Inspection on 02/08/06 for South Africa Lodge Nursing Home

This inspection was carried out on 2nd August 2006.

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

South Africa Lodge Nursing Home 21/09/05

South Africa Lodge Nursing Home 18/04/05

South Africa Lodge Nursing Home 15/09/04

South Africa Lodge Nursing Home 22/04/04

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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 South Africa Lodge Nursing Home Stakes Hill Road Waterlooville Hampshire PO7 7LA Lead Inspector Michael Gough Unannounced Inspection 2nd August 2006 10:00 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 South Africa Lodge Nursing Home DS0000011473.V306052.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. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Africa Lodge Nursing Home Address Stakes Hill Road Waterlooville Hampshire PO7 7LA 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) (023) 92 255556 South Africa Lodge Limited Mrs Maria Stavert Care Home 55 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (55), Learning disability (10), Mental disorder, of places excluding learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (55) South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No service users under the age of 50 will be admitted. No more than twelve (12) service users may be accomodated between the age of 50 years and 65 years. 21st September 2005 Date of last inspection Brief Description of the Service: This service is a nursing home for older people and for those with mental health difficulties. There are 55 individual rooms 54 of which are en suite. The service is offered on two floors that are divided into group living facilities. The home is within large grounds and service users have access to a garden, which is landscaped to meet resident’s needs. Fees at the home range from £750 - £813 per week and service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by 2 inspectors from the Commission for Social Care Inspection (CSCI) and took place over 6 hours. The home had less than 24 hours notice of the inspection taking place. The homes registered manager and her deputy assisted the inspector’s during the course of the inspection. The home is registered for a total of 55 service users and at the time of the inspection there were 55 service users living at the home. Evidence for this report was obtained by speaking with the homes manager, from reading and inspecting records, touring the home and from observing the interaction between staff and service users. It was not possible to obtain clear evidence from service users due to their dementia, however the inspectors did speak with 8 service users, 8 members of staff and 4 visitors to the home. What the service does well: What has improved since the last inspection? Since the last inspection, the home has obtained the Investors In People Award, which is a national quality standard, which assesses good practice in an organisation. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 6 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. South Africa Lodge Nursing Home DS0000011473.V306052.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 South Africa Lodge Nursing Home DS0000011473.V306052.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. New service users have a needs assessment undertaken prior to moving into the home this allows both the home and the service users and their relatives the opportunity to see if the home can meet the service users needs. The home does not provide intermediate care. EVIDENCE: The home carries out an individual needs assessment prior to service users moving into the home and there is a clear admission process. Assessments were on file at the home and were looked at for the 3 service users case tracked. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. The health, personal and social care needs of service users are set out in an individual plan of care, which give details of the care to be provided and also gives details on how this care should be given, however some care plans need to be amended to ensure that there is clear information for staff so that they have all the information they need to give the right support for service users, this will improve the care that service users receive. To ensure continuity and regular monitoring South Africa Lodge has a contract with a local GP practice, where all service users are registered and there are visits to the home twice per week on Tuesdays and Fridays. All service users can choose to register with a GP of their choice but are encouraged to register with the contracted GP service offered by the South Africa Lodge. The home ensures that all service users have access to all relevant health care professionals and the health care needs of service users are met. Service users are protected by the homes policies and procedures for dealing with medicines and generally medication procedures are good, however clear information is required for staff with regard to the monitoring and subsequent actions to be taken with regard to blood glucose levels for service users who are diabetic, this will help to provide a better response to service users in this area. Service users at the home are treated with dignity and respect and their right to privacy is upheld. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 10 EVIDENCE: Care plans were seen for 3 service users and these were clear and easy to follow and contained relevant information and informed staff of individual needs and how these should be met. Care plans are reviewed monthly and service users families are involved in the care planning process and attend service users reviews. One care plan contained information from a service users wife who did not want her husband to wear hip protectors and there was also information on how support was to be given. Wound care plans were clear and gave details of the size of the wound, treatment given and there was regular evaluation of the wound to show improvement or lack of it. There was information in daily records that one service user could be difficult to support and could be aggressive with certain staff and medication was prescribed to reduce aggression. One service users care plan stated that the person could be aggressive when sat in the lounge, there was information for staff to ensure that empty chairs were to be on either side and for 30 minute observations, however there was not clear information that that observations were always carried out. A care plan noted that a service user used a stand aid, sling and wheelchair, and that sometimes the person was unable to balance and refuses to stand and puts herself on the floor, this was clear information for staff but there was nothing to indicate to staff how they should manage issues of balance, putting herself on the floor or refusing to stand. It is a requirement that care plans must be amended to provide clear information to staff so that they have all the information they need to give the right support for service users. Service users have access to all relevant health care professionals. The home has a visiting chiropodist and a continence nurse provides advice to the home. The home uses a monitored dose system for medication and medication records were found to be up to date with no gaps and there are clear procedures for the receipt storage, administration and return of medication. The home has some controlled drugs – liquid temazepam and this is stored appropriately and is administered and stored correctly. 6 service users at the home have their blood glucose levels monitored regularly and these can be 2.3 – 30 . Each service users normal range is different but there is no clear information for staff on what each person’s normal range is or information on what staff should do if the reading falls outside the range. It is recommended that the home discuss with the service users GP and obtain clear information on each service users individual “normal Range” and then provide clear South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 11 instructions for staff on what action they should take for each individual should there blood glucose fall outside their normal range. Staff were seen to behave appropriately with residents and the inspectors observed staff interacting with service users and using service users preferred form of address. Staff were seen to knock on service users doors before entering and visitors spoken to confirmed that staff treat service users with dignity and respect. South Africa Lodge Nursing Home DS0000011473.V306052.