Inspection on 28/03/07 for Kings Lodge

This inspection was carried out on 28th March 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

Kings Lodge 29/09/08

Kings Lodge 29/08/07

Kings Lodge 23/05/06

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 Irene Miller Key Unannounced Inspection 28th March 2007 09:30 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.V334514.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. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 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 Fonseka Mrs Patricia Jeffs Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Learning registration, with number disability (1) of places Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person within the category DE (E) can be admitted where there are already 21 persons of category DE (E) already in the home. A named service user within the category of LD may be admitted to the home for a period of not more than 6 weeks. 23rd May 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 £364 per week, with additional charges for hairdressing, chiropody, newspapers, transport and dry cleaning. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 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 (CSCI) is based upon outcomes for service users and their views of the service provided. This inspection was a 2nd ‘Key Inspection’ that focused on the key standards under the National Minimum Standards, the Care Standards Act 2000 and the Care Homes Regulations 2001 for homes providing care for older people. The inspection took place over a period of approximately eight hours during which time the inspector spent two hours observing the care of five residents. The period of observation was carried out within one of the lounges, between 10:40 am to 12:40 pm. The care of three residents was looked at in depth, which involved viewing records on how the home planned to meet the residents needs in particular their care plans (a care plan sets out how the home aims to meet the, personal, health, social and emotional needs of the resident), and discussions took place with residents, staff and visitors to the home and general care practices were observed. The policies, procedures and records in relation to staffing recruitment and training, concerns and complaints, medication management, and general maintenance and upkeep of the home were viewed. The inspector spent approximately four hours planning the areas to focus on at this inspection, based upon information gained from reviewing the homes previous inspection reports and other information relating to the home. The registered manager Patricia Jeffs was available at the home on the day of inspection. What the service does well: Residents living at the home have a diverse range of physical and emotional needs, and in an effort to respect choice the home had sought information on individual preferences in relation to the kinds of activity they wished to participate in. The home works closely with families to ensure that the pastimes residents engage in are in keeping with their preferences. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 6 The staff were observed to spend time with residents having natural open discussions, showing an interest and responding appropriately through the use of touch, verbal and non-verbal body language ensuring that all residents had the opportunity to express their emotions. Pets are welcomed into the home, there is a resident cat that belongs to the home and a dog that belongs to one of the residents, and within the garden there is an aviary and fishpond. What has improved since the last inspection? What they could do better: Risk assessments for the use of bedside rails need to be individualised to identify the vulnerability and level of risk their use may pose to the bed occupant and to ensure they are safe and suitable for use. Where window restrictors are not fitted, risk assessments should be in place to identify vulnerability and level of risk to individual residents and reviewed on a regular basis. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 7 Risk assessments for the Control of Substances Hazardous to Health (COSHH) should be in place to identify the vulnerability and level of individual risk to residents through having denture-cleaning tablets readily available within bedrooms. Reporting systems need to be improved to ensure that residents changing needs are identified, investigated and appropriately healthcare advice sought. 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. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (Standard 6 is not applicable to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that they will only move into the home once an assessment of their needs has been carried out, and that it has been established that the home can fully meet their needs. EVIDENCE: The home is registered to care for people diagnosed with a dementia illness and due to associated memory and verbal communication difficulties and many of the residents spoken with had little recollection on how they had made the choice to live at the home and some were unable to confirm their views about the home verbally. One resident spoken with who had recently moved into the home said that they had moved into the home as their spouse was to ill to care for them, when asked if they were being cared for well they said that they had made the right choice. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 10 Visitors confirmed that acting on behalf of the resident that they had been provided with sufficient information on the range of services provided at the home and that they had been fully involved in the admission procedure, which had involved other health care professionals such as the residents general practitioner, social worker and community psychiatric nurse. Contract of care were in place that had been signed by the residents representatives acting on their behalf. Within the three care plans viewed there was pre assessment documentation available that had identified the health, personal and emotional needs of the prospective residents and this pre assessment information had created the care plans that were in use. