Inspection on 16/09/08 for Latimer Lodge

This inspection was carried out on 16th September 2008.

CSCI found this care home to be providing an Adequate service.

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

Latimer Lodge 14/05/10

Latimer Lodge 29/03/10

Latimer Lodge 25/08/09

Latimer Lodge 08/09/06

Latimer Lodge 01/12/05

Latimer Lodge 31/08/05

Latimer Lodge 03/03/05

Latimer Lodge 02/11/04

Latimer Lodge 29/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Latimer Lodge 38 Preston Road Yeovil Somerset BA21 3AQ Lead Inspector Jane Poole Unannounced Inspection 16th September 2008 10:30 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 Latimer Lodge DS0000016088.V368122.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. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Latimer Lodge Address 38 Preston Road Yeovil Somerset BA21 3AQ 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) 01935 474520 01935 432380 Mr Christopher Michael Bruce Wharton Mrs Heather Elizabeth Neal Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who may be accommodated is 14. Date of last inspection Brief Description of the Service: Latimer Lodge Residential Home is part of a continuing care complex that includes Tyndale Nursing Home, which provides nursing care and Coverdale Court, which is a sheltered housing complex. All businesses are run entirely independently but come together to share resources, interests and activities. Latimer Lodge Residential Home is a fourteen-bed care home providing personal care for older people. It is situated close to the centre of Yeovil. It stands in its own gardens, in close proximity to Tyndale Nursing Home and Coverdale Court. There is good access for frail people and wheelchair users, including pleasant garden areas. Car parking is available. Communal rooms and some bedrooms are located on the ground floor with further bedrooms on the first floor, some of which are very spacious. A passenger lift is available for service users. Fees at the home range from £471.66 to £598.58 per week. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The inspection was carried out over a one day period. People living and working at the home were spoken with and care practices were observed. Unrestricted access to all areas of the home was granted and some records requested were made available. 9 people living at the home, 7 members of staff and 3 health and social care professionals completed questionnaires prior to the inspection. Some of their comments have been incorporated into this report. Prior to the inspection the manager completed an Annual Quality Assurance Assessment (AQAA) This gave information about the home but did not demonstrate a commitment to ongoing improvement. The following is a brief summary of the inspection findings and should be read in conjunction with the whole of the report What the service does well: Latimer Lodge is a comfortable home and the standards of cleanliness are good. At the time of the inspection there was a happy relaxed atmosphere. People living at the home were very complimentary about the service they received and the staff who assisted them. One person said “Its lovely here I couldn’t have gone anywhere better” another said “It’s the next best thing to home.” There are no strict routines in the home and people are able to choose how they spend their time. There are some organised activities and trips out for those who wish to join in. Visitors are always made welcome in the home. People felt that they were treated with respect and everyone said that they would be comfortable to share any worries or concerns with a member of staff. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 6 There is a four-week menu in the home and food served is of a good quality. People were happy with the food and the choices that they had. What has improved since the last inspection? What they could do better: Due the fact that there is no deputy manager and no senior carers when the manager is away from the home there is no leadership. At these times there are no clear lines of accountability and responsibility for the quality of care in the home. The home needs to improve its admission policy to ensure that everyone has a pre-admission assessment. This assessment needs to take account of the level of staff in the home and the need for additional training to meet needs. Once an assessment has been carried out a comprehensive care plan needs to be drawn up that gives clear guidelines for staff to follow. Care plans should be reviewed on a monthly basis to monitor how well needs are being met. Bedrails should only be used after a full assessment of need and risk has been completed. There must be a safe robust system for the receipt, storage, recording and administration of medication. All staff who administer medication need to receive appropriate training and ongoing support in this area. The registered person must keep the staffing levels under review to ensure that they continue to meet the needs of the people living at the home. The home should set up formal quality assurance systems that seek the views of people living in the home and other interested parties. This should be used to inform plans for development and ongoing improvement. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 7 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. Latimer Lodge DS0000016088.V368122.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 Latimer Lodge DS0000016088.V368122.