CARE HOMES FOR OLDER PEOPLE
Lloyd Lodge 2 St Georges Road Bedford Bedfordshire MK40 2LS Lead Inspector
Ms Louise Trainor Unannounced Inspection 21st July 2008 10:00 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.V368731.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.V368731.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 denisehookham@bchal.org 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.V368731.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 10th July 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 £457.00 per week, to £480.00 per week, depending on the care needed. Lloyd Lodge DS0000014931.V368731.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 2 stars. This means the people who use this service experience good quality outcomes.
This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection for this year for this service. Regulatory Inspectors Mrs Louise Trainor carried it out on the 21st of July 2008 between the hours of 10:00 and 15:00 hours. The home Manager was present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care of two people were case tracked. This included the most recent admission to the home. This involved reading their records and comparing what was documented to the care that was being provided. Documentation relating to: staff recruitment, training and supervision and medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this five hour inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. What the service does well:
The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 6 needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. Personal healthcare needs are clearly recorded in individual’s care plans. Medications records are fully completed, contain required entries and are signed appropriately by staff. Observations of care practices indicated that staff are competent in their roles, and relationships between staff and residents were familiar but respectful. People who live in this home are encouraged to maintain relationships with families and friends. Residents are involved in meaningful activities of their own choice, which are risk assessed where necessary. The complaints procedure is supplied to everyone living in the home, and a record of complaints, including any investigation and actions taken. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. This home provides a clean, comfortable and homely environment for the people who live here. The manager demonstrates a clear understanding of the key principles and focus of this service. She is enthusiastic and is striving to make continuous improvements to promote the health, safety and welfare of the residents who live in this home. Supervision records were examined, and indicate that staff are receiving regular 1:1 sessions with the manager. 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. What has improved since the last inspection?
There is a Service User Guide and a Statement of Purpose in place for this home and both documents had been reviewed within the last year. At the last inspection, we identified that a bathrooms was out of use. It was very cluttered and was being used as storage space. This bathroom has been cleared and there are now plans for it to be converted into a wet room / shower, which the manager feels will be more suitable for these residents. We look forward to seeing this project completed.
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 7 At the last inspection we identified that the garden and the greenhouse were storing old broken furniture that was awaiting disposal. During this visit we observed the garden had tubs of brightly coloured flowers, and the greenhouse had been cleared of rubbish, and now had tomato plants and peas growing in it. The garden now provides a more pleasant and safe environment for the residents who wish to use it. We examined the personal files of three staff. All three had Criminal Record Bureau checks and POVA first checks in place. All had fully completed application forms that detailed employment history and personal qualifications. All three had completed an induction programme, had appropriate references in place and had signed contracts in their files. Home Office documentation was in place where appropriate. At the last inspection we reported that the home had been experiencing problems appointing a suitable manager to this home, and one the owners had stepped into manage the home. This has resulted in many improvements being achieved over the past year. The manager now has a team of committed staff that demonstrated their loyalty and support for her and the residents that they care for. Accidents and incidents are being reported appropriately. What they could do better:
The service recognises the importance of training and tries to deliver a programme that meets the requirements of the home. However there are presently some shortfalls and gaps in the training records that are being addressed. The staff in this home have received training in safeguarding, although some are in need of refresher courses to ensure they are up to date with knowledge. The complaints policy is kept in a drawer in the entrance of this home and available for visitors to view if they ask. It would be preferable if it was openly on display. Most of the staff have attended mandatory training, however up dates and refresher sessions are now overdue for some staff. The manager has addressed quality assurance through questionnaires to residents and their relatives, and has put individual improvement and action plans into residents files to identify actions that have been taken as a result. However she has not yet completed an overall plan. Questionnaires could be extended to include other professionals who work with the home.
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There is a Service User Guide and a Statement of Purpose in place for this home and both documents had been reviewed within the last year. Although there is no evidence of the range of fees charged for living in this home in either document, there are clear details of what is included in the fees, and what is provided at an additional cost, such as hairdressing.
