Inspection on 30/01/06 for Ireland Lodge

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 20/06/06

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 Jane Jewell Unannounced Inspection 10:30 30 January 2006 th 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.V250144.R01.S.doc Version 5.0 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.V250144.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ireland Lodge Address Lockwood Crescent Woodingdean Brighton East Sussex BN1 6UH 01273 296120 01273 296145 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) Brighton & Hove City Council Care Home 23 Category(ies) of Dementia - over 65 years of age (23) registration, with number of places Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The number of service users must not exceed twenty three (23) Service users must have a dementia-type illness. Service users must be over 65 years of age on admission. That one named day centre service user may be accommodated in communal areas between 15:30 and 19:00, taking the registered numbers to 24 for part of each day That a named service user may be accommodated (who is under 65 years) for rolling respite 1st June 2005 5. 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. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which was undertaken over seven hours. The inspection was undertaken with Louisa Young (Manager). The inspection involved a tour of the premises, examination of the homes records, consultation with staff and residents. As some residents were not able to tell the inspector their experiences of life at the home much of the inspection was spent observing residents in their daily routines and interactions with staff. Subsequent to the inspection a further visit was undertaken to monitor the progress made towards addressing the areas of concern, which were noted at the inspection. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? None of the previous requirements and recommendations have been fully addressed and positive steps must be taken in order to improve residents safety, consistency in staffing, staff competence and self-assessment. Staffing levels have been increased in accordance with the introduction of interim care beds opening at the home. Ongoing recruitment drives have enabled some permanent staff to be employed. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 6 What they could do better: There is currently a lack of leadership and direction as born out by the number of shortfalls in practices noted and outstanding requirements. This has results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. These include: Medication practices did not safeguard residents and closer monitoring of staff practices is needed to ensure that the homes policy is being followed and residents protected. Care plans need to be regularly reviewed in order to promptly identify changes in residents needs so staff are able to meet them. The procedures for the recruitment of staff are not sufficiently robust and do not provide the necessary safeguards of residents. Dangerous practices in the handling of hazardous chemicals, placing staff and visitors at risk. Staff deployment and training needs to be better co-ordinated to ensure that staff have the skills and training they need to complete their roles. Following the draft inspection report the provider responded with an action plan, which detailed how the shortfalls in practices noted in this report were to be addressed. 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.V250144.R01.S.doc Version 5.0 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 Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 The home provides information for prospective residents on the services provided and what to expect when living at the home. Residents only move into the home following an assessment of their needs and if the home has assessed that their needs can be met. Residents looked comfortable in their environment and those consulted all spoke positively about their life at the home. EVIDENCE: There is a range of information about the home and the services it provides, this includes a statement of purpose and service user guide, which are displayed and given to prospective residents, representatives and other interested parties. The home provides thirteen long term and five short-term care beds. In addition five interim care beds have recently been introduced. The aim of these beds is to provide a designated period of care following discharge from hospital. The manager stated that the homes literature is in the process of being reviewed to reflect the changes in services being provided. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 9 Documents seen for recent admissions showed that residents had been accommodated following an assessment of their needs. The assessment involved obtaining copies of social services needs assessments, and the home conducting its own assessment of needs. Combined these documents provided information on the needs of a prospective resident. The manager stated that the assessment documentation is in the process of being reviewed. This is to increase the level of information that is obtained so a more comprehensive picture of a persons needs is obtained. The homes needs assessment forms the basis of a care plan. This helps ensure that staff are aware of the recorded needs of new residents. In the main it is senior carers who undertake assessments. Some assessments had not been signed or dated by the person undertaking the assessment. The manager agreed to address this in the review of the documentation in order to ensure accountability. Good practices were noted in resident’s needs being re-assessed following hospital admissions prior to any discharge. This is to identify any changes in needs and to determine whether their needs can continue to be met by the home. There is a wide range of residents needs including some residents who have physical needs in addition to dementia. The home demonstrated that it is meeting most of the needs of residents. Prompt support from health care professionals has been obtained when residents needs increase or change and can no longer be met at the home. Residents looked relaxed and comfortable in their surroundings and all spoke positively about their experiences and life at the home, saying the following: “love it here” “knowing that there are people around makes me feel safe” and“ its lovely here” Opportunities are made available for prospective residents and their representatives to visit the home. The inspector was informed that it is predominately relatives who visit the home on a prospective residents behalf. Many referrals are already known to the home through residents attending day services at the home. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans seen generally provided a good framework for the delivery of care. Further work is needed to ensure that care plans are accurately reviewed to reflect any changes in residents needs. The management of individual risks faced and posed by each resident was good. There is evidence of regular input from health care professionals. The system for the administration of medication are poor and potentially place residents at risk. EVIDENCE: Four individual plans of care were inspected. These comprised of many documents including risk and needs assessments, basic information, daily notes and a plan of care. Good practices were noted in the use of personal histories, which enable staff to be aware of significant events and individual lifestyles prior to the onset of dementia. Comprehensive moving and handling guidelines had been identified which provided staff with very clear guidance on safe handling techniques for individual residents. The standard of daily recording was noted to be good with a clear account of actions and events that had occurred for each resident. Comprehensive individual risk assessments were completed on the risks faced and posed by residents. These covered core and specialist areas of risks and recorded the actions need to manage any identified risks. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 11 Care plans were recorded as having been regularly reviewed and each time a resident is admitted for short-term care. However, an example was noted whereby a care plan had been recorded as having been reviewed but it did not reflect the complex changes in needs of the resident. Therefore there was limited guidance for staff to follow. With the opening of interim care beds the manager said that they are planning to adapt the care plans to incorporate short term objectives. This is to ensure that staff are clear on the individual goal/objectives for each residents who will be in receipt of interim care. Records of medical intervention showed that 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. Residents consulted said that when they have asked to see a Doctor then this has been sought promptly. Much poor practice was noted in the management of medication, which placed residents at potential harm and is required to be immediately addressed. These areas were: • Medication administration Records not being accurately maintained. Therefore it was not always clear what medicines had been prescribed, if medicines had been administered, stopped or changed. • Lack of guidance for staff on the administration of “PRN” medication. • Discrepancies were noted in the balances of some “PRN” medicines. The manager was required to undertake an investigation into this matter. This concluded that additional training and guidance for staff was need to ensure that the correct procedures were being followed. These concerns were discussed with the provider following the inspection. A subsequent monitoring visit to the home highlighted that action had started to be taken to address these concerns. The storage arrangements for previous medication records did not enable information to be easily retrieved for auditing or answering queries. Therefore it is recommended that the current storage arrangement be reviewed so all previous records are stored together. Residents were dressed appropriately, in accordance with preserving their dignity and the prevailing weather. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Flexible routines are part of daily practice at the home. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents maintain contact with family and friends and with the local community as they wish. EVIDENCE: Flexible routines regarding going to bed, rising and bathing are respected by staff, enabling residents to exercise some control over their lives. During the inspection residents were observed to move around the home freely, choosing which rooms to be in and what level of company they wanted to enjoy Weekly activities programmes were displayed in each unit, which included sing a-longs, quizzes, TV afternoons and bingo. Staff said that these are undertaken in the afternoon when there is an overlap of staff. The consensus of residents consulted felt that their time was suitably occupied with most residents saying they preferred to make their own arrangements for occupation. Residents spoke of their visitors being able to visit at any time and were offered hot drinks and being always made to feel welcome. Residents spoke of going out to the local amenities / shops with staff or relatives. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 13 Residents described the food as: “very nice” “lovely” “nicely presented” “if you don’t like it they will get you something else” and “they give me to much I can’t always eat it all”. The inspector had lunch with residents and observed that resident’s individual preferences were being catered for. The meal was appetising and presented well. A staff member was observed offering discrete encouragement and prompts to residents who needed assistance, while another was observed not providing residents with choices. This was fedback to the manager. Guidance was provided for staff on good practice guidelines on how to present and serve meals to people who have dementia. This is to be commended. The head cook said that although they had not had any specialist training in dementia care and food they had undertaken their own research, and showed a good level of understanding. The cook reported that they visit each unit at lunchtime to obtain feedback on the food prepared. This information is then used to inform future menus. Records showed that specialist diets are catered for. The kitchen was found to be clean and the cook reported that there was no recommendations made at the most recent Environmental Health Visit. Each unit has their own kitchenette where drinks and snacks are made available throughout the day. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system with residents feeling confident to air any concerns they had. The home’s processes and procedures should protect residents in the event of an allegation of abuse. All staff need to have undergone training on adult protection. EVIDENCE: There is an accessible complaints procedure for residents their representative and staff to follow should they be unhappy with any aspect of the service. There has been one complaint relating to the residential services since the last inspection. This is currently being investigated by the manager. Several residents consulted said that they felt able to approach staff with any concerns they had. It was previously recommended that the storage of complaints investigation records be reviewed to enable ease of retrieving information. The manager reported that this had not yet been completed. There is an adult protection procedure to guide staff on identifying abuse and who to report to if abuse is suspected. Staff consulted showed some understanding of their responsibilities under adult protection. It was previously required that staff undergo training in adult protection. The manager reported difficulties in obtaining this training for the remainder of staff. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26 The home continues to provide a good standard of accommodation, which was clean, comfortable and well decorated. Residents have the specialist equipment they require to maximise their independence. EVIDENCE: The location and layout of the home is suitable for its stated purpose. Resident’s accommodation is provided at level access and is spacious. Much thought has gone into providing interesting décor to assist with orientation. Maintenance staff are on site. Maintenance staff promptly addressed exposed wiring from a call bell, which was noted by the Inspector. Further maintenance issues of loose bathroom tiles and a broken bulb guard also requires attention. The home is laid out into three units with the day centre occupying part of the site. 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. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 16 There are three units each with their own lounge/dining room. Décor and furnishings are domestic in character. One unit has a conservatory and small garden area. There is also a further enclosed small garden, which staff said is popular in warmer weather. Both gardens were in need of attention to make them more inviting spaces. One resident said that “they were a disgrace as they have looked really nice in the past”. It was a previous requirement that the inner courtyard be redecorated. This had not been yet been undertaken. There are sufficient number of toilets and bathrooms located throughout the home, including all bedrooms providing ensuite facilities. Residents consulted said that there was always hot running water available when they wanted it. All bedrooms are single occupancy and provided with a good standard of furniture and décor. The bedrooms of residents who receive long term care have been personalised with small items of furniture and personal belongings. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, hoists, ramps and grab rails. A call system is fitted throughout the home to enable residents to call for assistance. Call points checked by the inspector were in working order but were not answered by staff at the time. The manager investigated this during the inspection. It was established that staffs handsets had not been turned on in order to receive the call signal. The manager agreed to address this with the staff concerned. The home was found to be warm and comfortable and all areas inspected were noted to be clean and free from odour. It was previously required that staff who deal with infection control receive appropriate training. The manager was unclear whether this had been undertaken. Although not all domestic staff had undergone training in the safe handling of cleaning chemicals they were aware of where to find information on the chemicals they were using. Feedback was received that quantities of bedding was quite low, which resulted in residents beds not always being re-made promptly. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Despite efforts to recruit permanent staff there remains a significant number of hours being covered by agency and care crew staff. This has affected staff morale and the continuity of care. Training was not being co-ordinated effectively, which has lead to not all staff having the core training needed to undertaken their roles safely and effectively. The procedures for the recruitment of staff are not sufficiently robust and do not provide the necessary safeguards. EVIDENCE: At inspection there were five care staff on duty. This was made up of permanent staff, agency and the councils care crew scheme. Much feedback was received by the inspector that staff morale was low and that the lack of permanent staff was affecting the continuity of care provided. The manager confirmed that where possible the same care crew are used to promote some continuity. It was noted that many of the permanent staff were originally care crew. On the day of the inspection an agency and care crew member had been allocated on the interim / short-term care unit. These staff had limited knowledge of the residents needs on this unit and practices were observed which did not promote individuality. The manager was required to re-dress this. It was subsequently reported that the manager has re-introduced the policy that agency and care crew only work along side permanent staff. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 18 Care staff provide senior/duty officer cover for four hours at the weekends. It could not be established the level of training, persons left in charge had undertaken. Not all care staff consulted felt confident that this arrangement protected staff and residents. Therefore it has been required that in the managers absence suitable qualified and competent persons are left in charge at all times. While residents and staff made positive comments about the staff team, many gave examples of poor communication, staff being unclear about what is expected of them, and practice being inconsistent between shifts. The manager reported that regular action has been taken to recruit permanent staff. This included a recent recruitment day, however this has not yet impacted on the number of permanent staff working in the home. Recruitment and selection documentation seen showed that not all of the necessary records required to protect residents were obtained. This includes proof of identification documentation and application forms. Records were maintained of training undertaken for each member of staff, however these were not being accurately maintained and kept up to date. Some key staff had not undergone all of the core training topics of: fire, adult protection, first aid, medication, moving and handling, dementia health and safety, but had undergone specialist training. It was not apparent who was co-ordinating training to ensure that staff training needs were being identified. New staff confirmed that they had undertaken a comprehensive induction, which had also involved a centrally held four-day induction course. Induction documentation carried out at the home could not be located at inspection. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 and 38 The manager is currently not fulfilling their responsibilities, as born out by the number of shortfalls in practices noted and outstanding requirements. This has results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The manager has been registered since summer of 2005 and is in the process of completing an NVQ level 4. The manager was open and friendly in their interactions with the inspector. Staff said that the manager was approachable and that they felt able to put forward new ideas. At inspection, the manager appeared to be under a significant amount of pressure. This was clearly affecting their ability to meet their legal responsibilities, as born out by the shortfalls in practices noted and the number of outstanding requirements from previous inspections. Discussion occurred, following the inspection, with the provider on reviewing the current Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 20 management structure to establish whether additional senior management support is needed. It was previously required that a comprehensive quality assurance and monitoring system be established. The manager reported that this has not yet been fully undertaken. Comment cards on the services and facilities provided have been distributed and feedback sheet included in the homes literature, but to date very few have been completed. Most staff said that they receive regular supervision with senior staff. The manager said that they are currently in the process of undertaking senior staff appraisals. Records inspected were found to be held securely. Residents can access their personal records, but the manager said that no one has as yet asked to do so. Written guidance is available on issues related to health and safety. Practices noted which promoted the health and safety of resident’s; staff and visitors included regular checking of fire safety equipment, fitting of window restrictors and the fitting of hot water mixer valves. The manager undertakes a monthly summary of accidents to monitor for any patterns. An example was noted whereby a resident was frequently falling and prompt action had been taken to establish any underline cause. The standard of accident recording was however variable. It is practice for senior staff to complete accident records on behalf of care staff and it was not always recorded who had actually witnessed or discovered the accident. The inspector received feedback that there was an increase in accidents on units where no permanent staff were deployed. However as the name of staff was not always recorded this concern could not be disproved or confirmed. The manager agreed to look into this matter. Exposed hot pipe work in a bathroom was noted to pose a potential risk of accidental scalding. This has been required to be addressed as a matter of priority. The inspector observed some dangerous practices in the handling of hazardous chemicals by kitchen staff, which was required to be stopped immediately for the safety of staff and visitors. There is a need to undertake a risk assessment for all safe working practice topics, which records significant findings and is reviewed regularly. This is with particular reference to: • The use of portable radiators in resident’s bedrooms, from the risk of accidental scolding and fire safety. • The use of low coffee tables from the risk of trips and falls. • Free standing wardrobes from the risk of toppling over. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 2 2 3 3 2 x 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 3 2 2 Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 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 OP77 Regulation 15(2)(b) Timescale for action That care plans are reviewed and 30/03/06 updated regularly to reflect changes in needs and preferences of service users. That medication administration 30/01/06 record is fully kept. (Made at inspection of 1/6/05 with timescales of immediate not met). That suitable arrangements are 30/01/06 in place for the recording, handling, safekeeping, safe administration and disposal of medicines at the home. Provide training to all staff in 30/04/06 adult protection. (Made at inspection of 1/6/05 with timescales of 31/10/05 no met). Redecorate the inner courtyard 30/04/06 around the middle garden as needed. . (Made at inspection of 1/6/05 with timescales of 31/10/05 no met). That the repair and maintenance 30/03/06 issues identified at inspection are addressed. That all staff who deal with 30/04/06 infection control situations have DS0000031718.V250144.R01.S.doc Version 5.0 Page 23 Requirement 2 OP9 17(1)(a)& Sch 3.3.i 3 OP9 13(2) 4 OP18 18(c)i 5 OP19 23(2)(d) 6 7 OP19 OP26 23(2)(b) 13(3) Ireland Lodge 8 OP27 18(1)(a) 9 OP27 18(1)(b) 10 OP27 18(1)(a) 11 OP29 19(1) & Sch 2(18) 18(1)(c) (i) 12 OP30 13 OP33 24 14 OP38 13(4) 15 OP38 13(4)(c) 16 OP38 13(4)(c) received appropriate training. (Previous timescale of 30/4/05 and 31/10/05 not met). That the deployment of agency and care crew staff be reviewed to ensure that at all times suitable competent staff are employed. Take action to increase the level of permanent staff in the home. (Previous timescale of 30/4/05 and 31/7/05 not met). That suitably competent persons are left in charge in the Managers absence and that they are recorded on the rota as in charge. That employment and recruitment documentation is maintained in accordance with the National Minimum Standard. That staff undergo training necessary to undertake their work. This includes moving and handling, fire safety, dementia, health and safety. Ensure that the home has comprehensive quality assurance and monitiring systems. (Previous timescale of 30/4/05 and 31/10/05 not met). Ensure staff have training in First Aid. . (Made at inspection of 1/6/05 with timescales of 31/10/05 not met). That hazardous cleaning chemicals are handled in accordance with COSHH regulations 1988 at all times. That a written risk assessment is carried out for all safe working practice topics, which records significant findings, with particular reference to the use of portable radiators, coffee tables DS0000031718.V250144.R01.S.doc 30/01/06 30/03/06 30/01/06 30/03/06 30/06/06 30/06/06 30/04/06 30/01/06 30/01/06 Ireland Lodge Version 5.0 Page 24 17 OP38 13(4)(c) and free standing wardrobe. That hot pipe work be fitted with guards or have guaranteed low temperature surfaces. 30/03/06 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 OP9 OP16 Good Practice Recommendations That the storage of previous medication administration records be reviewed to ensure that this information can be easily retrieved. Review the complaints investigation records. Ireland Lodge DS0000031718.V250144.R01.S.doc Version 5.0 Page 25 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.V250144.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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