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Inspection on 06/06/06 for Higher Park Lodge

Also see our care home review for Higher Park Lodge for more information

This inspection was carried out on 6th June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service users confirmed the home provides good quality, wholesome and a choice of food in this home. The standard of cleaning and hygiene in Higher Park Lodge is very good. The ongoing redecoration work is of a high standard indicating that the owner is committed to ensure the service users are in a very comfortable home. Work carried out has included a new fitted kitchen and all service users bedrooms have been redecorated and many areas in the home have been painted. The comments on the staff surveys received stated that what the home does well is provide "excellent care to all clients" and "treat staff very well". Another said "A happy family and homely atmosphere and care". Another says "Good communication very clean and tidy, staff are always very kind and friendly to both colleagues and service users" "good nutritional and healthy balanced meals".

What has improved since the last inspection?

The home has introduced new risk assessment forms and extended their care plan information. The introduction of the new risk assessments will minimise risk to service users and protect against further risk. The care plans had been updated since the last inspection and included additional information particularly for staff. These care plans now give detailed instructions to new and agency staff to ensure intimate personal care is being provided in a manner that meets with that service users approval, especially where a service user is unable to express themselves verbally.

What the care home could do better:

The home should complete risk assessment forms for all service users in the home for the their protection. Attention should be paid to risk assessments for the hot water outlets available to the service users, specifically in their bedroom sinks, as these have not yet been physically adapted to eliminate risks from hot water. Radiator covers and thermostatic valves should be fitted throughout the home for the health and safety of service users to prevent burns and scalds from hot radiators and uncontrolled hot water.

