Inspection on 20/04/06 for Heath Lodge

This inspection was carried out on 20th April 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

Heath Lodge 01/05/07

Heath Lodge 29/12/05

Heath Lodge 27/04/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heath Lodge Danesbury Park Road Welwyn Hertfordshire AL6 9SN Lead Inspector Mrs Sheila Knopp Unannounced Inspection 20th April 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 Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 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. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heath Lodge Address Danesbury Park Road Welwyn Hertfordshire AL6 9SN 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) 01438 716180 01438 716181 www.goldcarehomes.com Gold Care Homes Limited Care Home 50 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (50), Old age, not falling within any other of places category (50) Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate one named service user who is currently under the age of 65. The above condition applies only to this named service user and ceases to be in force when the service user leaves the home for any reason. 29th December 2005 Date of last inspection Brief Description of the Service: Heath Lodge provides residential care for up to 50 older people. This includes a separate dementia unit accommodating up to 13 service users. The residential accommodation is arranged on three floors. The dementia unit is on split-levels and is therefore not suitable for wheelchair users. The majority of rooms have en-suite facilities The third floor has been converted to provide additional accommodation, which has not yet been registered for use as part of the home. Heath Lodge is set in extensive grounds, which while accessible by car, are not close to public transport or local amenities such as shops. Detailed information about the services offered including the latest report by the Commission for Social Care Inspection can be obtained from the home on request. Fees are based on an assessment of individual needs and start at £500. Additional charges are made for newspapers, hairdressing and chiropody. (This information was correct on 20.4.06). Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced visit to the home by two inspectors who spent a total of 14.5 hours in the home. The report includes information provided by residents (10), visitors (3) and staff (6). Information received about the home since the last inspection in December 2005 has also been reviewed and included in this report. Previous reports have indicated unsatisfactory standards within this home many of which were inherited by Gold Care Homes Ltd when they took over the running of Heath Lodge in December 2004. Following a period of instability the new operations manager and deputy manager have made progress in improving the quality of service provided to residents. No concerns have been raised directly with the Commission by relatives or other health & social care professionals between inspections which is further evidence of the progress being made. This reports identifies that while there is still work to be done progress is in the right direction and residents and relatives are aware of the improvements being made. What the service does well: Residents were positive about the support provided by staff. The residents felt that there was plenty to do. Positive comments were received about the standard of meals being served. One resident said she was ‘being well looked after, the staff were nice and the food is good and there is plenty’. These comments were reflected by other residents who also said the staff were polite. One person said staff were ‘always ready to help’. However another person described having to wait for attention. Residents and relatives are able to express their views about the service provided at Heath Lodge through regular meetings and questionnaires issued as part of the company’s quality assurance system. An open and positive approach to addressing concerns brought to the attention of the company by relatives was demonstrated. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Gold Care Homes Ltd need to ensure that they communicate a clear approach in relation to the model of dementia care that influences how they run the service. This will ensure that the refurbishment and use of the building, level of staff training, staffing levels, activities and the involvement of residents and their representatives in care planning reflects current dementia care practice. Staff need to talk to residents when they are interacting with them and respond appropriately. A resident clearly told the staff serving lunch several times that they did not want sprouts yet this was served to them. Residents had to wait a long time sitting in the dining room before they were served lunch which caused them to express feelings of irritation. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 7 Staff need to ensure that drinks are regularly offered to residents who are unable to request drinks for themselves. The company need to look at ways of encouraging and enabling staff, whose cultural experiences do not match those of the residents. So that they are able to prompt residents to talk about their lives and past experiences to promote a sense of well-being and purpose, which is important for residents with dementia. Hopefully this will be part of the developing key worker role. Further work is required on care planning to ensure they reflect the individual needs of resident and include their health needs and risk assessments. Relatives have been requested to contribute information on life histories and preferences to assist with this. Minimum staffing levels are being provided and need to be kept under review reviewed to enable staff to move away from being task orientated to providing a more individual approach. Staffing continues to be an issue. The majority of care staff have been recruited from overseas and at the time of the inspection there was no housekeeping team. Locally recruited staff continue to be sought to provide a balance. The company need to look at the hours allocated to senior staff to carry out their roles in relation to care planning and supervision of staff. The company need to look at how they monitor the safety of residents and staff as immediate requirements were made in relation to raised hot water temperatures, raised surface temperature of a radiator, removal of a window restrictor, hazardous substances not being locked away and the need to keep access to a fire exit clear. Confirmation was received following the inspection of the action taken to address these concerns. The company needs to pursue the recruitment of a manager with relevant qualifications and experience to manage the home and submit an application to the Commission for registration. The deputy manager is currently covering this role, which in turn reduces the management cover available. 