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. In general the residents health and personal care needs are met, however shortfalls in keeping records of residents changing needs and of the involvement of healthcare professionals, places residents at risk of their needs not being fully met or effectively communicated. EVIDENCE: The three care plans viewed had information available on the 24-hour health and personal care needs of the residents, to include assessments on the residents dependency capabilities and moving and handling, nutrition, pressure area care and continence management needs. There were records available on what pressure relieving equipment was required for each individual resident and through the case tracking method the appropriate equipment was seen to be in use. Within the daily records there was an entry where staff had identified that a resident was at risk of developing a pressure sore, although there was Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 12 reference to this being closely monitored by the staff there was no record of any involvement of the visiting district nurse. In discussion with the registered manager it was confirmed that there was good relationships with the district nurse and that the information would have been passed on verbally, the registered manager acknowledged that all communications regarding residents healthcare needs should be recorded within the residents individual care plan. Within the daily notes there was an entry that a resident had been found lying on the floor in their bedroom, it was recorded within the daily notes that the resident had later complained of being in pain. There were no records available to demonstrate what action had been taken to investigate the reason for the resident being in pain, and there was no evidence that the accident had been formally recorded within the accident reporting procedures. In addition no risk assessment had been initiated to identify the possible hazard or cause of the fall or of the actions required to minimize the risk of the resident sustaining further falls. The care plans contained a consent form for the use of cot side (bedside rails) that had been signed by the resident’s representatives and a basic risk assessment had been completed which stated that the resident was at risk of rolling out of the bed and that staff needed to ensure that the bed rail was in the up position when assisting the resident to bed. Discussion took place with the registered manager on the importance of ensuring that thorough risk assessments for the use of bed rails are carried out as highlighted in a Medical Devises Alert issued on February 2007 Ref: MDA/2007/009. To assist in devising a more thorough risk assessment the inspector provided the registered manager with a copy of the Medical Devises Agencies ‘Advise on the Use of Bedside Rails’ for guidance. The medication storage and administration records were viewed and were in order and safe systems for the management of controlled medications were being followed. The training records demonstrated that medication training was provided and staff verbally confirmed that they had completed medication training. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home aims to provide residents with a lifestyle that matches their expectations and preferences. EVIDENCE: Pets are welcomed into the home and one resident had been supported in bringing their dog to live with them, this had been suitable at the time of admission based upon what animals were living at the home at the time. Through discussion with the resident and observations this decision had been the right for the resident and the home. The home also has its own resident cat, and fortunately the dog and the cat got along with each other well and the effect of having animals within the home was a very positive experience. A volunteer visit’s the residents each afternoon during the week and on the afternoon of the inspection was observed playing board games with a small group of residents within one of the lounges. In discussion with the volunteer she confirmed that spends time with residents playing board games, quizzes and doing crafts and where residents are unable to join in with this type of activity she spends time spending time reading poetry and articles out of newspapers and magazines, doing hand massage, and taking residents out Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 14 into the garden in a wheelchair. In addition to the activities that the volunteer provides, outside musical entertainers visit the home. Staff training had been provided on Dementia Care and during the two-hour observation period observations were made of good staff interactions with the residents, and there was evidence of staff providing comfort, a sense of identity, attachment, occupation and inclusion. The home cares for residents who have a diverse range of physical and emotional needs, through observing the care practices the residents appeared relaxed in the company of staff and were observed initiating contact with staff, and other residents. The staff were observed to spend time with residents having natural open discussions, showing an interest and responding appropriately through the use of, touch, verbal and non-verbal body language ensuring that all residents had the opportunity to express their emotions. Residents were observed to move about independently, and those who were not independently mobile were observed to receive support from staff. The main kitchen was viewed, and food safety systems were followed, the cook was knowledgeable of each resident’s nutritional needs, dietary requirements, and food preferences. The food menu followed a four-week pattern, and was seen to contain a variety of meals, and choice offered on an individual