Inspection on 08/01/08 for Humfrey Lodge

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Humfrey Lodge 18/03/09

Humfrey Lodge 26/02/07

Humfrey Lodge 13/12/05

Humfrey Lodge 13/07/05

Humfrey Lodge 02/03/05

Humfrey Lodge 21/07/04

Humfrey Lodge 22/03/04

Humfrey Lodge 13/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Humfrey Lodge Rochelle Close Thaxted Dunmow Essex CM6 2PX Lead Inspector Diana Green Unannounced Inspection 8th January 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Humfrey Lodge DS0000017855.V357498.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. Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Humfrey Lodge Address Rochelle Close Thaxted Dunmow Essex CM6 2PX 01371 830878 01371 831187 humfrey.lodge@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc 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) Mrs Estelle Gordon Ballard Care Home 48 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (48) of places Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 48 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 24 persons) The total number of service users accommodated in the home must not exceed 48 persons The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 26th February 2007 Date of last inspection Brief Description of the Service: Humfrey Lodge is a care home for older people over the age of 65 years. The home is registered to care for 48 people, 24 of whom may have dementia. The accommodation is all single rooms and is situated all on the ground floor. The home is divided into four units which each have communal rooms. There are a number of informal seating areas around the home and several garden and patio areas that are wheelchair accessible and secure. The home is situated in the attractive village of Thaxted in a residential area but close to shops and other amenities. The home is owned by Runwood Homes PLC. Fees for accommodation in the home are £449.54 - £600.00per week and do not include hairdressing, chiropody, newspapers, transport, toiletries or clothing. This information was provided to CSCI on 15/02/08. Humfrey Lodge DS0000017855.V357498.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 1star. This means the people who use this service experience adequate quality outcomes. This was a key unannounced inspection that was undertaken on the 8/01/08 and lasted 7 hours. The inspection process included: discussions with the acting manager, operational manager, the laundry assistant, the cook, eight residents, five care staff, three visitors and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Evidence was also taken from completed surveys and the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. Twenty-five standards were inspected, three requirements including two repeat requirements and eight recommendations were made. The acting manager, operational manager and staff were welcoming and helpful throughout the inspection. What the service does well: Humfrey Lodge provides and friendly and welcoming environment that is secure. The home is pleasantly decorated and well maintained. Rooms are well personalised and residents encouraged to bring their own possessions into the home, subject to space availability. Friends and relatives are able to visit at anytime and meet with residents in private. Residents’ personal needs are well met and there is good access to local health services with regular visits from general practitioners and district nurses. Residents’ privacy and dignity is upheld and staff are respectful in their approach with them. A good range of individual and group social activities are provided. Complaints and allegation of abuse are investigated thoroughly and appropriate action taken where relevant. Care team managers are skilled and experienced. Recruitment procedures are robust and care staff have access to an established training programme. Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Humfrey Lodge DS0000017855.V357498.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 Humfrey Lodge DS0000017855.V357498.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): Quality in this outcome area is good based upon sampled inspected standards 1, 3, & 6. Residents were well informed and had their needs assessed prior to moving in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and a service user guide that were on display in the reception area of the home. Feedback received from relatives indicated that a copy of the statement of purpose had been made available to them. Five service user files were sampled. All had an assessment of needs undertaken by the acting manager/care team manager prior to admission that included all elements as detailed under this standard. The assessment comprised a tick box that was used to inform the care plan. Information was Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 9 brief but did cover all needs. Care management assessments were obtained where relevant and held on file. This home does not provide intermediate care. Humfrey Lodge DS0000017855.V357498.