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. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 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 Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 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): 3 – standard 6 does not apply to this service. Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Assessments are carried out before admission to ensure that that home is able to meet the needs of the individual concerned. EVIDENCE: A pre-admission assessment procedure is in place. The care records examined confirmed that assessments had been carried out before admission. This included obtaining information from other health & social care professionals. On the day of inspection two people were also visiting the home to see if it was suitable for their relative. They confirmed that information about the services at Heath Lodge had been made available to them. The categories and conditions of registration currently in place were found to accurately reflect the needs of the residents living at Heath Lodge. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. Overall the personal care and hygiene of residents seen on the day of inspection appeared to be good. However the care plans reviewed did not demonstrate that an individual approach had been taken to identifying needs. In some cases important information about the care required by residents was missing. Staff need to ensure that they promote the dignity of residents by acknowledging them and talking with them during contact. Residents have access to community nurses, general practitioners and other health care professionals to support their health needs. There are safe systems in place for the administration of medicines but alterations are required to a storage cupboard to fully comply with the Misuse of Drugs Act. EVIDENCE: Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 11 More attention is required to ensuring that each person’s care plan identifies how staff are to meet their individual needs to demonstrate that appropriate care is being provided. Residents and or their representatives need to be involved in putting the care plan together and reviewing it with staff to ensure their individual preferences are taken account of. A pre-written format is used to assist staff with developing care plans. A space is left in the text for staff to add the name of the resident. In some cases this had been left blank and individual information had not been added to supplement the standard information that applied to all residents. The care plan of a new resident with diabetes had not been completed a week after admission. A requirement regarding a similar issue was made following the last inspection. The individual concerned was receiving a diabetic diet but was anxious because they did not receive confirmation of this from the staff serving lunch. A resident had not been weighed on admission and monthly weights had not been followed up in all cases so it was difficult to assess whether the nutritional needs of residents were being met. The acting manager reported that no residents had pressure sores. Where a risk had been identified the community nurses had provided pressure-relieving equipment. However staff need to ensure that they record risk assessments in relation to the safe use of equipment such as electrically adjustable beds and the actions required to prevent pressure sores in the care plan. The manager has taken positive action to involve the local falls prevention service for individual residents. The majority of staff were observed being sensitive and gentle in their contact with residents. They have received training on respecting privacy and dignity. However this needs to be reinforced with some staff who need to ensure that they respond appropriately to resident requests and speak to them as meals and drinks are served. The systems in place to manage medication safely had recently been reviewed by the dispensing pharmacist. A new competency assessment has been introduced for staff administering medication. The continued competency of staff will be reviewed annually. Now that there is a procedure in place it was advised that it is used as a baseline to record the competency of the staff currently administering medication. Overall the medication systems were assessed as meeting the required standards. For ease of auditing staff, should ensure they take medicines out of the blister packs in order. To fully meet the Misuse of Drugs Act 1971 the fixings on the Controlled Drug Cupboard need to be reviewed. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 12 As part of the redevelopment of the home the company may wish to consider providing a larger treatment room and area for staff to store and write care plans away from areas used by residents. It is good practice to have hand washing facilities in these areas. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 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 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are being involved in planning the social life and experiences available to residents. Service users commented positively on the choice of meals being provided. The meals provided on the day of inspection were hot, appetising and tasty. EVIDENCE: Residents felt there was plenty to do. Activities were being enjoyed by residents in the main lounge and also a smaller group working on a craft based activity. A Cockney evening with a buffet and entertainment was taking place that evening to which relatives had been invited. The home does not currently have an activities organiser and the post is being advertised. In the interim period the previous activity organiser who provides an excellent service is covering some days of the week and entertainment is being brought in. Staff are also allocated on each shift to support residents in what they would like to do. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 14 The minutes of the relatives meeting indicated that ideas on how to bring the community to the residents given the isolated spot this home is in were being discussed. A shop to enable them to purchase items was suggested. The acting manager reported that he had access to a mini bus from another home in the group and was looking at short outings for the summer. The operations manager reported the new menus had been nutritionally assessed. Residents confirmed they enjoyed their meals. Good portions were served on warmed plates. Fruit and drinks were available in the lounges and water jugs provided in bedrooms. As well as fruit squash staff should offer water as a choice during the day. Staff need to ensure residents who are unable to ask for drinks themselves are regularly offered them in addition to the routine tea and coffee rounds to ensure they have an adequate fluid intake. There was a long delay in serving residents their lunch once they were seated. It was reported more hot trolleys are on order, which will mean each of the dining areas can be served at the same time. As stated in the summary staff did not acknowledge requests from residents on all occasions or speak to them when providing a service. The inspectors also requested that the vacuuming of an adjacent lounge was discontinued during lunch time as this was very loud and disturbing the residents. The company have responded to requirements made by the Environmental Health department when they inspected on 29/11/05. Updated food hygiene training for the chef is being organised. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 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 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure in place, which ensures that any complaints will be properly investigated. Letters of appreciation had been received from relatives. Staff training in relation to protecting residents from abuse has taken place, raising awareness of these issues and the need to provide care, which protects and supports the dignity of residents. EVIDENCE: The record of compliments and complaints received by the company was examined. This indicated that the company were taking a rigorous approach to investigating concerns and take action to improve services for residents where required. A recommendation made following the last inspection to amend the complaints procedure to include details of the Commissions involvement has been addressed. No concerns have been raised with the Commission about services provided at Heath Lodge between inspections. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 16 Staff interviews and training records confirmed staff had received training in protecting vulnerable adults. No concerns were raised about the safety of residents in discussions with residents, relatives or staff. Staff were aware of their responsibilities and procedures to bring issues to the attention of managers. They confirmed there was an open atmosphere in which they could talk to the manager or operations manager. The Hertfordshire multi – agency adult protection procedure was available in the home meeting a requirement from the last inspection as it had not been available when the home was last inspected. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 17 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, 21, 24, 25 & 26 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. Some serious health & safety issues related to the premises were identified and subject to an immediate requirement notice. These are detailed under standard 38 of this report. Work to improve the premises for residents is continuing. The company have reported they have carried out a full environmental audit and put a programme of work in place to address the issues identified. The continued progress of the work being carried out was confirmed. However work is still required in all areas to fully meet the standards. Discussions have taken place with the company regarding reviewing how the different groups of residents are accommodated within the building. A recommendation has been made to introduce risk assessments where keypad door locks are used to ensure the rights and safety of residents are regularly reviewed. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 18 Overall the home was found to be fresh and clean but in the absence of adequate numbers of domestic staff spills were not attended to in a timely manner and areas in individual rooms and bathrooms needed attention. EVIDENCE: A full tour of the building was carried out with the acting manager who took an inventory of the issues raised requiring further attention. There is considerable movement and noise associated with the floor boards in some areas which need to be addressed as new carpets are fitted. An update to the refurbishment programme for the house and grounds has been required as a result of this inspection. Work is required to improve the lighting in individual rooms & public areas of the home. The main lounge is in the centre of the building and has no natural light. Similarly the corridors are dark and in some room s the central light is inadequate for the size of the room. Comfortable chairs have now been provided in bedrooms. Lockable drawers have been provided but work to provide handles and locks on bedroom doors is still to be completed. Residents have been provided with an increased choice of areas they can sit in during the day. Day areas have been enhanced with items such as music centres and flower arrangements. There was only one bathroom in use at the time of the inspection as they are being upgraded. The majority of rooms have a shower in the en-suite bathroom. The company need to ensure a choice of bathing and shower facilities with suitable aids to assist residents are provided on each floor. Requirements in relation to hot water systems have been made under standard 38. Hand washing facilities are required to be provided for staff in the laundry to reduce the risk of infection. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. The company need to review the staffing levels and skill mix across the staff groups to ensure residents are provided with a consistently high level of care and support in all areas. An intensive programme of staff training has taken place to provide staff with the basic skills required to do their jobs. The required checks are being carried out on staff before they start work to ensure that residents are protected. EVIDENCE: The last year has seen the recruitment, training and establishment of a new staff team. It was the assessment of the inspectors and recognised by the company operations manager that while baseline training has now been provided further work is required to develop staff skills and understanding particularly in relation to the care of residents with dementia. There was also evidence that staff hours need to be increased in line with an increase in occupancy levels and to provide time for senior care staff to supervise their colleagues and develop care plans. The current hours do not enable staff to move away from a task orientated approach. An example given by a resident was that distress was being caused because they were told staff Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 20 were not able to take him to the toilet until all the other residents had finished their breakfast. Following the inspection the deputy manager confirmed that an extra care assistant had been added to the morning and afternoon/evening shifts in response to increased numbers of residents. The home does not currently have any domestic staff employed. The care staff are working additional shifts to cover the shortfall and these are identified separately on the rota form the hours allocated to residents. The company urgently need to review this situation as evidence on the day demonstrated that this arrangement provided inadequate cover and had led to unsafe working practices and a poor response to attending to spills and stains. Recruitment of locally based staff continues to be difficult. A programme to achieve a level of care staff with 50 NVQ qualifications in care has not yet been achieved. A requirement has not been made under standard 28 as there is a programme in place to achieve this. The records of 4 new members of staff were reviewed and found to be in order with police / criminal records checks having been completed. It was recommended that the company application form be amended to include a full employment history. Currently a 10 year history is requested. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 21 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 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. Heath Lodge does not currently have a registered manager. Serious concerns in relation to health & safety issues were identified and subject to an immediate requirement notice which the deputy manager has since responded to confirming the required actions have been taken. The company has introduced a quality monitoring system, which includes the views of residents, relatives and other professionals involved with the home. There are suitable systems in place to enable residents to have access to personal money and store valuable items should the need arise. A record of valuables that are deposited by residents for safekeeping needs to be introduced. The company have worked hard in the last 6 months to provide induction and mandatory training covering safe working practices. However in relation to the Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 22 health & safety issues identified there needs to be greater awareness among the staff to putting this into practice and reporting non-compliance Formal supervision sessions to assess and review the working practices of care staff have not been fully introduced. Copies of service records to demonstrate systems are being monitored in line with legislation have also been requested. EVIDENCE: There has not been a registered manager in this home since Gold Care Homes Ltd was first registered in December 2004. The deputy manager is being supported and monitored by the company operations manager, who is regularly in the home, and known to the residents. To fully comply with legislation the company need to put forward a suitably qualified manager with experience in managing services for older people and older people with dementia. The current management structure is weak. The deputy manager is acting up as manager therefore the hours allocated to this role are not being used. The company needs to provide further day-to-day management input to support and supervise residents and staff. The appointment of a housekeeper would also assist with improving standards. It was reported that the annual audit cycle is nearing completion and questionnaires are to be sent out to residents, relatives and other people involved with the home. The operations manager anticipated a report would be made available to residents, relatives, funding authorities and the Commission within 3 months. Monthly reports by a representative of the company are provided to the Commission as required. The policies and procedures seen indicated they are subject to regular review, audit and document control. Policies and procedures are in place to safeguard residents financial interests. The system for enabling residents to have access to their personal allowance was reviewed and found to be in order. A separate record of valuables deposited for safekeeping including the details required under Schedule 4 (9)(a)(b) needs to be kept. Interviews with staff identified that they were not receiving formal supervision sessions with senior staff. A requirement has not been made at this stage as the acting manager has put together a timetable and allocated senior staff to carry this out. It was advised that staff receive training in supervision and that Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 