Inspection on 13/06/07 for Princess Lodge Care Centre

This inspection was carried out on 13th June 2007.

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

The inspector 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

Princess Lodge Care Centre 13/10/08

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Princess Lodge Care Centre 17 Curie Avenue Off Okus Road Swindon Wiltshire SN1 4GB Lead Inspector Steve Cousins Unannounced Inspection 13th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Princess Lodge Care Centre DS0000068837.V334244.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. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Princess Lodge Care Centre Address 17 Curie Avenue Off Okus Road Swindon Wiltshire SN1 4GB 01793 715420 01793 715430 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) Life Style Care (2005) Plc Miss Patricia Anne Martin Care Home 75 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (23) of places Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager for Princess Lodge Care Centre may act as registered manager for 91A and 91B Okus Road until a manager has been appointed to this role. New service. No previous inspections. Date of last inspection Brief Description of the Service: These purpose built premises are situated on a new housing development just off Okus Road in Old Town, Swindon. The premises consist of a three-storey building with parking and level access to the ground floor. The home was opened in December 2006 and is registered to accommodate older people who need nursing care. The first and second floors are intended for older people who have dementia. The home registered provider is Lifestyle plc who have five other care services of varying types, across the UK; including services for people with dementia, physical disability and older people with nursing needs. The registered manager is Mrs Patricia Anne Martin. The current range of fees is £447 - £775 per week. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 6th June 2007 in order to inspect all of the key minimum standards relating to care homes for elderly people. The Commissions pharmacy inspector reviewed the arrangements regarding medications. The lead inspector returned to the home on the 6th July 2007 in order to discuss the outcome of the visit and the findings of the residents and relatives comment cards. This was the homes first inspection. The findings from this inspection are based on a tour of the premises, speaking to people who live in the home, their relatives, the manager and staff, and visiting frail residents. There were 36 people living in the home, thirteen on the nursing floor and 23 in the dementia unit. The top floor of the home is currently unoccupied. A number of records were inspected, including care plans, medication records and staff records. The inspector reviewed the care of six residents in detail, male and female. They had varying physical, social and mental health needs. Some were new to the home and others had been at Princess Lodge since it opened in December 2006. The care of other residents was reviewed in less detail. Consideration was given to issues of ethnicity and diversity. Comment cards were received from eighteen residents’ following the inspection (many of which had been completed by relatives on their behalf) and their views are incorporated in this report. The judgements contained in this report have been made from evidence gathered during the inspection and take into account the views and experiences of people using the service. What the service does well: Princess Lodge is a well managed home where people are looked after in a pleasant, safe and well-equipped environment. Admission procedures are good and people are given the opportunity to find out about the home before moving in. The staff endeavour to ensure people receive the support and care they require, social activities are offered and the meals are good. Relatives and friends are welcome in the home. There is a commitment to ensure that staff are well trained and recruitment practice protects the people living there. Medicines are safely stored and handled. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 7 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 Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 does not apply to this home. People have the information they need to make a choice about living at the home and their needs are assessed before they move in. Contracts are issued but a minority of people said they had not received one. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear statement of purpose and comprehensive service user guide was available. The statement of purpose describes the intent of the organisation to provide person centred care. A copy of the service users guide was available in each bedroom. In response to the comment card question: Did you receive enough information about this home before you moved in so you could decide if it was Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 9 the right place for you? Sixteen people replied ‘Yes’ and none replied ‘no’. Comments added included ‘Staff extremely supportive and attentive’’ and ‘the staff we saw were friendly, so this made us decide’. One relative of a person on the dementia unit told the inspector “The staff were very good and made moving into the home easy. We chose it because of the nice atmosphere, due to the staff”. The majority of people who returned comment cards indicated that they had received a contract, however four said that they had not, this may be because relatives are handling their financial affairs. Pre admission assessment documentation was reviewed. The manager or her deputy had completed assessments and assessment forms were included in residents’ care plans. The assessments were of a good standard and conversation with the manager indicated that she seriously considers whether the home is able to meet a person’s needs before they are admitted. The staff team are also involved in decisions and the impact on the other people living in the home is considered. Princess Lodge Care Centre DS0000068837.V334244.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 and 10 Peoples’ health and personal care needs are being assessed and met. Care planning is generally of a good standard, but some areas could be enhanced further. People are treated respectfully and their right to privacy is upheld. They are also protected by the home’s procedures for the safe handling of medication. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A comprehensive care planning system is in place. Care plans reviewed were generally an accurate reflection of needs and were based on appropriate assessment. They were reviewed monthly or more often if required and an audit system was in place. Plans were also in place relating to end of life decisions. There were some areas relating to individual residents plans that required further development. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 11 One person who had been assessed as nutritionally at risk did not have a care plan in place to direct care and allow for formal review of their nutritional status. Another person’s plan contained a statement relating to resuscitation, but there was no evidence of agreement or discussion with the person, or their advocates or General Practitioner (GP) about this issue. In some plans, not all details in the section relating to the person’s ‘Routines and Choices’ had been completed. The inspector visited the residents and found that interventions were in place to meet their assessed needs, such as pressure relief equipment, continence aids and manual handling equipment. Care must be taken to ensure that when plans indicate that a person’s fluid or nutritional intake is to be recorded, staff ensure that any records are completed accurately as some charts had gaps in recording and others had been filled in retrospectively. Records indicated that staff are prompt in referring people to their GP when required and to other health care professionals, such as the continence advisor or the community mental health team. All the people living at the home are registered at the same surgery and a GP makes regular visits to the home. When asked ‘Do you receive the medical support you need?’ Fourteen said ‘always’ and three ‘usually. One person added the comment: ‘If we ask for it, they will give it to us’. Those who returned comment cards were generally positive in their opinion of the support given to meet their care needs. In reply to the question ‘do you receive the care and support you need?’ Eight stated ‘always’ and ten replied ‘usually’. Comments included, ‘We get all the support we need from the staff and manager’ and ‘Pleased with care and support – such a relief to me’ and ‘Extremely pleased with the support received’. Other comments were ‘I feel there are too many agency staff, organisation could be better’ and ‘ The main staff seem more patient ---one of the young staff was impatient with me’. This latter issue was discussed with the manager, who felt that this referred to an agency staff member who was no longer working in the home. An entry in the complaint log confirmed this. All but one of the eighteen people who returned comment cards felt that staff listened and acted on what they say. One replied ‘staff are so friendly, everyone takes the time to say hello and smile’. However one relative added the comment ‘when things are pointed out we are not happy with, we sometimes have to repeat it on the next visit’. There was evidence to suggest that peoples’ privacy and dignity was respected. It was observed that personal care was being given behind closed doors and staff knocked on doors before entering a room. People seemed to be Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 12 having their personal hygiene needs met and those who were unable to dress themselves were dressed in clothing that maintained their dignity. One person who lived in the home told the inspector ‘they (the staff) are very kind’ The Pharmacist Inspector looked at arrangements for the handling of medicines. Medicines are stored and recorded appropriately. All staff who administer medicines have received training from the pharmacist and further training sessions have been arranged to enhance this. A comprehensive policy and medicine reference sources are available on each floor. Evidence was seen of the manager’s regular audits and the action taken following these. Medicines prescribed ‘as required’ are clearly documented with the time and reason for use; care plans support the use of these medicines. Nurses were seen to take time over giving medication, particularly to residents who required more help, however this meant that the round took a long time. Some medicines need to be given at set times and these should be removed from the round and given individually at the correct time. No residents currently self medicate, however a procedure is in place should anyone wish to do so. Princess Lodge Care Centre DS0000068837.V334244.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Social activities are available which people appear to enjoy however comments received indicate improvements could be made. People are supported to maintain contact with friends and relatives. Efforts are made to support people to live their lives as they wish. The standard of meals appears good. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs an enthusiastic activity organiser and the manager reported that there were plans to recruit another as the occupancy increases. A range of in-house activity is provided and includes therapeutic activity, such as gentle exercise sessions and music and movement. People’s birthdays and anniversary’s are celebrated along with other occasions such as Mothering Sunday and Easter. In response to the question on the comment card ‘Are there activities arranged by the home that you can take part in?’ Two people responded ‘always’, one replied ‘usually’, nine ‘sometimes’ and two ‘never’. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 14 Relatives were around the home at different times during the inspection and there were no restrictions on visiting. People confirmed that they could receive visitors in their rooms or the communal sitting room. Residents and relatives reported that they were able to keep in touch with each other. Many of the people living at Princess Lodge depended on staff to meet their needs however some of their comments during the inspection indicated that they had some control over how they lived their lives. For example two people confirmed that they were able to get up, or go to bed when they wanted, another said ‘I generally do as I please, with a bit of help’. Those with dementia were able to spend time as they wished, some were in bed resting and no institutional routines were observed in practice. The staff working on the dementia unit were seen to treat people with kindness, were relaxed and responding well to peoples’ concerns. Menus reviewed indicated that people were offered a choice of varied meals and those spoken to were generally positive about the food available. Those who returned comment cards stated that they either ‘always’ or ’usually’ enjoyed the food, although two replied ‘sometimes’. Comments included ‘All meals are 100 ’ and ‘No complaints whatsoever, always very good and tasty and plenty of it’ and ‘The food is excellent’. One person said ‘difficult to eat hard food, prefer small, soft food’. People were observed eating in their own rooms or in the dining room or lounge if preferred and staff were observed assisting some residents to eat and giving them sufficient time. Special diets were catered for and there are facilities for people to make drinks and snacks. Princess Lodge Care Centre DS0000068837.V334244.