Inspection on 22/01/08 for Heath Lodge

This inspection was carried out on 22nd January 2008.

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

Heath Lodge 02/03/10

Heath Lodge 29/01/09

Heath Lodge 11/07/06

Heath Lodge 31/10/05

Heath Lodge 05/07/05

Heath Lodge 29/09/04

Heath Lodge 13/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Heath Lodge St Georges Avenue Weybridge Surrey KT13 0DA Lead Inspector Helen Dickens Unannounced Inspection 22nd January, 2008 10:10 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 DS0000013668.V349668.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. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heath Lodge Address St Georges Avenue Weybridge Surrey KT13 0DA 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) 01932 854680 01932 851792 Surrey Rest Homes Ltd Sheryl Amanda Smith Care Home 26 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (16) of places Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 65 years and over 11th July 2006 Date of last inspection Brief Description of the Service: Heath Lodge is a registered care home for up to 26 older people. It is one of four homes owned by Surrey Rest Homes Ltd. The home is a large detached house with a purpose built extension, set in a large garden in a residential road close to Weybridge railway station and town. The accommodation is on two floors with a chair lift that falls short of the last few steps to the ground floor. The home has single and double rooms, some with en-suite facilities. There is a garden to the rear of the premises and parking to the front of the building. The fees range from £318 to £593 per person per week. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate quality outcomes. This key inspection was unannounced and took place over 7 hours. The inspection was carried out by Mrs. Helen Dickens, Regulation Inspector. Mrs. Sheryl Smith, Registered Manager, and two senior staff, represented the establishment. A partial tour of the premises took place and a number of files and documents, including resident’s assessments and care plans, staff recruitment files, quality assurance information, and the annual quality assurance assessment (AQAA) were examined as part of the inspection process. A number of questionnaires returned to the service from residents, relatives and healthcare professionals were also used in writing this report. Three residents were interviewed in their rooms, and several others conversed with throughout the day. The inspector would like to thank the residents and staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Improvements since last inspection include meeting four out of the six Requirements made at that time. In addition, new menus had been introduced and there was plenty of praise for the food and the chef. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 6 A new care planning format was being used and whilst not everyone had a new care plan yet, this project was well underway. A recruitment evidence file and checklist has been put in place including a list of CRB numbers, contracts, and hours worked etc for each staff member. The manager said resident’s finance records had also improved since the last inspection. A training matrix has been drawn up by the manager to identify which staff have done which training courses, and when refresher courses are due. 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. The summary of this inspection report can be made available in other formats on request. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 7 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 DS0000013668.V349668.R01.S.doc Version 5.2 Page 8 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): 2 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents are assured their needs will be met prior to moving into the home, but residents and staff would benefit from better records being kept in relation to assessed needs. EVIDENCE: Three resident’s needs assessments were sampled during the inspection. Each had the home’s own detailed assessment, carried out prior to admission to check the suitability of the home for each individual resident. The main areas covered included personal care, mobility, continence, and communication. Risks to the resident had been identified for example the risk of falls, and risks involved in moving and handling. One resident who had special cultural needs had these clearly identified. One staff member interviewed was found to be very knowledgeable about the needs of this resident in relation to their faith and culture. All residents at this home have now been asked about their Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 9 gender preferences in relation to receiving support from staff, i.e. whether they would prefer a male or female member of staff. The Annual Quality Assurance Assessment (AQAA) completed by the home prior to this inspection stated that prospective residents and their families were welcome to spend some time at the home, for example for a meal, prior to choosing to move to Heath Lodge. One new resident who wanted to move to a different room had discussed this with the manager who was actively trying to arrange the transfer. The admission arrangements need to be reviewed as there were some shortfalls in relation to resident’s records. For example falls risk assessments which had not been dated or signed; one person had not been weighed, yet had been at the home for over a month; another had incomplete risk assessments for nutrition and pressure sores; another had their foot care and oral health assessments left blank and their social interests were only briefly recorded. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from having their social and health care needs identified and set out in their care plans, and care delivered in a way that protects their privacy and dignity. Arrangements for medication administration continue to improve, therefore safeguarding resident’s interests. EVIDENCE: Three resident’s care plans were sampled. They had been drawn up from the pre-admission assessments and were reviewed on a monthly basis, or more often if changes were needed – good records were in place regarding these monthly reviews. The manager has introduced a new format for care plans; samples of both the old style plans, and the new format, were examined. There were good guidelines to staff about how residents would like their care delivered, including what gender they preferred care staff to be for assistance with personal care. There were daily notes kept, and a key worker sheet in each file noting any significant events relating to personal care of each resident. Two staff were interviewed and found to be knowledgeable on all Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 11 aspects of resident’s care. There were no negative comments relating to staff from the residents spoken with, and several were complimentary about the care they received and how good the staff were. Two residents commented that the staff were very good with some of the residents who could be ‘difficult.’ Resident’s at this home have access to all the local community healthcare facilities including a weekly visit from the GP, and regular visits by the chiropodist, optician and dentist. Healthcare professionals note their visits and any treatment given on a professional’s contact sheet in the back of each resident’s file. Specialist advice has been sought in relation to continence and there were no unpleasant odours in any part of this home – Heath Lodge was clean and fresh throughout. One resident was unwell on the day of the inspection and the manager and staff were very attentive in monitoring that persons condition; timely advice was sought from the GP and instructions followed by staff. This resident was spoken with later and she said she liked it at Heath Lodge and was well looked after. All staff who administer medication at this home have had specialist training, though some had this in 2005 so refresher courses are currently being completed. Medicines are kept securely and records were in good order. Three resident’s medication records were sampled and contained no unexplained gaps. The manager carries out regular monthly medication audits and two senior staff monitor the records throughout the week. An issue relating to a medication error has been investigated by the Safeguarding Team since the last inspection and the home has co-operated with the relevant authorities. The manager said policies and procedures have since been revised and medication administration competency assessments have been introduced for staff. The privacy and dignity of residents is respected at Heath Lodge and staff were seen to knock on doors before entering. Assistance was observed being given in a sensitive way, for example when residents needed help to walk, and with their meals. Residents can choose whether they wish to have a male or female member of staff to assist them, especially with their personal care. Cultural and religious needs have been taken into account by staff and those spoken with were knowledgeable on how to support residents in this regard. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 12 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from being able to take part in some activities at the home if they wish, whilst maintaining outside family and friendship links. Residents enjoy their mealtimes at Heath Lodge. EVIDENCE: The home has a regular activities plan including bingo and sing-a-longs. The manager has allocated two members of staff to carry out the activity each afternoon and the 2008 Annual Development Plan for the home shows 2 hours of dedicated staff time is going to be allocated to this task each weekday. There are also one off entertainments, for example a ‘Minstrel’ is coming to provide musical entertainment in February. There were several different entertainments arranged over the Christmas period, including a Christmas party. There is a well-kept garden which staff say residents enjoy in the summer, when there was a very successful barbeque which relatives were invited to attend. The home has two lounges, one with a TV and one without. Two newspapers are also delivered to the home each day. Heath Lodge has a pet budgerigar called ‘Billy’ who is looked after by one of the residents. The 8 Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 13 annual questionnaires returned by residents to the home, showed that there were no negative comments in relation to activities. Residents have a variety of links with the local community and use local health services such as the GPs surgery, the district nurses and the chiropodist. The manager has organised for the mobile library to visit the home and this is advertised on the notice board in the hall. One relative comes in to play the piano which was purchased and donated by them. Another comes in with a church group to visit residents. A few residents attend the local day centre. Relatives are made welcome at the home and the manager and staff were knowledgeable on family and friendship links. There was plenty of evidence that residents had brought personal possessions with them to the home, and those bedrooms visited contained pictures, photos and ornaments brought in by them. There were opportunities for residents to exercise choice, for example in relation to when they get up, what time they have their breakfast, and food choices for their lunch. They are free to join in activities or not, and to use either of the communal lounges or the garden, or to stay in their rooms. Some residents had chosen to eat in their rooms on the day of the inspection. As there is no lift at this home, resident choice is restricted in regard to going up and down stairs. Those needing assistance have to call a member of staff to help them use the stair lift, and anyone who cannot walk down the last three steps would not be able to go downstairs at all. Mealtimes are very pleasant at Heath Lodge and the chef received a great deal of praise. There are published choices on the menu with a large sign on the dresser in the dining room reminding people about being able to choose alternatives. On the day of the inspection the main course was either beef stew with boiled potatoes, swede and runner beans, or a tuna pasta bake. The chef said most of the food is home-made and he had made banana cake and custard for pudding. Residents commented very positively on the food one saying it was ‘perfect’ and others saying it was ‘very good’ and ‘first class.’ No complaints were received at all. One resident described how she had enjoyed a nice piece of white fish for her lunch demonstrating that alternatives to the choices already on the main menu were indeed available. The dining room is pleasant with linen tablecloths and silk flowers on each table. Resident’s were offered help discreetly, and some special adaptations, e.g. a plate with a raised edge, were in use to help resident’s maintain their independence at mealtimes. Issues relating to weighing residents and to completing a nutritional assessment tool are noted earlier in this report. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 14 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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from having an easily accessible complaints procedure, but further work must be done on the safeguarding adults procedure to fully protect residents. EVIDENCE: The AQAA from Heath Lodge stated that a record of complaints is kept and none had been received either to the home, or to CSCI within the last 12 months. There is a complaints procedure in place which is widely available in the home including in communal areas and in each resident’s bedroom. Questionnaires to residents and families, together with residents meetings and care reviews, also allow opportunities for raising complaints and concerns. There is a protection of vulnerable adults (POVA) policy in place and the home has a copy of the Surrey local procedures for safeguarding adults. Those recruitment files checked showed staff had had Criminal Records Bureau checks and their names had been checked against the POVA List to ensure they had not been deemed unsuitable to work with vulnerable people. One safeguarding matter raised since the last inspection has been investigated and the home co-operated with the relevant authorities. The new safeguarding adults ‘alert card’ is displayed in the office, and a poster with the same information is on the resident’s notice board. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 15 It was identified during this inspection that the company policy states that the home should ‘investigate’ any suspected abuse, and this is not in keeping with the Surrey local procedures. Staff spoken with thought it was their responsibility to investigate, though they also said they would inform the manager and head office. The definitions of abuse within the policy also differ from the Surrey policy which could cause confusion for staff. The current company policy must be changed so that it fits with the Surrey local policy and accepted practice in this county, and refresher training or new guidance must be given to staff. On discussion with the service manager following the inspection, he said the policy has been changed some time ago but for some reason Heath Lodge did not have an up-to-date copy on file. One of the two staff files checked showed there were shortfalls in recruitment practices which could have an impact on the safety of residents – this is discussed under recruitment and management, later in this report. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Heath Lodge residents benefit from a homely environment with high standards of cleanliness, but some more work needs to be done on the safety aspects of the premises to fully protect residents. EVIDENCE: Heath Lodge offers a homely environment for residents to enjoy. A partial tour of the premises took place, including visiting three resident’s bedrooms. Rooms were noted to be very personalised with people bringing their own pictures, photographs and ornaments. Communal areas were well maintained and the manager said there was a programme of redecoration underway. There is a well-kept garden, and the lounge and some resident’s rooms, overlook this. Some issues need to be reviewed and action taken accordingly. Not all residents had hot water in their hand basins; the flooring needs replacing in Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 17 the first floor bathroom; and risk assessments must be carried out regarding the door to the narrow stairs on the first floor landing and the radiator in one bathroom which has no cover. Storage arrangements must be reviewed as currently clean towels are stored on open shelves over a toilet in one downstairs bathroom. A bottle of disinfectant in the staff toilet and a floor sealant in one of the spare rooms being decorated, were removed by staff as soon as they were discovered. The laundry area was clean and tidy with separate baskets for each resident’s clothes. A staff member who assisted with the tour of the home stated that all staff were given training in how to use the laundry. A disinfection system is in place for the washing machines, and hand washing facilities throughout the home are good. The home was clean and fresh-smelling throughout, and there were no unpleasant odours. Care workers were noted to change their aprons when moving between different tasks within the home. A relative had noted on their questionnaire to the home; ‘Excellent for quality of care, friendliness of staff and cleanliness of the home.’ A risk assessment must be carried out for the laundry area, and this should include any risks in relation to the door being unlocked. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff who are competent to carry out their roles. However, recruitment practices needs more work to fully protect residents. EVIDENCE: There is a staff rota in place with additional staff at busy times – for example there are five staff on in the morning. Staff have some individual ‘leads’ for various activities within the home, for example the weighing of residents, and carrying out some health and safety checks. Staff were observed to be attentive to residents needs, for example at lunchtime when some people needed assistance with their meals. Residents spoke well of the staff and said they were well cared for. On their Annual Quality Assurance Assessment returned to CSCI prior to the inspection, the manager stated that currently 56 of staff have National Vocational Qualification Level 2 or above or are in the process of doing this qualification. Recruitment arrangements have improved since the last inspection and the manager now keeps a checklist of recruitment and personnel information on all staff. Files were in good order and individual documents could be located Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 19 quickly. Three staff files were checked and all had a CRB and POVA check, to ensure they had not been deemed unsuitable to work with vulnerable adults. However, one did not have a reference from their last care employer, and two had references from friends. As the application form does not ask for dates when full time education ceased, it was difficult to see if staff had given a full employment history. One file which had clear gaps in employment history had no documented evidence that the gaps had been followed up. The manager said she would have this form properly completed by the member of staff in question. This Requirement is outstanding from the previous inspection. The issuing of a Regulation 43 Notice for not completely complying with Regulation 19 and Schedule 2 of the Care Standards Act [as amended] was considered. Failure to comply was highlighted at the previous Key Inspection and a Requirement made to address this. However as stated earlier in this section of the report, improvements in recruitment practices were noted during this visit. It is hoped therefore that the home will be more diligent in ensuring that ALL information as detailed in the Regulation and Schedule is obtained in the future. The home follows the Common Induction Standards for new staff and all three staff files checked showed new staff following this induction programme. Whilst there is no training and development programme as such, the manager has completed a staff training matrix so that she can identify which staff have been on which training courses, and when refreshers are due. The manager had identified a few shortfalls, for example with medication training. Though all staff giving medication had had training from a specialist medication training consultant, some now needed refresher courses and the manager is arranging this, together with medication competency assessments for staff. Some staff had not done protection of vulnerable adults training since their induction and a new date has been set for this course. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have benefited by the improvements made by the new manager at this home. Quality assurance systems ensure their views are taken into account, and arrangements for assisting them with money protect their financial interests. Health and safety arrangements must be reviewed to ensure the health and welfare of residents is promoted at all times. EVIDENCE: The service has recently registered a new manager who is making a number of improvements to the service; she is thought well of by staff and residents alike. She has been managing the home since July 2007 and holds the Registered Managers Award qualification. She has kept her own level of knowledge up to date and has completed several training courses relating to Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 21 the care of older people including in dementia care. Unfortunately, at the time of writing this report, it is known that the manager will be leaving Heath Lodge in order to take up a position nearer to where she lives. Staff said they had learned a lot from her and were sorry she would be leaving. The organisation must inform CSCI of the interim management arrangements for the home until a new manager can be appointed. The home has an annual development plan and this covers refurbishment and maintenance, improving activities for residents, and plans for staff training. They are trying to develop a relatives support group in addition to inviting relatives to ad hoc events such as the Christmas party and the summer barbeque. Questionnaires were sent out to stakeholders, including residents and relatives, in December 2007. Some had been returned at the time of the inspection and the manager made them available. A number of very positive comments had been received so far including staff ‘always helpful’; ‘….very warm and welcoming.’; and one resident said they enjoyed activities at the home ‘ a lot.’ There are also resident’s meetings and Reviews of resident’s care, both of which give residents the opportunity to participate in decisions about their care and about the home. However, a number of shortfalls identified on the day of the inspection (see Requirements at the end of this report) had not been identified in the home’s own quality assurance and monitoring processes, and this needs to be reviewed. Residents at this home do not manage their own money but the home assists those who wish to pay for day-to-day expenses (such as hairdressing) by keeping money for them, together with a record of expenditure and receipts. Some residents have their financial arrangements managed entirely by their relatives, and the bills for day-to-day expenses are sent directly to them. Two resident’s accounts were checked and the amount of cash matched the record in the cashbook. There is a health and safety policy in place at this home and the company has an appointed person to oversee all health and safety matters. Within the home, one member of staff takes a lead on this and carries out a monthly audit. Any issues highlighted are either remedied or passed on, e.g. to the maintenance man for action. There was a good record of issues highlighted and then dealt with in this way. The home were displaying their Employers and Public Liability Insurance Certificates, and CSCI Registration Certificate. The manager has been doing some work on monitoring falls within the home and all those residents named by the inspector as having had falls reported to CSCI, had already had a referral made to the rapid response team. There are however some areas of concern including a fire safety officers visit, made earlier in the month, which highlighted a number of shortfalls at this service. These included not having a current fire risk assessment carried out by a competent person; fire doors which had holes in them where locks had been removed; some doors which should be fire doors and were not; some door Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 22 closers which do not work properly; and a training video which the fire service do not think covers the subject in sufficient depth. It was also noted that a recent fire alarm at the home highlighted some confusion among staff about following the proper procedures, and this too needs to be reviewed. The fire service will be following up on these issues and therefore there will be no additional Requirements from CSCI. In addition, there are some risk assessments which need to be carried out as mentioned earlier in the report, and there were two occasions during this inspection when potentially harmful substances were not securely locked away. A review of safety arrangements must be carried out to ensure the safety and welfare of residents. Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 23 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1)(a) Requirement Timescale for action 22/02/08 2. OP18 13(6) 3. OP21 23(2)(l) 4. OP38 13(4)(a) (b)(c) The admission arrangements need to be reviewed in relation to resident’s records as set out under Standard 3 in this report, to ensure each resident has a fully completed assessment prior to, and in the early days of admission. The company policy on the 22/02/08 protection of vulnerable adults must be changed to dovetail with the Surrey local procedures, for example in relation to staff not investigating allegations, and the definitions of abuse. Refresher training or new guidance must be given to staff. The registered person must 22/02/08 ensure that suitable storage facilities are provided in the care home. Not met from 24/08/06 A review of safety arrangements 29/01/08 must be carried out to ensure the safety and welfare of residents, this should include carrying out risk assessments on the laundry, the door to the stairs on the first floor, and the DS0000013668.V349668.R01.S.doc Version 5.2 Heath Lodge Page 25 radiator in the upstairs bathroom with no cover. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Heath Lodge DS0000013668.V349668.R01.S.doc Version 5.2 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. 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