Inspection on 30/06/05 for Hart Lodge

This inspection was carried out on 30th June 2005.

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

Other inspections for this house

Hart Lodge 04/09/07

Hart Lodge 01/08/06

Hart Lodge 23/01/06

Hart Lodge 19/11/04

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

CARE HOME ADULTS 18-65 Hart Lodge 10 Whalebone Grove Chadwell Heath Romford Essex RM6 6BU Lead Inspector Joanna Moore Announced Inspection 30th June and 29th July 2005 10:00 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hart Lodge Address 10 Whalebone Grove, Chadwell Heath, Romford, Essex RM6 6BU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8590 7077 020 8500 9339 R Hart Care Ltd post vacant CRH Care Home 9 Category(ies) of MD Mental Disorder (9) registration, with number of places Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19 November 2004 Brief Description of the Service: Hart Lodge a registered service for nine people of either sex who have mental health needs which has been regsitered. Hart Lodge opened in the latter Part of 2004 and this is the second inspection carried out under the Care Standards Act. The inspector was advised that current referrals are mainly as part of the reprovision from longstay hospitals. At the time of the inspection the home was full. The building is situated in a residential area which is accessible to central Romford shopping amenities via local bus routes and is easily reached by road from the A12 and A13. The service users are physically mobile, of either sex and aged between 18-65 years.The building had been converted and provided a high standard of accommodation. Hart Lodge is owned by Hart Care Ltd which have owned and operated another mental Health home in the Southend area for two years. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was unannounced inspection carried out over 1.5 days as part of the annual inspection program. It is the second inspection of the home and the home has addressed the majority of the requirements and recommendations from the previous inspection. During the inspection the inspector met with service users, staff, the current acting manager, the previous acting manager and the proprietors. In addition to this the inspector viewed records and toured the building. What the service does well: What has improved since the last inspection? The service has worked hard to address the majority of the requirements and recommendations made in the last inspection report. Since the last inspection a permanent team of staff have been appointed and this has meant that service users have continuity of care from familiar and competent people. This has also enabled the home to put into place an effective training program for staff. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 6 What they could do better: 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. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 & 5 Service users were given full information about the home and encouraged to visit and test drive the home before they made a final decision about whether to live at the home. Staff and service users benefited from a clear, comprehensive, multidisciplinary assessment process prior to admission. Service users had been fully involved in the comprehensive admission process and were clear the home was able to meet their needs. EVIDENCE: A statement of purpose was in place which had been updated to include all information required by the previous inspection and to reflect management and staff changes since the previous inspection. A service users guide was in place, which service users confirmed that they had been given a copy of. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 9 Two referrals to the home were monitored to ascertain the homes processes in relation to pre-admission assessment and information. The home was able to evidence a comprehensive pre admission assessment process. Information obtained included a detailed and extremely useful application form developed by the home, which supported the information, provided by the placing authority. Service users it was evident were fully consulted about their proposed moving into the home and were encouraged to take an active role in the assessment process, their wishes were recorded on the assessment form and where possible they had completed this section. Detailed information was received from the placing authorities including copies of previous CPA reviews. Clear information was recorded as to service users legal status under the Mental Health Act. The manager advised the inspector that all service users were encouraged to visit the home prior to admission and that these visits consisted of short day visits which were then were increased to overnight stays. This was confirmed by observation of one prospective service user visiting during the inspection. The inspector was advised that a three-month trial period was offered. The inspector was advised that no emergency admissions would be accepted. A service user’s licence agreement was in place and met the national minimum standards. The inspector was satisfied from discussions with service users and from viewing service user files that staff were able to meet their needs effectively. The comments made by service users regarding staff and the home in general were highly praising such as …” staff always knock on doors and offer support”….”nothing but praise for it, its excellent”… “The staff are lovely”…” I would recommend it to anyone its excellent”.” I am happy here, it’s nice”…. “ I was supposed to go and look at a few places but this was the first one I saw and I didn’t want to leave”. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 ,9 & 10 Service users and staff benefit from a detailed care plan, which reflects service users changing needs and aspirations. Service users were consulted on all issues regarding their lives and the day-to-day running of the home. EVIDENCE: A comprehensive assessment process enabled the home to develop an initial care plan, which was in time further developed in discussion with the service users. The care plan was comprehensive and addressed all aspects of the service users life. The care plan devised by the home was linked to the Care programme approach (CPA) put in place by the mental health team. CPA review processes were known to the manager. Service users files demonstrated regular clear records held of care and support provided. It is required that a current / recent photograph of the service user be placed on their file. Information on advocacy services was available and displayed on the notice board in the communal lounge area. Arrangements had been made for an advocate to visit. Service users were encouraged to manage their own finances and medication with support. Service users were observed to have autonomy over their daily lives and choices as to how they wanted to spend their time. Service users meetings were regularly held and service users said Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 11 that they were consulted about matters within the home. An example of consultation as a group regarding managing access to the communal telephone following one service user making repeated 999 calls. The Proprietor had asked the inspector whether they could place a keypad lock on the door and the inspector had expressed reservations with this, as it would limit all service users access to the phone. From discussions with service users however it was evident that the proprietor had discussed this with them and they were fully in support of the suggestion. The inspector is satisfied that if written records are held that all service users are consulted and are in agreement to a keypad lock to the telephone room that this may be installed. This must however continue to be discussed at least twice a year at service user meetings to ascertain whether service users continue to be in support of the keypad. Comprehensive risk assessments were in place relating to all aspects of the service users care. Risk assessments on self-harm and aggression were carried out as part of the admission process and subsequently linked to the care plan. A confidentiality policy was in place and service users were confident that any information they disclosed to staff would not be inappropriately shared with other people. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 & 17 Service users benefit from a service, which is geared up to supporting their individual independence skills and personal development. Service users were supported to undertake a variety of activities and to maintain family relationships. EVIDENCE: Five out of 9 service users purchase and cook their own food. A weekly budget is given to them with which to do this. Communal stocks are held of basic provisions such as fruit, vegetables, butter, tea and coffee. The self-catering service users are encouraged to maintain a healthy diet but in reality cook what they want. Staff cook for those residents who need assistance and the kitchen according to service users can become somewhat cramped as people try to cook at the same time. It is strongly recommended that this matter be discussed at a service users meeting and possible solutions examined. A record of food consumed is held for each resident for whom the staff cook. It is required that this record be completed for each and every meal. It is recommended that the menus be reviewed following comments from one resident that they were very repetitive. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 13 Service users are supported to develop their own activities schedule as most travel in the community independently. Service users are on admission taken round the area by staff and introduced to local facilities. Information was displayed in relation to local job centres, libraries, benefits advice, advocacy and colleges. One service user works in the family business most days, another maintains links with and interest in a local theatre group. One service user was undertaking driving lessons and went to men’s group twice a week. The manager advised that the home was looking into day service provision for one new resident. Service users are able to go to church if they wish. On the day of inspection three went out to Romford shopping. Service users are encouraged to do all the household and self care tasks such as laundry, cooking and medicating that they are able to. Service users are supported in maintaining contact with their family if they are unable to do so independently. Family and friends are welcome to visit them at the home. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 Service users benefit from a variety of health and social care professionals to support their ongoing physical and mental well being. It is recommended that all service users be registered with a local dentist. Service users benefited from familiar staff who provided support in a non-intrusive way and who enabled them to do every thing they can for themselves. EVIDENCE: All service users are registered with a local gp but not with a dentist. It is recommended that all residents be registered with a local dentist. Case files evidenced that service users are referred to their gp for any issues of concern about their health. One resident’s file evidenced ongoing referrals to their health practitioner to investigate possible concerns regarding health matters. All service users are supported by community psychiatric nurses and a consultant psychiatrist. The home manager was clear as to the process, which would be invoked if a service users needs became such that they could not be safely managed by the home. Those service users subject to a supervised discharge met with their community psychiatric nurse fortnightly. Mental health risk assessments were in place as part of the overall care plan. Service users in discussion confirmed that staff provide support in a way, which enables them to have as much control of their lives as they feel able to undertake. Service users spoke very positively of the staff….” You wont get Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 15 better”…” the staff are lovely” “ the staff help me with everything, they have showed me how to use the washing machine and cooker” …“they have helped me so much its because of them that I am where I am now and able to do so many things for myself”. Staff have one to one sessions with their key client to discuss matters of concern to the resident or future plans, these are then recorded in their care files. All service users said that staff consulted them on how they wanted to do things and always spoke to them politely and respected their privacy. All service users bar one were able to carry out their own personal care with no supervision other than reminding them to bathe etc. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 &23 Service users are protected from abuse by robust procedures to respond to abuse. Service users felt able to make a complaint and were confident that it would be listened to and dealt with. In order to protect the service users from financial abuse it is required that service users are encouraged to sign for every transaction. EVIDENCE: Service users finances are in the main managed by the service user them self or their family. Only two service users require the home to assist with the management of their finances. One service users financial records were checked. The service user has a set amount paid by the Court of Protection into the homes account on a regular basis and this is then issued at £5 per day to the service user. The service user signs for their money however this record was not completed for every recorded transaction. The registered person is required to ensure that the service user signs for the money each time it is issued. If the service user refuses to sign, this fact must be recorded and signed by the staff. A complaints procedure was in place which was displayed and which residents were aware of. Service users said they felt able to complain but said they did not did not feel the need to do so as the services were good…“You wont get better than this” “ very good place, no complaints… recommend it to anyone…I am happy here its nice... Two complaints had been received from a neighbour in relation to discarded cigarette ends and the home has put into place appropriate measures to prevent any further such complaints. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 & 30 Service users benefit from a well-maintained, safe, well-furnished and pleasant place to live. EVIDENCE: The home was registered within the past year and meets the national minimum standards. The home is supported by well-serviced transport links to central Romford’s extensive shopping and leisure facilities. All service users are provided with a single lockable room and a lockable facility within that room. Bedrooms were furnished according to the wishes of the service user. The building was well decorated furnished and maintained. A leak had occurred in an upstairs toilet which had caused damage to the lounge ceiling. At the time of the inspection this was still drying out and the inspector was advised that this would be repaired within the following month once it had dried out. The communal stairwell had sustained wear and tear and would benefit from repainting. The building is accessible for people with limited mobility and is provided with some ground floor bedrooms and a shower however would not suit wheelchair users. The building meets all requirements of fire prevention and Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 18 environmental health. It is recommended that the registered persons consider the need for areas for staff meetings and training. The inspector was advised that it is the homes intention to extend a small way out to the front of the building on the ground floor to provide extra space. The homes phone service users advised had not been accessible to the service user group as a whole because one service user insisted on using it to make hoax 999 calls. This matter had previously been discussed with the owner who had proposed a combination lock be placed upon the phone room, which the inspector was not in agreement with. From discussions with the service users however it was abundantly clear that it was indeed the service users wishes as a group to have some form of locking system in place so that they could gain entry to use the phone whilst preventing the service user making hoax calls. Residents said they were happy for the telephone room to be locked by a key or by a combination lock. It is required that the registered person fully consult each resident regarding the placing a lock on the phone room and record this consultation process. The garden area was a pleasant landscape designed decked area with plants to enhance it. No special adaptations were required for the client group. The premises were clean, hygienic and odour free. Service users comments included its lovely place the building is well maintained and kept clean… Steven and Richard come all the time to keep the garden nice… Its always nice and clean, staff are always busy cleaning it when they are not with us… we keep our rooms clean…I was supposed to visit a few places but this was the first I came to and I really liked it, its fresh and clean and nicely decorated” Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 &36 Service users benefit from a staff team that is competent and familiar to them. In order to fully protect service users from undesirable persons taking up the post of care staff the registered person must improve the staff checks carried out as part of the recruitment process. The home was not able to evidence regular individual one to one supervision for staff. EVIDENCE: “The staff are lovely, staff always knock on doors and offer support”…”staff are great and help me do all my bits and pieces”. All staff had a clear job description, which outlined their roles responsibilities and lines of accountability. The home has a clear structure with the manager reporting to the owner and all other staff reporting to the manager however there are senior staff and a deputy post. All staff were issued with contracts of employment. A detailed induction in line with skills for care was in place for staff. Four staff recruitment files were sampled to check the homes recruitment procedure. In each of these files was held evidence of the person’s identity, a copy of their birth certificate and or passport (or confirmation from the home Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 20 office), a recent photograph, a criminal records bureau check, an application form, and declaration of health. For three out of the four two written references were held for the fourth person these references could not be located. The registered person must ensure that two written references are in place prior to the member of staff commencing employment. On one application form it was noted that the employment history was not fully completed and that care work had been undertaken within the past year for which no reference was sought. The registered person is required to ensure that a full employment history is obtained which covers the last ten years and that references are taken up for all care work posts that the applicant has undertaken to ascertain the reason for them ceasing employment. Both the manager and deputy are qualified nurses the proprietor had however not taken up a verification of their status of registration, which would state whether they had been removed from the nursing register for malpractice. The registered person is required to carry out an NMC check on staff with a nursing qualification whether or not employed in a nursing capacity. The General Social Care Council