Inspection on 24/10/05 for Rela Goldhill Lodge

This inspection was carried out on 24th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rela Goldhill Lodge 12/06/07

Rela Goldhill Lodge 04/10/06

Rela Goldhill Lodge 10/04/06

Rela Goldhill Lodge 20/06/05

Rela Goldhill Lodge 24/02/05

Rela Goldhill Lodge 04/06/04

Similar services:

Ashlong House

Foxley Lane (121a)

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

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

CARE HOME ADULTS 18-65 Rela Goldhill Lodge Wolfson Court Limes Avenue London NW11 9TJ Lead Inspector Anthony Lewis 24 October & 7 th th Unannounced Inspection November 2005 09:50 Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rela Goldhill Lodge Address Wolfson Court Limes Avenue London NW11 9TJ 020 8905 5229 020 8455 8250 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) Jewish Care Mr Steven Mark Wax Care Home 21 Category(ies) of Physical disability (0), Sensory impairment (0) registration, with number of places Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Limited to 21 adults with a physical disability including visual impairment. Two specified service users who are over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as either of the specified service users vacates the home. 20th June 2005 Date of last inspection Brief Description of the Service: Rela Goldhill Lodge is owned and managed by Jewish Care, who are the largest providers of health and social care services for the Jewish community in the United Kingdom. The home is registered to provide residential accommodation and care for a maximum of twenty-one young Jewish adults with physical and sensory impairment. The home provides for respite and short-term care. The staff also provide respite care for people living in their own flats, opposite the home. Staff are available on a twenty-four hour basis. The home is situated in a residential part of Golders Green, near to Golders Green and Brent Cross underground stations, local shops, and bus routes and Brent Cross Shopping Centre, all of which are a short distance from the home. The home is purpose built as part of the Wolfson Court, which was opened in 1992. The home occupies all of the first and part of the second floors. The rest of the building provides warden supported accommodation for elderly people. The home is wheelchair accessible throughout. There are twenty-one single bedrooms, each with en-suite shower and toilet facilities. The home also provides support with all aspects of personal care and daily living. There is also support for residents to enable them to be part of the local community and to develop and maintain work, education, leisure and social activities. The home adheres to the customs of the Jewish religion, taking into account religious holidays and festivals. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 24th October 2005 at 09:50am and was completed at 5pm. The registered manager was on annual leave. The team leader was available for the first two hours of the inspection and the deputy manager was available for the rest of the inspection, both were very helpful and accommodating. A further visit to the home was conducted on 7th November 2005 at 3.15pm and was completed at 17.10pm, to discuss issues raised at the previous inspection and to view further files and documents and to discuss the issues raised by residents and staff. The registered manager and service manager were both present. In order to gather evidence for this inspection, seven residents were spoken to, four formally and three informally. Two members of staff were spoken to privately and two informally. Two relatives and a District Nurse were spoken to privately. Evidence was also gathered by viewing six resident’s files, eight staff files and various safety certificates, files, and documents. An extensive internal and external tour of the home was conducted with the Team Leader. What the service does well: What has improved since the last inspection? What they could do better: Ten requirements were made at this inspection, two of which have been restated. The identified resident who wishes to live more independently must be reviewed to see if this is possible. Residents must be consulted regarding menu planning to ensure that their choices are taken into account. To ensure the health and safety of residents who self-administer their own medication, individual assessments must be carried out. The damage to the identified Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 6 resident’s bedroom must be repaired and an assessment made as to whether the resident should continue to remain in the bedroom if it has damp. Residents, staff and visitors are at risk from infections if health and safety procedures are not adhered to. The extractor filters above the oven in the kitchen must be cleaned or replaced to ensure the health and safety to all people in the home. To ensure that residents, other staff and visitors are protected at all times, all staff files must contain full and satisfactory information on the persons employed in the home. To ensure that all staff are being supported and their personal development is being monitored, they must receive regular supervision. The registered manager must ensure that the complaints raised by residents and staff are investigated to ensure that they are being taken seriously. To ensure continual improvement in service delivery, the quality of care to residents must be continually monitored using an appropriate quality monitoring system. Regular fire drills must take place to ensure that residents, staff and visitors are safe whilst in the home. In order to ensure the safety of residents, staff and visitors, the water tank must be cleaned and chlorinated and a certificate obtained. 