Inspection on 26/02/07 for Hare Lodge

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hare Lodge 30/04/09

Hare Lodge 09/02/09

Hare Lodge 13/03/06

Hare Lodge 19/12/05

Hare Lodge 14/09/04

Hare Lodge 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Hare Lodge 57 Harebeating Drive Hailsham East Sussex BN27 1JE Lead Inspector Melanie Freeman Key Unannounced Inspection 10:20 26th February 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 Hare Lodge DS0000021126.V323758.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. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hare Lodge Address 57 Harebeating Drive Hailsham East Sussex BN27 1JE 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) 01323 849913 01323 849913 The Harebeating Care Company Vacant Care Home 32 Category(ies) of Dementia (32) registration, with number of places Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtytwo (32) Service users must be older people aged sixty-five (65) years or over on admission Service users with a senile dementia type illness only to be accommodated 13th March 2006 Date of last inspection Brief Description of the Service: Hare Lodge is a large, detached, purpose built care home situated in a residential area of Hailsham, approximately one mile from the town centre. Accommodation is provided on two floors and a shaft lift is available to assist those residents who may have mobility problems. The home is registered to accommodate up to 32 older people with a dementia type illness. The registered owners are the Harebeating Care Company. The home provides care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 January 2007 range from £366.00 per person per week to £600.00 depending on the funding arrangements. Additional costs are charged for chiropody (approx £10) hairdressing (£5.00-£30), newspapers and dry cleaning at cost. The homes literature states that the aim of the home is to provide a high standard of personalised care and support in a homely and friendly environment which is geared to the needs of individual residents thus enabling those in the homes care to enjoy as much independence and dignity as their own condition will allow them. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Hare Lodge will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and a further visit, which was completed via an appointment to follow up issues with the acting home manager and to provide direct feedback. In addition visiting health and social care professionals were contacted. The unannounced visit was facilitated by one of the deputy managers who was working in the home the proprietor was also spoken to. The inspection focussed on meeting and talking to residents and accessing the homes progress in meeting the requirements made at the last inspection. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, the provision of terms and conditions of residency, duty rotas, medication records, and recruitment files. In addition the care documentation pertaining to three residents was reviewed in depth. The inspector was able to eat a midday meal with the residents in the communal dining room and spend time with residents in the communal lounge area. Service users surveys were given to 10 residents or their representatives and 7 of these were returned to the inspector. Staff surveys were given out to 5 staff members and three of these were returned. The contents of these surveys have been incorporated into this report. In addition the acting manager completed a pre-inspection questionnaire to inform the inspection process. What the service does well: The home provides prospective residents and their families, with a good level of information about what services are provided at the home. All feedback received about the home reflected a very high satisfaction with the care provided and positive comments included ‘I have found the staff here very helpful, friendly and cheerful. Myself and my sister are both happy with what we find at Hare Lodge more over my mother tells me she is happy here’. ‘It is humbling to see how the staff make so much effort for the residents. I Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 6 am very impressed with the care my mother receives. I visit at least once a week and am always made very welcome’. Hare Lodge is a purpose built care home and provides a light and airy environment where residents can move around safely. Observations made during the inspection confirmed that staff are caring and respectful in their interactions with residents, and that their needs were being attended to with individual choices being respected. What has improved since the last inspection? What they could do better: Procedures and practice around the administration of medicines need to be established with associated procedures and care documentation so that al medicines are administered in a safe and appropriate manner. All staff must be trained on adult protection issues and have a good understanding on what constitutes abuse and what action must be taken following an allegation or suspicion of abuse. This is to ensure residents as far as possible are protected from abuse. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 7 The procedures in respect of the cleaning and emptying of commode pots need to be reviewed to ensure residents are protected from any risk associated with cross infection. The advice provided by the Environmental Health Officer in respect of the redundant sluice in the medicines rooms is confirmed in writing and within a procedure to ensure suitable infection control measures are in place. The bathing facilities fall short of the national minimum standards and need to be reviewed to ensure residents have choice on when and how they are bathed. Staff training needs to be further established and recorded to ensure all staff are suitably trained and competent to do their job. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hare Lodge DS0000021126.V323758.