Inspection on 23/05/06 for Kings Lodge

This inspection was carried out on 23rd May 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 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

Kings Lodge 29/09/08

Kings Lodge 29/08/07

Kings Lodge 28/03/07

Kings Lodge 20/02/06

Kings Lodge 26/05/05

Kings Lodge 15/11/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Kings Lodge 50 North End Higham Ferrers Northants NN10 8JB Lead Inspector Stephanie Vaughan Unannounced Inspection 23rd May 2006 09:10 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 Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kings Lodge Address 50 North End Higham Ferrers Northants NN10 8JB 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) 01933 315321 01992 710401 Mr Claude Fonseka Mrs Viola Fonseca Mrs Patricia Jeffs Care Home 21 Category(ies) of Dementia - over 65 years of age (21) registration, with number of places Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person within the category DE(E) can be admitted where there are already 21 persons of category DE(E) already in the home. 20th February 2006 Date of last inspection Brief Description of the Service: Kings Lodge provides personal care and support for up to 21 people over the age of 65 years who have a dementia related condition. The home is situated on the outskirts of Higham Ferrers, with public transport links to neighbouring towns. The home is a conversion of a large residential property, with 2 larger communal lounges and 2 smaller sitting rooms. Bedrooms are located on the ground and first floors and a shaft lift provides access to the first floor. There is a garden at the rear of the property, which contains an aviary. The home has been in the hands of the current owners since 2004. The fees charged at the time of the inspection are £348 per week, with additional charges for hairdressing, chiropody, newspapers, transport and dry cleaning. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon the outcomes for residents and upon their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting a sample of 3 residents and tracking the care they receive through review of their care records, discussions with them (where possible) and with care staff, and observations of care practices. Equality and diversity was taken onto account in the selection of residents for case tracking purposes, however the residents at the home are predominantly Western European and no residents with specific disabilities were identified. The inspection took place during a weekday over a period of 7 hours and was carried out on an unannounced basis, involving 2 inspectors. Communal areas and some bedrooms were visited. A selection of essential records of the home was reviewed and medication procedures were checked. A number of the residents and several staff were spoken to as part of the inspection process. The deputy manager was available throughout the inspection and the registered owner, Mr Claude Fonseka, was present for some of the inspection. Responses from residents and their relatives to a questionnaire sent by the Commission for Social Care Inspection also contributed to this inspection. What the service does well: Residents appeared reasonably well presented and were able to confirm that their satisfaction with the food provided at the home. The home benefits from having a qualified chef, who demonstrated knowledge of individuals’ preferences and special dietary needs The lunchtime service was viewed and food appeared to be well presented, offer a balanced diet, although portions appeared small second helpings were offered. Residents have access to a range of seating areas, which provided the opportunity to sit in a communal environment or to spend time in an alternative quiet, more private seating area. A number of visitors were seen to arrive in the home in the afternoon and a relative commented that visitors are always welcomed by staff and offered a cup of tea Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 6 Interaction between residents and staff were seen to be good when supported by adequate staffing levels. Residents’ benefit from a loyal and constant staff team who have a good understanding about the needs of the residents and were able to demonstrate their commitment to the care of residents. Residents money is handled well, staff were actively supporting residents to organise their finances for convenient access. Accurate records are maintained which cross-reference with the balances. The home is generally free from hazards. What has improved since the last inspection? What they could do better: Greater detail about an individual’s life history would help in planning their care and in meeting their emotional needs. Residents contracts held on file should be signed and dated, if possible by the resident, and if not, by their representative. The standard of individual plans of care should be further improved to ensure that the resident or their representative are involved in the development and review. Residents who do not have access personal representation should have access to local advocacy services. Guidance should be sought from appropriate specialists regarding the management of continence, tissue viability and mental health specialists. Staff should not undertake nursing duties such as dressings without training and the written authority of the Community Nurse. Care should be given as specified within the individual plan of care Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 7 Risk assessments should be reviewed to ensure that they provide staff with meaningful information to reduce and manage the risks identified for falls, pressure, nutrition and movement and handling. Medication systems should be reviewed to ensure the safe administration and disposal of medicines Staffing levels must be reviewed to ensure that there are adequate levels of staff on duty throughout the day to ensure the continuity of residents’ routines i.e. personal care, supervision, oral care, bathing and toileting. The programme of activities should also be reviewed to ensure that residents have access to a range of stimulating communal activities and personalised activities that reflect their previous