Inspection on 10/07/07 for Lloyd Lodge

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lloyd Lodge 21/07/08

Lloyd Lodge 22/02/07

Lloyd Lodge 06/11/05

Lloyd Lodge 22/06/05

Lloyd Lodge 24/02/05

Lloyd Lodge 09/07/04

Lloyd Lodge 16/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lloyd Lodge 2 St Georges Road Bedford Bedfordshire MK40 2LS Lead Inspector Mrs Louise Trainor Unannounced Inspection 10th July 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 Lloyd Lodge DS0000014931.V340347.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. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lloyd Lodge Address 2 St Georges Road Bedford Bedfordshire MK40 2LS 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) 01234 268757 01234 272927 Lloyd Lodge Limited Vacant Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (18) Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. There are no conditions associated with this registration Date of last inspection 22nd February 2007 Brief Description of the Service: Lloyd Lodge is situated in a pleasant residential suburb of Bedford. The home has been registered to the current owners since 2001, and is registered for 18 residents over the age of 65 years with a diagnosis of dementia and/or physical disabilities. The bedroom accommodation is on three floors. Currently in use as bedrooms are twelve single, and two double rooms, all with en suite toilet facilities. There are two lounge/dining areas on the ground floor, and all floors are served by a lift. The home has a garden at the rear accessed by a ramp. The home is in within walking distance of a park, a local bus route and Bedford Town centre. The fees for this home vary from £443.74 per week, to £460.00 per week, depending on the care needed. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Key Inspection for this service this year. Regulatory Inspector Louise Trainor carried it out between the hours of 09:30 and 17:00 hours on the 10th of July 2007. The owners, Mr and Mrs Hepworth- Lloyd were present throughout the day to assist as necessary. The focus of this inspection was to look at the key standards and to follow up on previous requirements. Three people who use this service were ‘case tracked’, and two members of staff were interviewed during this inspection. Documentation including four staff files, three service users care plans/ files, service user s financial records, accident records, service user information documents and medication charts were examined. Care practices were observed throughout the visit, and the inspector had the opportunity to spend some time with two people who live in this home and their visitors As this was the first visit to this home for this inspector, a full of the premises interior and exterior was carried out. The inspector would like to thank everyone involved for their assistance and support during this inspection What the service does well: Generally people who use this service have a pre admission assessment carried out prior to admission to ensure that their needs will be met in this home. There were contracts in place for everyone who lives in this home, and they were all clearly signed and dated, and detailed the individual cost of care. The health needs of the people who use this service are set out in individual care plans. There were visitors in and out throughout the day, and some advised the inspector, that they visited very regularly, were able to do so at a time that suited them, and were always made to feel very welcome. There is a complaints policy in place for this home, it is summarised in both the ‘Residents Guide’ and the Statement of Purpose, so that it is easily accessible to everyone who lives in the home and their relatives. This was reflected Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 6 through discussions with both the people who live in this home and their relatives. People who use this service expressed their satisfaction with the care they receive and all felt that they were treated in a respectful and dignified manner. Observations of care also reflected that the dignity and privacy of the residents was promoted in this home. What has improved since the last inspection? What they could do better: The systems for checking recruitment documentation of staff prior to commencing employment are insufficient to ensure that the people who use this service are protected at all times. Relevant information documents are in place for this home. How ever despite recent review, they require further attention to ensure their accuracy. All staff are not adhering to the procedures for the administration of medication so that care may be compromised. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 7 Bedtime appeared to be of choice to most residents, however everyone that was spoken to, indicated that they are up between 06:00 hours and 06:30 hours in the morning. This seemed very early and people indicated that they did not always get a choice in the matter, particularly if they required assistance with personal care. It was unclear whether all staff had a full understanding of safeguarding procedures, therefore the people who use this service may not always be protected. This home provided a pleasant and homely environment, however the removal of broken and unused furniture is essential to ensure these premises provide a safe environment for the people who live here. The upstairs bathroom, which housed the ‘Parker bath’, was out of use. This meant there was only one functional bathroom at present in the home. The home has appropriate policies and procedures in place, however systems for reporting incidents within the home need reviewing to ensure service users’ health, safety and welfare are promoted and protected at all times. 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. Lloyd Lodge DS0000014931.V340347.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 Lloyd Lodge DS0000014931.V340347.