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 11 The individual fee for each resident is clearly identified within their contract of terms and conditions. These documents were checked and were all signed and dated appropriately. We viewed the file of the two residents, both had been admitted since our last inspection in July 2007. The pre admission assessments had both been carried out well in advance of the admission, and contained sufficient detail to ensure that staff would be able to meet his needs. This home does not provide intermediate care. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 12 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. People who use this service experience good quality outcomes in this area. Personal healthcare needs are clearly recorded in individual’s care plans. Medications records are fully completed, contain required entries and are signed appropriately by staff. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we examined two resident’s files in detail. Each file contained a pre admission assessment that had been completed prior to admission. Documents contained a diagnosis of the resident’s condition, and then went on to explain the level of assistance required for the individual tasks of daily living.
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 13 One person’s file identified that they were very agile and enjoyed walking and other physical activities such as exercises, ball games and singing. It was recorded that this person was anxious and forgetful, and needed prompting and reminding to wash and to eat meals. Risk assessments had been completed to reflect areas of care where the resident maybe at risk, such as the Malnutrition Universal Screening Tool (MUST), for the risk of weight loss. The personal profile was completed in detail, with information about personal preferences and dislikes. It also outlined some regular activities that this person particularly enjoyed and benefited from, for example helping in the kitchen and going to visit friends in another home, which is situated across the road. These activities were also risk assessed. There were care plans in place to support all areas of care where assistance was required, and these were in sufficient detail to ensure that all staff knew what they were required to do for this person. One care plan, relating to mealtimes read. “Escort to the table – establish mealtime routine, remind ----to finish their meal, monitor weight”. Although this was brief and lacked some specific detail, it gave sufficient information so that continuity of care could be maintained for this person. Another care plan was ‘to support a good quality of life’ and this described how this individual should be encouraged, and how her physical activity should not be hindered. Although this person’s verbal communication skills were limited, she told us. “Foods good”, “I go for walks”. And “look after me well”. It was apparent from observations that she regularly goes out for walks with staff. On the day of the inspection she was going to spend some time visiting Lloyd Lodge’s sister home. There was a care plan agreement in place that had been signed by this resident’s representative and dated, and care plans were being reviewed monthly. The second file we examined was equally as detailed. It focused on this person’s lack of confidence due to recent falls prior to admission, and risk assessments reflected how this was to be managed with the use of a frame and an escort when walking. This person had also been admitted with small a pressure wound. This was reflected in both risk assessments and care plans, and was being reviewed regularly. The district nurse was also involved with this resident. As with the first file, evidence indicated that this resident and her family had been involved in planning her care, and her likes and dislikes and personal preferences had been considered and clearly documented. Observations of care practices indicated that staff are competent in their roles, and relationships between staff and residents were familiar but respectful. During this inspection we checked the Medication Administration Record (MAR) sheets. All had been completed appropriately with signatures and omission codes where necessary. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 14 The next months medication had just been delivered and one senior care staff had signed them all in correctly. We reconciled PRN (as required) medication that was not in the blister packs, and these reconciled correctly to be carried forward or returned. There is presently no one in the home receiving controlled drugs (CDs), however appropriate storage and a CD register were present in the home. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good quality outcomes in this area. People who live in this home are encouraged to maintain relationships with families and friends. Residents are involved in meaningful activities of their own choice, which are risk assessed where necessary. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a part time activity worker, who presently visits the home three times a week, and engages with residents in exercises, quizzes and bingo, beetle drive and other pass times. In addition, there are numerous religious groups that visit each month to lead communion and hymn singing, and a professional musician entertainer visits the home regularly. Residents are also encouraged to be involved in tasks around the home that are meaningful to them. One person’s notes identified that they liked to spend time tidying up. There was a risk assessment to minimise risks for her helping in the kitchen.