interests and lifestyles. Improvements to the staff training records should; be made and the required training in the Protection Of Vulnerable Adults must be provided to all staff. The Complaints policy should be reviewed to ensure that it has up to date information and includes information about response and investigation times The communal hoist should be stored in a location that does not compromise the privacy and dignity of residents. Staff handwashing faciltiies should have an adequate supply of soap and handtowels Training on the protection of vulnerable adults has not been provided for staff in the home for some time, despite an undertaking from the registered persons that this would be arranged by the end of April 2006. This is a repeated requirement from the last 2 inspections. A training profile to evidence the dates of training and the names of staff attending should be available for inspection. A programme of mainatinance should be submitted to the Commission for Social Care Inspection to address the maintenance and décor of the premises. Regsitered persons must notify the Commission in writing of the arrangements to be made whist the Regsitererd Manager is on extended leave ie in excess of 28 days. Quality assurance sytems and staff supervision should be developed to support the management of the home, continuos improvement and risk management. Kitchen records should be further developed to ensure that more detailed information is recorded and specify the names of staff responsible for cleaning and their responsibilities. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 8 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. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 9 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 Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 10 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): 2, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The process of assessing the needs of prospective residents is adequate. However, the home needs to ensure that contracts held on file are signed and dated, if possible by the resident, and if not, by their representative. EVIDENCE: Care files examined as part of the case tracking process indicated that residents’ needs were assessed prior to moving into the home, involving other professionals where appropriate. However, greater detail about an individual’s life history would help in planning their care and in meeting their emotional needs. (A recommendation has been made). In 2 of the 3 files selected, the contract was undated and unsigned. The home should ensure that where possible the resident signs the contact, and that relatives or other representatives are involved in the admission process wherever possible. (A recommendation has been made). Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from positive relationships with staff. The personal and healthcare needs of residents are adequately met, but some care plans are not fully implemented. EVIDENCE: Each of the care files examined contained an individual plan of care with a good level of detail. Daily care records were consistently dated, signed and contained useful information. However, there was no evidence of the involvement of relatives in developing or reviewing care plans. (A recommendation has been made). Greater use could be made of specialist health care professionals available locally, such as nurses specialising in mental health, continence and pressure sore issues. For example one resident was distressed due to a bereavement and there was no evidence found that her emotional needs were being addressed. (A recommendation has been made). Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 12 Daily records indicated that care staff were undertaking dressings for some residents. This was discussed with senior staff who confirmed that although this was being done the staff had no formal authority from the Community Nurse, nor had they had any training. (A recommendation has been made). Some aspects of the care plans were not fully implemented, for example, care plans for all 3 individuals indicated that their weight should be recorded at least monthly, and staff confirmed that this was not being done. One resident’s care file had insufficient detail on oral care and a visit to this resident’s bedroom indicated that their oral care may have been overlooked. There was some evidence of disruption to residents’ toileting routines (which was confirmed by staff), resulting in a noticeable odour of urine in the lounge/dining room. Staff also confirmed that opportunities for residents to have a bath or a shower was reduced due to current staffing levels. (A recommendation has been made). Individual plans of care contained basic risk assessments, however these were inconsistent and lacked the necessary detail to reduce and manage the risks. For example Notifications received by the Commission indicated a high level of incidents where residents had been found on the floor. Detailed risk assessments for falls had not been conducted for all residents which take into account the considerable amount of vinyl flooring in the home and the fact that one mobile resident was only wearing socks at the time of inspection. (A recommendation has been made). A sample check of medication was carried out and was found to be in order. However, there is a build up of discarded and refused medicines that needs to be disposed of safely. Medication record sheets would benefit from being filed in a folder rather than as a bundle of loose sheets. (A recommendation has been made). The residents appeared to be generally well-presented and positive relationships between residents and staff were observed. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The meals offered in the home are of a good standard and special dietary needs are catered for. Some general activites are offered but these are not individualised and there is no evidence that these activities are based on residents interests and previous lifestyles. EVIDENCE: The home has a pet cat and the aviary in the garden provides enjoyment for some residents, although no residents were seen to access the garden on the day of inspection. Notices on display in the home and discussions with staff indicated that a minimal level of group activities is offered, for example throwing a ball around or playing skittles. One questionnaire response from a relative commented that provision of activities in the home had declined recently. The respondent said that their relative who is a resident would benefit greatly from individualised activities and regretted this lack of provision, attributing this to current staffing levels. On the day of inspection there was no evidence of individualised activities, although residents’ bedrooms did contain items that indicated the type of Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 14 activity appropriate to people with dementia, for example dolls. (A recommendation has been made). A number of visitors were seen to arrive in the home in the afternoon and a relative commented that visitors are always welcomed by staff and offered a cup of tea. The home benefits from having a qualified chef, who demonstrated knowledge of individuals’ preferences and special dietary needs. The meal served on the day of inspection was roast chicken, potatoes, mixed vegetables and gravy, followed by lemon tapioca pudding. The main meal appeared appetising and although portions were generally small, staff were observed to offer second helpings to residents and requests for condiments were met. Residents requiring assistance to eat received help in a sensitive manner. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents continue to be placed at risk of abuse due to lack of appropriate staff training and supervision. EVIDENCE: The Commission for Social Care Inspection has received no complaints since the last inspection. The home’s complaints procedure dates back to the previous owner and would benefit from being reviewed and updated. Complaints forms were available in the entrance hallway of the home and the record of complaints indicated that these forms are used and that complaints are generally responded to promptly and appropriately. However, the file also contained a letter of complaint from a relative for which no response had been recorded. Advice was given on how a systematic analysis of complaints could form part of a quality assurance process to help improve standards in the home. (A recommendation has been made). Training on the protection of vulnerable adults has not been provided for staff in the home for some time, despite an undertaking from the registered persons that this would be arranged by the end of April 2006. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of decor and furnishings in the home is adequate, although improvements are needed to ensure the on going maintainance of the premises and infection control. EVIDENCE: The premises are suitable for their stated purpose and are maintained to a basic level of repair however would benefit from further attention to the décor as the paintwork is marked and the wallpaper is peeling in places. A requirement was made in the previous inspection report for the Owners to submit a Development plan to the Commission for Social Care Inspection, which has not yet been submitted. However.the owner has commenced replacing some of the vinyl flooring with carpets, which helps to create a more homely environment. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 17 The management confirmed that the delivery of the required radiator covers is now iminent and that arrangements had been made for these to be fitted at the earliest opportunity. The communal hoist is currently stored in a residents bedroom and this should be removed and stored elsewhere to mainatin the privacy and dignity of residents. (A recommendation is made) The residents benefit from a range of communal areas, which include small quiet areas, in addition to the larger sitting rooms. Individual accomodation evidenced a varying degree of personalisation. Staff handwashing faciltiies lacked an adequate supply of soap and handtowels. (A recommendation is made) The premises appeared clean and hygeinic throughout. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Current staffing levels are having an adverse impact on the outcomes of care provided to residents. Staff recruitment procedures are not robust, placing residents at risk. EVIDENCE: Feedback from relatives and service user surveys indicated the staff team is stable and provide positive comment on the kindness of staff. However concern was expressed about staffing levels and the impact on the care provided. The Owner confirmed that current staffing levels are calculated on the residents dependency levels and following the Guidance of the Residential Forum, which indicates that a level of two carers throughout the day and night are adequate. However the registered manager is on an extended period of leave at preset. In the interim the Deputy Manager has taken on the Management responsibilities, whilst also attempting to act as one of the two carers on shift. Many residents require the support of two carers in addition the layout of the building also means that residents are at times left unsupervised This has a direct impact of the outcomes for residents, with care not being Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 19 delivered according to care plans (e.g. recording of weight and provision of oral care); opportunities for interaction and activities for residents were limited; a significant number of incidents where residents had been found on the floor, indicating a poor level of supervision. An immediate requirement was made at the time of the inspection for staffing levels to be reviewed to ensure that the health and welfare of residents is maintained at all times. A requirement was made at the previous inspection that staff must not be employed without povafirst and Criminal Records Bureau Clearances. However, it was noted that a further member of staff had commenced employment within the home (13.02.06) prior to receipt of a satisfactory POVAFIRST or Criminal Records Bureau clearance (received 09.03.06). However, the homes owner was able to confirm that this second incident occurred simultaneously with the previous inspection and that he is now fully aware of his