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 Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides prospective residents, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensure residents are suitably assessed prior to admission by a competent person, who ensures that the home admits only those residents who’s needs can be met by the home. Intermediate care is not provided at Hare Lodge. EVIDENCE: Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 10 The home has a comprehensive statement of purpose and service users guide that are retained within the office and available when requested. This continues to be updated regularly to reflect the management changes. A review of the admission process included the review of the last two admissions to the home. This confirmed that each resident had been fully assessed by the acting manager and an additional member of staff. These assessments are completed in the prospective residents place of residence and incorporates the views of professionals involved in their care and any appropriate family members. Following the assessment the proprietor writes to the prospective resident or their representative to provide a copy of the homes information and to confirm that the home ‘will attempt to meet all the care needs of the resident’. Once any resident is admitted to the home the pre-admission assessment is included in the care documentation and used as a foundation to the plan of care and is built on through continual assessment. The acting manager confirmed that intermediate care is not provided at Hare Lodge care home. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was found to be meeting resident’s health and general needs with assessed additional community support when needed. Although some improvements have been made with regard to medicine recording further improvements are needed to ensure safe handling, recording and administration. Residents are treated with respect and dignity. EVIDENCE: The care documentation pertaining to three residents was reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 12 The documentation used has been changed since the last inspection and now provides a clear and structured system for recording residents care needs. It was clear that the staff had worked hard on improving the care documentation to ensure it provides appropriate guidance on how to meet resident’s needs and have had training to help them implement it. However it was noted that it still needs to be fully developed to ensure that all information gathered is cross-referenced and used to inform the care provided. The system adopted includes a further needs assessment following admission to the home and care plans seen were found to be person centred promoting an individual approach to care. The documentation includes a nutritional assessment and a risk assessment for falls and discussion with the acting manager confirmed that resident’s wishes in respect critical illness and dying can also be recorded in this documentation and staff are progressing this. It was confirmed from the care documentation and discussion with staff that professional health care staff visit the home regularly and are involved in the care provided in the home. Health care professionals spoken to following the inspection visit were positive about the care and services provided. Comments received from residents and representatives have also all been positive about the care provided with one resident saying ‘I enjoy being at Hare Lodge’ and relatives commenting on the ‘swift medical support’ and ‘excellent hygiene care’. A selection of residents medicine records were reviewed and on the whole the records were full and clear and handwritten entries onto the medicine sheets are now dated, signed with an explanation of the reason for a handwritten entry being detailed in accordance with a requirement made at the last inspection. The following shortfalls were however identified. • Although a new system to record medication non-administration has been implemented it was identified that this is not being followed on all occasions and there is no written procedure to underpin the practice to be followed. • It was noted that those residents who do not take their medicines on a regular basis did not have a corresponding plan of care to give guidance to care staff. • The administration of prescribed creams was not being recorded on the medicine records. During the inspection the inspector observed a staff member administrating medication and this was seen to be completed in a safe manner. Individual guidance for medicines prescribed on a ‘when required’ basis are not available and this was discussed with the acting manager. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 13 The medicine storage room was found to be tidy and medicines were stored safely. The acting manager confirmed that the Environmental Health Officer had been contacted and his advice on the sluice being in the medicines room and the risk of legionella has been followed. Written confirmation on this matter was not available and the need for this was discussed with the acting manager. During the visits to the home it was noted that all staff including domestic staff treated residents in a positive and respectful manner being very patient and attentive to their movements around the home. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Current arrangements in the home mean that residents have a choice of activities and entertainment. The home has well-established links to local community events and activities. Where able, residents are encouraged to have control over their lives and to exercise choice. Residents receive an appealing diet within an attractive setting. EVIDENCE: During the inspection visits the inspector was advised of the different opportunities for stimulation in the home and that a full time activities coordinator works in the home. Staff and residents spoken to during the inspection said that there was plenty to do in the home and that the mini-bus was used regularly for outings. The contents of the surveys received also confirmed that activities are provided including ‘Weekly musical afternoon and Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 15 occasional outing in the summer. Also occasional family get together parties’ one resident recorded ‘We have a good activities programme’. Funds for activities are generated for the residents ‘Occupational Therapy Fund’ by sponsored events held within the home. All staff actively contribute to this fund by carrying