basis, the meal on the day of inspection was chicken casserole and one resident who disliked chicken had been provided with an alternative of faggots which was their preference. Residents living at the home that required full supervision and practical assistance to eat their meals were observed being supported with sensitivity to their individual needs and capabilities, and their dignity maintained. Within the care plans there was records of residents individual preferences in relation to the type of activity they wished to participate in, and there was records within the daily notes of when residents had engaged in their chosen activity. The staff had endeavoured to gain information on resident’s lifestyle preferences, hobbies and interests and previous work occupations and where it was not possible to obtain this information due to communication difficulties the home had worked closely with families, this had been useful in ensuring that the activities were individualised. Due to the risk of residents becoming disorientated or lost if they venture out into the community alone any access into the community was limited as to when staff could escort residents. The garden was in the process of being redesigned and when completed should provide a pleasant outdoor environment for residents to access, however the garden was not secure and consideration needs to be given to ensure that it is fully secure to enable Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 15 residents the freedom to access the garden unescorted if they wished, and in relative safety. A number of visitors were available during the inspection and comments received were positive, praising the friendliness of the staff and the registered manager, saying that they were kept informed about their relative and that they were always made welcome into the home at any time of the day, which confirmed that the home operates flexible visiting times. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be assured that any concerns or complaints they may have about the service, will be listened to and acted upon, and that the resident’s rights are respected and they are protected from abuse. EVIDENCE: There was a complaints procedure available within the front hallway and should a complainant be dissatisfied with the providers response or wish to raise their complaint direct with the Commission for Social Care Inspection (CSCI) there was comment leaflets available which could be sent direct to CSCI. Northamptonshire Care Management had raised one concern with the provider since the last inspection visit and the Commission for Social Care Inspection were satisfied with the provider’s response. Staff training had been provided on safeguarding vulnerable adults, and further training was planned to take place the home had a copy of the Northants Inter Agency Policies and Procedures on reporting abuse should the need arise. In discussion with staff they had an awareness of the importance of safeguarding the residents within their care from any abuse and should they Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 17 have cause to witness or suspect any abuse within the home, they were aware of the reporting procedures. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 18 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): Standards 19,20,21,22,23,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean and pleasant, and further work in the risk assessment processess and building refurbishment would ensure that residents have access to safe and comfortable internal and external facilities EVIDENCE: Improvments to the environment had taken place to include the replacement of carpets (on the day of inspection a new carpet was being fitted to the lounge diner) and redecoration had taken place to communal and private accomodation. In addition refurbishment had taken place to one of the bathrooms to created a shower room (wet room) and work was in progress to refurbish the hairdressing facility. During a limited tour of the building it was noted that radiator covers had been fitted and the residents rooms viewed contained items of persoalisation such as televisions, personal photographs, pictures and small items of furniture. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 19 Within one of the bedrooms viewed the resident had a small refridgerator available. The laundry was viewed which appeared clean and well managed there was two washing machines and one tumbledryer available, however one of the washing machines was out of order which the registered manger confirmed was awaiting repair. Work had commenced on improvements to the garden and extensive work had taken place in an effort to create a pleasant outdoor faciity, the registered manager confirmed that plans were to create a sensory garden and a vegetable garden. There was a patio seating area and a paved walkway around the garden, there was areas of interest such as an aviary, and a gazebo seating area. An established fish pond had been retained as a feature which the registered manager confirmed would be fully enclosed to ensure the safety of residents and visiting children accessing the garden. The garden was not enclosed and to fully utilise the theraputic potential of the garden and ensure that residents can fully access this facility great consideration should be made to ensurethat it is fully secure. Windows above the ground floor level did not have window restrictors fitted, discussion took place with the resigestered manager on the need to have individual risk assessments in place based upon the vulnerability and risk to the a confused resident occupying the bedroom and those who may enter unsupervised. When viewing resident bedrooms it was noted that denture cleaning tablets were readily available, in discussion with the registered manager it was identified that there was a need for risk assessments to be in place based upon the vulnerabilty and risk to a confused resident occupying the bedroom and those who may enter unsupervised from mistakenly consuming the tablets. Hand sanitiser was available within the front hallway to assist in reducing the risks of cross infection. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 20 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): Standards 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in staff recruitment and training processes ensure that residents are supported and protected by staff that are skilled and competent within their roles. EVIDENCE: On the day of inspection there were sixteen residents at the home supported by three care staff, one domestic, one cook and the registered manager. The recruitment files of two newly appointed staff were viewed and documentation available within the files demonstrated that improvements had taken place in recruitment practices. There was evidence of criminal records bureau clearances (CRB) and protection of vulnerable adults clearances (POVA 1st) having been obtained prior to staff taking up employment at the home. There were records of staff induction training and ongoing training to include, Dementia Care, Medication Management, Fire Safety, Food Hygiene, Moving and Handling and Safeguarding Adults. The homes annual training schedule was viewed that identified individual staff training needs, and dates when training had been completed and future training planned. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 21 The home has met the National Minimum Standards target of 50 of staff being trained to a National Vocational Qualification (NVQ) level 2 in care and some staff are working towards the (NVQ) Level 3 The registered manager confirmed that one to one staff supervision was taking place and records of supervision and appraisal meetings were available to view that demonstrated supervision is an ongoing process within the home. In discussion with staff it was confirmed that formal supervision takes place during which their development and training needs are identified. Observations of care practices demonstrated that the staff provide support and companionship to residents, there was evidence of staff spending time with residents and promoting a sense of identity and inclusion. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 22 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): Standards 31,32,33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents, however shortfalls in communicating residents changing needs places them at risk of their health, safety and welfare not being fully met. EVIDENCE: The registered manager has the skills and the knowledge to manage the home, and from observations made during the inspection it was demonstrated that the home is run and managed in the best interests of the residents. Residents were observed to be at ease with the registered manager and to talk openly with her, and the visitors were very praising of the home saying that manager and the staff always make them welcome and that there was a family Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 23 feel about the home. Observations of visitor’s interactions with the registered manager evidenced that an open door culture is promoted. The registered provider and the registered manger are committed to compliance with requirements set at the previous inspections, and improvements have been made to ensure that residents live in a home that promotes their health, safety and welfare. Shortfalls identified within the health and personal care outcome area of this report had identified a need for communication to be improved in responding to the changing needs of residents, and on recording when advice and support has been sought from the district nurse and general practitioners. In addition a proactive approach needs to be taken in the management of accident reporting and risk assessments to ensure that risk assessments are based upon the vulnerability and risk to individual residents A system of gaining feedback from residents and their representatives had been introduced through a satisfaction survey, and discussion took place with the registered manager on how the home could gain feedback from residents with limited verbal communication such as using an observation method to gain an insight into the residents well being and how this could be improved. Money held on behalf of residents was stored securely and a sample check demonstrated that accounts were in order. Staff supervision and appraisal systems were in place, and staff training records demonstrated that the staff had received appropriate training. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 24 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 2 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 2 2 3 3 3 3 3 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 3 3 X 3 3 X 2 Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 25 No 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 OP8 Regulation 13 (b) Requirement Records must be made of the treatment or advice and other services from health care professionals. Risk assessments must be in place to identify the vulnerability and level of risk to service users from environmental hazards. Changes in the resident’s heath care condition must be fully investigated and appropriate healthcare advice sought. A record must be retained of all accidents and near misses to ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Timescale for action 30/04/07 2 OP19 13 (4) 30/04/07 2 OP38 12 (1) (a) 30/04/07 3 OP38 13 (4) (c) 30/04/07 Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 26 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 OP20 Good Practice Recommendations To ensure that residents have safe unlimited access to the garden it should be fully enclosed. Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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. Extracts may not be used or reproduced without the express permission of CSCI Kings Lodge DS0000061540.V334514.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!