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): Quality in this outcome area is adequate based upon sampled standards 7, 8, 9 & 10. The health and personal care needs of residents are generally well met but medication practices do not always adhere to guidance, placing some people at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of five residents’ files were viewed. All included an agreement to the care plan that had been signed for by the resident or their representative. However one agreement form was last signed on 9/07/03; care plans had been regularly updated but there was no recent signature to evidence that updated care plans had also been agreed with the resident or their representative. All files contained an assessment form completed on admission and used to trigger care plans. This form contained standard categories of need, each with a range of descriptors selected by tick boxes. Additional individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, pressure areas, etc.), and these Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 11 had been regularly reviewed. Manual handling assessments seen contained good detail of the action required by staff when assisting with mobilising residents and were reviewed monthly. However a risk assessment for falls did not include detail of how the risk was to be minimised and a continence assessment form had not been completed for one resident three weeks following admission. Care files viewed included nutrition assessments; residents were being weighed regularly (and weights recorded) and fluid intake charts were in place for residents who were at risk. The records viewed confirmed that residents had access to GPs, district nurses, physiotherapists, opticians and chiropodist etc. and that emergency services were called when required (e.g. when someone had a fall). One relative commented in a completed survey ‘individual care/medical intervention is very good’. The home had a medication/clinical room that had an air conditioning unit installed. The room had a drug refrigerator, Controlled drug (CD) cupboard and appropriate storage facilities. There were two drug trolleys that were used for storage and administration of medicines that were both secured to the wall. Monitoring of room and fridge temperatures were undertaken and recorded with appropriate action taken as required. The home had medication policy and procedures that were available for staff guidance. Care team managers administered all medication at the home and the records confirmed they had all received appropriate training. Medication was supplied through a local pharmacy in pre-dispensed packs and appropriate ordering and disposal procedures were followed. Medication profiles were recorded for individual residents with side effects of the relevant drugs recorded. Medication administration records and medicine supplies were checked for four residents. Supplies were available as prescribed for three residents and were appropriately recorded. However for the fourth resident, one medicine had not been recorded as given for three days with no action taken. The care team manager initially thought the medicine had not been given due to it not being available. However the medicine was eventually found in the drug trolley. Several ommissions were noted on the MAR sheet for one resident and no reason was recorded. The staff member thought this may have been when the resident went out with a relative who took the medicine with them. The date of opening for medicines with a short shelf life was recorded on the carton but not on the actual container. One CD drug had been recorded as having been received by the family but no address was recorded. Care files contained clear information and indicated each person’s preferred name. Staff were noted to treat residents with courtesy and dignity. Residents and their representatives who completed surveys stated that care staff were caring and respectful at all times, had empathy with residents and always supported them with sensitivity. Humfrey Lodge DS0000017855.V357498.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): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15. People living at Humfrey Lodge can expect to have a lifestyle that meets their social and cultural expectations with therapies provided that meet their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employed an activities coordinator who worked five hours daily with a care assistant also working in the afternoon. This was her first experience in undertaking the role. However she had attended all required training including protection of vulnerable adults and had undertaken updated sessions in dementia care. A snoozelum room had recently been established in the home to provide a designated area where residents could receive therapy to assist in calming them. The coordinator had also received training to enable her to be competent in this type of therapy. A range of activities were organised during the week (e.g. games, art and crafts, musical bingo, etc.) and were seen on the programme of activities that was displayed for information. Additional therapies were also provided including aromatherapy and hand massage. Individual records were maintained of residents’ assessment and involvement Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 13 in the activities and were seen to include good detail of the outcome for residents who attended. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. Staff reported that one resident’s spouse was able to join them for lunch each day. A church service is held in the home each month, and staff reported that some local community groups had visited the home at Christmas (e.g. bell ringers, local school children carol singing). Relatives said that reception staff were very welcoming. Residents’ rooms seen were mostly well personalised, showing that people could bring their own possessions into the home with them. Information on advocacy services was included in the statement of purpose and available in the home. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, meals, etc. A relative commented that staff enabled their loved one to stay in their own room, as they preferred and not to take part in activities in the communal room. Another relative stated in a completed survey that the care home respected the fact that their loved one was a ‘private person’ and preferred to stay in their room. The home operates a four weekly menu that could be adapted to reflect local residents’ preferences. A menu was observed displayed for residents’ information. Residents spoken with were generally positive about the meals served at Humfrey Lodge. Positive comments were also received in completed surveys from residents and their relatives: ‘the food is excellent’; ‘they cater well with meals’; ‘visitors always made to feel welcome and offered refreshments’. The main meal served on the day of the inspection comprised cottage pie or poached haddock and parsley sauce with vegetables and potatoes. The meal looked and smelt appetising, and residents observed were enjoying this. Hot drinks were seen being served during the day, and water jugs were seen in residents’ rooms. Nutritional records were maintained on behalf of residents and those viewed confirmed that their weight was regularly monitored and nutritional supplements provide as relevant. Humfrey Lodge DS0000017855.V357498.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): Quality in this outcome area is good based upon sampled standards 16 & 18. People living at Humfrey Lodge can expect to have their concerns listened to and acted on and to be protected from abuse through robust recruitment, staff training and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. Residents spoken to were clear that they felt able to tell someone if they had any concerns. The homes’ record of complaints detailed the investigation and action taken as a result. All had been investigated and appropriate action taken where relevant. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy for staff guidance. The records confirmed that all staff had received training in protection of vulnerable adults and that regular updated training was provided. From discussion with the acting manager and previous knowledge of the home it was evident that all allegations would be taken seriously and referred appropriately to social services. Humfrey Lodge DS0000017855.V357498.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): Quality in this outcome area is adequate based upon sampled standards 19, 22 & 26. People who use this service can expect to live in comfortable surroundings but cannot be assured that there is always good odour control or that staff adhere to safe infection control guidelines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms, the kitchen, clinical room, the sluice rooms and the laundry. The home was decorated and generally well maintained. Communal rooms were clean and well decorated and furnished to provide a homely environment for residents. Relatives who completed surveys stated that ‘the home has excellent facilities’ and ‘residents are encouraged to have personal items to make their room more homely’. Some work had been undertaken to provide seating and planting in two of the quadrangle gardens Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 16 that were accessible for wheelchair users. However two further garden areas were neglected. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had was single storey and accessible to wheelchair users. Ramps were provided to enable access to the patio and gardens. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided. Call systems were provided throughout all individual and some communal rooms, but were within reach of one resident spoken with. One resident who was confined to bed had a non-adjustable bed that was not appropriate to ensure staff safety when they assisted the resident with moving and handling. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. The home was clean and hygienic throughout with exception of a small kitchen that had not been cleaned that day and three rooms that had a strong smell of urine. A relative who completed a survey also raised concerns that ‘one area in one unit has a smell of urine’. Liquid soap and paper hand towels were provided for staff hand washing throughout the premises and staff were observed to follow correct procedures in hand washing, use of appropriate gloves and aprons and disposal of them in clinical waste bins. The laundry had two separate rooms for clean and soiled laundry. The laundry was well equipped with two washing machines (one with sluice cycle), two driers and rotary iron and domestic iron. Procedures for laundering foul laundry were discussed with laundry staff who confirmed that the appropriate alginate bags were used and placed directly in the washing machine. However they were then placed on a rinse cycle and once removed from the alginate bag were placed back in the machine to be washed at 60°Centigrade. This does not meet recommended safe infection control guidance (i.e. all infected/foul linen must be washed at 65°Centigrade for a minimum of ten minutes). Humfrey Lodge DS0000017855.V357498.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 27, 28, 29 & 30. People living at Humfrey Lodge can expect to be cared for by skilled and experienced staff employed in sufficient numbers and who have been robustly recruited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels comprised 2 care team managers and 8 care staff including one on induction and were seen to be appropriate to the care needs of residents. Comments were received from relatives that ‘care team managers are available to speak to and are helpful’; ‘excellent staff’; ‘they are very caring people and do their jobs well’. However one relative raised concerns that they had observed some inexperienced care staff working alone (i.e. without direct supervision) and the lack of communication skills for some staff potentially caused misunderstanding for those residents with a sight and hearing impairment. Another relative stated they were confident in the care team managers ‘who are experienced in the care of elderly people’ and that previous use of agency staff did not now appear to be an issue. Ancillary staff also on duty included the administrator, one maintenance person, 4 domestic staff, 1 laundry assistant, 1 cook and 1 assistant cook from 11am. Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 18 The home had 11 care staff with NVQ level 2 training. A further 8 staff were working towards NVQ level 2 which is more than the recommended 50 of staff with NVQ level 2 training needed to meet the National Minimum Standard. The recruitment files of four recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards and this was also confirmed from staff spoken with. The supervision records viewed were mostly variable in their content with some being comprehensive. However for two domestic staff who had been transferred to work in the kitchen, their records were brief and did not provide evidence that they had received sufficient instruction on handling food. A care team manager did provide assurance that appropriate instruction had been given on handling of food, appropriate hand washing etc., but this had not been recorded. The home had an established training programme that included regular updated training in dementia care. The records viewed also confirmed that staff had completed training on Protection of Vulnerable Adults, fire safety, moving and handling, first aid, health and safety and food hygiene. Humfrey Lodge DS0000017855.V357498.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled standards 31, 33, 35 & 38. The health and safety standards in the home were in the main well met but some practices were evident that pose risks to service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was on sick leave and an acting manager was managing the home. The acting manager had substantial experience in care and had been deputy manager for a number of years and was supported by a team of care team managers. There was evidence on the training records that all senior staff had undertaken regular and updated training since the previous key inspection. Feedback from relatives who completed surveys indicated that senior staff were approachable and they found them helpful. However there Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 20 were some issues (standard 26) identified at the last key inspection that had not been appropriately resolved. There is a corporate quality assurance programme whereby an annual audit is undertaken of Runwood care homes. An annual quality audit report from the audit undertaken during June 2007 by the quality team was seen. The home was commended in a number of areas including the warm, friendly atmosphere with customer care demonstrated, up to date staff supervision and efforts made to achieve NVQ targets. The home monitored all complaints and compliments and also had a suggestion box for residents and visitors where comments were used to improved standards. Relatives meetings had been held monthly since the home was registered. Visits required under regulation 26 had been undertaken. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped ‘pouches’. Four residents’ monies were inspected, and records, receipts and cash all balanced. The home had a health and safety policy manual that included procedures for staff guidance and the records confirmed that all staff had attended relevant health and safety training. However some risks to health and safety were evident that pose a risk to staff and service users (e.g. a box of polyfilla was observed in a bathroom; also reference standard 22 & 26). Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. evidence of electrical/gas certificates, PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 21 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 2 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 3 X X 2 X X 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 2 X 3 X 3 X 3 2 Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement To ensure residents have their medication as prescribed: 1. Medicines must be given as instructed. 2. Omissions must be followed up and the reason recorded. 3. Medicines with a limited shelf life must have the date of opening recorded on the container and the carton. 4. Controlled drugs must have the name and address recorded on receipt and disposal. To minimise the risk of infection: 1.Action must be taken to eradicate unpleasant odours from the home. 2.Handwashing facilities must be available where personal care is provided. 3. Staff must comply with the infection control policy in relation to the management of soiled linen. This is a repeat requirement. Timescale of 26/02/07 not met. Timescale for action 15/03/08 2. OP26 16 (2) (k) 15/03/08 Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 23 3. OP38 13 (4) (c) To ensure the safety of residents and staff Controlled Substances Hazardous to Health (COSHH) items must be kept locked when not supervised. This is a repeat requirement. Timescale of 26/02/07 not met. 15/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP7 OP7 OP7 OP19 OP22 OP30 OP30 OP38 Good Practice Recommendations To ensure residents are safeguarded, risk assessments should demonstrate how the identified risk is minimised. To ensure current care plans have been agreed, updated signatures of agreement should be obtained and recorded on reviewed care plans. To ensure residents’ needs are met, a full assessment of continence needs should be undertaken within 48hours of admission. To provide residents with a pleasant outlook that is safe, the gardens should be well maintained. To ensure residents receive assistance as needed, call bells should be within reach at all times. To ensure all staff are clear on management of soiled linen, infection control training should include instruction for laundry staff. To ensure staff are skilled in management of swallowing difficulties, training should be provided. To ensure the staff are not placed at risk when moving and handling residents, adjustable beds should be provided as needed. Humfrey Lodge DS0000017855.V357498.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Humfrey Lodge DS0000017855.V357498.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. 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