Inspection on 17/10/07 for Ivy Lodge Retirement Home

This inspection was carried out on 17th October 2007.

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

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

Other inspections for this house

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Abbey The

Larchfield Manor

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The Grove Waltham

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ivy Lodge Retirement Home Briergate Haxby York YO32 3YP Lead Inspector Anne Prankitt Unannounced Inspection 17th October 2007 09:15 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 Ivy Lodge Retirement Home DS0000070026.V348497.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. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy Lodge Retirement Home Address Briergate Haxby York YO32 3YP 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) 01904 760629 01904 760636 Ivy Lodge Care Limited Mrs Linda Joan Porteus Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 34 N/A 2. Date of last inspection Brief Description of the Service: Ivy Lodge has been adapted and extended to provide good quality accommodation for older people who require support with their personal care. The building is situated in a residential area of Haxby, some four miles from the centre of York. The home provides accommodation on two floors for a maximum of thirty four people. The home has a garden area, and parking places are available for visitors. There is a choice of communal space, and a passenger lift to all floors accessed by people. Service areas, for example the kitchen, are located on the ground floor. The registered manager confirmed on 17 October 2007 that the current weekly fees range from £378 to £458.50. However, the majority of rooms are offered at the rate of £420. Services or items not included within the fees, and for which extra charges are made, include hairdressing, chiropody, newspapers and magazines. Information about the home is given to prospective residents within a brochure and the home’s service users’ guide. A summary of the inspection report is kept in the hallway of the home, but people who want to see the full report can ask the registered manager for a copy. Since the last inspection of the home there has been a technical change in company arrangements. Therefore the service is classed as a ‘new registration’, following a completed application made to the Commission for Social Care Inspection. However, it is an existing service, and this arrangement has made no detrimental changes to the way that the home is run. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the site visit the registered manager, Linda Porteus, returned a self assessment called an ‘Annual Quality Assurance Assessment’, which provided information about Ivy Lodge. Surveys were sent to a selection of people who live at the home, some relatives, and some visiting professionals. A record has also been kept about what has been happening at the home since the last key inspection, and since the home re-registered in April 2007. During the visit, we spent time talking with people who live at the home, and observations were made to see what life at Ivy Lodge is like. We also spent time talking with staff and looking at some documents. We made a general tour of the communal areas. Some people’s bedrooms were inspected, after checking that this would be acceptable. The site visit took approximately seven hours to complete. All of the information gathered was used to form a judgement about the service that Ivy Lodge offers to the people who live there. Feedback was provided to the registered manager. What the service does well: People receive good consistent care from a staff team who understand their needs. Their comments included: ‘The staff are lovely. Friendly and always willing to help me. They talk to me and make me feel happy’, ‘The staff do everything I ask. They treat me with respect but we have some good humour’. ‘I like it here. It’s the next best thing to home’. A relative said ‘Caring and kindness in abundance’. People’s health care needs are met, because staff make sure that they are referred to the doctor or district nurses where problems arise so that they can be quickly resolved. A visiting professional commented upon staff’s ‘Individual approach’ to people. They said that they were ‘professional’, and demonstrated ‘team work’. There is good and stable management support, which reassures people. A relative commented ‘I feel strongly that Ivy Lodge should have the gold standard by which other care homes should operate. I cannot fault anything but must say that I really appreciate the attention to personal details’. Another said ‘It is excellent in every single way. Mr and Mrs Hill keep a marvellous residential home. All the staff are excellent’. Ivy Lodge Retirement Home DS0000070026.V348497.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. Ivy Lodge Retirement Home DS0000070026.V348497.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 Ivy Lodge Retirement Home DS0000070026.V348497.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): 3 and 6 People who use the service experience good quality outcomes in this area. People’s needs are assessed before they are admitted. But there is a chance that they may not be personally involved in the assessment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Designated staff at Ivy Lodge obtain information about people in a variety of ways before they are admitted, and before deciding whether the home is able to meet their needs. Sometimes they meet the person in their current situation. This may be at hospital, or in their own home. Alternatively, information may be collected from the person’s care manager, who may have already completed an assessment. At other times, where the person lives too far away for staff to visit them, staff normally speak to the person’s family to collect information about why their relative needs care. On these occasions extra consideration could be given to ways of involving the person directly in this assessment. This would make sure that they have been personally involved in the decision about whether Ivy Lodge will be a suitable place for them to live. