Inspection on 13/10/05 for Lodge (The)

This inspection was carried out on 13th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lodge (The) 05/03/09

Lodge (The) 14/03/08

Lodge (The) 17/08/06

Lodge (The) 28/12/05

Lodge (The) 26/07/04

Lodge (The) 13/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Lodge (The) Lodge (The) Roman Way Farnham Surrey GU9 9RE Lead Inspector Pat Collins Unannounced Inspection 13th October 2005 14:10h Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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 Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lodge (The) Address Lodge (The) Roman Way Farnham Surrey GU9 9RE 01252 717021 01999 999999 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) Ability Housing Association Ms Sandra Alexandra Passingham Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. In addition to the primary condition Learning Disability up to 3 (three) service users below the age of 65 years may be within the category PD - Physical Disability and 2 (two) within the category SI - Sensory Impairment. In addition to the primary condition Learning Disability up to 2 (two) service users above the age of 65 years may be within the category PD(E) Physical disability and 1 (one) within the category SI(E) Sensory impairment. 26th July 2004 2. Date of last inspection Brief Description of the Service: The Lodge is a care home providing personal care for up to five adults with learning disabilities, some of whom may have a physical disability or sensory impairment as secondary conditions. The current service users group is mixed gender and two individuals are over 65 years of age. The home is situated in a residential area on the outskirts of Farnham. It is within walking distance of the town centre and convenient for public transport and all community amenities. The accommodation is wheelchair accessible on one level and is domestic in scale. Bedroom accommodation is in single rooms and a comfortable communal lounge and separate dining room is provided. The kitchen is suitable for use by wheelchair users and there is a utility room, assisted bathing and toilet facilities. The home has an enclosed garden shared with tenants living in an adjacent property managed by the same organisation. Parking facilities are available and service provision includes a wheelchair accessible vehicle. The home is owned and managed by Ability Housing Association who specialises in housing, care and support services for disabled people. A full time registered manager is employed responsible for the day-to-day management of the home. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first inspection for the year 2005/2006. It was unannounced therefore staff and service users were not informed in advance of the inspection being undertaken. The inspection commenced at 14.10hrs and concluded at 18.00hrs. The home manager was on duty at the time of the inspection, also two support workers. The inspection entailed following up progress for compliance with requirements of the last inspection. A partial tour of the home was carried out and some records and policies and procedures were examined. The inspector spoke with the manager and both support workers, one of whom was employed by an agency who worked regularly at this home. The inspector had conversations with four of the five service users and an in depth discussion with one service user to illicit views and information about life at The Lodge. Following this inspection a comment card was completed by a service user with the assistance of a key worker. This information contributed to the inspection outcomes. The inspector would like to thank the service users, the manager and support workers for their courtesy and cooperation during this inspection. What the service does well: The quality of information produced about the home was considered good. The service users guide and statement of purpose were in accessible formats. This instilled confidence that prospective service users, with the help of their family and representatives, would be able to make an informed choice about the suitability of the home. The home had a committed, albeit currently depleted staff group. The manager and support workers were observed in their interaction with service users. They were respectful and age-appropriate in their manner of address to service users. Staff demonstrated good knowledge of service users’ needs, ensuring appropriate methods of communication and overall providing an enabling and inclusive environment. Staff on duty were observed to be caring and professional in their approach to service users at the time of the inspection. Two service users informed the inspector that staff were “nice” and responded “yes” when asked if staff treated them well. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 6 Service users were actively encouraged to participate in the day-to-day running of their home within individual levels of capacity. There was individualised risk assessment supporting service users in responsible risk taking. Care plans reflected an individualised approach to meeting needs. Observations confirmed staff respected service users’ dignity giving due attention to dress and personal appearance, thereby enhancing self – esteem. Service users benefited from a well - structured, daily living activities programmes that afforded opportunities for integration in the community and use of community facilities. Service users were encouraged and supported in maintaining relationships with families and friends. Self - advocacy groups external to the home were accessible to service users. Service users had opportunity to go on supported holidays and on day trips to places of interest of their choice. Administration and record keeping was well organised. Staff training files demonstrated arrangements for new staff to receive induction training and continuous further training and development. What has improved since the last inspection? What they could do better: Further attention was required to the home’s staff recruitment procedures to ensure prospective staff provided a statement as to their mental and physical health. Personnel files held at the home must include all statutory information and documentation. This must include a full employment history and proof of identity including a recent photograph. A record of CRB Disclosures for staff must be available for inspection at the home. The care home must be visited at least monthly unannounced and in accordance with statutory requirements by an employee of the organisation not directly concerned with the home’s conduct. A written report of these visits must be prepared and held in the home. For management to draw to the attention of the pharmacist responsible for supplying the medication Nomad system, that cassette labels on the reverse of these boxes are not all accurate. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 7 Key workers need to ensure the date of reviews for risk assessments and care plans is recorded on care documents. Care plans must be reviewed with the service user and involving relevant, significant third parties at least every six months. 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. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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 Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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, 2, 3 and 4 The home was operating effectively in respect of these standards. Prospective service users and their representatives had adequate information to enable informed choice about the suitability of the home. The admission procedures were based on comprehensive assessments of need. Prospective service users were offered opportunity to visit the home before moving in and admission procedures included trial placement periods. EVIDENCE: The Statement of Purpose depicted the services provided by the home and contained all statutory elements. The Service users were involved last year in formulating a new Service User Guide produced in a format using language and symbols to aid comprehension of the contents of the document. There had been no new service users since the last inspection. Records sampled confirmed that prospective service users received a full and comprehensive assessment of needs prior to moving into the home. Information in the assessment viewed was relevant and background information collated that enabled staff to identify risks, also strengths and needs and know the aspirations of this individual. Prospective service users had opportunity to visit the home and to get to know other service users prior to admission. Admissions were based on trial placements for a specified period. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 10 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 Service users were aware of their care plans and these were drawn up in consultation with them. Evidence gathered demonstrated each of these standards 7, 8 and 9 were met effectively. Attention was required to aspects of record keeping and frequency of reviews in relation standard 6. EVIDENCE: Discussions with individual service users established they were aware of their care plans within individual levels of capacity. Two service users plans were sampled and information therein found to be well organised. Risk assessments, behaviour management guidelines if needed, personal, health and social care plans were in place. Attention was drawn to the need to ensure review dates were recorded in all of these documents and to ensure these were updated at regular intervals. It was noted that staff vacancies had adversely impacted on the schedule for six monthly reviews and some slippage evident in carrying out reviews. Discussion with the senior support worker confirmed she was in the process of planning review dates. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 11 Service users choice and involvement in running the home was evidently of high importance to staff. The day-to-day operation of the home ensured user choice regarding individual lifestyles, based on assessment of needs and personal aspirations. There were systems for involving service users in planning menus, in shopping for food and in food preparation. Individual programme plans promoted independence. A service user informed the inspector that staff supported and encouraged him to keep his room clean. Minutes of service users meetings also demonstrated regular consultation with service and their involvement in decision making about their home. Comments from one service user that a member of staff sometimes did not give sufficient attention to communication with this individual was later discussed with this person’s key worker. It was noted that the key worker intended to address this with the team at the next staff meeting. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 12 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): 11, 12, 13, 14, 16 and 17 The home met each of these standards. It was demonstrated that service users were encouraged and supported to be as independent and lead as fulfilling lives within individual capabilities. EVIDENCE: It was evident from the available information that service users continued to receive sustained encouragement, instruction and stimulation as continuing elements of their daily lives. Life skills training opportunities were afforded service users who were supported in budgeting and managing their personal finances to promote independence. Arrangements had been made to ensure that service users with complex multiple disabilities and behaviours had received specialist interventions and services as required. Service users had opportunity to access local support networks to facilitate integration in the local community. There was a range of information supplied to service users and staff support enabled service users to make appropriate choices in their daily lives. Care plans indicated suitable arrangements for stimulation and involvement of service users within individual preferences in community events and educational and vocational activities. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 13 Service users exercised their right to choose when to be alone or be in the company of others and whether or not to join in activities. Choices and rights were balanced with agreements in individual plans. Any restrictions to service users rights were explicitly stated in the service user plans sampled. Rules in the home were minimal and existed to protect the welfare and safety of service users and/ or to promote harmonious communal living conditions. Service users engaged in menu planning using visual cues. The meal served in the dining room on the evening of the inspection had been prepared by a support worker. This was observed to be substantial and appetising. A service user who was developing independent living skills cooked her evening meal and joined the group of service users and staff to eat her meal. She had earlier gone shopping with the senior support worker and drawn money out of her bank account. The presentation of food and the dining table was of a good standard. Recognition was given to the social importance of meal times in the home. Staff were observed to encourage service users to socialise at the table and talk about their day. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 14 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 Systems were in place for consulting service users, ensuring preferences were accommodated in the delivery of personal care. Access to treatment and support from health care agencies was demonstrated. Systems for the safe management of medication were in place. EVIDENCE: Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 15 The home’s routines for determining times for getting up/going to bed, meals and other activities were reasonably flexible, structured by pre arranged personal social, leisure and training programmes and service users’ individual preferences. Personal intimate care and support on the day of the inspection was delivered in private. On the basis of information discussed with service users and staff and direct observation of care records it was concluded that the core value principles of privacy, dignity, independence, choice, rights, fulfilment and individuality underpinned staff’s care practice and the home’s operation. Service users were registered with a General Practitioner and received support to access NHS health care facilities and specialists in accordance with individual needs. Discussions included staff training and support in the management of stoma care and epileptic seizures. Medical emergencies were managed within clear protocols agreed with the General Practitioner. Medication policies and procedures had been reviewed and updated and staff training in the handling of medication and in administration of prescribed rectal medication was evidenced. The latter practice was not undertaken however due to being unable to verifying staff competence based on practice assessments. Staff were instructed to call for para medics in the event of service users having multiple seizures. Medication storage was inspected, also administration and recording practices. Discussed with the manager was for staff responsible for checking in medication to be instructed to contact the pharmacist in respect of inaccurate labelling of Nomad cassettes. Observations confirmed labels did not all reflect current prescriptions. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 16 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): 23 Service users were protected by the organisation’s training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: Discussions with individual service users and observation of notes of service users meetings confirmed the willingness of staff to listen to service users and to try to resolve problems in any way that they could. The establishment had a copy of the revised multi-agency vulnerable adult protection procedures. The staff team had received adult protection training. Some had attended adult protection awareness training organised by Surrey County Council. All staff had undertaken training earlier this year under the Learning Disability Award Framework, which included a module on adult protection matters. The adult protection procedures were invoked earlier this year in response to an incident at the home involving a number of service users. Subsequently risk assessments and procedures were revised and agreed. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 17 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, 25, 26, 27, 28, 29 and 30 The home met each of these assessed standards providing accommodation appropriate to the needs of the current service users. EVIDENCE: The location of the home was suitable for its stated purpose. A ramp was fitted to the front door which had an automatic opening/closing device fitted. Ramped access to the garden was provided and new garden furniture had been recently purchased in consultation with service users. All areas of the home had been redecorated since the last inspection. Individual service users informed the inspector of how much they valued having their own bedrooms. The kitchen had been refurbished with wheelchair accessible units, appliances and sink unit. A new shower chair had been recently purchased. All areas of the home viewed were observed to be clean and comfortable and bedrooms well personalised. Infection control procedures and practices were not assessed. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 18 The number of toilet and bathing facilities were adequate and these were fitted with appropriate aids and adaptations. Hot water temperatures appeared safe at the time of the inspection and valves were fitted for controlling water temperatures. Regular monitoring of hot water temperatures was evident. Laundry facilities were domestic in scale. The utility room was not accessible to wheelchair users. At the time of the inspection the washing machine was not functioning. Service users’ washing was done using a washing machine in an unoccupied flat on the first floor. A new washing machine was on order. Provision of equipment to meet individual needs included shower chairs, grip rails, raised toilet seats, hoist, walking aids, wheelchairs and an emergency call system throughout the home. Observations confirmed strategies were in place to enable service users with visual impairments to safely navigate their way around the home. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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): 31, 32, 33, 34, 35 and 36 The home’s staffing arrangements and staffing levels offered flexible levels of support as necessary to meet the service stated purpose and service users’ needs. Staff recruitment procedures required attention and additional information must be held on personnel records in the home. Discussions with the manager and support workers confirmed commitment to supporting service users, with training and development given sufficient priority. EVIDENCE: Staff on duty were observed to be caring and professional in their approach to service users at the time of the inspection. Two service users informed the inspector that staff were “nice” and responded “yes” when asked if staff treated them well. Support workers had generic roles and were responsible for ancillary duties in addition to responsibilities for personal care and support. There had been some staff turnover since the last inspection. Interviews for two support workers vacancies were arranged for the following week. A support worker had been appointed to a third vacancy and was awaiting CRB clearance before taking up post. A good response to the latest recruitment campaign was reported. Staffing levels appeared adequate and continuity of care was being maintained through the use of regular agency staff. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 20 Personnel documentation was now held in the home available for inspection. Personnel records were held securely and confidentially. Observations identified the need for details of staff’s previous employment, current photograph and other ID information as specified in Schedule 2 of the Care Homes Regulations, 2001 (amended) to be held on staff’s files in the home. Additionally it is a statutory recruitment for recruitment procedures to include staff declarations relating to mental and physical health. A record of CRB Declarations for staff must also be available in accordance with the CRB policy statement on the ‘Secure Storage, Handling, Use, Retention and Disposal of Disclosures and Disclosure Information’. Staff received induction and core training within their six months probationary period wherever possible. The induction and core training under the Learning Disability Framework (LDAF), which was supposed to be undertaken within this period, was difficult at times to access. This could lead to probationary periods being extended. On – site LDAF training was delivered for the whole team earlier this year. Observation of staff training certificates identified the need for moving and handling training to be updated for individual staff. The manager was aware and confirmed her intention to arrange the necessary training. At the time of the inspection the senior support worker was the only staff member to have NVQ Level 2 in care and had just started NVQ Level 3. The manager stated two support workers were being encouraged to enrol for NVQ Level 2 training. A staff supervision structure was operational. The manager and senior support worker shared responsibility for supervising support workers every six weeks. The senior support worker had received training in staff supervision since the last inspection. The manager confirmed a performance related pay structure had been introduced for key workers based on twelve competencies. A new appraisal system was also being implemented. The manager and senior support worker directly supervised Day staff. Discussed with the manager was the need to implement arrangements for monitoring night staff’s practice. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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, 40, 41 and 42 There was sound leadership and consistent management direction to the team to ensure service users received consistent, quality care. The management of the home promoted and protected the health, safety and welfare of service users. EVIDENCE: The home manager had relevant knowledge, skills and experience and was registered by the Commission. She also held a management qualification and was currently studying for the Registered Manager in Care Award, NVQ Level4. Observations concluded that the home was managed effectively and efficiently promoting good practice and users rights. Observations confirmed changes within the organisation’s management structure and line management responsibilities. The new line manager was stated to visit and to be accessible and supportive as much as possible given her substantial areas of responsibilities and workload pressures. Observations confirmed that the last report for the statutory monthly provider visits was dated 14th July 2005. The manager confirmed new arrangements being Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 22 implemented for a team leader from another area to conduct these visits in future. Records viewed were mostly up to date; comment has been made in the relevant section of the report on the need for care documentation reviews to be recorded. Security of records was demonstrated and staff were aware of the boundaries of confidentiality. Staff conferences were held annually at which staff were encouraged to express their views and made suggestions. The organisation also convened working parties where policies and procedures were written and staff and service users invited to attend. The manager was informed that the Care Homes Regulations 2001 had been revised and advised to obtain a copy. The electrical certificate and portable electrical appliance testing records were examined. Also the fire safety risk assessment and fire records. Discussion took place with the manager on changes suggested for improvement to the fire risk assessment. The need to ensure regular fire practices were conducted was identified. The manager was aware that the employer’s liability certificate displayed was just expired and would be following up the issue of a new certificate. Staff held appointed person first aid certificates and accident records were appropriately recorded and stored. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lodge (The) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X 2 3 3 X DS0000013584.V256293.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation Requirement Timescale for action 13/11/05 2 3 YA34 YA34 4 5 YA34 YA34 6 YA40 14(2)(a)(b) For care plans to reviewed at least six monthly and all care documentation to include review dates. 17 Sch2.7 For a record of CRB Disclosures to be available for inspection for the staff team. 17 Sch2.8 For the staff recruitment procedures to include a statement by the applicant as to individual mental and physical health. 17 Sch2.6 For personnel files in the home to include a full employment history. 17 Sch2.1 For personnel files in the home to include all statutory proof of identity including a recent photograph. 26 For statutory visits to be (2)(4)(c) undertaken unannounced by an employee of the organisation at least once a month in accordance with Regulation 26. (4)(a)(b)(c) of the Care Homes Regulations. 13/11/05 13/11/05 13/12/05 13/12/05 13/11/05 Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 25 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 Refer to Standard YA40 YA42 Good Practice Recommendations For the home to obtain a revised copy of the Care Homes Regulations 2001 (Amended). To review the fire risk assessment and revise some risk assessment outcomes. Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Lodge (The) DS0000013584.V256293.R01.S.doc Version 5.0 Page 27 - 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!