Inspection on 17/09/07 for The Lodge

This inspection was carried out on 17th September 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Lodge 12/01/10

The Lodge 19/02/09

The Lodge 30/08/06

The Lodge 29/06/05

The Lodge 08/12/04

The Lodge 24/08/04

The Lodge 01/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Lodge, The Bridge End Eldersfield Gloucestershire GL19 4PN Lead Inspector Dianne Thompson Unannounced Inspection 17 September 2007 14:00 th Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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 DS0000018687.V338407.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 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 DS0000018687.V338407.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lodge, The Address Bridge End Eldersfield Gloucestershire GL19 4PN 01452 840088 01452 840088 eddavics53@btinternet.com 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) Glevum Farm Trust vacant post Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate one named person with a learning disability who is over the age of 65. The home may accommodate one named person who has an additional physical disability. 10.09.06 Date of last inspection Brief Description of the Service: The Lodge provides residential accommodation for a maximum of six adults, one of whom is over the age of 65, who have learning disabilities. The home is located in Eldersfield and forms part of a working farm. The farm is staffed separately from the residential accommodation and offers day activities in farming and horticulture to individuals from the surrounding communities. The day activities of residents who live in the home are not limited to the onsite facilities and are developed in a way that reflects individual interests outside the farm environment. Glevum Farm Trust owns the property. The trustees are registered as providers and as such carry responsibilities for the overall development and management of the home. Mr E Davies is identified as the Trust Manager, Company Secretary and Responsible Individual. The home currently has an acting manager. The Glevum Farm Trust operates another establishment in New Street, Ledbury, Herefordshire, which is included in the registration as an annexe of the Lodge. The fee levels for The Lodge range from £314.06 to £584.85 depending on individual assessed needs. Charges that are additional to the fee include personal toiletries and clothing, holidays, major extra outings, hairdressing, leisure and activities. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit to see what the home was like to live in for the people who live there. The inspector talked to some of the people who live at The Lodge and some of the staff working there. We looked at some of the policies and procedures in the home. Policies are rules about how to do things. We spent some time looking at records. The Responsible Individual completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). What the service does well: What has improved since the last inspection? What they could do better: Produce the Service User guide in the new format that will make information more accessible to people who use the service. Daily routine information sheets should be dated to show that they are current and that they are reviewed regularly. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 6 Person centred care plans should be completed for everyone who lives at The Lodge. Glevum Farm Trust needs to make checks on the quality of the service being provided at The Lodge. They should ask people for their views about the home. A report should then be written and plans made to make any changes that are needed. Staff need to be trained to help them develop their understanding of how to meet peoples’ needs and give them the support they want. All staff should be trained in how to give first aid. The service needs a manager who has the skills and experience to make sure the home is well run. Staff need a manager who can support the staff team. 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. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 7 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 DS0000018687.V338407.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a range of information about the home that is made available. Assessments are completed before people move into The Lodge, to make sure their individual needs can be met. EVIDENCE: There has been one new admission to the home since the previous inspection. It is evident when talking to staff and checking records that Glevum Farm Trust (GFT) policies and procedures were followed. There is a brochure about the home, a Statement of Purpose and Service User guide available. The information has been produced in different formats such as pictures and symbols and makes it is easier for people to understand. The Responsible Individual (RI) states in the AQAA that ‘we have produced a suite of user friendly documentation’ in the past 12 months. It is disappointing that this improved documentation has not yet been made available to everyone. Full assessments were completed for everyone before they moved into the home. A care plan is written based on the information from the assessments, when a person comes to live at The Lodge. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 9 The IR states in the AQAA that ‘we have a selection procedure that involves all stakeholders in all aspects of the choice process. We provide user-friendly information about our services including an informative web site’. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans are currently being updated and reviewed. This will make sure that all staff have the information they need to provide consistent support and make sure that individual needs are being met. Risk assessments show how risks are to be reduced and the ways that independence is promoted and maintained. EVIDENCE: Care plans for three people were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. The care plans have improved in content and recording since the previous inspection and are more accessible to individuals and staff to provide consistent support. The daily routine information sheets have been completed Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 11 for each person and clearly show each persons preferred daily routines and how their independence is promoted. These information sheets should be dated to show that they are current and that they are reviewed regularly. The RI states in the AQAA that ‘our IPP programme for each resident reflects the changing needs of every person and allows them to make their own decisions about their lives’. One resident said ‘I was locked up in an institution before – look at me now’. ‘I like being at the Lodge, I don’t want to look back only look forward’. Staff explained that individual care plans are being updated and this was evident in the files. Each person is allocated a key worker to oversee his care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. There is evidence of key worker support and encouragement to make sure that people who use the service are fully involved in making choices and decisions in their lives. Staff said they are fully aware of the plans and follow them to guide their practice. Risk assessments are completed to keep people safe, and suitable guidelines have been developed to provide assistance as necessary. A risk assessment must be completed for a resident where a risk of choking has been identified, and guidelines established of action to take should choking occur. This was a requirement of the previous inspection and has been partially met. The risk assessment should be developed further to provide agreed responses should choking occur. The current risk assessment identifies that ‘all staff are to be first aid trained’ as a control measure. Staff training records indicates that not all staff are first aid trained. Further reference to staff training is included in the section NMS 35, Staffing section. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive help and encouragement to lead active and interesting lives. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are generally well catered for with a varied and healthy menu provided. EVIDENCE: People who use the service were welcoming and participated throughout the inspection visit. Time was spent talking with people who live at The Lodge and the staff on duty. Staff talked to residents respectfully and appropriately throughout the evening. The atmosphere was welcoming, friendly, very relaxed and homely. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 13 One resident said ‘ I’m independent now, I go and do my own shopping, I go on the bus on my own and do my own washing’. ‘I can be private when I want’ when asked about living at the Lodge. A range of activities is promoted for people who use the service, both inhouse, on the farm and within the local community. These activities include going to the Rainbow Club, attending day centres, shopping, going to the local pub, walking, working on the farm, music, crafts, and watching TV. Everyone is given the opportunity to take part in events that are organised. Staff said that opportunities are discussed regularly with people who use the service through their weekly meetings. Planning activities, menus, and any other issues within the home are discussed. Activities include Jacuzzi, gardening, recycling, deconstruction, art and craft, and work skills. People who use the service said they enjoy listening to music in their rooms. One person said he had a CD player for his birthday and a TV from his family. All residents have their own music players and TV, and enjoy listening to their music, sometimes listening to different kinds of music at the same time!! One person talked about the fence painting he had done. He had enjoyed this and was very proud of his skills and his achievement. Day trips have included trips to Barry Island and shopping trips to Cheltenham. One person said he had ‘been to the Forest of Dean for a holiday’. A holiday to Butlins is being planned. ‘ I like the beer and the Hi di Hi’ said one resident, but he doesn’t like Blackpool! Evidence shows that regular contact with friends and family is supported. One person said his brother had visited him last week. Records show that regular visits to family are supported. Menus are planned during meetings when people make their choices for the coming week. At the time of the inspection the evening meal was being cooked. This consisted of fish fingers, mashed pots and fresh beans. Menu records were checked and showed a well-balanced and varied selection of meals and options. People are able to help themselves to snacks and drinks that are available in a separate fridge. People who use the service said they are able to choose their own foods such as cereals. They also said they eat a lot of fresh fruit and vegetables. Some people said they could cook simple meals. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Details of individual personal and healthcare needs are identified in care plans, but would benefit from using health action plans. The Lodge has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service and staff. EVIDENCE: People now have their health information included in their individual care plan and not in a communal file as previously. It is now easier to access information and follow routine checks and monitoring. The health records could be further developed through the use of Health Action Plans. There is an improvement in the level of recording and information available in care plans to advise and inform staff, although information recorded on medical records needs to be more detailed. For example, one record shows Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 15 that high calorie foods are needed to help with weight problems. There is no information about the kind of food to be encouraged and provided. A medication sheet provides details of prescribed medication for each person. These should be dated to ensure they are current and up to date. People have good access to medical support through their GP, opticians, speech and language therapists, dentist, chiropodist, psychiatrist and the community learning disability team. People are offered annual health checks through the community nurse. Medication is well managed by the staff at The Lodge. Medication is stored securely and given to people at the right time and full records are kept which show this. Medical information contained in files that is out of date should be archived. Staff said that some archiving of information is being done. A medication policy and procedure is in place and provide guidelines to follow should any medication error occur. Additionally, procedures advise that errors are to be reported to the CSCI. The risk assessment in regard to the administration of medication states the GFT manager ensures that medications are done correctly. This monitoring is not currently being done, as the home does not have a full time manager in post. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are protected from abuse. They have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. EVIDENCE: There are suitable procedures in place at The Lodge to respond to any allegations of abuse and for managing any complaints made about the service provided. A copy of the local procedures is also available. Staff support people who live at The Lodge should they wish to make a complaint. Staff said that no complaints have been made to the home and the CSCI has not received any complaints about the home since the previous inspection. The RI has identified in the AQAA that ‘we could attempt to involve our residents relatives and carers more effectively to identify concerns or complaints early’, and is planning to develop this during the coming year. There are suitable finance procedures in place and the RI confirms in the AQAA that ‘more simple cash accounting has been introduced into the home’. People who live at the home said they have their own money and they are happy with the way they are supported to manage their money. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at The Lodge enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A partial tour of the home was conducted. The lodge is a detached home, which has a large lounge and dining room, a separate smaller lounge, a large kitchen with dining table, and sufficient bathrooms, shower and toilets to accommodate the needs of residents. The home has been extensively refurbished since the last inspection. New furniture has been purchased for the lounge and is more comfortable and attractive. The kitchen has been redecorated and has new equipment including a dishwasher. A new cooker has been installed to replace the range, a new fridge and an additional freezer has also been purchased. The RI states in the AQAA that ‘ we have completely refurbished all communal areas at The Lodge’. ‘We have undertaken extensive redecoration over the Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 18 last 12 months’. ‘ We intend to continue with a programme of refurbishment which will include a complete revamp of the central heating system’. One resident spoke of the new furniture he has in his room. He has had a new bed, a new carpet, a bookcase and the room has been repainted. One resident said ‘I chose the furniture and all the bedding as well’. ‘I went to a furniture place down the road and chose new curtains as well’. Another resident said that ‘I chose pine, and I chose yellow and cream for the walls’. Policies and procedures for infection control are in place. Communal bathrooms have paper towels and liquid soap available. All cleaning materials are stored in locked cupboards. Staff were seen wearing appropriate protective clothing for the work they were doing. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at The Lodge. Staff work together to provide consistent and good quality care. GFT’s recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at The Lodge. EVIDENCE: A committed and stable staff team work at The Lodge. The staff team are very well motivated and actively seek ways to improve the lives of the people who use the service. According to the Staff Training records staff training for the past year has been inconsistent. Training courses completed includes epilepsy, mental health awareness and some people have completed their first aid. Challenging behaviour training was completed in 2006. Fire fighting training records show Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 20 the last training completed for some people was two years ago. First aid training for some staff is well out of date (completed 2005). A risk assessment for choking states that first aid training of all staff is the control measure for the identified risk. During the last inspection it was identified that staff needed training in Health Action Plans and risk assessments. There is no evidence to show that these training courses have been completed. At the time of the inspection only one member of staff in a team of ten staff working at The Lodge is qualified to NVQ level. At the last