responsibilities; and confirmed that all staff now have appropriate clearances, and that the procedures are now being strictly followed. The Commission has reviewed this potential non-compliance with Requirements, however acknowledges the owners assurance that this will not happen again and therefore does not intend to take any further action at this point. A separate letter has been sent to the owner setting out the Commissions concerns and expectations. Staff spoken to confirmed that the home provides essential training in most areas, for example in fire safety, food hygiene and dementia care, but no certificates were available at the time of inspection and the training programme was seen to be out of date. ( A recommendation is made) Some staff have completed National Vocational Qualifications, although it was not possible to identify the percentage due to the state of the training records. ( A recommendation is made). In addition, as noted earlier in this report, training in the protection of vulnerable adults is outstanding. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Practices for handling residents personal finances are robust. However, some aspects of record keeping are poor and there are no quality assurance processes in place. EVIDENCE: The Registered Manager is currently on extended leave, and although the management responsibilities are currently being undertaken by the Deputy Manager; the Registered Persons have not notified the Commission in writing of the formal arrangements that are to be made to cover the Registered Managers absence beyond the 28 day period.(A Recommendation is made) The Owner confirmed that there were no Quality Assurance procedures in place to establish residents’ views about the level of care provided and no audits in Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 21 place to analyse information such as the accidents records to identify areas where improvements might be made to the safety of residents. A spot check of residents’ monies was conducted and found to be in order. There continues to be no system in place to ensure that staff are appropriately supervised, this was confirmed by staff and by the management. Kitchen records should be further developed to ensure that more detailed information is recorded and specify the names of staff responsible for cleaning and their responsibilities. A fire officers inspection was also being conducted at the home on the same day, discussion with the fire officer confirmed that he was satisfied with the arrangements for fire prevention and safety at the home. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 22 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 1 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 3 1 Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18 (1a) Requirement Staffing levels must be reviewed to ensure that the health and welfare of all service users is maintained at all times. (Immediate Requirement) Timescale for action 26/05/06 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 Refer to Standard OP1 Good Practice Recommendations Greater detail about an individual’s life history should be included in planning their care and in meeting their emotional needs. Residents contracts held on file should be signed and dated, if possible by the resident, and if not, by their representative. Individual plans of care should developed to ensure that the resident or their representative are involved in the development and review. Guidance should be sought from appropriate specialists regarding the management of continence, tissue viability and mental health specialists. Care should be given as specified within the individual plan DS0000061540.V294479.R01.S.doc Version 5.1 Page 24 2 OP2 3 OP7 4 OP8 5 Kings Lodge OP8 6 OP8 7 OP8 8 9 OP9 OP12 10 OP16 11 12 13 OP17 OP18 OP19 14 15 16 17. 18 OP22 OP26 OP28 OP30 OP31 19. 20 21 OP33 OP36 OP38 of care Staff should not undertake nursing duties such as dressings without training and the written authority of the Community Nurse. Risk assessments should be reviewed to ensure that they provide staff with meaningful information, based on the Guidance issued by the Health and Safety Executive to reduce and manage the risks identified for falls, pressure, nutrition and movement and handling. Medication systems should be reviewed to ensure the safe administration and disposal of medicines The programme of activities should be reviewed to ensure that residents have access to a range of stimulating communal activities and personalised activities that reflect their previous interests and lifestyles. The Complaints policy should be reviewed to ensure that it has up to date information and includes information about communication with the complainant, response and investigation times Residents who do not have access personal representation should have access to local advocacy services Training for all staff should be arranged for the Protection of Vulnerable Adults. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be sent to the Commission for Social Care Inspection. The communal hoist should be stored in a location that does not compromise the privacy and dignity of residents. Appropriate hand washing facilities should be available to staff at all times. The training development programme should continue to ensure that 50 of care staff are qualified in NVQ 2 A training profile indicating dates of training and the names of staff attending should be available for inspection The Registered persons should notify the Commission in writing of the arrangements to be made whist the Registered Manager is on extended leave ie in excess of 28 days. A system of quality assurance should be implemented and records of this audit be available for inspection. The Registered Persons should develop systems for staff supervision and staff appraisal in line with the National Minimum Standards. The kitchen-cleaning rota should state clearly the names of staff responsible for cleaning and their responsibilities. Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Kings Lodge DS0000061540.V294479.R01.S.doc Version 5.1 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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