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 and 18 People are aware of how to complain if they need to and staff are aware of procedures in place relating to reporting alleged abuse, and receive training in abuse awareness. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written complaint procedure, which is available in the home along with suggestion and comment cards in the foyer. A complaint record is kept. This showed that the manager dealt with complaints promptly and any actions taken were recorded. The manager was able to demonstrate how she had dealt with a recent complaint, written records were kept which recorded prompt action, and that complainant was happy with the outcome. Comment cards received indicated that the majority of people knew who speak to if they are unhappy, one person replied ‘I make a point of bringing issues straight to the manager. All of the people who returned cards said that they knew how to make a complaint. One person commented ‘Have not needed to but imagine the manager or deputy would take care of it’. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 16 The company have a vulnerable adults reporting procedure and a ‘whistle – blowing ‘ policy. There have been no vulnerable adult referrals relating to this home. Records indicated that staff had received Protection of Vulnerable Adults (POVA) training and a copy of the POVA alert leaflet was on view in the staff training room. Recruitment records indicate that all staff have the required checks undertaken before they commence working in the home. Princess Lodge Care Centre DS0000068837.V334244.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): 19,20,21,23,24 and 26 The home meets, and in some areas, exceeds the standards, providing a clean, comfortable, well-equipped and safe environment for it’s residents, which meets their needs. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and the overall the quality of the accommodation, décor, fixtures and fittings was very good and in many areas exceed the National Minimum Standards. One person described the home as ‘Clean, comfortable, light and airy’. Records supplied indicated that the home is well maintained, including essential equipment and services. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 18 All rooms have en-suites with toilets and hand-wash basins. All toilets have yellow surrounds on the doorframes, with the intention of making them easily visible. The bedrooms have a mix of non-slip pseudo laminate flooring or carpet. The positions of the en-suites in the bedrooms allow for flexible space to be used in the rooms. All rooms had a profiling bed installed, with a lockable bedside cabinet, wardrobe, chest of drawers, upright chair, over chair table and a dining style chair. There are assisted baths and assisted showers (walk in) and assisted toilets on all floors. Store rooms and space on the corridors to store wheelchairs and hoists, are available. Corridors are wide and allow from room for more than two people to pass each other. There are two dayrooms and one dining room on each floor along with a servery attached to the dining area and space to make light snacks and hot and cold drinks. The home also has a sensory room, with portable equipment, including optic fibre tubes, lights and music, an activity room and a hairdressing salon. There is a keypad code to use the lift, and to exit the building. Outside there is an enclosed garden space to the front of the home, with level pathways and space for seating and patio tables and chairs. The kitchen is large and fully equipped as is the laundry, which has a separate sorting and ironing area. In response to the comment card question ‘Is the home fresh and clean?’ Twelve people responded ‘always’ and six ‘usually’. One resident added ‘The cleaning staff do a good job’ and another said ‘Always very clean and tidy, smells nice and fresh’. Another resident commented The cleaning could be better; although the inspector’s findings did not support this. The inspector visited all bedrooms and communal areas. These were found to be clean and free from unpleasant odours. The laundry was clean and uncluttered and clear infection control procedures were in place. The kitchen was clean and food safety checks undertaken and recorded. A recent food safety inspection by an Environmental Health Officer recorded ‘Excellent standards throughout’. Princess Lodge Care Centre DS0000068837.V334244.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 and 30 The number and practice of care staff needs to be reviewed as some comments indicate that delays in answering call bells are common. There is a genuine commitment to ensuring staff are well trained. People living in the home are protected by the homes recruitment practice. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records indicate that there was normally three nurses and seven care assistants on duty throughout the day and two nurses and two care assistants at night. There were 36 people living in the home at the time of this inspection. The findings detailed in the ‘Health and Personal Care’ section of this report indicate that peoples needs are being met however comment cards received indicated that there were some concerns about staff availability. When asked ‘Are staff available when you need them?’ Four said ‘always’ and thirteen ‘usually’. Comments included ‘carers and nurses might not turn up straight away because they are usually busy, but they do their best’ and ‘Have difficulty to get care from staff first thing in the mornings when needing the toilet’ Other comments were ‘Staff are very busy sometimes and so I have to wait’ and ‘On Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 20 the odd occasion, all relevant staff have been engaged with other residents, but they have responded when free’. The inspector’s observations supported these comments when on two occasions there were delays on answering call bells and one person told the inspector “staff are lovely but you have to wait a bit sometimes’ and another said, “You have to wait a while to be seen, but that’s life”. The home should review current care staff practice and staffing levels at various times of the day in light of these comments. The efficiency of the laundry, domestic and catering services would indicate that the number of support staff is appropriate. The training arrangements were reviewed. The deputy manager is responsible for training and has between 12 to 18 hours a week allocated to this. The home has a well-equipped training room. Induction training is comprehensive and all staff undertake it prior to starting work in the home. The induction training needs to be reviewed to ensure that it meets Skills for Care common induction standards. Records indicated that there is an ongoing programme of mandatory training provided for all staff and nurses are able to access specialist training, such as venepuncture, tissue viability and catheterisation. There is a commitment to ensure new care staff commence NVQ training and the current level of staff either with, or undertaking an NVQ is 60 . Records indicated that care staff receive the Social Care Codes of Practice on induction. The recruitment records of four recently recruited staff members were reviewed. Criminal Records Bureau checks had been obtained and references and POVA checks had been obtained prior to the person starting employment in all cases. Other documentation required was in place. Princess Lodge Care Centre DS0000068837.V334244.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): 31,33,35 and 38 The home appears well managed in the best interests of the residents. Quality assurance systems are in place and the health safety and welfare of the residents and staff are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Martin is the home’s registered manager. She has worked as a nurse in the field of mental health and learning disabilities, including working with people who may have acute and complex needs. She has worked in services for older people with dementia. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 22 A deputy supports Mrs Martin in her role and she is line managed by a regional manager. Conversations with the manager, allied to the findings of this inspection indicate that she has the knowledge, skills and ability to run the home. The arrangements for monitoring the quality of the service were reviewed. The manager reported that she held a ‘surgery’ every three to four weeks for families and friends in order to allow them to discuss any problems. A surgery was also held for staff and there are monthly heads of department meetings. In depth monthly audits are carried out, covering subjects such as care planning, medication and kitchen systems. The manager reported that heads of departments were responsible for carrying out the audits. If improvements are required then these are raised and monitored as issues during staff supervision. A representative of Life Style Care undertakes a monthly-unannounced visit, which includes talking to people who live in the home and a report is produced. The arrangements regarding the handling of people’s money were reviewed and found to be satisfactory. Accounts are regularly audited and receipts for expenditure obtained. The management of health and safety was also reviewed. Health and safety is discussed as an agenda item during monthly heads of department meetings and training records indicate that staff receive training in health and safety related subjects such as moving and handling, COSHH and first aid. Moving and handling equipment is available along with profiling beds and bedrooms are spacious, reducing the risk of injury to people. Accidents are recorded, along with any action required to reduce risk. Some fire safety checks had not all been carried out at the required intervals however a new maintenance person had been appointed and the manager felt this issue was now resolved. Equipment safety checks are also undertaken. Cleaning products are stored safely, infection control measures are used in the laundry and food safety procedures are used in the kitchen. Princess Lodge Care Centre DS0000068837.V334244.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 3 2 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 17 X 18 3 3 4 4 X 4 3 X 4 STAFFING Standard No Score 27 2 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Princess Lodge Care Centre DS0000068837.V334244.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 OP7 Regulation 15 (1) Requirement Timescale for action 01/08/07 2 OP7 15 (2,b) 3 OP9 13(2) The registered person must ensure that, when a service user is assessed as being nutritionally at risk, a care plan is put in place to direct care. The registered person must 18/07/07 ensure that when plans indicate that a person’s fluid or nutritional intake is to be recorded, staff ensure that any records are completed contemporaneously The registered person must 18/07/07 ensure that medication is administered at the correct time according to the prescription. 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 OP2 Good Practice Recommendations It is recommended that the company check that all service users have received a contract. DS0000068837.V334244.R01.S.doc Version 5.2 Page 25 Princess Lodge Care Centre 2 OP7 3 4 5 6 OP9 OP12 OP27 OP30 It is recommended that where decisions relating to resuscitation are made, evidence of agreement or discussion with the person, or their advocates or General Practitioner (GP) be recorded. The medication policy should make it clear that errors in the administration of medication should be reported to the Commission as a Regulation 37 notice. In light of the comments received, it is recommended that the current activities programme be reviewed to ensure that it meets individual needs. In light of comments received it is recommended that current staff practice and numbers are reviewed to ensure there are no undue delays in delivering support to people. The content of the care staff induction training should be reviewed to ensure it meets the Skills For Care common induction standards. Princess Lodge Care Centre DS0000068837.V334244.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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