Code of Conduct had been issued to all staff. The duty rota evidences two staff on shift at all times. The staffing situation had significantly improved since the last inspection with all staff now permanent employees rather than agency staff. Staff training records evidenced training in manual handling, staff supervision, health and safety, food handling, first aid, mental health, medication and adult protection. The inspector was advised that 5 out of 15 staff had completed NVQ level 2/3 and the rest of the staff have been enrolled. The home has a clear training plan relating to mental health needs, which it intends to provide to its entire staff over the next six months, all the training will be provided by the homes clinical advisor who also provides clinical supervision to the manager. It is recommended that a staff training profile be developed for each member of staff and the staff team as a whole. Staff meetings were recorded as occurring regularly since March 2005. A supervision contract was in existence however no evidence was available to suggest that staff had ever had one to one supervisions or that a staff performance appraisal system was in place. It is strongly recommended that each staff receives one to one supervision at least six times per year and that each staff receives a formal annual appraisal. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41, 42 & 43 EVIDENCE: The manager is a Registered mental Nurse who has experience of managing a forensic psychiatry ward. This is the manager’s first community post. The manager has recently been registered by the Commission and found to be a “fit person”. As the manager has no management qualification it is strongly recommended that he undertake management training to NVQ 4 level. Statutory records were viewed and were satisfactory. The registered person has arranged for an independent person to complete visits to the home each month under regulation 26. Policies and procedures were accessible to staff. Service user meetings were recorded as happening in March and June. It is recommended that service user meetings take place at least six times per year. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 22 Some out of date foods were noted in the fridge, these were disposed of immediately, the registered person is required to ensure regular monitoring off food stocks to ensure that no out of date foods are held. No issues of concern in relation to health and safety were noted other than the food storage issues detailed above. The building is less than one year old and all safety certificates remain valid. Fire records evidenced that fire appliances were checked weekly, fire drills held regularly and that a maintenance contract was in place. Other than fire checks there was initially no regular system in place to monitor issues of health and safety, this had been implemented by the second day of inspection. Appropriate insurance was in place for public, employers and malpractice liability. There was no information to suggest that the home was anything other than financially viable. Whilst the office door is only accessible via a keypad lock it was apparent during the inspection that the manager makes themselves available to staff and service users. Service users and staff also commented that the proprietors are regularly onsite and accessible…. “Richard and Steven are always here doing bits and we chat with them”. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 4 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hart Lodge Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 2 3 G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 24 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. 2. Standard 6 17 Regulation 17 17 Requirement It is required that a current / recent photograph of the service user be placed on their file It is required that the record of food provided is fully completed. Timescale for action 1.10.05 immediate and ongoing no later than 1.9.05 immediate and ongoing no later than 1.9.05 immediate and ongoing no later than 1.9.05 immediate and ongoing no later than 1.9.05 immediate and ongoing no later than 1.9.05 3. 23 17 4. 24 12 5. 34 19 6. 34 19 The registered person is required to ensure that the service user signs for the money each time it is issued. If the service user refuses to sign, this fact must be recorded and signed by the staff. It is required that the registered person fully consult each resident regarding the placing a lock on the phone room and record this consultation process. The registered person must ensure that two written references are in place prior to the member of staff commencing employment. The registered person is required to ensure that a full employment history is obtained which covers the last ten years and that references are taken up for all care work posts that the applicant has undertaken to G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Hart Lodge Version 1.30 Page 25 7. 17 13 ascertain the reason for them ceasing employment.The registered person is required to carry out an NMC check on staff with a nursing qualification whether or not employed in a nursing capacity the registered person is required to ensure regular monitoring off food stocks to ensure that no out of date foods are held. immediate and ongoing no later than 1.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard 17 17 18 24 35 35 36 37 39 Good Practice Recommendations It is strongly recommended that the cooking arrangements be discussed at a service users meeting and possible solutions examined It is recommended that the menus be reviewed following comments from one resident that they were very repetitive. It is recommended that all residents be registered with a local dentist. The communal stairwell had sustained wear and tear and would benefit from repainting. It is recommended that the registered persons consider the need for areas for staff meetings and training It is recommended that a staff training profile be developed for each member of staff and the staff team as a whole. It is strongly recommended that each staff receives one to one supervision at least six times per year and that each staff receives a formal annual appraisal As the manager has no management qualification it is strongly recommended that he undertake management training to NVQ 4 level. It is recommended that service user meetings take place at least six times per year. Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 Hart Lodge G55_S0000059918_Hart Lodge_V227951_300605_Stage 4.doc Version 1.30 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!