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): 1, 2, 3, 4, 5, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Relevant information documents are in place for this home. How ever despite recent review, they require further attention to ensure their accuracy. EVIDENCE: There is a ‘Residents Guide’ and a Statement of purpose in place for this home. Both of these documents are well detailed containing information about the services provided. These documents were both reviewed in February 2007, however some details require further attention to ensure their accuracy. Although the ‘Residents Guide’ includes financial arrangements, it does not presently include the specific cost of this service. Under the heading ‘Quality Assurance and Standards of Service’, this document refers to the home as Hepworth House, which is the sister home to Lloyd Lodge, and under the section on Complaints, Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 10 the document refers to NCSC. This is out of date and should read The Commission for Social Care Inspection (CSCI). The Statement of Purpose details Mrs P Hepworth-Lloyd as the present manager for this service. Although she is managing this service, she is presently registered as the manager for the sister home, Hepworth House. There are therefore some administration processes that require attention to formalise her position as registered manager for Lloyd Lodge. The personal files of three people who use this service were inspected. They indicated that pre admission assessment s do take place, although one did identified the pre admission assessment as the same day as admission. This is acceptable in emergency circumstances. There were contracts in place for everyone who lives in this home, and they were all clearly signed and dated, and detailed the individual cost of care. The inspector had the opportunity of speaking to visiting relatives during this inspection. Some confirmed that they had visited the home prior to their loved ones being admitted, enabling them to make an informed choice about the placement. This home does not provide an intermediate care service. Lloyd Lodge DS0000014931.V340347.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. The health needs of the people who use this service are set out in individual care plans, however the procedures for the administration of medication are not being adhered to by all staff so that care may be compromised. EVIDENCE: The files of three people who live in this home were examined during this inspection. The manager has clearly worked hard to improve the process of care planning since the last inspection in February of this year. All the files contained a suggested care plan document. This contained personal choices and preferences of the individual, including preferred bedtimes, food preferences and preferred activities. One file identified how the individual liked to have a bath after breakfast and preferred the assistance of a female carer, another identified that the individual enjoyed the Sunday morning church service, liked to read a certain newspaper and liked to bathe twice a week. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 12 Each file contained numerous risk assessments ranging from slips, trips and falls to pressure area care. Individuals had been risk assessed in relation to their medical diagnosis. From these risk assessments care plans had been formulated. These were written with specific detail and gave a clear guidance to the staff of the level of care required for each individual. Both risk assessments and care plans were being reviewed and updated regularly to reflect the changing needs of the individual. People who use this home and the relatives that were spoken to by the inspection confirmed their awareness of the care plans and their contents. The storage area for the medication trolley was identified as being insufficiently safe at the previous inspection. This has now been rectified, and the trolley is securely stored in a locked cupboard. The medication Administration Record (MAR) sheets were inspected. All prescriptions were clearly written and when variable doses were prescribed, staff identified the dose that had been given. Unfortunately there were one or two errors found. Two of the charts examined had missing signatures and omission codes, and on one chart where there was only Salbutamol prescribed, Movicol and Senna has been administered and written on the reverse of the chart. This was not acceptable, as they had not been prescribed for this individual. The inspector was unable to check the returns book and reconciliation of the drugs, as a member of staff had gone off duty with the key for the cupboard where this information was kept. Two people who live in this home and their relatives were informally interviewed during this visit. All expressed their satisfaction with the care they receive and all felt that they were treated in a respectful and dignified manner. Observations of care also reflected that the dignity and privacy of the residents was promoted in this home. At a previous inspection the privacy of one individual had been questioned, as their bedroom door had a glass panel in it, which enabled anyone passing to look in. This matter was discussed again with the manager, and also with the individual concerned and their family. The window has now got a net curtain in place, and although it does not give complete privacy, everyone concerned has expressed their wish for it to remain like this, because of the individual’s condition and need for regular observation. The inspector suggested other ways that full privacy could be maintained whilst allowing observation to continue. This matter has been left for all concerned to discuss further. Lloyd Lodge DS0000014931.V340347.