Inspection on 24/05/06 for Lodge The Residential Care Home

This inspection was carried out on 24th May 2006.

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

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

Other inspections for this house

Lodge The Residential Care Home 23/10/08

Lodge The Residential Care Home 02/11/07

Lodge The Residential Care Home 03/11/06

Lodge The Residential Care Home 07/02/06

Lodge The Residential Care Home 17/08/05

Lodge The Residential Care Home 17/03/05

Lodge The Residential Care Home 24/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lodge The Residential Care Home Heslington York YO10 5DX Lead Inspector David White Key Unannounced Inspection 24th May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lodge The Residential Care Home DS0000038016.V295036.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. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lodge The Residential Care Home Address Heslington York YO10 5DX 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) 01904 411087 01904 411087 Colourscape Investments Limited T/A The Lodge Residential Home Mrs Geraldine Ann Timbs Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24) of places Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: The Lodge is a care home registered by Colourscape Investment Limited to provide accommodation and personal care to up to twenty-four older people who may have dementia. The company has recently been sold and new directors have been appointed. The home consists of a large, detached, pre-Victorian house with a newer purpose built extension. It is situated in the village of Heslington and is within walking distance of local facilities and amenities including shops, cafes and pubs. The amenities of York city centre are also accessible by transport. Twenty of the twenty-two rooms are for single accommodation, two are for shared accommodation. None of these rooms has en suite facilities; there are however sufficient bathroom and WC facilities for the residents that are located close to bedrooms as well as ground floor shared rooms including the dining room, lounge and quiet room. Bedrooms are situated on the ground and first floors, the latter being accessed by one of two staircases. The home does not have a passenger lift but one of the staircases has a stair lift. There is ramped access to the home. The home has a large well-maintained garden and there is an area of hard standing for parking to one side of the building. The current fees for the home range from £410-£425 per month. The fees do not include the use of services such as hairdressing and chiropody. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 24th May 2006. This visit was carried out by one Regulation Inspector and took 9 hours with 3 hours preparation time. Since the last inspection of the home there have been complaints from people previously associated with or working at the home relating to the care of services. This resulted in a planned meeting with staff currently working there on 27th April 2006 to find out if they had any concerns about care. These matters are referred to in the body of the report. The home was not able to return the requested information before this site visit due to the short timescales. It was therefore decided not to use service user surveys at this key inspection. The site visit comprised of a full inspection of the premises. The care records of four service users were looked at which included service users assessments, care plans and medication records. Staff rotas, some policies and procedures and health and safety documentation were inspected. Time was spent talking to three service users, one visitor to the home, three members of staff and the deputy manager and manager of the home, observing the activity in the home and the interaction between service users and staff. Information was also used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The focus of the inspection was on a number of key standards, inspecting the case records of a number of service users to establish whether they corresponded with their experiences of life in the home. The registered manager was available throughout most of the inspection and the findings were discussed at the end of the inspection. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home’s complaints procedure is not clear and people making a complaint are not aware of what will happen afterwards and when. Staff need training and clear guidance about how to protect service users’ from risk of harm and how to make referrals to social services if concerns arise. The flooring in the downstairs bathroom is loose and must be repaired or replaced to safeguard the health of service users’. There are some requirements made by the Environmental Health Officer which also need attention. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 7 The dining room carpet is in a poor state and must be cleaned or replaced and the ceiling above the landing stairs needs to be re-decorated to improve the living environment for service users. Urgent action needs to be taken to make sure service users’, staff and visitors of the home are not placed at risk from not being able to have clear access to a fire exit. A formal letter was left at the site visit requiring the provider to deal with this problem. Urgent action needs to be taken to ensure that service users in order to protect their safety do not have direct access to chemical cleaning products. A formal letter was left at the site visit requiring the provider to deal with this problem. Service users’, relatives and other professionals must be given more opportunity to express their views about the care and services provided and how the home is run. Staff must have fire safety training so they are clear about what to do in the event of a fire so that the safety of service users’, staff and other visitors to the home is protected. Some of the problems in the home were linked to previous conflicts between senior people within the company. The registered person must ensure that proper management arrangements are maintained. The registered provider is requested to send an improvement plan to the Commission detailing the outcomes to be taken to improve the performance of the home and outcomes for the service users. 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 Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Proper pre-admission arrangements were in place to ensure that service users’ could have their needs met by the home. EVIDENCE: The statement of purpose and service user guide providing information about the home had been updated and was made available to prospective and existing service users’. The statement of purpose provided up to date information about facilities and services in the home but needed to be more detailed. Four pre-admission assessments were seen. They identified that staff at the home collect information from a number of sources prior to admission so that they were able to make an informed decision as to whether the needs of prospective service users could be met. The registered manager undertook the pre-admission assessments of prospective service users. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 10 Each pre-admission assessment looked at the identified needs of each service user and a care plan was drawn up from this to describe how the assessed needs were to be met. Information was obtained from local authorities for those service users’ who were subject to care management arrangements and the home’s needs assessments reflected the information provided by the placing authority. Those service users’ spoken to were able to say what their needs were and what kind of support they required. The care records confirmed that the staff team were giving the necessary care and support. The home did not provide intermediate care. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Overall service users’ receive a good standard of care, which ensures that their needs are met. EVIDENCE: The Commission had received some information since the previous inspection visit expressing concerns about the quality of the care plans and the medication procedures at the home. The care records of four service users’ were looked at. These were written in simple language and a recently appointed member of staff said that the care records were easy to understand. Each service user had a care plan that considered how areas of the individual’s life were to be met although the plans did tend to focus mainly on the physical needs of service users’. A number of risk assessments were in place to promote independence and safety and this included reducing risks from falls. One service user had difficulty communicating and the care plan described what actions the staff were to take to maintain effective communication with the service user. Care plans were reviewed on a monthly basis to respond to any changing needs. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 12 A number of the service users’ were incontinent and advice would be sought from the continence adviser on their behalf. None of the service users’ had a pressure ulcer but the registered manager said that guidance on skin care would be given by the district nurse and tissue viability services. Each service user had a GP and the daily records reflected referrals to GP’s and other healthcare professionals. Due to the frailty of some service users’, visits are made to the home by a GP and other specialist services. Some care records were not fully dated to indicate when events had occurred. The home had a call bell system and call bells were accessible in all individual and communal parts of the home. Each service user spoken to said, “call bells were responded to quickly”. Service users’ spoke positively about the care provided at the home. One said, “the care was very good and staff were helpful”, another described staff as “efficient and cheerful”. The home’s medication system and facilities were inspected. Proper procedures were in place for the ordering, administration, storage, recording and disposal of medication. The home had a system whereby on receipt of service users’ medication this was recorded on the Medication Administration Record (MAR) so a record of individual medication supplies could be kept for each service user, however in some cases this information was omitted from the MAR sheet. A random check of the medication supplies was made against MAR sheets that did contain information about received medications and these tallied with the records. Some staff had attended medication training at a local college to keep their knowledge updated, however two members of staff administering medication in the home were in need of this updated training. During the inspection service users’ were seen to be treated with respect and were addressed by their preferred names. Service users’ were able to confirm that their privacy was respected and that their dignity was maintained by staff when receiving personal cares. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines enable service users’ to make their own choices about how they live their lives. EVIDENCE: Since the previous inspection the Commission had received some concerns about the lack of activities in the home. The manager said that activities were available and tended to be planned on a daily basis in accordance with service users’ wishes. Service users’ said that they played dominoes and one service user enjoyed the quizzes in the home. Some service users’ said they preferred not to join in with the activities and this was adhered to. There were occasional visits made to the local pub and trips out. An entertainer visited the home and church services were held on a monthly basis and covered a range of religious denominations. At the time of inspection some service users’ were seen going out with family and friends. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 14 The individual choices and preferences of the service users’ were recorded within their care records. Those service users’ spoken to said they were able to plan their own daily routines. One service user said “I choose when I get up in a morning and when I go to bed” and another said “I could get a bath at any time and do not have to do anything that I don’t want to do”. Service users’ made positive comments about the quality of the meals provided in the home. It was observed on the menu that choices were available at all mealtimes although there was no option at lunchtime for people who did not wish to eat meat. The newly appointed cook said that a review of the menu was taking place and that a non-meat option would be introduced into the menu as part of the review process. Staff said that an alternative meal would be provided if a service user did not like the food options available on the menu. Some of the service users’ were not able to communicate their food preferences, however these were recorded within their care records. The cook also said that observation of food left on service users’ plates from meals could indicate if service users’ were not enjoying a certain meal and this informed the menu planning process. Service users’ said that the food was “very good quality” and “lots of choice was offered”. Staff were observed to be sat assisting service users’ where required and the mealtime observed was unhurried. Any special diets and food needs could be easily met. Visiting arrangements were very flexible and one visitor said “I can visit whenever I want and am always made to feel welcome by friendly staff”. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of staff training, proper guidance and staff’s understanding of adult protection procedures could not ensure that the interests and safety of the service users’ were safeguarded. EVIDENCE: The home had a complaints procedure that provided very little information to complainants and did not explain clearly and in sufficient detail what would happen when a complaint was made and the timescales for completion of any investigations and actions undertaken. The manager of the home said that the home had not received any complaints since the previous inspection, however there were no complaints records available and the home had no system in place to record any complaints made. Despite the lack of proper complaints procedures service users’ did say that they would speak to the manager if they needed to raise any concerns and felt “confident” that their concerns would be addressed properly. The home had a policy and procedure for the protection of vulnerable adults, however this was not in accordance with local NYCC (North Yorkshire County Council) policies and procedures for the protection of vulnerable adults. It was evident from discussions with the manager and members of staff that people were not totally clear about what actions would be needed if abuse was alleged or had happened. None of the staff had attended any abuse awareness training and there were no plans in place for this to happen. The policy for managing challenging behaviour needed to be reviewed. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the environment was comfortable, however some poor care practices and problems with the physical environment mean that the comfort and safety of the service users’ could not be assured. EVIDENCE: On the day of inspection the home was clean with one exception, warm, well ventilated and free from offensive odours. The home had ramped access to enable wheelchair users and people with mobility problems to be able to enter and leave the home. Service users’ accommodation was over two floors, which could be accessed via a stair lift. Hoisting equipment was available to assist service users’ with mobility problems. The bedrooms were of adequate size and were well maintained. It was observed that a bedroom was being decorated for a prospective service user before they moved into the home. Service users’ said that their rooms were “comfortable and kept clean and tidy” and personal belongings could be seen within each individual service user’s room. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 17 There were toilets and bathrooms close to bedroom and communal areas, however on the ground floor two toilets were not clearly marked to direct service users’ to their location. The Commission had received some previous concerns that the cooker in the home was in need of replacement and the home had experienced some problems with the hot water and heating systems in some of the bedrooms. During a look around the environment it was observed that a new cooker and ventilation system had been installed in the kitchen. Work had also been carried out to address the hot water and heating problems and the manager said that these were no longer issues for concern. Random hot water temperatures were checked and found to be within safe levels. Appropriate arrangements were in place for the laundering of bedding, linen and personal clothing and there were adequate supplies of aprons and gloves. Proper procedures were being followed for the disposal of clinical waste. However a number of health and safety concerns were identified during a look around the home. A bed mattress was laid in one of the corridors of the home causing obstruction to a fire exit. Some containers storing cleaning solutions were lying by the mattress and a cupboard in which other cleaning products were stored was open and left unattended to. Service users’ had access to both these areas. The deputy manager said that the bed mattress and cleaning products had only been delivered shortly beforehand and immediately arranged to have the bed mattress stored properly and all the cleaning products securely stored. Immediate requirements were issued in relation to these matters. In the downstairs bathroom of the home a part of the flooring had become loose and could have caused harm to service users’ from tripping and falling. The general décor in the home was satisfactory and well maintained. However the carpet in the dining room looked dirty. On the first floor of the home there was an attractive dome shaped ceiling. It was observed that some wallpaper was loose and hanging from the ceiling and this was not pleasant to look at for service users’ or visitors to the home. The heating and lighting throughout the home was generally satisfactory, however lighting in the staff office was poor. The deputy manager said that the matter had been reported for attention. An environmental health officer undertook a recent visit to the home and made a number of requirements relating to health and safety in the home. Some of these requirements had been addressed and the management of the home had made arrangements to address the remaining issues. The timescale for meeting these requirements had not yet elapsed and it was the intention of the environmental health department to carry out a further visit to the home to look at the progress made in meeting the requirements. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were sufficient and recruitment procedures were robust to safeguard the interests of service users’, however inadequate staff training could not ensure that the staff team were appropriately equipped to meet the needs of the service users’. EVIDENCE: The Commission had received some concerns that staffing levels in the home were inadequate and that staff training was poor. The duty rotas were inspected and these showed that there were three staff and the manager and/or deputy manager on duty in a morning, three afternoon staff, three evening staff and two night staff to care for 23 service users’. Three staff had left the home recently and staff said that the atmosphere in the home was affected and staff morale had been poor. Since then three new members of staff had been appointed and staff said that this had improved both the atmosphere and morale in the home. Service users’ said that the atmosphere in the home was “good” and felt there were “always enough staff on duty”. The home employed a sufficient number of kitchen staff and cleaners to meet the needs of the service users’. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 19 The staff files of three newly appointed members of staff were looked at. These showed that all the necessary pre-employment checks had been carried out prior to the new workers starting in post. Recruitment procedures promoted equal opportunities for all applicants. Training records were not available, but the manager said that all staff had recently received moving and handling training and some had received an update on first aid. However none of the staff were up to date with fire safety training and required updated training in health and safety, food hygiene and infection control practices. The manager had a rolling programme for staff to attend NVQ training. Some staff attained NVQ level 2 but had since left the home. A recently appointed member of staff said that some induction training had been given by a senior member of staff upon starting work at the home. However there were no records to confirm this had taken place. Arrangements had been made by the manager for new workers to attend a formal 1-day induction course. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Improvements needed to be made to the way the home was managed to make sure that the home was run in the best interests of service users’ and their safety protected. EVIDENCE: There had been some conflict between senior people within the company who own the home, which according to staff was “unsettling” and had contributed towards a strained atmosphere and low staff morale in the home. The conflict had been resolved and staff felt that the atmosphere of the home had improved as a result of this. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 21 The home had a registered manager who had experience of running the home was about to complete the Registered Manager’s Award. However the conflict within the company had caused problems with the management of the home and had contributed to a fall in standards in the home and led to problems with staff training, health and safety practices, issues with the physical environment and service users’ involvement in decision making about the home. There was little evidence that any quality assurance systems were in place to seek the views of service users’, relatives and other professionals about the care and services provided. Relatives and other healthcare professionals were invited to attend care plan reviews with the service users’ agreement and needs were regularly assessed, however otherwise there were no other systems in place to seek feedback about the care and services provided. As mentioned earlier under the heading environment there were a number of concerns relating to the maintenance and safety of the environment and some health and safety practices. A bed mattress had been left in one of the downstairs corridors causing obstruction to a fire exit and chemical cleaning agents were left unattended to and were not kept secure enabling service users’ to have access to them. The downstairs bathroom had some loose flooring which could cause service users’ to trip or fall, the dining room carpet looked dirty and some wallpaper was loose and hanging from a ceiling above the landing stairs. Staff training was inadequate and basic training in a number of safe working practice areas had not been given to staff. Whilst some moving and handling training had been given to all the staff and first aid training to some staff, all of the staff required fire safety training and updates were needed in safe food hygiene, infection control and health and safety practices. A number of health and safety certificates were looked at and were satisfactory. There were individual risk assessments within service users’ records to promote independence and safety, and some general risk assessments had been carried out to promote health and safety within the home. However a risk assessment of moving and handling practices needed to be carried out and staff needed to be provided with updated guidance on how to dispose of sharps safely. The home’s financial systems were looked at. Personal monies were stored securely at the home. Monies deposited and withdrawn from individual accounts were accounted for and a random check of the monies held at the home tallied with the records. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X 3 1 STAFFING Standard No Score 27 3 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No • STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 22 • Requirement The registered person must ensure that the complaints procedure provides information about the stages and timescales of the process so that people making a complaint are aware of what will happen afterwards and when. The registered person must have a system in place to record all complaints and details of the investigations, outcomes and any action taken as a result of the process. The registered person is required to make arrangements for all staff to attend abuse awareness training and to be conversant with local authority procedures for reporting abuse issues. 30/07/06 Timescale for action 30/06/06 • 2. OP18 13 • Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 24 • The registered provider must give clear guidance to staff on how to deal with challenging behaviour exhibited by service users’. 24/05/06 3. OP19 13 • The registered person must ensure that fire exits are kept clear at all times to ensure an adequate means of escape so that service users’, staff and other peoples’ safety is not put at risk. An immediate requirement was issued. The registered person is required to make sure that chemical cleaning agents are not left unattended to and must be stored properly and securely at all times so that service users’ are not at risk of harm from having access to these materials. An immediate requirement was issued • 4. OP19 13 • The registered person is required to make arrangements to have the dining room carpet thoroughly cleaned or replaced to improve the living environment for service users’. The registered person must make arrangements to repair or replace the flooring in the downstairs bathroom to prevent risks to service users’ from tripping and/or falling. 30/06/06 5. OP19 13 31/05/06 6. OP19 23 The registered person must 31/07/06 DS0000038016.V295036.R01.S.doc Version 5.2 Page 25 Lodge The Residential Care Home make arrangements to have the ceiling above the landing stairs re-decorated to make the living environment more pleasant for service users’. 7. OP33 24 The registered person must 31/07/06 put in arrangements for seeking the views of service users’, staff, relatives and others about the care and services provided at the home so that they can be involved in decision making about how the home is run. • The registered provider must make arrangements for risk assessments to be carried out on moving and handling practices and provide clear guidance to staff on how to deal with the disposal of sharp materials. The registered provider must make arrangements for all staff to attend fire safety training and receive updates on health and safety, food hygiene and infection control practices. 30/06/06 8. OP38 13 • RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 26 No. 1. 2. 3. Refer to Standard OP1 OP7 OP9 Good Practice Recommendations More detailed and current information should be included in the home’s statement of purpose and a copy of the document should be submitted to the CSCI on completion. Daily entry records should be fully dated. Two of the staff that administer medications in the home should have further medication training and the registered manager should review the current arrangements for recording of medications received by the home. A non-meat menu option should be provided at all mealtimes for people who for whatever reason prefer not to eat meat. Toilets on the ground floor of the home should be clearly indicated to promote the independence and orientation of service users’. The problem with the staff office lighting needs to be addressed. Records should be kept of any induction training provided in the home to new workers. The registered manager should complete training towards achieving a management qualification. 4. 5. 5. 6. 7 OP15 OP19 OP25 OP30 OP31 Lodge The Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Residential Care Home DS0000038016.V295036.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!