difficult to differentiate between care and ancillary staff. All accidents and incidents in the home must be accurately recorded. A sample of accident forms which were read, lacked detail, full names of witnesses and the date. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 7 Some clarity will be necessary as to the time periods covered for extra service charges. One person who commented was of the opinion that hairdressing is billed in advance, which could lead to over payment if a resident was ill or in hospital and did not receive the service. 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. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 The quality of this outcome was good. This judgement has been made using available evidence, including a visit to the service. Prospective residents are given all the information necessary to make an informed choice about where to live and they have their needs assessed prior to moving in to Extwistle Lodge. EVIDENCE: Extwistle Lodge ‘Statement of Purpose’ and the ‘service uses guide’ provide prospective residents and their families with the information they need before making the decision to move in to the home. Both documents have been recently updated, are readily available to interested parties, the service user guide being posted in the hallway. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 10 The care files of three residents were seen and each of these residents’ needs had been assessed prior to admission by relevant professionals on referral, and by staff from Extwistle Lodge, to ensure that the home can offer a service to meet assessed needs. The standard assessment tool in use in the home includes aspects of support needs relating mental health, risk, nutrition, mobility and history of falls. The outcomes of assessments form the basis of each individual care plan. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. Residents’ health and personal care needs are set out in a care plan and their health and personal wellbeing are promoted through access to medical advice and treatment. Residents’ dignity and diversity is generally respected in care giving and daily routines. Respect for their dignity is compromised through lack of consideration for their feelings and capacity to complain, regarding noise levels on the upper floor. EVIDENCE: There was evidence in the three care files inspected, that residents and their representatives are consulted regarding the care to be provided in Extwistle Lodge. A placement aims form was contained on each file, to establish the goals and outcomes to be achieved in the care plan. The three care plans inspected were checked against the outcomes of residents’ assessments. Each had an action plan to meet the individual’s assessed needs. Care plans had been reviewed monthly by home’s staff and there was evidence of reviews by mental health professionals and social workers. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 12 Regarding the information held on one care file, it is advised that alternative arrangements are made to weigh residents who cannot use stand-on scales. There were records of each resident’s state of physical and mental health, with referrals to their G.P. and regular access to chiropody, ophthalmology, audiology and continence services. For a resident of higher dependency, assessed at risk of pressure sores, interventions were recorded. The risks associated with confusion (ie. wandering/leaving the building/lack of awareness of risk) had been assessed, for ambulant residents. The relative of a resident of higher dependency was spoken with and she said the care in the home has been excellent and she had been a party to and was kept informed of her relative’s progress and changes to the care plan. She said she visits Extwistle Lodge regularly and considers the standards in the home to be consistently good. The resident (whose care plan had been inspected), looked comfortable and well cared for. This resident did not comment but appeared to have some understanding of what was being said. Two people who visit the home regularly said that at time their relative’s clothing was sometimes stained (with food) and more care could be taken with personal grooming. The home has a procedure for managing residents’ prescribed medication and staff who administer medication, receive training and ongoing advice and updates from the supplying pharmacist. Medication administration records were generally satisfactorily maintained. For respite residents, where the drugs and doses are handwritten, these should be signed by the writer and checked and signed by a colleague. The medication cupboard was secure but was in need of cleaning. There was evidence in care plans that residents are consulted regarding their social preferences, preferred rising and retiring times and changes to their care. Contact names, social histories and residents’ religious affiliations are recorded in their personal details. One resident commented briefly on one aspect of her care plan, another said she had no concerns and went on to talk about her past experiences. All residents spoken with appeared at ease with the staff on duty. The French doors were open and residents had freedom of movement on the ground floor and ramped access to a secure area of the garden, where seating had been placed for them. Out of respect for residents’ dignity and diversity, it is required that the faulty lift be repaired. When the lift is in motion, the noise from the motor on the upper floors is extremely loud and could disturb residents’ sleep and peace when relaxing in their bedrooms. Some residents do not have the capacity to complain or understand the source of this extremely loud and disturbing noise. It may be that for this reason, the problem appears to have been unresolved for an unacceptable period of time. The lift must be available to residents at all times (other than in case of fire) and unacceptable noise levels to rooms within hearing distance, could render the rooms unfit for occupancy if the problem is not rectified. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The home has a relaxed and friendly atmosphere but there is scope for improvement to the range of activities and outings on offer to residents. There are some restrictions on freedom of movement in accordance with each individual’s awareness of risk and decision-making capacity. The home provides a varied diet, served in a pleasant and congenial setting. There are potential risks presented by the management and rotation of food stocks. EVIDENCE: The home has a friendly and relaxed atmosphere and residents appeared at ease in each other’s company and with staff. A visitor was spending time in private with her relative, and she said staff are always helpful but are not intrusive. The comments of some relatives, either read in care notes or obtained verbally give evidence that there is scope for improvement in the activities on offer. “Carers often appear to be busy cleaning and cooking rather than arranging activities.” “…….has settled but could do with more activities.” Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 14 “The videos are not always appropriate, not everybody is interested in watching war films.” “Nothing goes on during the afternoons when I visit.” “Staff could interact more with residents instead of watching television.” “Sometimes they bat a balloon to one another and appear to enjoy that.” There was evidence in reports that residents occasionally go out to local shops or for a walk and the garden is accessible in fine weather. There are two comfortable lounges and a dining room with some easy chairs for residents use during the daytime. Staff said that a number of ways of providing interesting activities, such as drawing, have been tried without success. Residents play dominoes and cards, entertainers are brought in and a trip to the Lake District took place recently. There was evidence in care plans of resident and representative participation in action planning, and a visitor said that she is informed of any changes to her relative’s care. Residents’ personal details held on their care plans contain details of next of kin/family and contact numbers. Their social preferences and interests are also stated in social histories. There was evidence in care files inspected, that residents have access to advocacy services, social workers and Court of Protection. Dietary preferences are recorded on residents’ care plans and there is a written menu with alternatives. The main meal is served around midday and a lighter meal at tea-time. The home employs a cook, who prepares breakfast and the main meal and care staff prepare the evening meal. The dining room is bright and pleasant and residents may eat in their bedrooms if preferred. A visitor confirmed that her husband’s meals and regular hot and cold drinks are brought to his bedroom. It is advised that special diets, (diabetic), are recorded and held on the individual’s care plan. During a visit to the kitchen, a carer was observed cracking eggs into a bowl for scrambling. Scrambled eggs were to be served along with sandwiches and bread and butter (which had been left prepared by the cook). One of the eggs was bad (the contents being brown and malodorous). On examining the sell-by date on the egg containers in use, the “best before” date was stated as 6/7/06 (five days previous to the inspection date). Staff were instructed to place the contents (several trays) in the refuse bin, to ensure that residents were not served stale and contaminated food. The cracked eggs were placed in a plastic container with the lid secured and also placed in the refuse. It was not possible to obtain the all residents’ levels of satisfaction with regards to their meals. A requirement is made regarding the ordering, storage and checking of food to ensure that it is fit for human consumption. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The home has an accessible complaints procedure and an adult protection procedure but staff lack understanding of Local Authority procedures to be following where abuse is suspected. EVIDENCE: Reference was made to the home’s complaints procedure, which is accessible to residents and their representatives in the home’s brochure. A visitor said she would have no problem informing the manager if she had a complaint, but so far, she has had no cause for complaint. The home maintains a complaints book where concerns expressed by residents or their representatives, outcomes and any remedial action taken is recorded. The home has an adult protection and “whistle blowing” polices. Staff are aware of the indicators of abuse but a member of staff said that she has not received training in Sefton’s procedures for the Protection of Vulnerable Adults and this requirement from the last inspection is repeated in this report. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The home is comfortable and generally in good order, other than as stated. Utility areas were not being maintained to a satisfactory standard. EVIDENCE: From a tour of the premises, the following was observed. The home is comfortable and generally well maintained. The lounges are pleasant and comfortable and the garden is neat though lacking in colourful planting which would interest residents. Residents’ bedrooms are highly personalised and furnishings in communal areas are domestic in style. A visitor said that sometimes “the place could do with a good clean.” Another visitor said some areas are often foul smelling when he/she visits. From a walk around the grounds, the following was observed. A water leak was observed running down the outside of the property from an upper floor, in the area near the laundry exit. This leak was pointed out to the manager, Janet Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 17 Marshall, during the inspection. As it was not raining, the leak appears to be from a bathroom or bedroom sink outlet. From a tour of the premises the following was observed. There is a wellequipped laundry on the ground floor. This room is spacious and airy with scope to protect against infection control in managing soiled and laundered items separately. The laundry was cluttered with unrelated items, and the sink and sluice and surrounding areas were dirty. There were cigarette butts on the ground outside the exit of the laundry. Cleaning materials were observed in the laundry as not being locked away in accordance with COSHH regulations. The service inspection report for the lift 19/5/06 states that the lift does not comply with disabled access standards and required urgent attention to the “slack chain switch.” The providers confirmed that this work has been carried out on 25/5/06 and the lift is in working order. The lift was called and seen to be working, but unacceptable levels of noise on the upper floor, persist though work was said to have been carried out, to rectify this problem without success. On visiting the kitchen, the following was observed. The kitchen floor, walls, pipe-work and electric sockets require a thorough cleaning as they were observed to be soiled and greasy. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 EVIDENCE: JUDGEMENT: The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The home lacks systems to monitor training and fully evidence vetting procedures for newly appointed staff. Some staff employed in the home have not undertaken all mandatory training/ updates, NVQ training and the training specific to the residents’ support needs. EVIDENCE: During conversations with staff, the following training had not been undertaken or updated, Challenging Behaviour, Protection of Vulnerable Adults, First Aid Equal Opportunities. It was not possible to fully assess levels of training achieved, as such information was not held in one place. It is advised that a training schedule be established with the names of all staff and their training recorded on this single document. The staff rosters record three day staff and two night staff on duty. There was a cook and domestic on duty during the inspection. The roster did not record the full staff names or their designations. Three staff files were inspected and contained schedule 2 documents. The files were disorganised and difficult to follow. A requirement referring to CRBs from the last inspection is repeated in this report, as all staff files were not checked. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 19 Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The quality of this outcome was adequate. This judgement has been made using available evidence, including a visit to the service. The manager has a good overall knowledge of residents’ needs, and residents and their representatives are consulted twice yearly regarding the service provided in the home. Some improvements will be necessary in the frequency of staff supervision, billing for services, accident reporting and health & safety measures. EVIDENCE: The registered manager, Janet Marshall is qualified in management and care. Some of her roles, such as medication administration, health & safety, are delegated to senior care staff. Ms. Marshall, in conversation, showed a broad Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 21 knowledge of residents support needs and the care plans in place to meet their mental and physical health and personal care needs. The home has a quality assurance system and questionnaires on satisfaction are distributed to residents and their representatives twice yearly. The residents’ quality summary for February 06 was seen. The manager said that the home does not manage residents’ financial affairs. They are billed for extra items such as hairdressing. A visitor to the home made comment saying the bills are sent out monthly in advance for her friend/relative’s contribution. To her knowledge, the hairdressing bill is also for the coming month and she queried this practice, as any resident may not have their hair done, for example, if in hospital or unwell but would be charged in advance. The bills for hairdressing should not be in advance and should include the dates when the service was provided. The home has a system for formal supervision of staff, however, for some staff, according to their files, supervision sessions were out of date. Health and Safety and Fire Safety Certification was satisfactory. Accident Records were not to a satisfactory standard giving brief details of incidents and neither giving full names of staff/witnesses nor the date of the incident. One upper window tested during the inspection, did not have an adequate restrictor to protect staff from falls. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 X 2 Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 23 Yes 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. 1. Standard OP9 Regulation 13(2) Requirement The registered person must, regarding the safekeeping and storage of medication, arrange for the medication cupboard to be thoroughly cleaned and maintained to the highest standards of hygiene. Timescale for action 21/08/06 2. OP10 13 (4) (c ) The registered person must arrange for the fault to the lift, which is causing unacceptable noise levels on upper floors, to be rectified. 16 (2)(i) 21/08/06 3. OP15 The registered person must 21/08/06 ensure that residents are offered a reasonable choice of meals and are provided with a wellbalanced and varied diet which is fresh and suitable for consumption. Records as to this should be maintained. The registered person must ensure that the management of food stocks includes the rotating and checking of food stocks to ensure that they are in date at time they are cooked and DS0000065950.V295377.R01.S.doc 4. OP15 13 (3) 21/08/06 Extwistle Lodge Version 5.2 Page 24 consumed by residents. 5. OP18 13 (6) The registered person must ensure that staff are provided with adult protection awareness and training linked to Sefton’s adult protection procedures. Outstanding from last two inspections. The registered person must ensure staff are provided with training in supporting people with mental health needs. The manager and registered provider must ensure adequate care staff are employed on duty for the afternoon period (a minimum of 3 care staff in total) so that resident’s needs can be fully met. The registered person must employ suitable cover for the kitchen during the afternoon period. (Requirement on previous inspection timescales 1.04.05 and 20.02.06 14.05.06 not met). Outstanding from last inspection, extended time limit given. 9. 10. OP28 OP29 19 (5) (b) 19 (1) (b) The registered person must arrange for 50 of staff to obtain NVQ qualifications. The registered person must arrange for all staff employed to receive the necessary POVA and CRB checks as well as adequate written references prior to full employment in the home. The registered person must ensure that food is stored appropriately at all times. DS0000065950.V295377.R01.S.doc 14/09/06 6. OP18 13 (6) 14/10/06 7. OP27 18 21/08/06 8. OP27 18 21/08/06 21/11/06 21/08/06 11. OP15 13 (3) 21/08/06 Extwistle Lodge Version 5.2 Page 25 12. 13 OP19 OP26 23(2) 13 (3) 14 15. OP26 OP26 13 (3) 13 (3) 16. OP38 17 (2) 17. OP38 13 (4) (a) The registered person must arrange for the leak at the rear of the premises to be repaired. The registered person must make arrangements for the kitchen and laundry to be thoroughly cleaned and maintained to a high standard. The registered person must arrange for cleaning materials to be locked away when not in use. The registered person must ensure that the home is maintained in a fresh, clean and odour free condition by instructing domestic staff and monitoring of work carried out by use of cleaning schedules. The registered person must ensure that accidents, which occur in the home, are recorded to give full details of the accident, names of witnesses and the date of occurrence. The registered person must arrange for all upper windows to be tested for adequate restrainers to protect residents from falls and injury. 21/08/06 21/08/06 21/08/06 21/08/06 21/08/06 21/08/06 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. Refer to Standard OP9 Good Practice Recommendations The registered person should arrange for handwritten MAR sheets to be signed by the writer and checked and signed by a colleague. The registered person should arrange for residents who cannot use stand-on scales to be regularly weighed. DS0000065950.V295377.R01.S.doc Version 5.2 Page 26 2. OP8 Extwistle Lodge 3. 4. 5. 6. 7. 8. 9. 10. OP15 OP27 OP27 OP28 OP29 OP35 OP36 OP10 The registered person should arrange for all special diets to be recorded on the individual’s care plan. The registered person should establish a training schedule for ease of reference when arrange training and updates. The registered person should arrange for the staff roster to include the full names and designation of staff on duty. The registered person should update staff training in First Aid and Challenging Behaviour. The registered person should organize staff files to follow a compartmented and standardized format. The registered person must arrange for residents to be billed for hairdressing after the service has been received by them. The registered person should consistently provide staff with formal supervision every two months. The registered person must ensure by instructing staff, that residents’ clothing is changed if stained with food. Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Extwistle Lodge DS0000065950.V295377.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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