Inspection on 20/06/06 for Ireland Lodge

This inspection was carried out on 20th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ireland Lodge 18/06/09

Ireland Lodge 31/07/08

Ireland Lodge 18/09/07

Ireland Lodge 30/01/06

Ireland Lodge 01/06/05

Ireland Lodge 24/01/05

Ireland Lodge 08/06/04

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

CARE HOMES FOR OLDER PEOPLE Ireland Lodge Lockwood Crescent Woodingdean Brighton East Sussex BN1 6UH Lead Inspector Debbie Calveley Key Unannounced Inspection 08:00 20th June 2006 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 Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ireland Lodge Address Lockwood Crescent Woodingdean Brighton East Sussex BN1 6UH 01273 296120 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) www.fosteringinbrightonandhove.org.uk Brighton & Hove City Council Louisa Young Care Home 23 Category(ies) of Dementia - over 65 years of age (23) registration, with number of places Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is twenty three (23). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. That a named service user may be accommodated (who is under 65 years) for rolling respite care. 30th January 2006 Date of last inspection Brief Description of the Service: Ireland Lodge is owned by Brighton and Hove City Council and is registered to provide accommodation and personal care for up twenty-three older people who have dementia. The home provides thirteen long term, five interim care and five short term care beds. The home is located in the Woodingdean area of Brighton with access to transport and local amenities. The home is single storey and all bedrooms are single occupancy with en-suite facilities. Shared facilities include three combined lounge / dinners. There are two enclosed patio areas. There is a day centre attached to the home, which the manager oversees. Fees charged as from 1 April 2006 are approximately £622.30 excluding extras. Extras charges include newspapers, hairdressing, chiropody, outings and taxis. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Ireland Lodge Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit took place on the 20 June 2006 over 7 hours and included a meeting with the Registered Manager who received the Inspector’s feedback at the end of the inspection. On the day of the home visit the inspector spent most of her time meeting with residents and their visitors, speaking with staff and observing practice in the home. During the inspection visit 6 residents care documentation was reviewed in depth. A further selection of documentation was reviewed as part of the inspection process and this included the statement of purpose and service users guide, staff duty rotas, training records, 5 recruitment files, records relating to health and safety and a number of policies and procedures. Seven staff members were also interviewed in private. In addition service users surveys were given to 10 residents or their representatives and 10 staff surveys had been sent to staff to return. The information contained in the returned surveys has been incorporated into this report. Following the inspection 10 G.P and health professionals were also sent a survey for feedback. What the service does well: The atmosphere in the home was comfortable and relaxed. All parts of the home were clean and comfortable. The residents’ benefit from a well maintained home that has level access to all communal areas. The décor of the home was designed to provide orientation and interest to the residents and the corridors are themed as is the film room. Even the bathrooms have been designed with thought and understanding of the residents cared for. The care staff have a good understanding of the residents needs and preferences and respond in a considerate manner to these. The quality and choice of meals remain good and all residents spoken with confirmed this. “ The food is very good”, “I really enjoy the food”, “and I have to be careful because I am putting on weight as the food is always nice” There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard service users finances. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 6 The home works closely with health care professionals to ensure that resident’s health care needs are being addressed. Flexible routines are an important part of daily life at the home with residents choosing when to get up and go to bed. What has improved since the last inspection? What they could do better: All residents whether regular respite or new, need to have an assessment of needs prior to admission to ensure that the home has the equipment and knowledge to meet their needs. A more in-depth pre-admission assessment as demonstrated in standard 3.3 of the National Minimum Standards would be beneficial for residents and staff. The care plans still need to be improved to ensure all the care needs of residents are recorded along with clear guidance to staff on how to meet these needs. The manager and senior staff are aware that the care plans are not an easily workable document and are currently looking at ways to develop the documentation. Quality assurance measures that respond to resident’s views need to be established and reported on. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 7 Staff mandatory training needs to be regularly provided and updated to ensure that all staff are safe and competent to fulfil their role in caring for the residents. 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. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. EVIDENCE: The Statement of Purpose and Service Users Guide have been updated so as to accurately reflect the services provided. Further new documentation was also seen in draft and was found to be clear and informative, detailing the structure of the home and the facilities available. A written contract between the home and the residents detailing the terms and conditions of any period of care provided has been developed and is available for use. Pre-admission assessments “ well-being assessments” for six residents were viewed and five were seen to have had an assessment prior to admission. The assessment in use at this time provides little information and it was discussed that an assessment with the indicators stated in standard 3. 