Inspection on 22/05/07 for Horsell Lodge

This inspection was carried out on 22nd May 2007.

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

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

Other inspections for this house

Horsell Lodge 04/11/08

Horsell Lodge 28/11/05

Horsell Lodge 16/08/05

Horsell Lodge 15/06/04

Similar services:

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Horsell Lodge Horsell Lodge Kettlewell Hill Horsell Woking Surrey GU21 4JA Lead Inspector Lesley Garrett Unannounced Inspection 22 May 2007 12:30 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 Horsell Lodge DS0000013682.V335302.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. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Horsell Lodge Address Horsell Lodge Kettlewell Hill Horsell Woking Surrey GU21 4JA 01483 760706 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) Horsell Lodge Limited Post Vacant Care Home 46 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (46), Physical disability over 65 years of age (6), Sensory Impairment over 65 years of age (6) Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 46 older people accommodated up to 8 may be in the category MD (E) and/or DE (E) Of the 46 older people accommodated up to 6 may be in the category PD (E) and/or SI (E) All residents to be over 65 years Date of last inspection 28th November 2005 Brief Description of the Service: Horsell Lodge is a care home providing personal care for older people. Located in an exclusive residential area, Horsell Lodge is within close proximity of Horsell village. It is also accessible to shops and other community facilities in nearby Woking town. Set in spacious, mature landscaped grounds, the building is a large, detached Manor house dating back to 1891. This was extended in 1947 and the modernisation programme over the years has retained the traditional architectural features of the original building. The home has good parking facilities and a secluded garden terrace and summerhouse. Bedroom accommodation is arranged on three floors accessible by passenger lifts. The home is wheelchair accessible except for the second floor and for this reason service users accommodated on that floor must be ambulant. Bedrooms are mostly singles, 24 of which have en-suite facilities. Three of the five shared bedrooms also have en-suite facilities. Communal accommodation is arranged on the ground floor, comprising of two lounges, a conservatory, main dining room, separate smoking room and dining/visitors room. Assisted bathing and shower facilities are available and wheelchair accessible toilets. The current fees for the home range from £320 to £775 per week. Charges for double rooms used as singles will be higher. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over six and a half hours. The inspection was carried out by Cathy Clarke, Regulation Inspector. The manager represented the establishment. A full tour of the premises took place. Discussions were held with most residents over lunch, and with five residents individually in private. The manager and four staff members were also interviewed. Returned ‘comment cards’ from residents, relatives and professionals involved with the home were also used to write this report. Four resident’s care plans and a number of other documents and files, including four staff files, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: Horsell Lodge offers a caring home for residents and visitors are welcomed. A number of positive comments were received from resident’s visitors including the following: • • ‘Always been good relations with management’ ratio of staff to residents. ‘There is a very good ‘The staff are very caring and seem to be alert to what is happening at all times’. ‘I feel they do care about residents and do try to please them in any way they can. ‘The facilities, leisure areas both inside and outside are conducive to a happy atmosphere which is very important’. ‘They have trips out for the ones who can get about and they celebrate special days ‘Mothers day’ etc, which is a nice touch’. ‘The home creates a loving caring family atmosphere this is due mainly to all staff at the home, of if I might say different nationalities, who all appear to get on well together, and whom I would want as friends’. ‘Very recently my relative was prepared extra early in the day in order to have an occasional communion service in her room’ • • • Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Daily records could be improved by recording factual information and not the use of assumptions. Although the care in the home is very good the maintenance of the building and the internal décor lets the home down. In particular the external window frames which are in a poor state of repair with paintwork flaking off. A fiveyear maintenance plan is in place however this was not available for inspection and the manager was not aware of the content of the plan. Comments received from visitors to the home asking how they thought the care home could improve include the following: • • • ‘The outside paintwork of the building needs redecoration –particularly the older part of the building’. ‘ More toilets are needed downstairs’. ‘At Horsell Lodge the food could definitely improve’. ‘I know a lot of residents in the home would like good basic food and not have it sometimes all mashed up and disguised with something’. ‘The one thing I do feel needs looking into is the food, my mother say’s they have a lot of the same thing and that there is not a lot of taste to the food. Also the vegetables are always hard’. ‘Once every six months invite relatives to a review with your relatives key worker for an assessment on their condition and progress’. ‘Further ‘activities’ to the programme. Another relative has stated ‘my only concern relates to outside activities ‘mystery tours’ (via mini bus) are advertised, and have not actually taken place, which has been disappointing’. • • 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. Horsell Lodge DS0000013682.V335302.