out sponsored activities such as sponsored walks, raffle ticket events and tea parties, amongst other events. One survey identified that an activities programme is not readily available and further individual social assessments should be recorded within the care documentation. The home provides a wide range of choice for the residents in order that they can maintain relationships and attend events within the local community. Resident’s family, friends and representatives are welcomed by the home and visiting is unrestricted. Residents are supported in exercising control over their lives whenever possible and include choices around going to bed and getting up in the mornings at times that they want to and spending time where they want to. The meal eaten with residents was attractive and appetising it was healthy and enjoyed by residents. It was noted that fresh vegetables are used although the amount of choice available is rather limited. The acting manager advised that she and the cook were attending a training day in the near future and will be reviewing the homes menus and confirmed that the home provides regular snack meals and fruit. Staff assisted residents as necessary with their meals and allowed them to be as independent as possible. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Procedures and practices in the home ensure that complaints made are responded to appropriately albeit that the complaint record is not full. Residents and their representatives are confident that they are listened to and responded to. Procedures and management in the home ensure should an allegation or suspicion of abuse be raised in the future this would be dealt with appropriately. EVIDENCE: The home has a written complaints procedure and this is displayed in the home and provided within the service users guide. Feedback within surveys received from residents and relatives recorded that they knew how to make a complaint and that it would be dealt with although most comments were around the fact that they did not need to complain ‘reporting a complaint has not been necessary’. Records on complaints received however need to be improved to clarify the investigation and subsequent action taken by the home. This was highlighted with the acting manager. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 17 The adult protection procedure is appropriate and the home has a copy of the Multi Agency procedures. This procedure and the Whistle blowing procedure are included within the staff handbook, which is given to all new staff. During the inspection process it was identified that an adult protection allegation raised by a staff member with the homes management some time ago was not responded to appropriately. This matter was raised directly with the homeowner during the first visit to the home, who took this matter very seriously as she had not been notified of this allegation. Once she was made aware of this matter she took immediate and appropriate action reporting to Social Services and investigating with the new acting manager under their direction. The follow up visit with the acting manager confirmed that a full investigation had been completed and a senior staff member is to be disciplined in respect to procedures not being followed. Although it is accepted that the acting manager and homeowner have a good understanding of adult protection and the procedures to be followed once an allegation is raised, all staff in the home need to receive full training on Adult Protection and the procedures in place to protect all residents. It is acknowledged that two staff have already received training provided by social services and there are plans to progress further training for staff. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hare Lodge is a purpose built care home and the physical standards on the whole are good, ensuring a comfortable well maintained and safe environment for residents. EVIDENCE: Hare Lodge is a large, detached, purpose built care home situated in a residential area of Hailsham, approximately one mile from the town centre. Accommodation is provided on two floors and a shaft lift is available to assist those residents who may have mobility problems. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 19 The home was found to be fresh bright, airy, well maintained and decorated. A tour of the home included visiting a selection of bedrooms and communal areas, which were all, found to be attractive and to have a good standard of cleanliness. It was however noted that some extractor fans in the en suite facilities were not working and that hot water supplied to one area accessible to residents was above the recommended safe temperature. Further examination of records identified that the hot water supplied to en suite baths are not being checked to ensure they are providing hot water at a safe temperature. These issues were raised with the homes management and it was confirmed at the second visit to the home that the extractor fans had been repaired and the hot water being supplied at an unsafe temperature had been adjusted to a safe one, and all hot water supplied to en suite bath has been checked and were found to be supplying hot water at a safe temperature. Procedures in the home have been improved to ensure the extractor fans are checked regularly along with the provision of all hot water to areas accessible to residents. The home has two assisted baths with a hoist facility and one further communal bath. This provision does not meet the minimum standards as although there are en suite baths the management of the home confirmed that these are not used. The bathing facilities in the home need to be fully reviewed to ensure all the needs of residents can be met. During the inspection it was noted that one bath was being used to disinfect commode pots and it was noted that the home does not have a sluice area for the emptying and cleaning of commode pots. This was discussed with the acting manager who needs to review the infection control practice in the home to ensure risk of cross infection is minimized. The acting manager was able to confirm that all staff have now completed infection control training. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. Although staff training is provided in the past it has not been managed to ensure staff are trained and competent to do their job. EVIDENCE: At the time of this inspection 31 residents were living at Hare Lodge Care Home. Staffing levels seen confirmed that they are good and appropriate to meet the specialist care and social needs of residents. Records confirmed that these levels are maintained and that staff turnover has been low. Staff spoken to felt they had enough time to provide individual care. The care staff are well supported by domestic and catering staff team and the acting manager is readily available at all times as she lives next to the care home. Observations made during the inspection confirmed that staff are caring and respectful in their interactions with residents. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 21 All feedback received about the staff was very positive and comments made included ‘Staff are very friendly attentive and supportive’ ‘I have found the staff here very helpful, friendly and cheerful’ ‘It is humbling to see how the staff make so much effort for the residents’ comments from visiting health care professionals included ‘staff are always pleasant and caring’ ‘Staff are attentive and responsive to the residents needs’. The recruitment practice and records were inspected for three staff members and were found to be comprehensive and clear. The acting home manager confirmed in the pre-inspection questionnaire that 56 of staff have achieved a National Vocational Qualification in care level 2. It was clear from contact with the staff group that staff training is given a high priority and the home now has an allocated person to co-ordinate staff training. Records examined in respect to staff training demonstrated the completion of induction training but did not record that staff had received all the necessary training for example safe moving and handling. Ongoing regular training for staff needs to be fully established and recorded. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home encourages an open, relaxed, homely and caring atmosphere where care staff are suitably supported and guided. Quality assurance measures allow for residents and representatives views to be taken in to account. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally well promoted and protected. EVIDENCE: Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 23 Sine the last inspection a new manager has been appointed, she is a registered nurse and has completed a National Vocational Qualification level 4 in management and is currently applying to the registration team for her registration as home manager. The new acting manager has been well received by all the staff who were complimentary about her saying she was ‘approachable and had implemented good management strategies’. Observation confirmed that the acting manager has an excellent rapport with residents and staff and has provided a stable management structure to the home. The acting manager has implemented an audit review of the standards in the home and this is used in addition to resident and their representatives questionnaires used to assess the quality of care and services in the home. Questionnaires are used every six months and the data received from these are audited and the results of this are made available in the office. The home now needs to report further on these results and provide an annual report for the CSCI and should consider having a questionnaire for staff and visiting professionals to the home to complete. Systems for dealing with resident’s monies and valuables are in place and were found to be robust. Records relating to Health and Safety in the home were reviewed and on the whole were found to be full and extensive. Issues relating to the provision of hot water are recorded under the environment section of this report. The home has replaced a damaged bath hoist since the last inspection in accordance with a requirement made in the last report. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 24 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 That the new system to record medication non-administration is underpinned by a clear procedure and followed at all times. That resident’s who do not take their medicines on a regular basis have a corresponding plan of care to give guidance to care staff. That all prescribed medication administered including creams are recorded on the medication records. That clear individual guidance is in place for all medicines that are prescribed on an ‘as required’ basis. That all staff are trained on what constitutes abuse and the procedures to follow is abuse is suspected. That the provision of bathing facilities in the home is reviewed to ensure appropriate provision for all residents. That the infection control practice in respect to the DS0000021126.V323758.R01.S.doc Timescale for action 01/05/07 2. OP9 13 (2) 01/05/07 3. OP9 13(2) 01/05/07 4. OP9 13(2) 01/05/07 5. OP18 13 (6) 01/06/07 6. OP21 23(2) 01/06/07 7. OP26 13(3) 01/06/07 Hare Lodge Version 5.2 Page 26 8. OP26 13 (3) (4) & 23 (5) emptying and cleaning of commode pots is reviewed to ensure suitable infection control measures are in place. That advice provided from the Environmental Health Officer regarding the risks of infection and Legionella from the homes redundant sluice located in the medication store is confirmed in writing and underpinned with a procedure. 01/06/07 9. OP30 18 (1) (a) That all staff receive ongoing and 01/07/07 appropriate training to meet the needs of all residents in the home. 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. Refer to Standard OP15 OP16 OP33 Good Practice Recommendations That further meal choices are provided to the residents That the complaint record is improved to demonstrate how complaints are investigated and responded to. That the Quality assurance measures are further reported on providing an annual report to the CSCI and good availability to any other interested parties. Hare Lodge DS0000021126.V323758.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hare Lodge DS0000021126.V323758.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. 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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