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 16 Two residents told us that although there are not planned activities every day, what they have is quite sufficient, as they do not always want to be joining in groups. One resident told us that she prefers to spend time in her room, but enjoys joining in activities occasionally. Throughout this inspection there were visitors coming and going. They all appeared very relaxed in the home. One person told us. “------ always seems happy and gets on well with the staff, it’s relaxed and homely, and she chooses when she wants to go to bed and get up”. Residents are encouraged to go out with friends and families, and when possible members of staff accompany residents out for walks to the park or to the local shops. The home has a four-week menu plan in place that offers a varied choice of meals. The residents are offered their choices each morning and these are recorded in a book for the cook to work from. On the day of the inspection there was the choice of beef stew or sausages, followed by jam roly-poly or ice cream. Unfortunately only one person had opted for the sausages, and the beef was rather tough for some people, therefore there was quite a lot of waste noted. However residents that we spoke to said they had enjoyed the meal and had had sufficient. One resident told us. “The foods lovely, it’s worth everything you pay”. The fridge and freezers were well stocked with both fresh and frozen produce. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home, and there is a record of complaints, including any investigation and actions taken. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a clear complaints policy, which is summarised in the Statement of Purpose and the Service User Guide. It gives clear timescales of expected response, and it details contact information for other authorities such as the Commission for Social Care Inspection (CSCI) and The Ombudsman, so that complainants know what to do if they are not satisfied with the way a complaint is managed by the home. These documents are kept in a drawer in the entrance of this home and are available for visitors to view if they ask. It would be preferable if they were openly on display. We looked at the complaints file for this home. Since the previous inspection one year ago, only one written complaint had been logged in the complaints file. This was from a resident and related to clothing going missing and his
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 18 plate being removed before he had finished his meal. Both of these issues had been clearly addressed and action plans put in place to prevent reoccurrence of these issues. We noted that compliments far outweighed complaints. One relative had written. “Residents are very well attended to by very pleasant staff”. Others had written. “I feel the home is well run and organised, and I am happy that mum is looked after so well”, and “Since moving into the home, ---- has improved in so many ways and is very happy”. There was also a note on one of the resident’s review, which had been written by a Social Worker, it read. “---- appears very well, her room is fresh and I feel they are managing her care very well. Prima has a wonderful influence on how the home is run”. The staff in this home have received training in safeguarding, although some are in need of refresher courses to ensure they are up to date with knowledge. However staff that we spoke to during this inspection, were able to demonstrate their understanding of what type of incidents should be reported and what processes they need to follow. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 19 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, 22, 23, 24, 25, 26 People who use this service experience good quality outcomes in this area. This home provides a clean, comfortable and homely environment for the people who live here. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and free from any offensive odours. One visitor commented to us about how thorough the cleaner was. She said. “The cleaner is excellent, he even cleans the windows”. Then in jest she added. “He’s sometimes too thorough”. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 20 There are two communal lounge areas, one of which is also a dining room. Although quite small, these were not overcrowded and residents were comfortable. Some residents prefer to spend the majority of their time in their rooms unless there is a particular activity in progress that they wish to participate in. Individual rooms are decorated and furnished to personal taste. Some rooms contained furniture that individuals had brought into the home with them, giving each one a feeling of individuality, others had their own telephones installed. Photographs and personal assets reflecting the individual’s life history also enhanced a homely atmosphere. One resident was very keen to show off her room, which was wall to wall with family photographs. Toilet facilities are sufficient in this home. All bedrooms have an en suite toilet and wash basin, and two have shower facilities. There is a bathroom or shower room on each floor. However the bathroom on the first floor remains out of use. At the last inspection, we identified that this bathrooms was out of use. It was very cluttered and was being used as storage space. This bathroom has now been cleared and there are plans for it to be converted into a wet room / shower room, which the manager feels will be more suitable for these residents. We look forward to seeing this project completed. At the last inspection we identified that the garden and the greenhouse were storing old broken furniture that was awaiting disposal. During this visit we observed the garden had tubs of brightly coloured flowers, and the greenhouse had been cleared of rubbish, and now had tomato plants and peas growing in it. The garden now provides a more pleasant and safe environment for the residents who wish to use it. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 21 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 People who use this service experience adequate quality outcomes in this area. The service recognises the importance of training and tries to deliver a programme that meets the requirements of the home. However there are presently some shortfalls and gaps in the training records that are being addressed. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: On the day of this inspection there were three care staff, a cleaner, a cook and the manager on duty. A senior carer had come in solely to sign in the new medication delivery. We examined the personal files of three staff. All three had Criminal Record Bureau checks and POVA first checks in place. All had fully completed application forms that detailed employment history and personal qualifications. All three had completed an induction programme, had appropriate references in place and had signed contracts in their files. Home Office documentation was in place where appropriate.