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 Horsell Lodge DS0000013682.V335302.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): Standards 3 and 6 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assessed prior to admission to the home to ensure that their needs can be met and information on the aims and objectives of the home are provided to ensure an informed choice. EVIDENCE: A pre-admission and dependency assessment is completed for all residents prior to their moving into the home. The home receives information from relevant health care professionals regarding the care needs of prospective residents. A local authority assessment was in place for one person who is funded by the local authority. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 9 Intermediate care is not provided by the home. Respite care is available for people who may be requiring short stays before returning home. The cultural and diverse needs of people wishing to live in the home are individually assessed and recorded in order to ensure that the home can meet their individual needs preferences and wishes prior to admission and this is information is continually being updated in their ongoing plan of care and personal biography. Horsell Lodge DS0000013682.V335302.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): Standards 7,8,9 and 10 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people living in the home, their relatives and health care professionals have praised the level of health and care provision. EVIDENCE: Care plans sampled during the inspection recorded all aspects of personal care needs. There are clear instructions on file in relation to the wishes of people on death and dying and these have been signed and agreed. Each person has a personal biography outlining their preferred language, country of origin and a potted history of their life. Care plans are audited and updated to include any changes in care needs quarterly or more frequently if changes occur. Daily records could be improved by recording factual information and not the use of assumptions. Staff interviewed confirmed that care plans were easy to follow. Regular health care checks are conducted and a district nurse visits the home at least fortnightly. A GP visits the home on a weekly basis and as and when required. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 11 There is a falls risk assessment on file and a malnutrition universal screening tool used. Community eye care is offered on a 6 monthly basis. Five to six weekly visits are made to the home by the chiropodist. Referrals are also made to the diabetic and respiratory nurses if required. Medication trolleys are used and medication is stored in a locked storeroom. The controlled drugs medication cabinet is in this room. The controlled drugs were counted during the inspection as correct. A list of trained staff is on file and medication administration records were correct with no gaps evident. Staff interviewed confirmed that only senior members of staff can administer medication. Each person has a current photograph in front of his or her medication administration record. The blister packs for the evening medications were checked as correct. The manager randomly audits the medication records on a monthly basis. There is a stock check every third Friday and medications no longer in use are returned to the Pharmacy. People who live in the home and their visitors are treated with respect. Personal care is provided in private and staff were seen to knock on doors prior to entry into a persons room. Staff demonstrated a good rapport with people during the inspection and are aware of their likes and dislikes. Please see recommendations section of this report. Horsell Lodge DS0000013682.V335302.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): Standards 12,13,14, and 15 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home can exercise choice and control over their lives and take part in a range of activities. Improvements could be made to both the meals provided and the opportunities for activities outside the home. EVIDENCE: The personal biography recorded on each individual does ensure that staff have an insightful view into the personal preferences of the people who live in the home. How people wish to be addressed is recorded in their biography and their cultural and diverse backgrounds. One relative has commented that staff provide care extra early in the morning to enable his relative to take Holy Communion services in her room. There is an activities programme in place and during the inspection people were seen to take part. One person who likes to sit in the garden stated that she enjoyed attending church and that her husband comes to the home to take her. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 13 Comments received from relatives include the following: ‘Further ‘activities’ to the programme. Another relative has stated ‘my only concern relates to outside activities ‘mystery tours’ (via mini bus) are advertised, and have not actually taken place, which has been disappointing’. The registered manager acknowledged that there had been a problem with the transport and that this had now been rectified and in fact a mystery tour to a local garden centre had taken place. There are frequent visitors to the home and relatives have commented that they are always made welcome. On the day of the inspection people were asked whether they were enjoying their lunch of chicken casserole and fruit tart. They thought the chicken casserole was very nice but the fruit tart was not to everyone’s taste. One person stated that the home has a very good cook. Relatives of people living in the home have made the following comments with regard to the food on offer: ‘At Horsell Lodge the food could definitely improve’. ‘I know a lot of residents in the home would like good basic food and not have it sometimes all mashed up and disguised with something’. ‘The one thing I do feel needs looking into is the food, my mother say’s they have a lot of the same thing and that there is not a lot of taste to the food. Also the vegetables are always hard’. The home has received complaints regarding the food in the home. This is now improving. The manager has stated that the home is advertising for a new chef manager. A bank chef, who is employed by Caring Homes Ltd., comes into the home on the sous chefs’ day off. Horsell Lodge DS0000013682.V335302.