CARE HOMES FOR OLDER PEOPLE Higher Park Lodge Devonport Park Stoke Plymouth Devon PL1 4BT Lead Inspector Kim Fowler Unannounced Inspection 6th June 2006 09:30 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 Higher Park Lodge DS0000003537.V295991.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. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Higher Park Lodge Address Devonport Park Stoke Plymouth Devon PL1 4BT 01752 606066 01752 606066 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) Higher Park Lodge (Plymouth) Limited Mrs Deborah Ann Norman Care Home 25 Category(ies) of Dementia (25), Dementia - over 65 years of age registration, with number (25), Old age, not falling within any other of places category (25) Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users may be admitted who are 60 years of age or above. Date of last inspection 9th February 2006 Brief Description of the Service: The service is a limited company called Higher Park Lodge (Plymouth) Ltd. The home is made up of a large detached building, approximately 100 years of age, overlooking Devonport park, with an attached purpose built extension to the rear of this building. The home is close to Stoke village in central Plymouth. A full range of amenities and facilities are within walking distance of the home in the Stoke village shopping area. The home can accommodate up to twenty-five residents over three floors. It has a shaft lift serving all three floors though only a few of the residents need to use this facility. The main lounge is by the front entrance of the building and is non-smoking. There is a second lounge on the first floor of the building. The dining room area is close to both the kitchen and the dining room on the ground floor. The ground floor of the extension opens onto a patio area. The home does not have a garden area but is adjacent to the large parkland area of Devonport park. There is one double bedroom in the home and all the others are single bedrooms. Due to the age of the original building many of the rooms have high ceilings. This helps the home in general to feel more spacious. There is a shaft lift that provides disabled access to all parts of the home. The service offered by the home is primarily for people with dementia or significant mental frailty needs. Some of the residents have some mobility difficulties but mostly the residents are fully mobile. The residents have a mixed range of abilities. The home allows smoking in either the staff area or in the patio area to the side of the home. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 2 days. A full tour of the premises took place and 21 service users, 1 visitors, 1 training personnel and 1 GP were spoken with. All comments received were very positive about the homeowners, the staff and the care all service users received. The Registered Manager, who is part owner, her husband and the deputy manager were available during the inspection. The Commission has received presently 1 Professional Comment card from a GP, 3 service users questionnaires, 4 staff surveys and 4 Relatives/Visitor feedback cards. Comments received included, “my mother receives excellent care and attention” another commented, “ a welcome addition to the home would be a mini-bus for trips out”. Other issues are included in the relevant outcome groups within the report. What the service does well: What has improved since the last inspection? Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 6 The home has introduced new risk assessment forms and extended their care plan information. The introduction of the new risk assessments will minimise risk to service users and protect against further risk. The care plans had been updated since the last inspection and included additional information particularly for staff. These care plans now give detailed instructions to new and agency staff to ensure intimate personal care is being provided in a manner that meets with that service users approval, especially where a service user is unable to express themselves verbally. 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. Higher Park Lodge DS0000003537.V295991.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 Higher Park Lodge DS0000003537.V295991.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1/3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Information provided to prospective service users assists them to make an informed choice of a care home. Detailed pre-admission assessments identify service users needs and ensure that the home has suitable choice. EVIDENCE: It was evident that each service user has a Statement of Purpose and Service Users Guide in their own bedroom. Both documents contain the relevant information and have been updated. The Statement of Purpose is a document that describes the aims and objectives of the care home and how the services provided will meet the needs of the residents Each of the service users spoken to during this inspection had a pre-admission assessment completed. The manager or her deputy meet with prospective Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 9 service users and complete these pre-admission assessments to ensure that their care needs can be met at Higher Park Lodge. The home showed as further evidence the form used to gather additional information before admission. This included likes and dislikes and any interests the service user may have. This provides the service users with information that the home can not only meet their health care needs but also their emotional, social, cultural or religious needs. 5 service users were spoken to and their care plans were examined. All the care plans seen in place had been improved upon since the last inspection as recommended at the previous inspection. These care plans now give detailed instructions to all staff on a daily bases as well as information to new and agency staff to ensure intimate personal care is being provided in a manner that meets with the service users approval. Especially where a service user is unable to express themselves verbally. Care plans also showed evidence from other professionals involved with each service user and this included information on visits by the District Nurse, CPN (Community Psychiatric Nurse) and Occupational Therapist. The involvement from other professionals are necessary to provide support for service users and staff in the management of health care issues such as the prevention of bed sores. Some care plans had not been signed by the service users. This practice would ensure the involvement of the service user in constructing them. Higher Park Lodge DS0000003537.V295991.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 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 good. This judgment has been made using available evidence including a visit to this service. The staff and manager provide good personal and health care support to the service users in the home. EVIDENCE: All service users care plans seen during this inspection had sufficient information to assist the staff in their delivery of care. It was recommended in the last inspection that staff use the new more detailed care plans for all service users. This recommendation has now been put into action. These care plans; held in service users bedrooms, ensure that staff are aware of service users needs and will promote consistency in care. The new Risk Assessment forms were shown to the inspector. These are comprehensive in detail and the format meets the required standard. The Registered Manager will now complete these forms for the protection of all service users. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 11 The District Nurse visits regularly. Information is recorded onto each care plan and individual personal treatment being carried out was recorded. The District Nurse is currently working closely with the home to monitor the needs of one particular service user. The home is to be commended on meeting the care needs of this service user who is bed bound. Information read during the case tracking provided evidence that one service user had been in contact with the CPN (Community Psychiatric Nurse) service. CPN services are being provided for this service user to support them with some issues surrounding their depression and motivation. Additional information evidenced was that some service users had input from the Dietician on nutrition and there was guidance on each file for staff to follow. Also on individual files was information on input from Chiropodist and optician and that these visits was carried out at regular intervals. One GP was in attendance during the inspection. The GP confirmed that the home has regular contact with the surgery if they have any concerns about the service users. The GP also felt that the home does well in dealing with any health care issues for individuals. Medication is managed through a monitored dosage system. Staff have received training to ensure they are aware of their responsibilities. Staff training files and in discussion with an external trainer visiting the home during the inspection that medication training had been carried out recently. Service users are supported to maintain responsibilities for their own medication. A risk assessment ensures that the service user is able to do so safely. The risk assessment included a disclaimer signed by the service user that he wishes to administer his own insulin. The staff monitor this regularly alerting GP or District Nurses if necessary to any changes in the service user health. The District Nurse has carried out training for staff on the administration of insulin and evidence was recorded to confirm this. During the inspection process it was evident that staff carry out all personal care needs in private and all service users spoken with confirmed that the staff respect their privacy and dignity at all times. Service users spoke highly of the care staff and said that they were being well cared for and were happy living at the home. Many of the service users named the owners in particular for their kindness and support. Higher Park Lodge DS0000003537.V295991.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 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 good. This judgment has been made using available evidence including a visit to this service. The service users at Higher Park Lodge can be confident that the home offers good wholesome meals. The home welcomes and encourages families and friends to visit. EVIDENCE: Displayed on the homes notice board is a record of activities arranged by the home and the date of these activities. These activities included bingo and an exercise class. This notice had several sessions booked and some of the service users spoken with confirmed that these sessions took place. The home has introduced an Activity record into each service users file recording their involvement. Some service users confirmed that they occasionally go out either with the home’s staff or with their families. One service user was going out during the inspection and the deputy informed the inspector that this had been agreed with the service users family. The interests of the service users in the home were seen recorded in individual care plans and on pre admission assessments. These interests included bingo and places service users like to visit. The Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 13 atmosphere within the home was happy and lots of laughter between the service users and staff. During this inspection 1 family member was visiting. This relative was able to confirm with the inspector that they do visit the home regularly and at any time of day. Several service users confirmed that they go out with their relatives, families or friends and also on occasion with staff. The owner confirmed that the home does not manage any main finances for any of the service users. The home will cover expenses and invoice the service users or their family for any expenses incurred including hairdressing bills. The home records of service users expenditure were seen and clearly show were the money is spent. All receipts that are obtained are filed so that they can be examined by family or advocates. All money is held in a safe. It was evident during a tour of service users rooms that all contained personal possessions and an inventory was held on each individual file. The Inspector was able to examine the 4 weekly menu used at the Home. The home employs 2 cooks who, between them cover 7 days a week. This ensures that the home has someone to provide a freshly cooked meal daily and individual preferences or special diets are catered for. Hot and cold drinks and snacks are available though out the day on request. All service users spoken with confirmed that the meals they receive are excellent and always home cooked using fresh products. Several service users stated that they always have a choice of food and the home will always provide additional food or drinks on request. Higher Park Lodge DS0000003537.V295991.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 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 good. This judgment has been made using available evidence including a visit to this service. The service users in Higher Park Lodge can be confident that their complaints or concerns will be listened to and acted upon. EVIDENCE: The home complaints procedure is distributed to each service user. It is included in the homes Statement of Purpose and Service Users Guide. These are kept in each service users bedroom as well as being displayed in the main hallway. There is a designated complaints record with details of any concern or complaint received. This system includes verbal concerns as well as formal complaints. The Inspector examined this system and identified evidence of action taken to resolve concerns. The home has all the required adult protection policies in place and all the homes staff have attended adult protection training to ensure they have acceptable knowledge and skills regarding adult protection proceedures. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19/26 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. Higher Park Lodge continues to maintain a clean and suitable environment for it’s stated purpose and the service users can be assured that they will live in an attractive and comfortable home that is regularly maintained. EVIDENCE: The inspector toured all parts of the building, on the 2-day of the site visit. The tour included every service users bedroom. During this tour the Registered Manager informed the inspector that since the last site visit the lower hallway has been decorated and new carpets are now due to be fitted. The home also has had a new modern fitted kitchen since this inspector last visited. The main hall on the top floor has also been decorated and all bedrooms have been fitted with new lighting, fire doors and many new Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 16 beds. Therefore providing service users with a safe and well maintained enviroment. Further maintenaince is planned. The inspector was advised that scaffolding is soon to be errected in order to prepare for the main external parts of the building to be redecorated including the baloncy area. The guttering will also be replaced. All service users bedrooms were tastefully decorated. The service users spoken with stated that they were involved with the choice of colour and new bedding when appropriate. The home has a CCTV fitted to cover the main enterance and the car park at the front of the building for the security of staff and service users. Service users benefit from a shaft lift, to assist them access the first floor of the home. The home was very clean, hygienic and odour free. The bathrooms, toilets, kitchen and laundry were exceptionally clean and well maintained. The standard of hygiene and cleanliness remains at an exceptional level. One staff survey received suggested that the home “have a table or trolley on each floor with such things as gloves, wipes and aprons so we are not searching around for theses things”. The home employs a staff member designated to carry out laundry duties and the inspector spoke to this staff member. It was evident from this conversation that this staff member was aware of all infection control and hygiene regulations. All the radiators in individual bedrooms had been covered to eliminate the risk of burns. During discussion the owners confirmed that all other radiators would be covered as funds became available. The hot water outlets at baths have hot water temperature control valves fitted reducing the temperature of the hotwater to a safe level and the home plans to fit controls to all sinks within the next year. Those sinks not adapted should have risk assessments to protect the service users from scolds. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 17 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 good. This judgment has been made using available evidence including a visit to this service. Ongoing staff training enables service users to receive a good service. EVIDENCE: The home is currently registered for 25 service users and the home is full. On the day of the inspection there were 3 staff on duty in the morning and 4 staff in the afternoon. In addition to this the homes registered manager and deputy manager were on duty. There is normally 4 staff members in the morning and 4 in the afternoon, but one staff member was sick. All staff interviewed agreed that the home has sufficient staff on duty the majority of the time. The Registered Manager, her husband and the deputy are in the home Monday to Friday and provide personal care if needed. The domestic staff consist of 2 cooks and a laundry assistant. An external trainer, brought in by the home, was present during the first day of the inspection. In discussion with the inspector the training officer confirmed that this home encourages staff training and they have regular input into the home. Also that the owners allocate time for the staff to see them when they visit the home to monitor work and course work currently being undertaken. One staff confirmed this adding that the owners pay for the staff training as well as allowing time to speak to the training officer during their shift. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 18 Those staff files examined contained the required pre-employment checks, including Criminal Record Bureau Disclosures (CRB), ensuring as far as possible unsuitable staff are not employed. There were 2 references were held on file for all but one staff member. This was due to the staff member being known to the owners. The inspector advised the home to obtain 2 references in each case. The staff’s individual signed contracts and application forms are held on file. One fairly new staff member stated that their recruitment and selection process was fair and they had completed a CRB check and shadowed other staff members during her induction. The staff-training files provided further evidence that regular training was carried out. All staff interviewed confirmed that they receive regular and updated training. This included First Aid, Manual Handling and Food Hygiene. Information sent to the Commission was that external training providers are used for specialist training such as Fire Safety training. 50 of care staff have NVQ training to level 2 or above. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 19 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): 31/33/35/38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The Registered Manager is competent has the respect of the staff team and is highly thought of by the service users. EVIDENCE: The Responsible Individual for the registered provider, Higher Park Lodge (Plymouth) Limited was not in attendance during the site visit. The Registered Manager, Mrs Deborah Norman, was available throughout the site visit. Mrs. Norman has completed the Registered Managers Award, the NVQ4 in care and the D32/33 NVQ assessor’s award. From discussion with the staff and the service users it is evident that the manager ensures that the home has an open, positive and welcoming Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 20 atmosphere. During the 2 days spent at the home the inspector witnessed good interaction between the service users and the staff. Interviews with the staff confirmed that the management and staff have a good working relationship. The staff are well managed and motivated thus providing a better quality of care and support to the service users. The service users and visitors spoken with during this inspection agreed that the owner is approachable and that the home is well run. The home has a quality assurance system in place but this does need some updating. It has been over 12 months since the last survey was completed. Questionnaires have been used and some completed ones were on file. The blank forms were avaliable and on display by the main enterance of the home for any visitors to complete at any time. The registered manager is on the premesis most days and will see the service users regularly. Any concerns or problems raised are dealt with quickly and promptly. The service users interviewed during this inspection confirmed that the manager is in regualar contact and they would have no hesitation in discussing with any concerns or issues they have. Various Health and Safety measures that should be put in place in the home are discussed within the environment section of this report and this included radiator covers and therostatic controls on sinks to control the hot water temperature. Also previously recorded in the report is that the infection control is well managed in the home and all staff members have their own alcohol hand scrub with them throughout their work to use continuously and thereby reduce the potential for cross infection. The fire protection system was well maintained. Maintenance checks are being carried out. Staff are receiving appropriate fire protection training to ensure they have the skills to deal with emergencies. Gas and electrical appliances were being routinely serviced and checked. Good health and safety practices reduce any unreasonable risk, affecting residents or staff, to an acceptable level. Records relating to service users money were completed accurately; invoices and receipts for individual expenditure were available allowing an audit of service users finances. The staff supervision records are appropriatly maintained. Some staff also had appraisals in place. Staff spoken with confirmed they received supervision and some confirmed that they had completed staff appraisals. These appraisals monitor work performances and highlight staff training needs. One staff survey Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 21 received stated that they were not aware of one to one supervision and that this was planned or recorded. Regular consultation with staff ensures staff can contribute to the running of the home and are aware of the home’s aims and objectives, philosophies of care and promotes consistency and improvement. The home has risk assessment files in place for the environment and individual risk assessments for service users held on their files, the manager plans to update these using a new format which was discussed with the inspector during the inspection. These completed risk assessments will reduce any unreasonable risk affecting residents or staff to an acceptable level. Accidents are recorded in detail. These records are reviewed in order to identify risks to service users or changes in their health. Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 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 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP3 OP7 Good Practice Recommendations All care plans should be signed. New risk assessments should be completed for all service users. Risk assessment should be completed for service users without thermostatic values on sinks. The Quality Assurance system should be updated. 3. OP33 Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Higher Park Lodge DS0000003537.V295991.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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