inspection the acting manager and RI said they were not able to address NVQ training at that time as a full evaluation of staff training was planned. This evaluation was to establish individual needs and a training and development programme, which would incorporate NVQ’s as required, would be completed. A copy of this programme should have been submitted to CSCI. To date this has not been received. All newly employed staff complete an Induction Course. The Induction process includes new staff being supported by regular staff to familiarise themselves with the home, people who use the service and safety matters. The acting manager confirmed at the previous inspection that a staff handbook was being developed to include the ‘Scils for Care’ induction course and individual staff training and development plans. A copy of this handbook was to be sent to CSCI. This handbook was not evident within the home. In the AQAA the RI states that ‘we could increase and improve our staff training programme’. GFT recruitment policy and procedures ensure that everyone completes an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. The new member of staff confirmed recruitment procedures had been followed. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does not have a registered manager in place. The Lodge needs a manager who can provide the leadership and management skills to develop this service. GFT monitor the home in various ways to make sure that the health and welfare of people using the service is protected, although a quality review process should be established. EVIDENCE: The Lodge does not have a registered manager and the home is currently managed by a part time acting manager and the RI. The acting manager works part time to meet with staff on a monthly basis to complete regular staff supervisions. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 22 The Annual Quality Assurance Assessment (AQAA) was completed by Mr Ed Davies the RI and sent to the CSCI within the required timescales. The AQAA says that ‘a clearer and more effective management style has been introduced’. Staff say that the acting manager provides regular staff supervision. When asked about observed practice staff confirmed that this does not happen routinely and they feel they need on the job feedback. The acting manager is available for telephone advice. The RI is available for contact, advice and on call, but this is not an effective management of the service. The lack of progress in the implementation of proposed changes to documentation that were shared during the last inspection demonstrates this. Copies of such documentation were shown to staff during the inspection visit. Staff said they had not seen this before but thought everyone using the service would find the new format very effective. ‘This is brilliant’ and ‘this would be very good for us to use’ being two of the responses. The lack of a permanent full time manager is evident within the service. Staff are feeling undervalued and need a leader to maintain consistency of approach and implement procedures fully. To comply with Regulations 8, 9, and 10 the appointment of a full time registered manager must be made. The provider’s monthly visits are one of the ways that GFT monitors the service and how the home is being run. These visits include interviews with staff and people who use the service. However, the monitoring of the quality of the service should include an audit of relevant parts of the service including records, environment, complaints received, and finance and safety. Any actions that may be needed to address shortfalls should be specified. The resulting reports should form part of the home’s quality assurance and monitoring system and form an annual development plan for the service. This report should include views on the service from people who use the service, stakeholders and interested parties. This was a requirement of the previous inspection and remains outstanding. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Fire drills are completed regularly. It is however important that people present during fire drills are identified in the records to make sure everyone takes part in regular fire evacuation procedures. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA9 Regulation 13 (4) Requirement A risk assessment must be completed for a resident where a risk of choking has been identified, and guidelines established of action to take should choking occur. Previous timescale of 20/11/06 partially met. The risk assessment must be developed further to ensure that the control measures in place are complied with. The home must ensure that there is a training and development programme for all staff that incorporates NVQ’s as required. A copy of this programme should be submitted to CSCI. Previous timescale of 20/11/06 not met The appointment of a registered manager must be made to comply with Regulations A quality assurance audit must be completed within the home in accordance with the NMS DS0000018687.V338407.R01.S.doc Timescale for action 20/12/07 2. YA35 18 20/12/07 3. YA37 8 19/01/08 3. YA39 24 20/12/07 Lodge, The Version 5.2 Page 25 regulations and requirements. Previous requirement of 20/11/06 not met 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 YA6 YA19 Good Practice Recommendations Daily routine information sheets should be dates to show they are current and that they are reviewed regularly. Information in medical records should be specific about the support that is needed for each individual. Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Lodge, The DS0000018687.V338407.R01.S.doc Version 5.2 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. 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