Inspection on 06/06/06 for Jacobs Lodge

This inspection was carried out on 6th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jacobs Lodge 02/12/08

Jacobs Lodge 10/01/06

Jacobs Lodge 06/01/05

Jacobs Lodge 22/07/04

Jacobs Lodge 18/03/04

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Dalewood Respite Care

Orchard,The

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Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Jacobs Lodge Jacobs Gutter Lane Hounsdown Southampton Hampshire SO40 9FT Lead Inspector Beverley Rand Unannounced Inspection 6th June 2006 11:00 Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 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 Jacobs Lodge DS0000040573.V291042.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 Adults 18-65. 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. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Jacobs Lodge Address Jacobs Gutter Lane Hounsdown Southampton Hampshire SO40 9FT 023 8066 1205 023 8066 1206 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) Hampshire Partnership NHS Trust Mrs Siri Greenfield Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Jacobs Lodge is a short break service located just outside Totton on the same site as the Hythe and Waterside Day service The home is purpose built, all on one level, and allows easy access for people who use wheelchairs. The home is owned by Hampshire County Council and managed by Hampshire Partnership NHS Trust. There is a kitchen, dining room, lounge and laundry facilities and each service user has their own bedroom when they come to stay. There is also a large garden providing additional recreational space. Fees are assessed by the local authority adult services teams so will vary for each service user. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced on the first day and announced on the second. The inspector spoke with two service users, who also completed comment cards, three permanent staff, one agency staff member, one visitor and the manager. The inspector was shown around the building. The inspector also looked at records such as support plans. What the service does well: What has improved since the last inspection? What they could do better: Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 6 The manager must make sure that it is safe for service users to do things like cooking or going out alone, and this must be written down. The service has procedures in place for giving medication, but the service has not followed these procedures completely, and must do so. The service does not have a good enough procedure in place to ensure staff know what to do if they believe another staff member is treating a service user badly. All the staff must have training twice a year about fire safety. 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. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are able to visit the home prior to making a choice, and their needs are assessed before they stay at the service. EVIDENCE: Service users have been staying for short breaks at Jacobs Lodge for many years and there have not been any new service users since the new manager has been in post. The manager was heard to be discussing a potential emergency admission and was identifying the difficulties with undertaking an accurate assessment for emergency placements. The manager told the inspector that if she needed to do an assessment she would visit the person, gather information from them and all involved parties such as family, healthcare professionals, etc. The information gathered at this point should be sufficient to draw up a basic support plan. Before she undertook an assessment she would write to invite the potential service user and their families to visit the service. This standard was previously met when the inspector looked at four assessments. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users all have a support plan which includes information about individual preferences, which informs the decisions service users make. Some service users undertake activities for which there is not a risk assessment in place to show how the risks are to be reduced. EVIDENCE: Support plans cover areas such as personal care, eating and drinking, sleeping, health, communication, medication, safety, leisure, community participation, personal money and relationships. Personal preferences were detailed such as how many pillows a service user had, how many sugars, food served in a certain way, the times people liked to go to bed, etc. Service users and their families are involved in care planning and reviewing. One of the two service users who completed a comment card said they knew they had a support plan. Three of the four staff who spoke with the inspector said they referred to support plans but one said that they never did, as they worked in the home irregularly and relied on staff to verbally update them. This was brought to the manager’s attention who agreed to address this issue. The three regular staff were very aware of individual needs, including how many staff should support Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 10 an individual with care needs, strategies for dealing with and preventing epileptic fits, when to give a certain type of medication, etc. Service users stay at the service for irregular periods, and may only come once or twice a year, yet staff were confident in their knowledge and abilities regarding individual service users. The manager told the inspector that reviewing the support plans in a routine way is difficult because of the infrequency of the stays by service users. The manager therefore reviews the plan when a service user stays at the service, and will also send plans to families to review prior to a visit. A regular visitor to the service