Inspection on 06/06/06 for Little Heath Lodge

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Little Heath Lodge 04/01/08

Little Heath Lodge 19/06/07

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

CARE HOME ADULTS 18-65 Little Heath Lodge 68 Little Heath Charlton London SE7 8BH Lead Inspector Maria Kinson Unannounced Inspection 6th June 2006 10:05 Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Little Heath Lodge Address 68 Little Heath Charlton London SE7 8BH 020 8317 7524 020 8317 7534 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) Cognithan Ltd Ms Emilia N Endeley Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Little Heath Lodge is registered with The Commission for Social Care Inspection to provide nursing care for five male or female service users, aged 18 to 65 years of age, with a mental health disorder. The home is located on a main road, in Charlton, which is served by several bus routes and within 10 minutes walk of a train station. The property consists of a large Victorian terraced house with five single bedrooms, dining room, kitchen, laundry, office/meeting room and lounge. The fees charged by the home range from £900 per week. This information was forwarded to the commission on 24.05.06. Further information about this home can be obtained by requesting a copy of the Statement of Purpose or by sending an email to enquiries@cognithan.com Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Little Heath Lodge was registered by the Commission for Social Care Inspection in January 2006. This is the first inspection of this service. This inspection took place on 06.06.06 between 10:05am and 15:35pm and on 22.06.06 between 09:00am and 11:35pm. The inspector viewed all of the communal areas and one bedroom. Care, recruitment and health and safety records were examined. Feedback about the service was obtained from one service user and one member of staff during the inspection. Three comment cards were returned to the commission. There were two service users living in the home at the time of this inspection. What the service does well: This home opened in December 2005. The arrangements for admitting and assessing new service users were good. Prospective service users were invited to view the facilities provided in the home and ask questions before making a decision to move in. Staff developed person centred care and activity plans with service users and support was provided where necessary to achieve personal goals and stay healthy. Feedback from service users and other professionals about the service was positive. Service users looked relaxed and comfortable interacting with staff and were satisfied with the support they received. The home provided a good variety and choice of home cooked food. Service users said that they were able to choose how and where they spent their time and were not subjected to unnecessary restrictions or rules. Service users were aware of the complaints procedure and felt able to approach staff or the manager about issues of concern. The home and grounds were clean, tidy and comfortable. The facilities provided in the home enabled service users to maintain their independence and learn new skills. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 6 The home has a stable staff team. This provided good continuity of support and security for service users who were often anxious about moving to a new environment. What has improved since the last inspection? What they could do better: Most of the standards assessed were met or almost met. The home provides good support for service users but some weaknesses were identified in relation to staff recruitment practices, health and safety issues and medication records. The manager indicated that staff had spent a lot of their time ensuring that service users were settled and developing individualised care plans. The manager must review and update the Statement of Purpose to ensure that it includes all of the information required. A record of all medication received in the home and returned to the service user or Pharmacist must be maintained. This will enable staff to complete a full audit trail and account for all medication. Policies and procedures must be kept in the home for staff to refer to. Action must be taken to reduce the risk of food contamination in the kitchen. Hand washing facilities must be provided and appropriate refrigerator and freezer temperatures must be maintained. The arrangements for recruiting new staff did not provide adequate protection for service users. The manager must ensure that the home has a robust recruitment procedure that complies with The Care Homes Regulations and National Minimum Standards. Staff should receive formal supervision to identify training and development needs. A training programme must be developed. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 7 The manager must establish systems to ensure that all of the necessary health and safety checks are carried out regularly and for monitoring the quality of care provided in the home. This will enable the manager to identify and address concerns promptly. 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. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose did not include adequate information about the service. The arrangements for assessing and admitting new people into the home were good. This made the transition into a new environment less stressful for service users. EVIDENCE: Written information about the service was provided in a Statement of Purpose and Service User Guide. Both documents were assessed prior to registration. The Service User Guide was found to be satisfactory but the Statement of Purpose requires some additional information to comply with The Care Homes Regulations. See requirement 1. The arrangements for admitting new service users into the home were good. The manager of the home or a senior member of staff visited prospective service users to undertake an assessment and discuss their individual needs. Staff also obtained reports and assessments from other professionals to assist them to understand and meet service users needs. Service users were invited to visit the home to meet staff and service users. One service user confirmed that he had spent a long weekend in the home to ensure that he liked it, Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 10 before making a decision to move in. Records indicated that service users were able to choose their bedroom. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and personal goals were reflected in their individual plan. Staff supported service users to make informed decisions where possible. EVIDENCE: Two sets of records were examined. Both of the files included up to date and detailed care plans, which outlined how service users individual needs were to be met and information about their personal preferences and goals. Care plans were agreed and signed by the service user and reviewed regularly. Risks to service users and others were assessed and strategies to reduce or manage risk were clearly recorded. Feedback from service users indicated that they were able to maintain an independent lifestyle and learn new skills. Service users told the inspector that they managed their own finances, decided how they spent their time in the home and community and said there were no restrictions about times for getting up or going to bed. The home had imposed some rules for health and safety reasons. This included a designated smoking area and time for Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 12 returning to the home. Staff showed flexibility about the time for returning to the home if the service user was attending a special event or visiting family. A weekly meeting was held in the home to update service users about changes, to discuss the menu and as an opportunity to raise concerns or make suggestions about the way the home was managed. Service users were encouraged to assist staff with chores in the home such as gardening, cooking and cleaning. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were supported to lead active and fulfilling lifestyles. The food provided in the home met service users needs and tastes. EVIDENCE: The home employs a part time Occupational Therapist who visits the home two to three times a month to prepare and review activity plans. The records maintained in the home indicated that detailed information was obtained from service users about their family and social history, personal interests and aspirations and daily living skills prior to developing individual plans. Records indicated that staff had supported service users to prepare and cook meals, use the computer, obtain passes for reduced admission to local leisure facilities such as the gym, swimming pool and public transport, attend work experience, assist with the upkeep of the home and grounds and obtain information about local college courses. Service users said that they enjoyed spending time relaxing and watching television in the home of an evening. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 14 The home employs a part time cook. The cook prepared a cooked meal for service users based on a menu that was discussed with service users during the weekly meeting. The inspector understood the cook was willing to work additional hours and days where necessary to meet service users needs. Week one of the menu was examined. The menu included a good variety and balance of different foods. On the day of the inspection the cook was preparing a chicken dish using herbs and spices that was served with noodles. Service users were seen making their own drinks and snacks and were encouraged to prepare their own meals of a weekend with support from staff. Service users said they enjoyed the food provided in the home. Service users told the inspector that they were free to come and go from the home as they pleased but were asked to inform staff about their plans. The manager advised service users about the availability and access to local services such as day centres, job clubs and support groups for people with mental health disorders. The current service users had only lived in the home for a short while but had started to use local shops, the leisure centre, GP surgery and public transport services. Service users were encouraged and prompted where necessary to keep their personal space clean and tidy and undertake their own laundry. Service users were able to maintain contact with friends and family via the telephone or could receive visitors in the home. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were supported to access community health care services. The home did not maintain adequate medication records. This issue could compromise service users health and safety. EVIDENCE: All of the service users living in the home maintained their own personal hygiene needs but required some assistance with medication. Service users were encouraged to let staff know when they were ready to take their medication. The manager said that staff were considering whether one of the service users could manage their own medication with support. Written feedback was obtained from two health care professionals that were in regular contact with, or had visited the home in recent months. The feedback received was good with both respondents stating that staff communicated clearly and understood service users needs. Service users were registered with a local GP and were supported to make and attend appointments where necessary. The care plan provided by sponsoring authorities outlined the arrangements for supporting service users in the Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 16 community and the action that staff should take if the service users