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): Standards 16 and 18 have been assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints made to the home have been acted upon. Improvements could be made to the time that the provider has taken to respond to complainants. People who live in the home are protected from abuse. EVIDENCE: The Commission for Social Care Inspection has not received any complaints since the last inspection. There have been three complaints made to the home since the last inspection and two of these have been substantiated and one partly substantiated. One complainant’s complaint was sent to the owner of the company and was not responded to in a timely fashion. There are policies and procedures in place and a complaints log is used to record any issues. The home responded to all complaints within a 28-day timeframe. There has been one vulnerable adult investigation undertaken since the last inspection and the Surrey Multi Agency Safeguarding Adults procedures were instigated. All staff interviewed, as part of the inspection process understood the ‘safeguarding adults ‘and’ whistle blowing procedures. Please see recommendations section of this report. Horsell Lodge DS0000013682.V335302.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,24 and 26 were assessed during this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has a homely environment work needs to be done to improve the environment in which residents live, including the maintenance and redecoration of the external paintwork and windows and the replacement and relaying of carpets in some of the rooms within the home. EVIDENCE: The registered manager has stated that there is a 5-year maintenance plan in place, however this was not available for inspection. A number of environmental health requirements are to be undertaken by the home by the end of June 2007 including the replacement of the hall and stairs carpet. There is a budget for the maintenance of the building but according to records seen this has already been used. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 16 One of the residents spoken to during the inspection stated that she ‘thinks the building needs maintaining especially the paint work outside it is embarrassing when anyone visits the home’. A relative has commented that ‘The outside paintwork of the building needs redecoration –particularly the older part of the building’. Most people spoken to during the inspection commented on the state of the outside paintwork. The carpet in the TV lounge must be cleaned and the black marks eradicated. The air vent in the laundry room must be affixed. The pedal to operate the bin in the downstairs toilet is broken and must be replaced. The sinks in the toilets must be cleaned. There are strong mal odorous smells in rooms 14 and 31 coming from the carpets and despite cleaning this had not been eradicated. These carpets must therefore be replaced. A new urine bottle is required for room 40 the ones in use are very worn and the plastic is starting to erode and discolour. The paintwork throughout the home is chipped and in need of repair and redecoration. Where wallpaper has been torn this must be redecorated. The furniture in some of the rooms is chipped and tired looking and it is recommended that this be replaced. One of the toilets does not have a sink in place for hand washing and the prevention of infection control it is recommended that this be rectified. Gloves for infection control must be available in every sluice room. The kickboard at the bottom of the door in room 56 is broken and must be replaced. There are cracks in the walls of the corridor and these must be maintained and the décor made good. The carpets in rooms 16 and 18 must be stretched and refitted to ensure the safety and welfare of residents using those rooms. It is recommended that where radiator valves are missing that these are replaced and that all radiator temperatures can be regulated. The shower hose and bath panel in the bathroom on the second floor must be replaced. The flooring in the upstairs toilet on the second floor must be replaced. The bedcover in room 27 has holes in it and this must be replaced. Laundry facilities were generally clean and tidy. There are two washing machines and two tumble dryers in the laundry, and the washing machine has Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 17 a sluicing programme. The air vent in the laundry room is not affixed and there is open brickwork to the outside. The maintenance person was interviewed during the inspection and he confirmed that he is responsible for maintaining the upkeep of the grounds, and any electrical, plumbing or joinery repairs. The external paintwork of the building comes under the Homes Property services. The maintenance person agreed to clean the fire escape stairs, which were covered in moss and falling twigs from a nearby tree. Please see requirements and recommendations section of this report. Horsell Lodge DS0000013682.V335302.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): Standards 27,28,29 and 30 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited in sufficient numbers with the required skills to meet the needs of people who live in the home. EVIDENCE: Staff in the home were very approachable and took a full and active part in the inspection process. Comments received include ‘The staff are very caring and seem to be alert to what is happening at all times’. ‘I feel they do care about residents and do try to please them in any way they can. There is a diverse group of staff working in the home from many different cultures. Some staff live on the premises. The home has a vacant deputy manager post and does not use agency staff. There is a full time administrator who is also covering a regional position. One relative has commented that there is a very good ratio of staff to residents. Two of the four recruitment files sampled contained incomplete dates for the member of staff’s previous employment history and gaps in employment had not been recorded. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 19 It is recommended that the service record the month of any previous employment history in order that gaps in employment can be easily identified and the reasons recorded. The manager stated that the dates of employment would be held at the head office for one member of staff who was recruited from abroad via the company’s recruitment agency. Application forms, written references, criminal record bureau and the protection of vulnerable adults list checks were in place. Staff interviewed had not received a copy of the General Social Care Council code of practice and the manager agreed that she would obtain copies for all members of staff. Three staff interviewed explained the training opportunities that they had received since starting at the home including a buddy system for one carer who was from the same cultural background as another member of staff. All staff undertook induction training using a workbook system that is signed off on completion by the manager. There is now an in-house moving and handling trainer. Sixty percent of staff have completed a relevant NVQ at level 2 or above. Five staff hold a current first aid certificate. Horsell Lodge DS0000013682.V335302.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): Standards 31,33,35 and 38 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people who live there. The manager where necessary seeks advice to improve any aspect of risk identified to promote the health and safety of people who live in the home. EVIDENCE: The registered manager is experienced in the care of older people and holds the NVQ Level 4 Registered Managers Award. The manager has attended supervision training and ensures that staff receive the appropriate supervision to undertake their role. There have been many compliments made regarding the care that people receive in the home and the management of the home has also been Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 21 positively commented upon as follows: ‘Always been good relations with management’. There is a quality assurance process in place and Those residents requiring assistance with their personal allowance have an individual wallet, which is kept in the safe and financial transaction sheets are completed for each expenditure made. There are fifteen residents living in the home who are subject to a Power of Attorney three who maintain their own benefit books and one who is able to handle their own financial affairs. Health and safety procedures are in place. The Control of Substances Hazardous to Health (C.O.S.H.H.) policy and procedure was reviewed and updated at the end of 2006. Fire equipment was checked in March 2007. There is ongoing in-house training on fire safety procedures. A health and safety department visit took place in October 2006. Gas and central heating has been checked and PAT electrical testing was undertaken in April this year. The registered manager has agreed to obtain advice from the appropriate fire safety advisors on the evacuation process for people who live on the third floor of the home. A recent fire drill with staff acting as residents took three minutes and the manager stated that it would be difficult to get residents on the third floor down the stairs. The third floor of the home does not have a fire escape. Horsell Lodge DS0000013682.V335302.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 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X 2 X 2 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 Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 (2) (b) Requirement The maintenance plan for the home must include the following: • Repair of chipped paintwork and redecoration of the home. • Cracks in the walls of the corridor must be maintained and the décor made good. • The flooring in the upstairs toilet on the second floor must be replaced. • The external paintwork and windows must be repaired and redecorated. • The air vent in the laundry room must be affixed. • The carpets in rooms14 and 31 must be replaced. • Carpet in rooms 16 and 18 must be stretched and affixed to prevent the hazard of trips and falls. • The kick board at the bottom of the door on room 56 must be replaced. • The shower hose and bath panel in the bathroom on DS0000013682.V335302.R01.S.doc Timescale for action 31/08/07 Horsell Lodge Version 5.2 Page 24 the second floor must be replaced. 2. 3 OP24 OP26 16 (2) (C) 16 (2) (J) The bedcover in room 27 must be replaced. All areas of the home must be kept clean and gloves must be in all sluice rooms to prevent cross infection. 30/06/07 30/06/07 Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP7 OP16 OP21 OP19 OP29 Good Practice Recommendations It is recommended that entries in daily records contain factual information and not the use of assumptions. It is recommended that the provider respond to complaints raised by individuals within the timeframe stated in their policies and procedures. It is recommended that a hand basin be put in place in the toilet. It is recommended that where radiator valves are missing that these are replaced and that all radiator temperatures can be regulated. It is recommended that the service record the month of any previous employment history in order that gaps in employment can be easily identified and the reasons recorded. Horsell Lodge DS0000013682.V335302.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 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 Horsell Lodge DS0000013682.V335302.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!