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 9 Where an assessment visit takes place, information about people’s needs is not always written down until after the person has been admitted, when they have a further initial assessment. It would be good practice for information to be documented when the assessment visit takes place, so that other staff have access to first hand information so that they can begin to write a care plan before the person is admitted. The registered manager agreed, and will make sure that this happens in the future. This will help to make sure that people get the right care from the offset. As part of the assessment, the registered manager also sends out information to people about what the home provides. Out of the five people who returned their survey, everyone was satisfied that they had been given sufficient information about the home so that they could decide whether it was the right place for them. One person spoken with said ‘I am very happy. I can do what I like, but they told me that before I came in’. The registered manager confirmed that the home does not provide intermediate care. Ivy Lodge Retirement Home DS0000070026.V348497.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): 7,8,9 and 10 People who use the service experience good quality outcomes in this area. People receive good consistent care from a staff team who understand their needs. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: An assessment of care need and associated risks is completed on admission. This highlights what people’s current needs are, and includes a life profile, so that staff also know what interests, lifestyle and social and family life the person had before they came to live at the home. From this information care plans are developed. Whilst very detailed information is recorded in the daily records and health professional intervention sheets, the care plan is not always updated at the same time. This means that the care plan is sometimes out of date, and reflects more the needs of the person when the plan was first drawn up. Discussion took place about ways in which the care plans could be presented and updated in a more consistent way, so that this important information from the daily records is transferred as changes in care happen, so that they can be looked at more easily as part of the monthly review. This will help to make Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 11 sure that all information about changing needs is always considered as part of this review, and will make the desired outcome for each individual much easier to understand. The registered manager intends to review the information gathered, and to introduce more formal triggers where risk is identified, so that important information about people’s health is always clearly documented and reviewed as part of their ongoing care. Despite this, people spoke highly of the care and attention that they get from staff. All those surveyed agreed that staff always act and listen to what they say, and that they always receive the medical support that they need. Comments included: ‘The staff do anything that I ask’, ‘Generally I am very satisfied with my care’. People agreed that staff spoke to them with respect and kindness. One person said that staff always give the right care when it is needed. A visiting professional commented upon staff’s ‘Individual approach’ to people. They said that they were ‘professional’, and demonstrated ‘team work’. Staff spoke to people with the utmost respect, and in a way which upheld their privacy and dignity. Staff who look after people’s medication have undertaken training to make sure that they are competent to do so. They assess whether or not people are able to manage their own medication. At the time of the site visit, staff looked after everyone’s medication. The registered manager has consulted with the pharmacist about the correct way for medication to be stored at the home, and improvements have been made in the way that it is dispensed. During an audit of the system, one medication, which the registered manager said was no longer prescribed, was still in stock, and was out of date. The registered manager said that this would be removed forthwith. The medication is audited monthly. This helps to identify problems at an early stage, and stops unnecessary errors from occurring. Ivy Lodge Retirement Home DS0000070026.V348497.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): 12,13,14 and 15 People who use the service experience good quality outcomes in this area. People are supported to make choices in their daily lives, and to maintain important contacts with their family and friends. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Of the five people who returned their survey as part of this inspection, one said that there were always social activities that they could take part in. The remainder said that there were usually or sometimes activities available for them. Comments received were mixed, and included ‘I would enjoy more activities’, ‘There are activities, and I like to read my newspaper and watch TV. I have been on trips’, ‘I am unable to take part’. The registered manager was already aware that some revisions were needed to the activities programme, which she has already made. Whilst social events happen regularly inside the home, trips out are also popular, and have increased in number since people told her in a recent survey that they would like more of them. The communal notice board advertised the home’s library, Christmas coffee morning, shoe sales and other communal activities such as a ‘sherry and socialising’ event. Fortnightly fellowship meetings take place, which are very Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 13 popular. In addition to this, the church visits the home and provides a service for people to assist in meeting their spiritual needs. Although individual activities undertaken are not recorded in any detail, the registered manager gave instances where these had been provided. For example, staff had assisted people individually to plant bulbs. Communion is also provided on an individual basis for people who are unable to join the main service. This helps towards making sure that everyone gets some form of social and spiritual recreation, and helps to make sure that they are not excluded. Relatives were very positive about the way in which they were welcomed into the home. One stated: ‘It’s just like an extended family. Absolutely lovely’. Another said ‘Good staff – resident liaison.’ They said the home ‘creates a nice friendly atmosphere, sensitive to people’s needs’. People were happy with the choices that they could make in their daily lives. One said: ‘I get choice from the staff.’ Another said ‘I am very happy. I can do what I like, but they told me that before I came in’. The dining room is beautifully set out. People are free to congregate there at coffee times as well as mealtimes. People said they like the food at the home. One said ‘The food is OK – I can ask for a choice’. The registered manager explained that comments returned from her recent satisfaction survey have resulted in changes being made to the tea time menu. Staff have access to the kitchen at all times, so that they can prepare food for people if they are hungry when the chef is not on duty. The chef was happy that he could order good quality food in ample quantity, which he said enabled him to prepare nutritious and wholesome meals for people. He explained that nobody currently living at the home needs a special diet because of their cultural or religious needs, but he was confident that he would be able to prepare these if needed in the future. Staff refrain from giving out medication at mealtimes. This helps to make the occasion much more of a social event. Ivy Lodge Retirement Home DS0000070026.V348497.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): 16 and 18 People who use the service experience good quality outcomes in this area. They are protected by staff who will take their complaints seriously, and who will pass on to the appropriate person any concerns which affect people’s welfare and safety. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the main entrance, so that people can see how they can make a complaint, and how their complaint will be dealt with. People agreed that the registered manager was very approachable. One stated ‘I would complain to Linda (the manager) if I had any problems. She’s always about’. Other people commented ‘I can complain and things get done’. ‘There are staff about to talk to but I am happy. Linda is always there to help me. There is a document with details on it if there was a serious complaint.’ A relative said that ‘Any issues are dealt with straight away by Linda. She sorts the staff out’. There has been one complaint made to the registered manager about how the specific needs of one person were being met. The registered manager had looked into the concerns, and no further issues have been raised since. At the time of the site visit she was collecting information as part of her investigation into a second complaint. The investigation was not yet completed. One anonymous complaint was also made direct to the Commission for Social Care Inspection. The information given, which was passed to the home to investigate, was very limited, but suggested that someone living at the home Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 15 was made to get up too early. Based on the information available, the registered manager had attempted to look into the matter raised, and has found the complaint to be unsubstantiated. There have been no further concerns raised about this matter. Staff have recently undertaken training in how to recognise abuse, and the action to be taken by them in such situations. All spoken with were clear about their responsibilities in reporting any matter which affects the safety and welfare of people who live at the home, without exception. This will help to make sure that people are properly protected. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience excellent quality outcomes in this area. People live in pleasant and comfortable surroundings which are kept to a high standard. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home is set in a quiet area of Haxby, but is within close proximity to the shopping centre and other amenities that the village provides, such as pubs and church. The garden area has some seating so that people can sit outside when the weather permits. There is a choice of three communal areas, which are comfortable and homely. The home is kept to a high standard of decoration and cleanliness. As part of an ongoing decoration plan, the corridors have been repainted. Bedroom décor is refreshed as and when necessary, or when a room becomes vacant. Future plans include the redecoration of one of the communal sitting areas. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 17 People’s rooms were individualised, and contained their personal possessions. One person said that they were nice and comfortable, whilst another said that they liked their room, and the view that it provided. Another commented ‘My room is always clean. The home is lovely’. The care staff complete laundry duties. The laundry provides appropriate equipment so that items can be washed at the correct temperature, including a sluice facility. Clothing looked well laundered and cared for. Staff are provided with a supply of protective gloves and aprons. This helps to reduce the risk from cross infection. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience good quality outcomes in this area. The recruitment and training programme helps to make sure that the staff who work at the home have the knowledge and skills to provide support to people in a safe and caring way. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People generally agreed that staff are available in sufficient numbers to meet their needs. They commented ‘The staff are very good and the care is good’, ‘I ring, and they come at my request’. People who returned their surveys thought that staff were always or usually available when needed, with one commenting ‘The staff are always there for me’. One isolated comment was made, and passed to the registered manager: ‘staff are very kind and helpful, but always too busy to stop for a chat.’ Prospective staff are properly recruited, and newly appointed staff receive a detailed induction. Following this, there is a programme of supervision and appraisal in place during the course of the staff member’s employment. In addition, there is a training programme in place, which includes studying towards National Vocational Qualifications in care, and regular updates on fire safety and moving and handling. The registered manager is currently updating training for all staff in infection control and food hygiene. In addition, the registered manager confirmed that there is always someone on duty who is qualified to carry out first aid. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 19 The registered manager is closely involved with a dementia support learning group, and passes relevant information on to staff, who attend some of the events which are held by this group. In addition, nine staff have completed training in dementia awareness. This is good practice, because it helps staff to have a better understanding of the people who have developed dementia needs whilst living at the home. The recruitment process and subsequent support that staff get helps to make sure that people are cared for by suitable staff, who are qualified and fit to provide care, and who understand the aims of the home in meeting people’s needs. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience good quality outcomes in this area. The registered manager runs the home in a professional way, taking into account the interests of the people who live there. People’s health and safety is protected, although there is one issue that needs addressing to help maintain this. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The registered manager is a qualified nurse, who also holds a professional management qualification. She has good experience in the care of older people. She holds regular meetings with her staff and said that this had improved the flow of communication. A staff member commented about the manager ‘She’s really good – she’s lovely’. Mr and Mrs Hill, the registered providers spend a lot of time on the premises. A relative commented ‘I feel strongly that Ivy Lodge should have the gold Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 21 standard by which other care homes should operate. I cannot fault anything but must say that I really appreciate the attention to personal details’. Another said ‘It is excellent in every single way. Mr and Mrs Hill keep a marvellous residential home. All the staff are excellent’. The registered manager is developing ways in which people who live at the home can have more of a say about how it is run. She has introduced twice yearly meetings, which people and their relatives can attend. She sends out satisfaction surveys to visiting professionals as well as people living at the home and their relatives, so that she can look at how satisfied they are with the service that they get. The results of these surveys are summarised, and where shortfalls are identified, these are acted upon. The most recent survey identified that people were very satisfied with their care, but that some changes to the menu and activities programme were needed. The registered manager tries to speak to people and their relatives about changes that have been made as a result of their collective comments. However, she should consider publishing the results, so that everyone has the chance to see what she has done with the information that they have provided. This will help them to feel involved, and will encourage them to make further comments in the future. There is no one for whom the home acts as financial appointee, but money can be kept on people’s behalf. This is kept separately and securely, and records are maintained of any incomings and outgoings, so that people can easily see what they have spent, and on what. However, people can also keep money in their private locked facilities if they wish. The information provided before the site visit, and the maintenance certificates seen, confirmed that the premises are kept well maintained and safe for people to live in. Weekly checks take place to make sure that the fire alarm system is in full working order. The registered manager has also carried out a fire safety risk assessment which the fire officer has seen, and which the registered manager confirmed was satisfactory to him. The registered provider explained that there is also a fail-safe system in place for making sure that water is stored and delivered at safe temperatures. The registered manager said that she also keeps a check of hot water temperatures from outlets that are accessible to people who live at the home. These measures should help to reduce the risk from scalds. Following advice given by the Environmental Health Officer on their routine visit to the home, the chef has been advised to follow ‘Safer Food, Better Business’ guidelines in the kitchen. This has not yet been implemented. Hot food serving temperatures had not been checked since July 2007, because the temperature probe was broken. The chef was not sure whether the new one ordered by him had been delivered. Nor had a record of the cleaning schedule Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 22 been kept pending the implementation of the new recording system. Although the chef gave assurance that this was still carried out. The registered manager was aware that these need to be reintroduced, along with records to confirm that food is being prepared and handled safely for people. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13 Requirement To protect people from unnecessary risk, a regular audit of the kitchen services must be carried out, to make sure that systems introduced, to ensure and evidence safe food preparation service, are being complied with. Timescale for action 30/11/07 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 Refer to Standard OP3 Good Practice Recommendations Rather than speaking solely with the family as part of the pre admission assessment, extra consideration should be given to ways in which the person who will be receiving care could be directly consulted about their needs and wishes. This would make sure that they have been personally involved in the decision about whether Ivy Lodge will be a suitable place for them to live. So that all applicable staff have an understanding of the care that a person is likely to need on admission, staff Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 25 2 OP7 carrying out the pre admission assessment should write down the results from the assessment and make the information available to other staff before the person moves in. Valuable information which signifies change in need and outcome which is currently recorded in people’s daily records, should be transferred to the care plan as changes occur, so that this information can be considered as part of the monthly review. More formal triggers to identify risks to people’s health should be considered so that staff have clear instructions about when help from other professionals may be needed. Ivy Lodge Retirement Home DS0000070026.V348497.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. 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