health deteriorated. Staff prompted service users to attend outpatient appointments and ensured that other health care professionals were informed about significant events. Records indicated that service users had attended Psychiatrist and GP appointments, received visits from an outreach worker and attended medication clinics in recent months. The home employs a part time Occupational Therapist, Psychologist and Psychiatrist. The Consultant Psychiatrist will assess and review service users health care needs, if the sponsoring authority is in agreement and will provide advice or support for staff. There was evidence of good communication between staff from the home and the GP about blood tests and medication. The home had a ‘Safe and Secure Handling of Medicines’ policy and procedure. This policy was not dated, did not cover some aspects of medicine management such as drug errors and made reference to ward stocks. A copy of ‘The Administration and Control of Medicines in Care Homes’ was provided for the manager to consider when reviewing and updating the homes policy and procedure. Medication was stored in a cupboard in the clinical room. Storage facilities were satisfactory but there were no temperature records to ensure that the temperature in the room was suitable for the storage of medicines. Records of administration of medicines were good but there were no records of receipt or disposal of medication. See requirement 2. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were aware of the procedure for raising concerns or complaints about the support they received in the home. EVIDENCE: The home has a complaint and adult protection procedure but these documents were not available in the home on the day of the inspection. The manager agreed to forward copies to the lead inspector. The home had not received any complaints since opening. Service users said that they were aware of the complaints procedure and said they would speak to a staff member or the manager if they had any concerns. See recommendation 1. The manager had made contact with the Adult Protection Coordinator in Greenwich to request a copy of the local authority procedure. The staff member that the inspector spoke with had a good understanding of abuse and knew what action to take if they were advised about or witnessed abuse in the home. Two members of staff had attended child protection and vulnerable adults training sessions. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home provides a comfortable environment for service users and their visitors. Systems to reduce the risk of infection could be improved. EVIDENCE: The home is situated in a three storey Victorian house close to local shops and public transport links. There are five single bedrooms, three toilets, two bathrooms, one shower room, a laundry room, lounge, dining room, kitchen, meeting room and computer workstation with Internet access. There is a good size garden at the rear of the property with decking and seating. All parts of the home viewed were in good decorative order and well maintained. Work was in progress to redecorate and improve the facilities in the lower ground floor shower room. The manager said the home was registered with the local environmental health department as a premises serving food but had not received any inspections. The kitchen was clean and tidy but there were no soap or hand towels and refrigerator and freezer records were difficult to interpret. See requirement 3. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had a stable team of staff that provided good continuity of care and support for service users. The duty roster did not always include all of the staff working in the home. Staff recruitment practices were poor. Staff must ensure that robust procedures are followed to protect service users. The manager had started to assess staff training needs but further work was required to meet this standard. EVIDENCE: The duty roster indicated that there was one member of staff on each shift. The staff team was stable and no agency staff had been used since the home opened. Some of the shifts on the roster did not include a registered nurse. The manager said that a trained nurse was always provided in the home but accepted that the off duty did not reflect this. See requirement 4. The two service users living in the home were very independent and spent long periods out of the home. The manager said that staffing levels would be increased to the ratio agreed with the commission once the number of service users increased. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 20 Three staff files were examined. The arrangements for recruiting new staff were poor. None of the files included an up to date criminal record bureau disclosure, health statement, contract, job description or interview notes. Two files did not have adequate references or proof of registration with the nursing and midwifery council and there was no explanation of the gap in one staff member’s employment history. The photographs included in the files were not always clear, as they had been photocopied from other documents. See requirement 5. Staff said they felt well supported, received adequate verbal and written information to meet service users needs. Information and advice could be obtained from the manager or on call person at any time of the day or night. There was no evidence that staff received formal supervision. See recommendation 2. The inspector was shown a list of staff that had attended a one-day induction training session. This record was not dated. The majority of staff working in the home were employed on a sessional basis and had other jobs in the NHS or private sector. Some staff had undertaken relevant training courses in connection with other jobs. Copies of certificates were kept in staff personnel files. Since the home had opened some staff had attended Mental Health Act, child protection and vulnerable adults training sessions. The manager had started to assess staff training needs and plan some training sessions. See recommendation 3. Service users said that “all the staff are good, they do what they are supposed to, write everything down, give us our medication on time” and usually listen and act on what we say. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The atmosphere in the home was open and supportive but there was no evidence that the manager was undertaking any quality assurance work. This meant that some issues of concern such as health and safety checks and poor recruitment practices were not identified or addressed promptly. EVIDENCE: The manager was assessed by the commission as a ‘fit’ and suitable person to manage a care home for people with a mental health disorder. The manager has worked in community and acute mental health services and had completed training relevant to this post. The manager has a Masters degree in mental health services and is a registered mental health nurse. The manager works twenty hours each week but also visits the home regularly and carries out assessments. The manager was advised to include all of the time spent working in the home on the duty roster. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 22 Staff and service users said that the manager kept them informed about significant issues, was approachable and helpful and listened to their views. The home was assessed during the pre registration visit to have all of the policies and procedures listed in the National Minimum Standards. The manager must ensure that staff can access policies and procedures at all times of the day and night. See standard 22 and recommendation 1. A random selection of health and safety records were examined. Fire exits were clear and extinguishers were positioned at relevant points around the home but there was no evidence that fire alarm tests, service visits or drills had been undertaken. Records of service visits for the emergency lighting and extinguishers were valid but were due for renewal in June and July 2006. The manager could not locate a fire risk assessment. Some staff had read the homes policy and procedures relating to fire safety but fire safety training had not been provided for staff. There was no evidence that hot water temperatures, portable electrical appliances or window restrictors were checked. Records indicated that gas safety appliances were last inspected in August 2004. The manager said more recent checks had been carried out and agreed to forward a copy of the report to the inspector. The commission has not received this information. Documentation relating to the mains electricity installation and water chlorination certificates were examined during the pre registration site visit. See requirement 6. This home had only been operating for just over five months so quality assurance systems were still under consideration. Feedback about the service was obtained from service users during the weekly meeting and from other professionals and relatives when they made contact with the home. See requirement 7. Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 2 X 1 X Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Not applicable. 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 YA1 Regulation 4 Requirement The Registered Person must review and update the Statement of Purpose to include all of the information listed in Schedule 1. The Registered Person must ensure that: • Adequate records are maintained for all medicines received in the home • Adequate records are maintained for all medicines disposed of by the home • The temperature in the medicine room is monitored and recorded • The medication policy and procedure is reviewed and updated to cover all aspects of medicine management The Registered Person must ensure that: • Suitable hand washing facilities are provided in the kitchen • Refrigerator and freezer temperatures are DS0000064562.V291514.R01.S.doc Timescale for action 02/10/06 2 YA20 13 01/09/06 3 YA30 13 01/09/06 Little Heath Lodge Version 5.1 Page 25 4 YA32 18 5 YA34 19 6 YA42 23 7 YA39 24 maintained within the recommended range The Registered Person must ensure that at all times a suitably qualified registered nurse is working in the care home. The Registered Person must not employ a person to work at the care home unless she has obtained in respect of that person, the information and documents specified in Schedule 2. The information and documents missing from existing staff files must be obtained by 01/09/06. The Registered Person must ensure that health and safety checks are carried out regularly and that all records are available for inspection in the home. The Registered Person must establish and maintain a system for reviewing and improving the quality of care and nursing provided in the care home. The system used must include consultation with service users and their representatives. 01/09/06 01/09/06 01/09/06 02/10/06 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 2 3 Refer to Standard YA40 YA36 YA35 Good Practice Recommendations The Registered Person should ensure that staff have access to the homes policies and procedures at all times. The Registered Person should ensure that staff receive formal supervision at least six times a year. The Registered Person should: • Develop a training and development plan which includes input from service users DS0000064562.V291514.R01.S.doc Version 5.1 Page 26 Little Heath Lodge • • Ensure that each staff member has an individual training and development assessment and profile Ensure that each staff member receives at least five paid training days (pro rata) per year Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Little Heath Lodge DS0000064562.V291514.R01.S.doc Version 5.1 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!