23 supernumerary time is allocated to ensure the hours allocated to support residents is not reduced. Immediate requirements have been made in relation to raised hot water and radiator temperatures, access to a fire exit, removal of a window restrictor and hazardous cleaning products being left unlocked. None of the issues had been picked up and reported by staff working in these areas. Copies of gas service and Legionella test records have been requested to ensure the required safety checks are being carried out. A record of accidents and incidents is being maintained. The records checked confirmed that the Commission was being notified of significant events as required. It was recommended that the acting manager include the time and place of accidents in the monthly audit to identify any patterns. Records of fire training, fire drills checks on equipments and fire alarm tests were all available. A previous requirement regarding the frequency of fire drills was assessed as being met on this occasion. Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 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 x x 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x 1 x x 2 1 2 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 2 x 1 Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(2) & (3) Requirement Measures must be put in place to ensure that residents are involved in decisions about their care, and that these are recorded appropriately. The care plans should be signed by the resident or their representative. Brought forward from 29/12/05 with revised timescales. Risk assessments for identified needs must be recorded and kept under review. This must include the use of specialist equipment. Requirement updated and brought forward from 29/12/05 with revised timescales. All health care needs must be recorded appropriately in order to prevent any avoidable risks to the resident’s health. This should include a regular review of weight and details of dietary needs. Requirement updated and brought forward from 29/12/05 with revised timescales. DS0000063065.V290632.R01.S.doc Timescale for action 31/07/06 2. OP7 13(4)(c) 31/07/06 3. OP8 12(1)(a) 31/07/06 Heath Lodge Version 5.1 Page 26 4. OP9 5. OP10 6. OP19 7. OP24 8. 9. OP26 OP27 10. OP27 11. OP31 12. OP35 13. OP38 Confirm action to ensure the wall fixings on the Controlled Drug cupboard comply with the Misuse of Drugs Act 1971. 12(4)(a) Ensure the staff approach to residents by speaking to them and responding appropriately promotes their dignity and autonomy. 23(1)(2) Provide an update on the progress and anticipated timescales to address the issues identified by the company environmental audit. 23(2)(e) Suitable over-ride door locks and handles must be provided on all bedroom doors Brought forward from 11/11/05 with revised timescales as work not complete. 13(3) Provide hand washing facilities in the laundry. 18(1)(a) Provide domestic staff in sufficient numbers on each shift to maintain the home in a clean & hygienic state. 118(1)(a) Review hours provided to enable senior care staff to fully develop, review and update care plans and provide formal supervision sessions for care staff. CSA 11(1) Gold Care Homes Ltd are required to submit an application to the Commission from a suitably qualified and experienced person to become the registered manager. 17(2) A record of valuables deposited for safekeeping needs to be kept in accordance with Schedule 4(9)(a)(b) 13(4) Hot water temperatures in areas (a)(c) used by vulnerable residents must meet health & safety requirements to reduce the risk of accidental scalding. A thermostatic mixing valve DS0000063065.V290632.R01.S.doc 13(2) 31/07/06 20/04/06 31/05/06 31/07/06 31/05/06 31/05/06 31/05/06 31/10/06 31/05/06 20/04/06 Heath Lodge Version 5.1 Page 27 14. OP38 13(4) (a)(c) 15. OP38 13(4) (a)(c) 16. OP38 13(4) (a)(c) 17. OP38 23(4)(b) should be fitted to maintain the water temperature at 43oC. Weekly temperature checks of bath hot water supplies should be recorded. A thermometer and procedure for checking bath water temperatures needs to be introduced. Subject to immediate requirement on day of inspection. Window restrictors need to be maintained in place and a system introduced for regular checks. Subject to immediate requirement on day of inspection. The use of the electric radiator in the identified room needs to be reviewed and steps taken, based on a risk assessment covering the individual and residents who may have access to this area, to ensure there is no risk of accidental scalding from the raised surface temperature. Subject to immediate requirement on day of inspection. The thermostatic valve on the low surface temperature radiator in this room must be replaced and the movement in the floor inspected. All hazardous substances must be kept in locked areas. Subject to immediate requirement on day of inspection. Access from the ground floor corridor by room 26 leading to the external fire exit must be kept clear and items stored in this area removed. Subject to immediate requirement on day of DS0000063065.V290632.R01.S.doc 20/04/06 20/04/06 20/04/06 20/04/06 Heath Lodge Version 5.1 Page 28 18. OP38 13(3) 16(2)(k) inspection. Provide copies of the annual gas safety check certificate and Legionella test certificate. Put a programme in place for the regular flushing of showerheads and shower drains. 31/07/06 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 OP19 Good Practice Recommendations Put in place generic and individual risk assessments where keypads door locks are used to demonstrate that the interests, rights and safety of residents have been considered and regularly reviewed. Refer regulation 13(7)(8) It is recommended that as part of the review of the premises the company consider how it can provide smallscale living units for residents with dementia within the home. Review application form to include a full employment history. Include the time and place of accidents in the monthly audit. 2 OP19 3 4 OP29 OP38 Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Heath Lodge DS0000063065.V290632.R01.S.doc Version 5.1 Page 30 - 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. 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