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): 3&5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are not always carried out and consideration is not given to staffing levels and training requirements to meet specific needs. Intermediate care is not provided. EVIDENCE: The home has a statement of purpose and service user guide, which is given out to everyone who moves into the home. Copies of these were seen in bedrooms during the inspection. There is also a copy in the reception area for visitors should they wish to read it. These documents were not examined on this occasion. People who completed questionnaires prior to the inspection said that they had received enough information about the home before they moved in. People Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 10 spoken with at the time of the inspection stated that either they, or their relatives, had visited the home before deciding to move in. Documentation in respect of the most recently admitted person was viewed. A pre admission assessment had been carried out by the home and they had obtained a copy of a full assessment carried out by professionals outside the home. There was no evidence that staff had received appropriate training to care for this person and their specific needs. Staff spoken with stated that they had not received appropriate training or support to meet the persons’ specific needs. On the day of the inspection one person was moving to the home for a short stay. No pre-admission assessment had been carried out and the home had obtained only very basic information about the person and their needs. When the person arrived at the home with their relatives staff attempted to carry out a basic assessment. It was apparent that the person had complex needs and that Latimer Lodge would not be the most appropriate place to meet such needs. The AQAA completed by the home states that “a detailed needs assessment is undertaken soon after admission and a care plan is drawn up with the assistance and agreement of the resident and also with their relatives and any professional input required.” The AQAA also states that new residents will be able to spend time at the home on a trial visit but does not state that the home assesses people before offering a place or ensures that the home is appropriately staffed. Latimer Lodge DS0000016088.V368122.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): 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. Care plans do not give clear guidelines for staff to follow to ensure they assist people in the most appropriate way. People have access to healthcare professionals from outside the home but staff have not received appropriate training to assist people with all their healthcare needs. People living at the home are treated with respect. EVIDENCE: Three care plans were viewed. Assessments of need were basic and gave limited information about physical care needs. Care plans were varied in quality. One persons’ care plan gave personal information about the individual and their basic needs. Another care plan only had one need identified. For a Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 12 person, who had been at the home for two weeks, there were no needs specifically identified and no guidelines for staff to follow. The assessment stated that the person was blind but there was no guidance to ensure that staff assisted them in an appropriate manner and no plan to promote their independence in the home. People living at the home stated that they had access to healthcare professionals from outside the home. One person said that a district nurse visited them regularly and others said that a doctor visits the home if they request it. A chiropodist also sees people on a regular basis. All healthcare appointments are recorded. Records of weights seen showed that people were weighed regularly and maintained a stable weight. In answer to the question “Do you receive the medical support you need?” 5 people answered ALWAYS, 2 answered USUALLY and 2 did not respond. One person has insulin dependent diabetes, there was no plan of care in respect of this and no guidelines in the care plan about the level of support required to manage this. Staff spoken with stated that they had not received specific training to assist this person and had ‘learnt as they went along.’ Some information about the monitoring of this persons blood sugar levels was stuck to the front of a cupboard in the office but was not included in the care plan. An immediate requirement was issued to ensure that a care plan was put in place within 24 hours. There was evidence that care plans were discussed with the people living at the home but they were not being reviewed on a monthly basis as recommended by the National Minimum Standards. Bedrails had been put in place for one person. There was a letter of consent, signed by a relative, in their personal file but no assessment of need or consent from the person living at the home. There was no evidence that alternative options had been explored and it was not clear why these were being used. Staff stated that the person refused to use the bedrails. The home uses a Monitored Dosage System (MDS) for medication. Staff spoken with said that they had received training in the administration of medication. One person said that their training had been in house and they felt that they, and other staff, would benefit from further training in this area. The Medication Administration Records (MARs) were viewed. It was noted that hand written entries had not been signed or witnessed. Medication that came to the home with the bulk order was signed in but medication that arrived at other times was not signed in on the MAR charts. This means that there was no record of the amount of medication on the premises and therefore no clear audit trail. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 13 One person was prescribed pain relief of ‘one or two tablets 4 times a day.’ The MAR showed that this was being given 3 times a day but the dose was not recorded. Again this means there is no clear audit trail and no way of accurately monitoring the effectiveness of this medication. One person at the home self medicates. An up to date risk assessment was in place and was kept in the generic risk assessment file. It was not in the persons’ personal file. The home has some controlled drugs, a controlled drugs register is maintained and records correlated with stocks held. Currently insulin is being kept in the kitchen fridge, it is not in a locked compartment and the fridge is not lockable. People living at the home were very complimentary about the staff who assisted them. Everyone felt that their privacy was respected. It was observed that staff spoke to people in a friendly and polite manner. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a range of activities for people to join in with if they wish to. The menu in the home is varied and people are able request an alternative if the meal is not to their liking. EVIDENCE: People spoken with said that they are able to choose what time they get up, when they go to bed and how they spend their day. People are able to choose whether to socialise or remain in the privacy of their personal rooms. People spoken with were happy with the activities provided by the home and some people continued to pursue their own interests. On the day of the inspection many people were playing cards and there was a very happy atmosphere in the home. Other activities include musical entertainment, speakers, flexercise, quizzes and drives out in the mini bus. Some people said that they were invited to activities at Tyndale, the nursing home on the same Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 15 complex. In answer to the question “Are there activities that you can take part in?” 7 people said ALWAYS, 1 said USUALLY and 1 said SOMETIMES. One person commented that they particularly liked the quizzes and trips out. Everyone said that visitors are always made welcome at anytime. The AQAA states that ‘a non-denominational service of communion takes place once a month’ and people spoken with confirmed this. People were happy with the food in the home. There is a four week menu and the main meal is at lunch time. Everyone asked stated that the food was very good. The main meal on the day of the inspection was well presented and appeared to be enjoyed by all. Care staff see each person in the afternoon to ask if they would like the meal on the menu or wish to request an alternative. One person wrote on their questionnaire “Food is very good, if I don’t like something they do something different for me.” Another person said “Very good food and we are asked what we would like.” People spoken with during the inspection said that they had been asked at a residents meeting to make suggestions for the menu. Throughout the day drinks were served and home-made cakes were available in the afternoon. One person said that the night staff were always happy to make them a cup of tea if they couldn’t sleep. The food cupboards were well stocked with good quality products. Latimer Lodge DS0000016088.V368122.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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel able to raise concerns with the staff at the home and are confident that they would be listened to. EVIDENCE: The home has a complaints procedure, which is available in the home. Everyone living at the home who completed a questionnaire said that they knew how to make a complaint. All answered YES to the question ‘Do staff listen and act on what you say?’ Everyone asked during the inspection said that they would be comfortable to raise any concerns or complaints with a member of staff. All staff who completed questionnaires answered YES to the question “Do you know what to do if a service user or advocate has concerns about the home?” No complaints have been received by the home or the Commission in the last 12 months. Staff spoken with said that they had attended a talk on the protection of vulnerable adults and had learnt about abuse as part of their National Vocation Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 17 Qualification. Staff were aware of the whistle blowing policy and the ability to take serious concerns outside the home. Latimer Lodge DS0000016088.V368122.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): 19, 21, 23 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Latimer Lodge provides a comfortable homely environment for the people who live there. The standard of cleanliness is good. EVIDENCE: The home is an older style building set in a residential area of Yeovil. Accommodation is arranged over two floors with the communal lounge/diner on the ground floor and accessible to all. Communal areas are homely and comfortable. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 19 A sample of bedrooms was seen, all had been personalised to reflect the individuals’ tastes and needs. People said that they had been encouraged to bring personal possessions with them to the home. There is a communal bathroom on each floor with assisted bathing facilities. Since the last inspection the shower room has been upgraded to a level access shower, which means that people now have greater choice. The laundry is outside the main building and is shared with the other facilities on the site. It was clean and well organised. On the morning of the inspection it was noticed that some wardrobes were not secured to the wall meaning that they were at risk of toppling forward and causing injury to people living and working in the home. This was rectified before the end of the day. People who completed questionnaires answered ALWAYS to the question “Is the home fresh and clean?” On the day of the inspection all areas seen were clean and there were no unpleasant odours. Latimer Lodge DS0000016088.V368122.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): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are no clear staffing structures in the home and therefore no clear lines of accountability and responsibility. EVIDENCE: The home employs 14 care staff, 7 (50 ) have a National Vocational Qualification (NVQ) in care at level 2 or above. There are 2 care staff on duty throughout the day and one person on duty overnight with an on call system in place. There is no staffing structure in the home and when the manager is not on duty no one person takes overall responsibility. On arrival at the home no one appeared to be in charge and the owner was phoned. Staff spoken with stated that due to the increasing dependency of the people living at the home they now had limited time to spend with individuals. However there appeared to be a relaxed and happy atmosphere in the home. Everyone who completed a questionnaire answered ALWAYS to the question “Are staff available when you need them?” Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 21 People living at the home were extremely complimentary about the staff and praised their kindness and patience. One person said “staff are marvellous, always kind.” Records of a comprehensive induction programme were seen in staff files. Staff who completed questionnaires all answered YES to the question “Are you given training that is relevant to your job?” As previously stated in this report staff had not received training on the specific needs of the people living at the home. Staff stated that they had received training in health and safety issues such as fire safety and moving and handling but records of these were not available at the time of the inspection. Two recruitment files were viewed these contained completed application forms and written references. In one file there was no confirmation that the person had been checked against the Protection Of Vulnerable Adults (POVA) register or had undergone a Criminal Records Bureau (CRB) check. The checklist on the front of the file had these items ticked. The checklist should detail the date items were received and the disclosure number. The AQAA states ‘all new staff are CRB and POVA checked before employment commences’ Latimer Lodge DS0000016088.V368122.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): 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lack of leadership and direction when the manager is away from the home. Quality assurance systems need to be expanded to ensure that they inform ongoing improvements in the home. EVIDENCE: The registered manager of the home is Heather Neal. She is a qualified nurse and has many years experience of working with older people. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 23 The manager was not available at the time of this inspection but the owner of the home came to assist with the inspection. There is no clear staffing structure in the home, no deputy manager and no senior carers. Therefore when the manager is away no member of the care staff team co-ordinates the shift or takes responsibility for the quality of the care provided. Staff stated that the owner of the home is always available. The owner and staff stated that there is always someone ‘on call’ but the previous weeks duty rota did not detail who was the person on call. The owner stated that the home do not act as a financial appointee or power of attorney for anyone living at the home. People are able to deposit small amounts of money in the office for safe-keeping. Records seen correlated with money being held by the home. There are residents meetings in the home, which are an opportunity for people to make suggestions about the running of the home and a chance for staff to gauge the level of satisfaction with the quality of care. There is a suggestion book in the entrance hall that people living at the home and their visitors can write in. The owner of the home stated that they used the Annual Quality Assurance Assessment (AQAA) as their main audit tool. The completed AQAA does not give comprehensive details of the homes plans for the future. Some steps have been taken to ensure the health and safety of people living and working at the home is maintained. The AQAA states that lifting equipment, fire detection system and emergency call bell system has been serviced within the last 12 months. The portable electrical appliances have not been tested since June 2003 (date provided on the AQAA) The owner stated that these were due to be re retested shortly. Staff stated that they had received training in health and safety issues but records of training were not available. All areas of the home appeared reasonably maintained and as previously stated immediate action was taken to secure wardrobes that posed a potential risk. Accidents in the home are recorded but records are not formally audited which may identify patterns or people potentially at high risk who require additional support. The carpet on the upstairs landing is very worn and would benefit from replacement before it becomes a trip hazard. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 24 Certificates of registration and insurance are displayed. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 25 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 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 x 3 x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (1) Requirement People must only be admitted to the home once they have had their needs assessed and the home is clear how needs will be met. This must take account of staffing levels and staff training needs. Care plans must be up to date and give clear guidance for staff to follow. The registered person must ensure that a comprehensive care plan is in place for anyone with diabetes. The care plan must detail the assistance the person requires from the staff at the home, the monitoring procedures in place and guidelines for the action staff should take should the person become unwell. (Immediate requirement issued) The registered person must ensure that there is a safe, robust system for the receipt, storage, recording and administration of medication. The registered person must DS0000016088.V368122.R01.S.doc Timescale for action 31/10/08 2 3 OP7 OP8 15(1) 12(1) 31/10/08 17/09/08 4 OP9 13 (2) 30/09/08 5 OP27 OP31 18(1) 31/10/08 Page 27 Latimer Lodge Version 5.2 6 OP29 19 (1) 7 OP30 18 (1) [a] review the staffing structure and levels to ensure that they are appropriate to the meet the needs of the people living at the home and provide clear management. The registered manager must provide evidence that new staff have been checked against the POVA register and undergone a CRB check before they commence work. (Immediate requirement issued) The registered person must forward to the CSCI details of all staff training undertaken and planned. 19/09/08 15/10/08 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 OP33 Good Practice Recommendations The registered person should put in place formal quality assurance systems, which take account of the views of all interested parties. Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Latimer Lodge DS0000016088.V368122.R01.S.doc Version 5.2 Page 29 - 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. 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