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. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 and 5. The staff team are ensuring that prospective residents, their family and representatives are able to spend time viewing the home to enable them to make an informed choice as to whether to live in the home or not and that they will have a clear understanding of the terms of their residency. EVIDENCE: The home has a copy of the Jewish Care Admissions Procedure, which is adhered to at all times by the senior staff. The deputy manager went through the admissions procedure. A resident, who moved into the home recently, and her parents, were spoken to regarding the admissions process. The parents said that the home provided respite care to their daughter prior to her moving into the home permanently. The parents said that their daughter was and continues to be well looked after. Eight resident’s files were viewed and all contained a copy of their terms and conditions. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7. Although some resident’s are confident that the staff will be able to meet all of their needs and that they will have the opportunity to make decisions and their decisions will be listened to and acted upon, not all resident’s concerns are taken seriously, which is having a negative impact on some resident’s quality of life. EVIDENCE: The care plans of six residents were viewed. Each contained a full assessment of the resident’s total care needs and are regularly reviewed. The deputy manager stated that all residents have their own key-worker. One resident who was spoken to at length in private, said he was no longer happy living in the home. He said that when he moved into the home five years ago, that he was less mobile and not able to do much for himself and needed a lot of staff support. He went on to say that he has since developed a lot and is able to walk with minimum support and that he is much more independent and self sufficient. He also expressed concerns about other residents, staff and the management of the home. Two other residents spoken to also raised concerns about the management of the home. The inspector has discussed these concerns with the registered manager and service manager. A requirement is made that the registered persons ensure that the needs of the identified Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 10 resident are reviewed and that they look into the possibility of the resident living independently. An investigation must be carried out into the concerns highlighted by some residents and a copy of the outcome sent to the Commission. A resident and her personal care worker, who has been provided by the resident’s family, were spoken to. The resident stated that her carer, who visits six days a week is her advocate and will speak up on her behalf when needed. According to the deputy manager, residents are able to make decisions about their lives either by talking to a member of staff or at the regular resident’s meetings. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15 and 17. Residents living in the home are confident that they will be supported to engage in their spiritual beliefs and traditions. Residents are not confident that their choices regarding the provision of meals will be acted upon. EVIDENCE: Staff ensure that the residents are able to participate in their religious beliefs. The deputy manager stated that many residents are able to access their preferred synagogue with staff or family support. Residents with multiple disabilities are supported by outside care professionals, who regularly visit them at the home. On the day of the inspection, many family members were seen coming and going freely and interacting with other residents and staff in a relaxed and confident manner. Residents were seen in their bedroom with family members present. Residents spoken to said that their family visit them quite regularly. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 12 All meals prepared are done so in accordance with the Jewish religion. Those responsible for catering relayed that they had a good understanding of Jewish customs and stated that when they were first employed at the home, they received an induction into many of the Jewish customs. The residents were actively celebrating “Sukkot”, a Jewish festival, which runs from 17th to 26th October. However, three residents said that they did not like the meals. One resident said that the home provides too much fried food and that she eats out a lot. Another resident said that the chef sometimes changes the menu without consulting the residents. A requirement is made that the registered providers ensure that resident’s views regarding meals are ascertained and that residents are consulted at all times regarding menu planning. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 21. The staff team are ensuring that resident’s health care needs are met with the support from health care professionals where necessary and that their wishes and customs are respected. However, residents are being put at risk due to staff not ensuring that an assessment is carried out with residents who selfadminister their own medication. EVIDENCE: Five resident’s files were viewed and all contained information on their health care in their care plans. There was also information on health care professional’s visits to the home and the reason for the visits. A District Nurse was spoken to. She said that she has just started visiting the home and visits regularly to change cressings on wounds, give insulin injections and to treat any pressure sores. The deputy manager stated that three residents self-administer their own medication. However, the deputy manager stated, when asked, that there are no assessments or agreements in place regarding this. A requirement is made that the registered persons ensure that individual assessments are carried out on each resident who self-administers their own medication and an agreement between the resident and the home is signed. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 14 The home has a policy and procedure on bereavement, which contains details regarding the Jewish tradition and customs in relation to funeral arrangements. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Residents are confident that the staff have received adequate training, which will ensure that they are protected from any form of abuse. EVIDENCE: Six staff files were viewed all contained a certificate regarding training in the protection of vulnerable adults. Staff completed the course in either December 2004 or May 2005. Five residents spoken to said that they were happy with the level of care received from staff and that the staff seemed well trained and competent. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Residents, staff and visitors are being put at risk of infection due to the staff not ensuring that they follow the correct health and safety policies and procedures by ensuring that all areas of the home are hygienically cleaned and well maintained. EVIDENCE: A resident has been moved out of her bedroom due to severe damp. At present there is a humidifier in the bedroom to remove the damp and keep the atmosphere moist. Parts of the hallway walls leading to the resident’s bedroom have been damaged due to the damp. One resident insisted that his bedroom be inspected. The wallpaper around his bed and bedroom door was badly damaged and peeling off due to the damp from the bedroom next door. A requirement is made that the registered persons ensure that the damage to the resident’s bedroom is repaired and that an assessment is made as to whether it is appropriate for the resident to remain in the bedroom when it has damp. An extensive tour of the kitchen was undertaken with the team leader. A discussion was had with the assistant chef with regards to the cleanliness of the kitchen. The large extractor has six separate filter plates fitted into the extractor. All of the filters were completely clogged up with dust. The two gas Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 17 stoves were severely heat stained with dark brown and black marks. Both stoves had grease around the sides. The two fat fryers also had grease around the sides and grease and dust had accumulated on other units below the extractor. The colour coded food preparation boards were underneath a unit piled on top of each other. A requirement is made that the registered persons ensure that a review of the kitchen cleaning is undertaken and that the extractor filters are replaced. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36. Although staff are being provided with the required training to ensure that they can best meet the needs of the residents, the registered manager is not ensuring that correct recruitment practices are followed and regular supervision is provided to staff, which is putting residents, staff and visitors to the home at risk. EVIDENCE: Eight staff files were viewed. All staff, including the domestic staff have Criminal Records Bureau (CRB) checks, which are kept separate and were brought over to the home for inspection. On looking though the deputy manager’s file no references or application form could be found. There were also no files for the domestic staff, which was a requirement at the previous inspection. A requirement is made and revised that the registered persons ensure that all staff working in the home has their own file and that the deputy manager’s file contains the information set out in Schedule 2 and 4 of the Care Homes Regulations. Many of the staff are undertaking or have successfully completed their National Vocational Qualification NVQ. On the day of the inspection, an NVQ assessor was in the home assessing a member of staff. The deputy manager, who is an assessor, was due to assess a member of staff on the day of the inspection. Certificates for NVQ level 3 were seen on some staff files. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 19 The home has a file where staff’s supervision records are kept. When asked for, the deputy manager was not able to locate the file. The registered manager produced the supervision file at the meeting on 7th November, which formed part of this inspection. Although many staff are receiving supervision, some had not had any supervision since July or August 2005. A requirement is made that the registered persons ensure that the staff supervision file is retained securely in the home and that all staff, including domestic and kitchen staff, receive regular supervision, which is recorded. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43. Residents and staff are not confident that the registered manager has the competence to manage the home and communicate a clear sense of leadership and that the quality of care to residents will be monitored and that safety issues will be dealt with promptly. EVIDENCE: The registered manager has been managing the home for a year. He has the experience of managing various other homes and has undertaken various training courses to enhance his skills. Two residents and two of three staff spoken to were dissatisfied with the manager’s approach and brought into question the competence of the registered manager to manage the home. One member of staff stated that the registered manager finds it difficult to delegate tasks and spends too much time in his office. The staff member also said that they were unclear as to what the manager’s role is and are uncertain as to the manager’s duties and responsibilities, even when the manager is not present. Another member of staff and a resident said that the manager spends most of his time in his office Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 21 and is not visible in the home monitoring the care being provided. The staff member went on to say that in the past, there have been issues about the management of the home and support provided to the staff team. A resident stated that the management of the home has deteriorated. The resident said that the manager is not approachable and will not act on their concerns. The issues raised by the residents and staff were discussed with the registered manager and the service manager. A requirement is made that the registered providers ensure that the issues raised by residents and staff are investigated and a record made of the outcome and a copy sent to the Commission. Information regarding the homes quality assurance system was not available for inspection. A requirement is made that the registered persons ensure that an effective quality assurance system is in place in the home for inspection. Safety certificates such as the lift inspection certificate, gas safety certificate, legionella test and Portable Appliances Test were viewed and were up to date including weekly fire safety tests and inspections are carried out regularly. The London Fire and Emergency Planning Authority (LFEPA), visited the home on 13th February 2004 and found three contraventions, all three contraventions have been met. However, a requirement was made at the previous inspection that a fire drill is carried out quarterly and the outcome recorded. On looking through the fire safety file, no drill has been carried out since the last inspection in June of this year. This requirement is restated. A requirement at the previous inspection that the water tank be cleaned and chlorinated and a copy of the certificate sent to the Commission has not been undertaken. This requirement is restated. The home has a financial and administration procedure manual. It contains information on contributions made to the day centre that residents attend. The home also has an affective financial procedure, which staff adhere to when doing shopping for the home or residents. All monies are kept locked in the home’s safe. Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X 3 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score X X X 1 3 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rela Goldhill Lodge Score X 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 1 1 X X 1 3 DS0000010535.V251482.R01.S.doc Version 5.0 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 14(2)(a) Requirement Timescale for action 03/02/06 2 YA6 22(3) 3 YA11 12(3)16(2)(i) 4 YA20 13(2) The registered persons must ensure that a review of the identified resident’s care needs is undertaken with a view to the resident being supported to live more independently. The registered persons 01/12/05 must ensure that an investigation takes place in relation the concerns highlighted by a resident and a copy of the outcome sent to the Commission. The registered persons 01/12/05 must ensure that resident’s views and choices regarding meals are ascertained and that residents are consulted at all times regarding menu planning. The registered persons 18/11/05 must ensure that individual assessments are carried out on residents who self-administer their own medication and an agreement between the resident and the home is DS0000010535.V251482.R01.S.doc Version 5.0 Page 24 Rela Goldhill Lodge signed. 5 YA24 The registered persons must ensure that the damage to the identified resident’s bedroom is repaired and an assessment made as to whether it is appropriate for the resident to continue to remain in the bedroom if it has damp. 16(2g&h)23(2c&d) The registered persons must immediately ensure that a review of the kitchen cleaning is undertaken and the extractor filters are replaced. 19(1)(b)(i) Sch The registered persons 2&4 must ensure that all domestic staff that regularly work in the home have their own file and that the deputy manager’s file contains the information set out in Schedule 4 of the Care Homes Regulations. (Previous timescale of 08/07/05 not met). This requirement is revised and restated. 18(2) The registered persons must ensure that all staff including the domestic and kitchen staff receive regular supervision and that it is recorded. 17(2) Sch 4 22(3) The registered persons must ensure that the complaints highlighted by residents and staff are investigated and the outcome recorded and a copy sent to the Commission. 24(1)(2)(3) The registered persons must ensure that an DS0000010535.V251482.R01.S.doc 13(4c) 23(1a,2bd) 01/12/05 6 YA30 18/11/05 7 YA34 31/10/05 8 YA36 13/01/06 9 YA38 01/12/05 10 YA39 01/12/05 Page 25 Rela Goldhill Lodge Version 5.0 11 YA42 23(4)(e) 17(2) Sch 4 12 YA42 13(3)(4)(c) effective quality assurance system is in the home. A report in respect of this must be available for inspection. The registered persons must ensure that a fire drill is carried out quarterly and the outcome recorded. (Previous timescale of 29/06/05 not met). This requirement is restated. The registered persons must ensure that the water tank is cleaned and that they obtain a further certificate to show that they have received a new water test. A copy of the certificate must be forwarded to the Commission. (Previous timescale of 29/06/05 not met). This requirement is restated. 13/01/06 18/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Rela Goldhill Lodge DS0000010535.V251482.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!