3 of the National Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 10 Minimum Standards should be developed to ensure that the home can meet all the residents’ needs prior to admission. One respite resident did not have the necessary information recorded and it was an immediate requirement that this residents’ documentation was put in to place. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. The manager and a senior care worker were able to verbally demonstrate their knowledge and awareness of the different specialities required in the home and ensures that the home can meet the needs of the residents that come to stay or live in the home. It is usually a senior care worker that visits and assesses the residents prior to admission; evidence was seen of a further assessment of a resident following admission to the local hospital. Trial visits to the home can be arranged, and due to the five respite beds (short-term beds) and five interim beds, residents can get to know the home and staff gradually before committing to a long-term placement. One resident said “I am only here for a short time, but I like it here, the staff are very kind”, another said, “ I am on holiday, and always come here, I know everyone and the food is good”. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 11 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): Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents would benefit from a more comprehensive care planning system that guides staff in all aspects of personal and health care and that ensures All risks are identified and planned for. Residents are protected by satisfactory systems for the recording, handling and storing of medication. EVIDENCE: The care documentation pertaining to six residents was reviewed as part of the inspection process. The care planning system in use consists of tick boxes to identify a need and then staff define the care to be given in the appropriate area. However, it was found not all were completed to guide staff in the care required to meet the identified need. This was discussed in full during the inspection and examples of missing information shared with the care team. The care plans are under review at present, as staff using them do not find them comprehensive enough. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need, another resident who has verbal outbursts did not have a recent risk assessment or care plan and therefore coping strategies for Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 12 staff had not been put in place. As previously mentioned the care plan for a specific resident was not in place and it was an immediate requirement that this shortfall was amended. This was attended to during the inspection. Not all parts of the plans were signed and dated and there was no evidence to show that service users or their representatives are involved in compiling and reviewing the plans. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main office area. They felt that their views were taken into account when planning resident’s care. “ My input to residents care is always taken seriously and I feel that I am supported in fulfilling my role”. “ We are given the opportunity to discuss the residents we care for”. Two residents said they enjoyed living in Ireland Lodge. From the records viewed evidence was seen that the medical needs of the residents’ are met by appropriate referrals to specialist nurses and other health professionals when required. Two residents at present are awaiting further assessment as to their increased medical needs. The home works closely with health care professionals including GP’s, District and specialist nurses and chiropodists to ensure residents receive the necessary health care intervention. Medication practices within the home were seen to be safe at this time. The Medication records were viewed and were correctly completed, however it was discussed that all verbal orders and changes to prescription need to be signed and dated by the person receiving the order. The Registered Mental Health Nurse (RMN) who is on secondment to the home is regularly reviewing the medication records and liaises with the G.P regarding any queries or PRN medication that is in need of review. Throughout the inspection residents were observed being treated with respect and kindness, and their dignity was maintained in respect of their appearance. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. Meals remain good in respect of both quality and variety that meets residents’ tastes and choice. The range and frequency of activities would benefit from a review to meet the resident’s expectations. EVIDENCE: The inspector observed residents being able to spend time where and how they wanted moving around the home freely. Set routines are avoided as far as possible and residents are able to determine when they would like to go to bed and what time they would like to get up in the morning. Residents are able to choose whether they wanted to join in the activities provided which are mainly available in the afternoons, and include bingo, puzzles, singing and art therapy. However it was confirmed by talking to staff that activities do not always happen and it is dependent on whom is on duty in the afternoon. It was discussed that it would be beneficial for the residents if there was a named person who organised an activity programme and that it is a regular occurrence in the home for all permanent residents. The residents that are in the home for respite continue to use the day centre service. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 14 Residents and their representative’s felt the activities and entertainment provided was appropriate when attended. Two surveys received stated that activities were sometimes available, whilst one said the activities were suitable for their relative. One resident said he would like to go out on trips more often. No activities took place on the day of the inspection. The midday meal on the day was well presented and nutritious and the residents were seen to enjoy their meal. Residents spoken with commented on the quality and choice of meals. “Too much food I am putting on weight” “the food is wonderful” “ we are very lucky here, the food is always good” Staff were seen giving support to residents during the meal in a discreet and respectful manner. Discussion with the cook and kitchen staff found that they are knowledgeable about special diets and take time to prepare tasty meals that meet special dietary needs. Menus for all meals are varied and choice is offered for all meals. All the units have their own dining area, which are pleasant and attractive and they also have facilities to make tea and coffee. On one unit the residents were seen washing up and making tea following the midday meal. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. One complaint has been received since the last inspection and the documentation evidenced that it was investigated and resolved appropriately by the home manager. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The training will be on-going. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate this procedure appropriately. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: The home is laid out into three units with the day centre occupying part of the site. The location and layout of the home is suitable for its stated purpose. The accommodation is single storey providing level access to all areas. All units have been individualised by interesting wall decor, which also provide orientation for the residents. The standard of décor is good with minor redecoration works needed to some communal areas to ensure consistent standards throughout. A programme of routine maintenance and renewal is maintained. The home was found to be warm and comfortable, with good levels of light and ventilation. The maintenance of the building is attended to by an on-site maintenance person. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 17 Security measures are in place to ensure that access from the day centre into the residential side is restricted, thus helping to promote the privacy of residents. All three units have communal areas, which are furnished with suitable good quality furniture and provide a comfortable and homely environment. One unit has a conservatory, which leads in to a small garden area; this is at present being upgraded and the fencing painted. The conservatory is the allocated smoking area for the residents. Resident’s bedrooms are decorated and furnished to a good standard with appropriate furniture and fixtures. Individual rooms were found to be personalised and clean. All bedrooms are for single occupancy with an ensuite facility. There are a variety of aids and adaptations around the building to promote residents independence. These include walking aids, raised toilet seats and grab bars. A call bell facility is provided in all parts of the building that are accessed by residents. Response to call bells was good, however it was noted that the residents in the conservatory did not have access to a call bell and staff were not seen to be supervising the residents. As this is the smoking area there needs to be a staff member in the vicinity and the residents risk assessment needs to evidence the systems in place to ensure safety. Two residents that are physically very frail and require nursing care need to be assessed by an occupational therapist as to the suitability of their chairs. Staff are concerned regarding their comfort and safety. This is being addressed by means of a referral, but in the mean time other specialist advice needs to be accessed. The laundry was clean with equipment that can wash soiled laundry at high temperatures. Since the last inspection staff training in infection control has been provided and were observed to be working in ways that minimised the risk of infection, with staff wearing gloves and aprons when required. The overall cleanliness of the home was good. The kitchen staff – relief staff included need to be reminded to complete their cleaning check lists on completion of their shift. Feedback from the surveys indicated that the cleanliness of the home is satisfactory. A resident said, “the cleaning is very good, they work very hard and my bed gets changed every day. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels are suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices, however the staff training records did not evidence the staffs competency in ensuring the residents health, safety and well-being. EVIDENCE: The staffing levels on the day of the inspection were six care staff for 21 residents with one planned admission due, one registered mental health nurse who is supernummery to the care staff and the registered manager. From practice observed, there were sufficient staff to meet the assessed needs of the residents at this time. The staff were a mixture of permanent members of staff and care crew- relief staff. There has been a recruitment day, where twelve applicants were selected for permanent placement in March 2006, but they are still waiting for the criminal record check clearance before taking up their post. The night shift and weekend shifts were seen to have a senior care worker on duty, but from viewing the previous rotas provided with the pre-inspection questionnaire it would appear it is not always possible, and this needs to be monitored carefully to ensure that the staff in charge are supported and feel confident. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 19 The manager confirmed the on-call system in place and staff spoken with said they felt supported by senior staff. The shifts were seen to be very flexible and there were handovers several times within the inspection. The staff said they were kept up to date with any changes in the resident’s health and that the senior staff were very supportive. The staff spoken with were still concerned by the staffing compliment of the home, but said things were better and would be a lot better when the new staff members commence employment. The staff also said that the care crew staff were staff that knew the residents so it helped give consistent care to the residents. The manager is well aware of the staff feedback and is actively trying to ensure that the staffing levels are sufficient. This was discussed in full during the inspection feedback, Criminal record guidance was also referred to and human resources contacted by the manager post inspection. Two respite residents were very pleased with the care, though one said “call me old fashioned, but I prefer to see the staff in a uniform”. Another resident “the staff are very nice, good fun”. Recruitment files of five members of staff were viewed, they contained the information required for commencement of employment, application forms, two references and proof of identity. Criminal record checks were in place. Training records of staff were viewed and evidenced that staff training is not up to date in the mandatory training required. There are courses booked in moving and handling in the latter part of June 2006. The manager confirmed that she is waiting for dates to be confirmed in medication training and fire safety. A rolling programme for training needs to be implemented to ensure that staff receive the training required to perform their job competently. Staff spoken with confirmed that they have received training in dementia, behavioural problems, people focused care and protection of vulnerable adults. The home has yet to develop a firm plan to demonstrate how 50 of staff will achieve at least NVQ level 2 in care by April 2007 although they have maintained a level of at least 30 of staff with this qualification over the last six months. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The overall management of this home is competent with systems in place to protect and support residents and staff. All aspects of resident’s health, safety and welfare need to be protected and promoted by suitably trained staff. EVIDENCE: Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 21 The Registered Manager has been in post for one year and has gained the experience and confidence needed to run the home effectively with support from the Responsible Individual. The feedback from residents and staff indicated that they felt supported and were able to approach the manager at any time. A quality assurance system has been implemented and consists of comment cards/surveys being available to residents, their families and health professionals but few comments have been received and collated at this time. Regulation 26 visits take place and are sent to the CSCI area office and there are regular staff meetings, which form part of the quality assurance system. Resident meetings are not regularly held and feedback from the residents would be beneficial in assessing the quality of the service. All senior carers have received responsibilities within the home so as to ensure that the manager is less pressured and this has benefited and contributed to the smooth running of the home. The Registered Manager confirmed that the employment policies and procedures, induction training and informal supervision have been implemented and are on-going. It was evidenced that formal supervision is in place, via a planned programme of at least six times a year, informal supervision is on going. Staff spoken with confirmed they have received supervision, two members of staff felt that more time was needed as it was a rushed meeting and they didn’t feel that much was accomplished. Training for all staff in supervision techniques may be beneficial for staff in this instance. All records required by regulation for the protection of the residents are in place and accurate. Individual records and home records are kept secure and up to date and are maintained in accordance with the Data Protection Act 1998. It was not possible to evidence that all staff have received the necessary training for Moving and Handling, Fire Safety and Food and Hygiene and this needs to be implemented to maintain safe practice and ensure the safety and well being of the residents cared for. It was confirmed by the manager that there is an immanent date for moving and handling and dates are to be confirmed for infection control and fire safety. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and Safety. Good practice was observed throughout the inspection in respect of the safety of residents when being moved and transferred. Fire precautions were seen to be adhered to and staff showed a good knowledge of the fire evacuation procedures in the home. Recommendations were discussed regarding the chairs used for two physically frail residents; contact with the necessary professionals was to be made. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 22 It was noted that some care staff wear excess amount of jewellery and this could be disadvantageous when dealing with residents with dementia and in moving and handling frail residents. Footwear of staff also needs to be protective especially when using hoists and other mobility aids. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 2 Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1acd) 12(1a&b 15(1)(2) 12(1)(a)( b) Requirement That all service users have a detailed pre-admission assessment before admission to the home. That all service users have a full needs assessment on admission. That the care plans accurately reflects the needs of the service users and are updated on a regular basis. That care plans include information on how service users are to enabled and encouraged to participate in the homes activities. That service users and/or their representatives are consulted regarding the formation of the care plans. That records and risk assessments pertaining to continence, communication and smoking are developed and accurately reflect the service users needs. Timescale for action 20/06/06 2. OP7 20/06/06 3. OP8 13(4bc) 20/06/06 Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 25 4. OP12 16(1)(2) (n) That all service users have a social care plan, that is designed to meet their interests and preferences and that activities are held on a regular more formal basis. That a training programme is developed to ensure that staff receive the training needed to fulfil their role and the aims of the home. Ensure that the home has comprehensive quality assurance and monitoring systems in place. (Previous timescale of 30/4/05 & 31/10/05 not met). That regular resident and relative meetings are held and recorded. 01/12/06 5. OP30 18 (1) (2) (a) (c) (i) 01/12/06 6. OP33 24 01/12/06 7. OP38 13 (2) (3)16 (2) (j) That the mandatory training records of all staff employed in the home are available for inspection and up to date. 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP24 OP38 Good Practice Recommendations That advice is sought regarding the suitability of two chairs used for two physically frail residents. That the uniform policies are reviewed regarding jewellery and footwear. Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Ireland Lodge DS0000031718.V292846.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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