Inspection on 26/03/07 for Oriel Lodge

This inspection was carried out on 26th March 2007.

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

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

Other inspections for this house

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Poldhu

Queensmount

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Belma

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

CARE HOMES FOR OLDER PEOPLE Oriel Lodge Oriel Gardens Lower Swainswick Bath Bath & N E Somerset BA1 7AS Lead Inspector Wendy Kirby Key Unannounced Inspection 09:30 26th March 2007 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 Oriel Lodge DS0000068736.V330879.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. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oriel Lodge Address Oriel Gardens Lower Swainswick Bath Bath & N E Somerset BA1 7AS 01225 310301 01225 482400 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) Grove Care Ltd Ms Susan Carol Margaret Honeywell Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Oriel Lodge is a Grade 2 Listed Building, extended and renovated to offer residential accommodation for up to twenty older people. The Home is situated approximately one mile from the centre of Bath in Lower Swainswick. Accommodation is over two floors and consists of sixteen single rooms and two double rooms. Eight of the bedrooms have en-suite facilities and all the other rooms are fitted with wash hand basins. Communal facilities include three bathrooms, a large lounge and a dining room. Both the lounge and the dining room have conservatories attached, which overlook the well-tended front gardens. Car parking is available to the front of the premises. The Home has a passenger lift; however, the width of the corridors and the general layout of the Home would make it unsuitable for someone who is a permanent wheelchair user. The cost per week to reside at the home is from £470.00 to £485.00. Fees are reviewed annually and if care needs increase. The weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. Oriel Lodge DS0000068736.V330879.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 conducted as part of the annual inspection process. The inspection lasted one day. Oriel Lodge has changed ownership since the last inspection, which was conducted in February 2006. It was evident at this inspection that efforts had been made to try and ensure that all people who use the service were unaffected by any changes that can be expected under new ownership. Prior to the visit the inspector spent some time examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire, notified incidences in the home, (Regulation 37’s) and the unannounced reports conducted by the Registered Providers (Regulation 26’s). The inspector sent “Have your say” questionnaires to residents and relatives prior to the inspection and twenty-one were completed and returned. Surveys were also sent to visiting health and social care professionals and two of these were completed. Information from these has been collated and is detailed throughout the report. The inspector spent time throughout the inspection in discussions with the management team, and members of staff, a number of records and files relating to the day-to-day running and management of the home were examined. Three residents were case tracked. Their care plans, care files and medication records were examined. The inspector had discussions with the residents and observed them indirectly going about their daily routines. The inspector toured the premises accompanied by the manager and the owner. Feedback was given to the management team on the outcome of the inspection. What the service does well: Pre-admission assessments were resident focussed and supportive in ensuring that the home can meet the residents needs. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 6 Staff have a good awareness of individuals’ needs and treat the residents in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. There are safe systems of medication. Meals were well presented and menus verify a healthy well balanced diet for all residents who benefit from a wide variety of choice. All complaints or concerns are documented, dealt with effectively and outcomes are recorded. Adequate staffing levels help to ensure that resident’s needs are met. Staffing levels are increased when the dependency levels of the residents change. The recruitment procedure is robust and serves to protect residents. Good accounting methods are adopted and policies and procedures are followed correctly when handling residents’ personal money. The manager and staff had built a good rapport with individuals and were knowledgeable about the care needs of the individuals living in the home. What has improved since the last inspection? What they could do better: To further ensure the resident’s safety and wellbeing the home must make arrangements to ensure that the building complies with the requirements of the local fire authority. CSCI must be notified of the outcomes. Provision must be made to reduce the potential risks of cross infection by providing adequate disinfector sluicing facilities. Manual handling equipment provided at the care home must be maintained at the required intervals. Residents feel that they would benefit from more varied activities programme, including some outings. These should meet individual preferences and expectations. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 7 Staff must receive mandatory training including manual handling and food hygiene at the required intervals. Residents and staff would benefit from additional training appropriate to the needs of the residents and to the work staff perform. Residents would benefit if staff received regular training updates on safeguarding vulnerable adults. An effective system must be put in place so that residents and their advocates have the opportunity to discuss any issues, views and level of satisfaction about the service they are receiving. Manual handling equipment provided at the care home must be maintained at the required intervals and in good working order. People who use the service would benefit if the toilets and bathrooms were clearly marked. 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. Oriel Lodge DS0000068736.V330879.