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): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in this home are generally encouraged to make choices and maintain control over their lives, however for some it would appear choices are sometimes limited. EVIDENCE: The people who live in this home appear quite content with their lifestyle. There is an activity worker who attends the home on daily basis, and residents are encouraged to participate in a variety of games, quizzes and reminiscent groups. Some of the residents prefer to spend time in the privacy of their own rooms, either alone or with visitors, this is also acknowledged. One person told the inspector. “I do go downstairs for my meals and things, but generally I like a bit of time on my own, but I would like to go out to the park sometimes”. Another person also stated that they preferred to spend their time in their room. During the morning of the inspection the majority of people living in the home, just appeared to be watching television, however in the afternoon, the activity worker arrived and appeared to be very well received by the residents in the lounge area. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 14 Bedtime appeared to be of choice to most residents, however everyone that was spoken to, indicated that they are up between 06:00 hours and 06:30 hours in the morning. This seemed very early and people indicated that they did not always get a choice in the matter, particularly if they required assistance with personal care. There were visitors in and out throughout the day, and some advised the inspector, that they visited very regularly, were able to do so at a time that suited them, and were always made to feel very welcome. The menus for this service have been reviewed are set out on a four weekly basis, and offer a variety of nutritious meals, including hot and cold desserts. Light alternatives are available on request. The food stores were inspected and appeared to be quite well stocked, although much of the produce appeared to be processed or frozen rather than fresh. One person who lives in the home said. “The foods very good you know”. Their relatives also commented on how well they had eaten since coming to the home. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all staff had a full understanding of safeguarding procedures, therefore the people who use this service may not always be protected. EVIDENCE: There is a complaints policy in place for this home, and it is summarised in both the ‘Residents Guide’ and the Statement of Purpose, so that it is easily accessible to everyone who lives in the home and their relative. This was reflected through discussions with both the people who live in this home and their relatives. The inspector saw the complaints file. There had only been two complaints logged since the previous inspection. Both had been addressed appropriately and copies of relevant letters and minutes from meetings were present. Everyone that the inspector spoke with, was satisfied with the service, and said they had never had the need to complain, however they were aware of who to speak to should the need arise. Two staff were interviewed during this inspection. One was very clear on safeguarding procedures and had done the relevant training. The other, although appeared very competent in her practices, was unable to demonstrate her understanding of safeguarding issues due to the difficulty she had with the English language. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 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. This home provided a pleasant and homely environment, however the removal of broken and unused furniture left in the garden is essential to ensure these premises provide a safe environment for the people who live here. EVIDENCE: This was the first visit to this home for this inspector therefore a full tour of the premises took place. The interior of the home appeared quite homely, however on the day of the inspection there were workmen present installing a new call system. This resulted in ladders being left unattended and blocking hallways, reels of cable lying around the floor potentially causing trip hazards, and a generally dusty and noisy environment. The inspector appreciates that this was only very Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 17 temporary but it should have been thoroughly risk assessed to minimise any potential hazards to the people who live there. The manager advised the inspector that although no formal risk assessment was in place, they were monitoring the situation very closely and no one was wandering around unaccompanied whilst this work was being done. Individual bedrooms were clean, they were decorated according to individual taste, and many were furnished with personal features that reflected the lifestyle and history of the person who lived there. One person had their own computer in their room; another had pictures of specific areas of France that were significant to the resident of this room. All the rooms had an en suite attached, two included shower facilities, others just a washbasin and a toilet. In one room the partition curtain had fallen down thus compromising privacy when using the toilet. The upstairs bathroom, which housed the ‘Parker bath’, was out of use. This was a very dark room with no windows and just a small air vent. It was very musty and appeared to be being used as a storage area for; an old clothes rack piled with laundry and wheelchairs. It had staff uniforms hanging on the back of the door, indicating that perhaps it was being used as a staff changing room. With this bathroom out of use, it meant there was only one functional bathroom at present in the home, although two bedrooms did have an en suite shower. The inspector also visited the rear garden. This was in need of some attention to make it safe for the residents to use, as there appeared to be a lot of broken and unused furniture including an old sink and a cooker around the garden area. The greenhouse even appeared to be a storage area for broken chairs. The owner advised the inspector this old / unwanted furniture was due to be removed from the premises imminently. There was also a large skip in the front garden awaiting collection. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The systems for checking recruitment documentation of staff prior to commencing employment are insufficient to ensure that the people who use this service are protected at all times. EVIDENCE: Staffing levels have been addressed since the last inspection, so that there is a minimum of three staff on duty at all times between 08:00 hours and 20:00 hours. There is two staff on at night; one works a ‘waking night’ and the other a ‘sleeping night’. During this inspection four staff files were examined. Each file contained a completed application form, however the section on employment history was incomplete on them all, and only identified information for the past two or three years. One file only contained one reference, which was from a friend not an employer. Three files contained Criminal Record Bureau checks that were dated after the employment start date, and although POVA first checks had been carried out, staff starting work on these alone had not been agreed with CSCI. Appropriate documentation from the Home Office for overseas staff was in order, and various forms of identification were present in the files. All files contained contracts, however these had not all been signed, and some staff appeared to be entitled to more bank holidays than others. This was brought to the attention of the manager during the inspection. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 19 Records indicated that staff are attending a wide range of training sessions both for mandatory and more specialist subjects. However although English is on the training list, no one is listed as attending. This was surprising as two of the staff on duty on the day of the inspection, were noted to have great difficulty understanding the language. Information submitted by the home to the Commission for Social Care Inspection showed that 50 of staff had completed their National Vocation Qualification in Care Observations of care practices, identified staff performing their duties in a confident and competent manner, although communication was clearly a problem for some. The staff that were interviewed indicated that they felt well supported, one said of the manager. “She is very approachable and supportive, I could talk to her about anything”. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appropriate policies and procedures in place, however systems for reporting incidents within the home need reviewing to ensure service users’ health, safety and welfare are promoted and protected at all times. EVIDENCE: The management of this home has been a problem for the owners over the past two years. The most recent manager has now left the service and the deputy is on long-term sick leave. To resolve this matter one of the owners has now taken on the role of managing this home, and has worked hard over recent months to instigate various improvements. The staff have responded well to her and have confidence in her abilities as a leader for them. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 21 Most of the staff are now receiving supervision on a regular basis. Quality assurance in the home has been addressed by a questionnaire being given to the people who live in this home and their relatives, however the manager now needs to formulate an improvement plan in consultation with the questionnaire responses. Health and safety records showed that the maintenance person employed at the home undertakes tests. Fire safety checks, water temperatures and fridge temperatures were some of the checks noted to be undertaken. Staff training records also showed staff had undertaken training in areas that included, moving and handling, food hygiene and fire safety. The inspector examined the accident file. Only five accident forms had been completed since the previous inspection, and these had not all been referred to CSCI as regulation 37 notifications. This matter was discussed with the manager who is now fully aware of what needs to be reported through this process. The home presently only holds money for a five of the people who use this service. The files of all five were checked. All transactions were clearly recorded and had been signed and dated appropriately. All balances reconciled with the funds remaining, and receipts were present to reflect all purchases and transactions. Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 X 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 x 2 Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 6(a) Requirement Timescale for action 30/09/07 2. OP9 13(2) The Statement of Purpose and the Service User Guide for this service must be kept up to date and contain the appropriate information. When medication is administered 31/08/07 to people who use this service, it must be clearly recorded to ensure that people have received the correct levels of medication. People who live in this home should be enabled by the staff to make choices regarding their care and lifestyle. All staff who work in this home must be able to demonstrate their understanding of Safeguarding procedures, so that the people who live here are protected. Bathing facilities in this home must be free from clutter and fully functional so that people who live in this home have sufficient facilities. Before employees commence work in this home, the manager must obtain all the information DS0000014931.V340347.R01.S.doc 3. OP14 12(2) 31/08/07 4. OP18 13(6) 31/08/07 5. OP21 23(2)(j) 31/08/07 6. OP29 19(1)(B) 31/08/07 Lloyd Lodge Version 5.2 Page 24 7. OP30 18(1)(a) 7. OP33 24(1) and documents specified in paragraphs 1-7 of schedule 2 Staff who work in this home must be appropriately trained to meet the needs of the people who use this service. This should include a good command of the English language. This home must have a clear system for the monitoring and improvement of the quality of care provided. This must include an annual improvement plan correlated from questionnaires issued and returned. All incidents that occur in this home must be reported appropriately. This should include regulation 37 notices and safeguarding referrals where necessary. 30/09/07 30/09/07 8. OP38 37 (1) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Lloyd Lodge DS0000014931.V340347.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!