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 22 Training records indicated that over 50 of staff have achieved NVQ certificates in care at varying levels, and a wide range of training course are available to staff including Mental Health, Nutrition (MUST), Bereavement and continence. Most of the staff have attended mandatory training, however up dates and refresher sessions are now overdue for some staff. We spoke to one member of staff who was from overseas, and at the last inspection was struggling with English. She has been attending classes, and her English is much improved. We looked at the supervision records for three staff. These showed that regular supervision is taking place. One carer told us that she felt very well supported, and that she could go to the manager, who is always available to her, with any problems. Observations of staff and residents interactions indicated that there is a relaxed and friendly atmosphere in this home, and staff were confident and competent in their roles. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 23 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, 37, 38 People who use this service experience good quality outcomes in this area. The manager demonstrates a clear understanding of the key principles and focus of this service. She is enthusiastic and is striving to make continuous improvements to promote the health, safety and welfare of the residents who live in this home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: At the last inspection we reported that the home had been experiencing problems appointing a suitable manager to this home, and one of the owners
Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 24 had stepped into manage the home. This has resulted in many improvements being achieved over the past year. The owner/manager now has a team of committed staff that demonstrated their loyalty and support for her and the residents that they care for. She is now ready to look at recruiting a permanent manager and deputy to the home. One person said. “She is always available to us for anything”. Another said. “There have been so many improvements”. Some of the senior staff have been given specific responsibilities such as signing in medication and doing more work with care plans and record keeping. This has been well received by staff that feel more valued and are more confident in their roles. Records and care plans were well written and up to date, and medication reconciliation was accurate. Supervision records were examined, and indicate that staff are receiving regular 1:1 sessions with the manager. 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. Accidents and incidents are being reported appropriately. Health and safety records showed that the cleaner / maintenance man employed at the home carries out most of the testing. Fire alarm tests are done weekly, emergency lighting is checked monthly, water temperature checks are done in every area every month, room safety awareness is done daily, first aid kits checked monthly and fridge temperatures daily. Moving and handling and fire equipment was labelled to identify that it had been tested within the last eight months. The manager has addressed quality assurance through questionnaires to residents and their relatives, and has put individual improvement and action plans into residents files to identify actions that have been taken as a result. However she has not yet completed an overall plan. Questionnaires could be extended to include other professionals who work with the home. Lloyd Lodge DS0000014931.V368731.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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 3 3 Lloyd Lodge DS0000014931.V368731.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 OP30 Regulation 18(1)(a) Requirement Staff who work in this home must be appropriately trained to meet the needs of the people who use this service. This should include mandatory refresher training. 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. Previous timescale partially met, extension applied. Timescale for action 30/09/08 8. OP33 24(1) 30/09/08 Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 27 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 OP16 Good Practice Recommendations The home should consider displaying the complaints policy in the home. Lloyd Lodge DS0000014931.V368731.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V368731.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. 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!