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 Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed prior to admission to determine the suitability of placement to ensure that their needs can be met. EVIDENCE: The Inspector looked at the pre-admission assessments, which were comprehensive covering activities of daily living, a full health screen and personal history background. The information gathered pre-admission provides a sound benchmark of the resident’s ability and state of health prior to admission. The prospective resident, family and carers are involved in the pre-assessment and all information is used to determine the suitability of the placement. Where possible the manager had obtained assessments and care plans from other professionals involved for example, social workers and hospital staff. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Because they are consulted about their health and personal care needs residents can be sure their views and expectations will be considered. There are safe systems of practice in receiving, storing, administering, and disposing of drugs. Residents can be confident that staff have a good awareness of their needs and that they will be treated with dignity and respect. EVIDENCE: At present the home uses the ‘Standex’ system of documentation for assessing, planning and evaluating care based on the activities of living. The documentation available overall completed to a satisfactory standard, although a little sparse in detail. The inspector was informed that a new system of care planning is to be instigated in the very new future. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 11 Following admission to the home, the staff gradually assess the residents needs and complete a long-term assessment plan. Each resident had person centred assessments, which means that staff put the views, wishes, likes and dislikes of each resident at the centre of all care provided. Records of the General Practitioner (GP) visits/contact with residents and the outcomes were also available. Specialist referrals and visits from other professionals were evidenced in care files including Community Nurses, Chiropodists, Opticians and Dentists. Results from the residents’ surveys evidenced that they feel that they receive all the medical support they require. The inspector was informed that each resident was referred to a GP of his or her choice on admission to the home and an initial first visit was then set up. Good working relationships with GP’s and District Nursing teams have been formed and they will visit on request. Although only one survey was returned by a visiting health/social care professional the comments received were positive and stated, “ Oriel Lodge is a super home!”. Policies and procedures for receiving, storing, administering and disposing of medications were examined and discussed with the manager; all systems in place are effective and well managed. The home operates a monitored dosage system for the administration of medication, which is supplied at regular intervals by the local pharmacist. The GP’s conducts a medication review for all residents every six months. The home also keeps an accurate stock check of medicines given on an as required basis. Fridge temperatures are recorded daily. The administration charts were legible and continuity of administration was shown with a signature from the person dispensing. The atmosphere in the home on the day of the inspection was relaxed. Staff, the manager and residents were observed to have good relationships. Staff responded to residents in a sensitive and professional manner. All residents’ rooms have a lock on their door. Staff knocked on residents’ doors before entering confirming respect for the residents’ individual privacy and dignity. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that they would benefit from more varied activities programme, including some outings. These should meet individual preferences and expectations. Encouragement from staff enables residents to maintain good contact with family and friends. Residents receive a varied and wholesome diet that they are able to influence. EVIDENCE: Only one out of ten residents felt that there were activities arranged by the home that residents could take part in. At present there is not an activities coordinator, however the cook and one of the carers do provide a variety of activities throughout the week. Unfortunately there is no formal process in place and residents are not given a programme of activities arranged in order to plan for which ones they would like to attend and are of particular interest. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 13 The manager told the inspector activities that are arranged include, music appreciation, flower arranging and arts and crafts. Entertainers also visit the home including a pantomime group and an organ player. In discussions with residents it was apparent that feelings were mixed. Quite a few residents stated that, “Sometimes it can be very boring” and “It does seem like a very long day when there isn’t anything to do”. Other residents made it clear that they liked their own company by staying in their rooms, watching television and listening to music. Relatives comments included, “I’m not too sure that my relative receives the mental/physical stimulation that would benefit them”, “An increase in staffing during the afternoon should allow for staff/resident contact on a one to one basis”, “The home could improve by doing the simple activities listed in the service user guide”, and “The home should arrange some outings and more in the way of entertainment and occupational therapy”. There were no outings arranged for the residents last year, however the new owners have stated that they are looking into providing transport so that future trips for residents can be organised. Residents are supported to attend their local place of worship and a church service and Holy Communion takes place in the home every four months. Residents are free to worship as they wish and any arrangements for services or communal prayers within the home are made in accordance with residents’ wishes and are entirely voluntary. The home operates an open door policy for visitors. Residents were able to see visitors in the privacy of their rooms and there were several semi-private seating areas around the home. Relatives/visitors comments included, “I am always made to feel welcome”, “Everyone is friendly and inviting to visitors, it’s a nice place to go”, and “ Staff are always welcoming and friendly”. The dining room was light, relatively spacious and the tables were attractively laid with tablecloths and napkins. The 4-week menu rota displayed traditional meals and choice was available at each sitting. The menus are reviewed to reflect seasonal trends and availability of produce. Extras are ordered on request for birthdays and special occasions. The kitchen was very clean and spacious and stores exhibited a good range of foods. The inspector spent time in discussions with the head cook who demonstrated an awareness of individual requirements and needs of the residents, including special dietary requirements and personal preferences. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 14 It was evident that she works hard to provide a good service to the residents in the home. Generally residents surveys indicated that they liked the meals in the home, comments included, “I am a very fussy eater but there is usually always something I like”, “The meals always seem to get eaten!” and “As a vegetarian I am very pleased”. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to ensure that complaints by residents or their families are taken seriously and acted upon. Staff should receive regular training in the area of protection of vulnerable adults so that they are more up to date. EVIDENCE: Information on how to make a complaint and to whom such a complaint should be addressed is included in the resident’s guide. The complaints book was examined; a reminder of the complaints procedure is given in the front of the book and the telephone number of the Commission for Social Care Inspection is also included. Only one complaint was received last year about staff not answering the call bells. The inspector saw that the action taken by the manager was appropriate and that the family concerned were happy with the outcome and how the complaint was managed. Residents said they knew who to speak to if they were not happy and that they were aware of the homes policies and procedures should they need to make a complaint. Comments included, “There is always someone you can speak to” and “I would always speak to Carole the manager”. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 16 Relatives/visitors surveys said that they new how to complain and referred to the information found in the service users guide. Comments were positive and stated that, “I have never had to question the care as it has been excellent and hope that this continues”, “ I have not raised many concerns but when I have the only problem has been with regards to the staff communicating the information between them”, and “I would speak to the owners or the manager, but we have never had a problem”. Although staff have received training awareness on safe guarding vulnerable adults, the majority have not had an update since January 2004. The home has written procedures for adult protection, whistle blowing and management of aggression. The ‘No Secrets’ document is also available. The inspector did not view all of these policies during the inspection. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of the protection of vulnerable adults from abuse. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. With the exception of some bedrooms and bathrooms the home is comfortable, tastefully decorated and furnished. It provides a peaceful environment for the residents to live in. The health, safety and wellbeing of people who use the service may be compromised due to potential risks of cross infection and fire safety issues. The home is clean, pleasant and hygienic. EVIDENCE: It was evident that some areas of the home require redecoration and in some cases refurbishment. Particular areas include a bathroom and some of the Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 18 residents’ bedrooms. Some of the residents rooms were cluttered and in need of more storage facilities. The new owners are aware of these issues and some rooms have already been tastefully redecorated and refurbished to a high standard. An improvement plan has been developed and the work is ongoing. The new owners also have plans to upgrade and change various parts of the home; however, it is understandable that the owners’ priority since registration last year has been to focus on ensuring a smooth transitional period for residents, families and staff. Although these areas need attention the inspector did not consider that the current state of the home was having any adverse effects on the residents and no comments had been received through discussions or from the surveys with regards to any complaints about the environment. One area that was a particular concern, however, was the possible risks around the fire safety in the home. Whilst the inspector was looking around the home it was noted that fire escape route signs were sparse and in certain areas of the home there was no indication of which way to go if there was a fire. It was also noted that several doors did not fit flush to the doorframes when closed and residents’ bedroom doors did not have intumescent strips. This was fed back to the owner who was visiting the home at the time of the inspection. He too had identified such concerns and had already started to put up fire escape route signs in the communal areas. A requirement will be made to arrange for a full Fire Safety audit to be undertaken by a competent individual in order to ensure that safety is not compromised. It was noted during the tour that many residents had commodes in their rooms. The manager confirmed that at the time of the inspection eleven residents required this facility. The home does not have sluice disinfector facilities and staff are using residents toilets and bathrooms to empty commode pans. This is poor practice with serious implications for potential cross infection. Bathrooms and toilets are decorated and equipped to a good standard, one remaining bathroom, which needs attention, is being considered as a shower room. The toilets and bathrooms doors were not marked to indicate where they were in the home. The home was clean and free from unpleasant odours. The home employs domestic staff on a daily basis. Residents’ and relatives surveys confirmed that the home was always fresh and clean and one relative stated, “The general cleanliness of the premises in very good”. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels help to ensure that resident’s needs are met. Residents are supported and protected by the homes recruitment policy. Staff require training so that residents can be assured that they will have the skills and resources to meet their needs. EVIDENCE: As expected with any change following a takeover, routines within the home in some instances are different to those previously adopted. Morning routines in particular have changed and staffing levels have been reduced. The new owners and the manager will continue to monitor the effectiveness of the reduced levels and the new routines that are in place. The manger and staff spoken with did not indicate that at present this has not had a direct impact on the residents care needs not being met. The manager told the inspector that the home ensures staffing levels are indicative of the needs and levels of care required by the residents. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 20 Some relatives had expressed some concerns about the above mentioned changes and comments included, “I hope the changes do not result in limiting the choices of the residents in their care”, “I hope that the current high standards are maintained” and “I hope the home will continue to make the residents feel individually cared for and loved for whom they are”. All residents stated on the day of the inspection and in their surveys that staff were usually available when they needed them and that staff listen and act on what they say. Several residents’ and relatives expressed very positive views about staff and the care they receive providing comments, “In general the staff do a magnificent job very cheerfully” and “There is a happy atmosphere and the staff have a good rapport with my relative”, “The staff are first class” and “Staff are patient and considerate”. The recruitment process was examined and all staff records examined showed that the home follows correct recruitment procedure and policies. Records contained application forms, references, and a CRB (Criminal Records Bureau) disclosure. The home continues to support their staff with NVQ training and the enrolling programme continues. Staff records evidenced that some mandatory training was out of date, including manual handling and food hygiene. Some staff had not received training updates in medication competency since 2004. Additional training relevant to the care needs of the residents living at Oriel Lodge would be advantageous to increase and support staff awareness and competencies including “Caring for people with Parkinson’s disease”, “Dementia awareness” and “Understanding visual impairment”. Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs and best interests are central to the management approach in the home. Good accounting methods are adopted and policies and procedures are followed correctly when handling residents’ personal money. The health and safety of people in the home may be compromised and potentially at risk due to fire safety in the home. EVIDENCE: Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 22 There is a dedicated team who work together to try and ensure that the highest standards of care are achieved and maintained and that the residents receive as much care, empathy, love and attention as they possibly can. The manager demonstrated a sound knowledge and understanding of the needs of the individuals living in the home. There was a high degree of satisfaction expressed by residents, relatives and visitors. Based on the comments made and through the inspectors observation it is evident that the home is run in their best interests and to ensure their needs are being met. Residents and relatives stated, “The home is well run and I hope this standards continues”, “Oriel Lodge has been run to a high standard of care to all residents, it is a happy, homely environment” and “Oriel Lodge has provided a stable caring home for my relative for the last four and half years. The staff are friendly and welcoming to visitors and I certainly don’t dread the days when I visit”. The manager informed the inspector that the previous owners had an annual quality assurance system in place whereby all residents and relatives were sent questionnaires about the services provided. Unfortunately this information was not available at this inspection. Although the manager makes every effort to see residents individually on a daily basis, residents/relatives meetings are not arranged. These meetings could assist the home towards their quality assurance. People who use the service could be kept more informed about new initiatives and any issues/news within the home and it would also give them an opportunity to assess the levels of satisfaction and address any concerns people may have. The policy and procedure for holding residents personal money was examined and four individual accounts were looked at. It was evident that good accounting methods are adopted which account for all transactions documented and receipts for sundries were available to see. Some of the Health and safety records in the home were examined. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms and equipment and emergency lighting. With the exception of manual handling equipment all records showed necessary service contracts were up to date including, gas and electrical services. As mentioned previously in the report health and safety of people who use the service may be compromised around areas of fire safety. Oriel Lodge DS0000068736.V330879.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 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X 2 x X X X 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 24 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 OP19 OP38 Regulation 23 (4) (a) Requirement Arrangements must be made to ensure that the building complies with the requirements of the local fire authority. CSCI must be notified of the outcomes. Provision must be made to reduce the potential risks of cross infection by providing adequate disinfector sluicing facilities. Arrangements must be made so that staff must receive mandatory training at the required intervals. An effective system must be put in place so that residents and their advocates have the opportunity to discuss any issues, views and level of satisfaction about the service they are receiving. Manual handling equipment provided at the care home must be maintained at the required intervals. Timescale for action 08/05/07 2. OP26 23(k) 17/07/07 3. OP30 18(1) (c) (i) 24(1) 29/05/07 4. OP33 17/07/07 5. OP38 23 (2) (c) 08/05/07 Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 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. Refer to Standard OP12 Good Practice Recommendations Residents must be given more opportunities for stimulation through leisure and social activities, which suit individual needs and preferences. Residents would benefit if staff received regular training updates on safeguarding vulnerable adults. People who use the service would benefit if the toilets and bathrooms were clearly marked. Residents and staff would benefit from additional training appropriate to the needs of the residents and to the work staff perform. 2. 3. 4. OP18 OP21 OP30 Oriel Lodge DS0000068736.V330879.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Oriel Lodge DS0000068736.V330879.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. 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. 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