said the support plan for their relative was reviewed annually and on an ongoing basis, and that staff knew the service user really well. Service users can make decisions on a daily basis and this was seen during the inspection as detailed elsewhere. They also keep any money they bring in a lockable place where they can access it. Some staff have had training on positive risk taking and others are booked to go. Service users take risks such helping in the kitchen, going out without support staff, etc. However, there were few risk assessments with regard to these activities. Although service users may undertake these actions at home and therefore their independence is being promoted, risk assessments must be in place which state this, as being an element which reduces the risk. One support plan looked at by the inspector showed that support was needed when walking outside, stated the risk, but did not state the action necessary to minimise the risk. Risk assessments must be in place for activities, and these will need to be reviewed when service users next stay at the service. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a flexible lifestyle within the home where choice, personal development and the dietary needs are well promoted. EVIDENCE: As service users change on a daily or weekly basis, there is not a programme of activities, but activities are provided suitable to individual needs. One service user told the inspector they had helped fill pots with summer bedding and they might watch DVDs later. The majority of service users attend day services and continue to go when they are using the service. On the day of the inspection one service user was supported to go to work as they usually did on that particular day of the week. A staff member told the inspector that inhouse activities included books, puzzles, salt dough craft and card making. Short trips are made to the shops and outings tend to happen at weekends, if appropriate. The manager told the inspector that an activities folder is being made, with the involvement of service users, which will be kept in a place where service users can look at it and get ideas for what they might like to do. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 12 Service users access the community whilst staying at the service by going to the local shops, sometimes for food shopping, and by visiting places such as Lymington. Any trips out have to be planned and risk assessed in advance to ensure that there is wheelchair access, for example. As the service is for short stays, visitors are not frequent, but visitors are welcome and can see service users in private. The visitor who spoke with the inspector visits very frequently and said that staff are always polite to her. The manager ensures she involves relatives if they do not visit the service. The two service users who spoke with the inspector said they can get up and go to bed when they like, and this was seen by the inspector. The inspector saw that a service user locked their bedroom door and took the key with them when they went out. The service user told the manager that the room did not need cleaning that day and the manager accepted this, saying that no-one would go in to disturb anything. Service users said that staff always had time to talk to them. Both the service users who spoke with the inspector said they liked the food and could choose what they ate. The inspector saw a service user choosing a breakfast cereal and their lunch, at the time they wanted it. Both residents also said all the staff were, ‘nice cooks’. The service does not employ a cook but all staff have food hygiene training. The manager said that staff will show service users the range of foods available so they can choose. Service users are supported to make drinks, snacks, or bake cakes, if they are able and wanting to. Details regarding the individual daily choices of service users are recorded in their support plans. Staff go food shopping twice a week, or more if necessary, and some service users like to go with them. The manager said that they accommodate individual requests from families, or dietary needs. Some service users need their food to be pureed and the manager said she thought the food was pureed together. She agreed to review this practice to ensure that different food items in a meal were pureed separately so that taste could be identified. The menu is devised by two named staff in conjunction with service users, but is regularly deviated from to accommodate choice. Service users can choose where they eat, for example, in front of the television, but they tend to sit at the dining table to eat with other service users. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The service ensures that service users personal and healthcare needs are met. Medication procedures are in place to protect service users but some aspects have not been adhered to. EVIDENCE: Staff gave the inspector examples as to how they supported service users with dignity: these included closing curtains and doors and not asking service users if they would like the toilet in front of everyone else. One staff member said they were mindful of how they would like to be treated themselves. Individual support plans showed clear procedures to follow when supporting with personal care. The manager told the inspector that some service users do not have the choice regarding what clothes to wear as some families detail what is to be worn on what day, and that sometimes this is because service users have not learnt how to make choices. The service has links with healthcare professionals as appropriate for a short break service. The local GP will visit if necessary and can prescribe medication if service users have come in without enough, or with the wrong medication. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 14 The service has a thorough medication policy in place. Medication is stored securely, and the medication belonged to the current service users. Any medication which needs to be stored in a colder environment is stored in a locked tin in the fridge. The inspector was told that one service user has medication hidden in food, as they are likely to refuse it. The home’s policy states this is to be done only if there is a multi-disciplinary decision recorded, and if the suitability of the medication to be put into food has been checked by a pharmacist. However, neither of these procedures has been followed. Other service users have medication put into food such as yoghurt because they are unable to swallow tablets. Staff told the inspector they always tell the service user it is time for their medication and they know it is in the food. However, the pharmacist has not been consulted with regard to the suitability of the particular medication. The manager said that families have told the service that they administer in this way at home, but there was no evidence to show families had sought pharmacy advice. On the second day of the inspection the manager told the inspector that she had already started actioning these issues raised. All staff receive medication training provided by the Hampshire Partnership Trust which includes three different assessments and annual updates. Staff have training regarding certain invasive medication techniques, but not with regard to one particular technique. The manager said that staff do not administer the medication to this service user, but outside support is provided by a trained person. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users feel able to complain and staff are aware of the initial stages of reporting allegations of abuse, but more attention needs to be paid to the complete procedures to ensure service users are protected. EVIDENCE: The home has a complaints procedure in place and complaints made are logged in a book. Complainants are given a leaflet which outlines the procedure in more detail which includes timescales. The Hampshire Partnership Trust has a complaints department and complaints are directed to them. The complaints log showed that formal responses were sent to complainants within the timescales. The two service users who were at the service during the inspection felt they knew who to complain to. All staff receive training with regard to the protection of vulnerable adults and this is provided by the Trust. The service has copies of relevant government and local authority guidelines which staff can access, but does not have a policy specifically for Jacobs Lodge. There is a ‘Whistleblowing’ policy but this was last reviewed in January 2004. An allegation of verbal abuse by a staff member to a service user was made in February 2006, but the alleged incident happened in the previous November. The manager said she has re-iterated to all staff the importance of reporting incidents as soon as possible. The inspector spoke with three staff about the procedures to follow if they suspected or witnessed abuse of any kind, all were clear that they would report it to the manager. However, the staff were not aware of the role of the local authority adult services department, or that they could report incidents directly to them. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 16 Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager ensures that service users stay in a clean and hygienic service which meets their needs. EVIDENCE: Service users said the home was, ‘nice and clean’ and that there were new lamps and the quilt covers matched the pillow cases. The cleaning is done by support staff and the home was clean and odour free. The service was purpose built and all bedrooms are single. The bedrooms contain furniture for storage and there is a variety of beds to meet specialist needs. The manager said that service users were welcome to bring in items to personalise their bedrooms whilst they are at the service, but that this was often the responsibility of the parents rather than the service users. The communal areas are light and airy, and lead onto a garden area, which staff and service users are working to improve. The garden has seating and a table. The shower has been repaired. The last report required that a hoist be fitted in the bathroom but the manager advised the inspector that as the shower was fixed, service users with mobility needs would shower rather than bath. Staff confirmed to the inspector that they did not think there was anyone who would need to be hoisted and who would prefer to bath. The bath has been fitted with a new bath seat. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 18 Information regarding infection control was visible in the laundry, and the washing machine has a sluice programme. The inspector spoke to two staff about infection control and both were fully aware of procedures to follow, such as using protective aprons and gloves, washing hands, what to do with soiled bedding, etc. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The service employs safe, well trained and supervised qualified staff to ensure residents are safe and their needs are met. EVIDENCE: The service has not recruited any new staff since the standard was last inspected and met. The recruitment process involves seeking the appropriate references and employment checks and is completed by the Human Resources department. The manager confirmed that new staff would be employed only after the checks had been completed. The manager said she would be involved in shortlisting and sending for references. All permanent staff said they had done ‘lots of training’. The manager explained that new staff go on an induction training course which is run by the Trust and which meets the Skills for Care induction standards. The induction course runs over four days, plus one day’s induction regarding the organisation, and is held monthly which means new staff are usually able to undertake the course fairly quickly. There is a training calendar in place which includes food hygiene, epilepsy, first aid, eating and drinking, personal communications, equal opportunities, person centred planning, positive risk taking, adult protection, resuscitation, strategies for crisis intervention and prevention, health and safety, infection control, medication administration and moving and handling. Core training was generally up to date, although not Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 20 everyone had had their moving and handling practice update which had been due two to three months ago. The manager said it was difficult to get staff on this particular course because of high demand but was being addressed. The service promotes the achievement of National Vocational Qualifications, (NVQ): out of eleven support staff employed, three staff have achieved NVQ2 and a further two are currently working towards it; four staff have achieved NVQ3 and a further one is working towards it. The remaining two staff have applied to take NVQ2. The standard suggests that a minimum of 50 have NVQ training, so this number of qualified staff is seen as good practice. Two staff who were asked told the inspector they have one to one supervision sessions on a monthly basis. One staff member said they could discuss anything with the manager and that she was, ‘very approachable’. Additionally, supervision was not generally cancelled, but if it was, it was re-scheduled promptly. Both staff said notes were made in supervision and that they received copies. The manager told the inspector that not all staff could make supervision during usual office hours, for example, night staff, and so she did supervision in the evenings to ensure staff benefited from supervision. This is seen as good practice. Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager continues to update her own training and quality assurance systems are in place to ensure the service is run in the best interests of service users. The service would benefit from a closer monitoring system regarding the need for all staff to be trained twice a year in fire safety. EVIDENCE: The manager has completed the NVQ4 in management and is working towards the Registered Manager’s Award. She has updated training such as fire safety and ‘train the trainer’ in fire safety. The manager ensures that her own training needs analysis is completed and actioned with her line manager. Service user meetings are held on a monthly basis and are attended by the service users staying at the time. These are facilitated by the staff member responsible for administration, as the manager feels the service users see her as impartial. The manager is planning to laminate the minutes and put them in a folder to be kept in the lounge. She is also researching communication Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 22 methods which use symbols to ensure the minutes are accessible to all. Parents and carers meetings are held quarterly and minutes are kept. Quality assurance regarding the fixture and fittings is monitored and issues passed on to the county council. Food was appropriately stored in the fridge. There is an ongoing rolling programme for maintenance of equipment. The inspector saw a maintenance certificate for the hoists, but the manager could not find one for the boiler. She said this was because some contractors did not leave a certificate at the individual service, and that it was likely to be held centrally at present. There is a risk assessment in place for the use and storage of hazardous substances and a named staff member has responsibility for ensuring good practice continues. Another named staff member undertakes a weekly health and safety checklist. A requirement was made at the last inspection that all staff must have fire safety training at least twice a year. Whilst records showed that the majority were up to date, two had not had training since July and August last year and there was not a date booked for these staff. The fire training is provided by the manager who is a qualified trainer in this regard. Jacobs Lodge DS0000040573.V291042.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13 (4)(b) Requirement Risk assessments must be in place for activities which involve a level of risk. These risk assessments must be completed and/or reviewed when service users stay at the service. The manager must ensure that the service’s procedures are followed regarding medication: i.e. • Medication given covertly must be done so only after a multi-disciplinary decision has been made and recorded. • There must be pharmaceutical evidence that any medication which is given in food or drink is safe to be given this way and remains effective. The service must produce a policy, regarding safeguarding vulnerable adults which is specific to the service and clearly explains the role of the local authority adult services. The registered person must ensure all staff receive fire training twice in a twelve month DS0000040573.V291042.R01.S.doc Timescale for action 31/07/06 2 YA20 13 (2) 15/07/06 3 YA23 13 (6) 15/07/06 4 YA42 23 (4)(d) 30/07/06 Jacobs Lodge Version 5.1 Page 25 period. (Repeated requirement of 10/1/06) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Jacobs Lodge DS0000040573.V291042.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Jacobs Lodge DS0000040573.V291042.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. 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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