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 at least once during a 12 month period. 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 the service. The home provides a range of activities for service users, which meet their expectations and the home was commended for the activities it provides. The religious and recreational interests of service users at the home are provided for and service users are able to maintain contact with family and friends and visitors are welcome at any time. Service users are supported to exercise choice and control over their lives as much as possible and they are provided with a balanced diet in pleasant surroundings at time convenient to them. EVIDENCE: The home employs and activities co-ordinator who works Monday – Friday 9 – 4.30 and she organises a range of activities for service users. Every morning there is exercise to music and there are different activities each afternoon. The activities co-ordinator has been at the home for over 3 years and knows the service users well, she keeps a record of all the activities and records who takes part and also those who passively enjoy watching others taking part. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 13 The inspectors observed activities on a Wednesday afternoon and service users were seen taking part in tennis using big bats and soft balls and there was a large soft dartboard type target and service users were throwing soft beanbags at it. Staff were seen sitting with service users and encouraging them to get involved and this was stimulating for service users. There were a range of books and magazines in all of the lounges at the home and some of these were quite old, the activities co-ordinator explained that none of the service users at the home read due to their dementia but they enjoy flicking through the magazines and books and this provides stimulation. The home was commended for the activities it provides for service users. There were notices on the board about church services and Holy Communion and a visiting vicar calls twice per month and a sister from a local convent visits weekly. The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway, the inspector checked the visitors book and there had been over 60 visitors to the home in the 3 days preceding the inspection. There is information for visitors and others on advocacy, relatives support groups, dementia and bereavement. There are also questionnaires for relative to complete should they wish to do so. The menu is available daily in the hallway and in the lounges, but due to service users dementia it was not possible to get their views on the choice of meals at the home but those spoken to said they enjoyed their lunch and relatives spoken to said they were happy with what they had seen and some had meals with their relatives when they visited. On the day of the inspection lunch was roast pork with roast potatoes, broccoli, swede and gravy, this was followed by lemon meringue pie and fresh cream or semolina. Fruit was seen to be available and residents can choose where to have their meals. Some service users have their meals liquidised and the inspector observed these meals, service users had the same meals as other service users and each individual item was pureed separately and placed on a plate, this was attractively presented and looked appealing. Meals to the ground floor are served through a servery direct from the kitchen, on the first and second floors, Food is sent up on trays in heated trolley’s and each floor has a small kitchen area and food is plated up for service users as they are required and this ensure that food is delivered to service users hot. The inspector sampled the lunch menu and this was tasty and hot. The home operates a 4 week rolling menu and staff ask service users what they would like 24 hours in advance. A list of food requested is kept in the kitchen and records of food consumed are also kept. The cook on duty said that alternatives can be provided if service users do not want what is on offer and on the day of the inspection one service user was having soup and then changed her mind and had the main meal and this was not a problem for the kitchen staff. The inspector looked at the food storage areas, dry food was stored appropriately and stock was rotated so that newer stock was put to the back, there were stocks of tinned food, mainly baked beans, tomatoes and spaghetti hoops but these were not in excessive numbers. Dry food is ordered and delivered once per week. Fresh fruit and vegetables are stored appropriately and these are South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 14 delivered to the home 3 times per week. Fresh meat is delivered 3 times per week and fresh bread and milk is delivered every other day. Bread is frozen and kept in a dedicated freezer and thawed and used as required. The home has a double freezer unit for frozen foods which are delivered once per week, the inspector looked in the freezer and this contained mainly ice cream and frozen deserts, there was some frozen snack meals, e.g. sausage rolls and pork pies and some frozen vegetables and the cook said that these were mainly used for back up if fresh produce was not available. The inspector observed staff supporting service users with their lunch and support was given appropriately and service users were not rushed and were supported to eat at their own pace. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. There is a simple, clear and accessible complaints procedure, and this includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures help protect service users from any form of abuse. EVIDENCE: The home has a policy and procedure for dealing with any complaints and this contained all of the required information and gave details of how to contact the CSCI. Since the last inspection there have been 4 complaints to the home and these were fully recorded and resolved to the satisfaction of the complainants. The manager has a log of complaints and concerns raised by staff, this showed that these have been investigated and there were records of action taken. The Commission for Social Care Inspection has received one anonymous complaint, which was also forwarded to Social Services and concerns raised were looked at as part of this inspection. Staff members spoken to were aware of the complaints procedure. Staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 16 South Africa Lodge Nursing Home DS0000011473.V306052.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Service users live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. The home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: The inspector toured the building and all areas of the home were clean and tidy and furniture was in a satisfactory state of repair. The home comprises of 3 floors and each has a lounge area. Service users were seen to be using all of the communal lounges in the home and these were bright and airy. The inspector discussed the corridor giving access to room 15, this has the door to the corridor secured and it is unlocked by means of a switch system that the service user may not understand. The manager has carried out a risk assessment for this particular room and staff are aware of the potential issues should a fire occur in this area. The home has dedicated domestic staff and they were deployed around the premises. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 18 The home has a laundry and has dedicated laundry staff. The home provides a full laundry service for service users and there are 2 industrial washing machines and 2 tumble driers, the staff member doing the laundry round stated that dirty laundry is placed in sluice rooms and it is then collected by the laundry staff, any soiled laundry is placed in red sack so that staff are aware of the contents. All areas of the home were clean and there were no offensive odours. South Africa Lodge Nursing Home DS0000011473.V306052.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 at least once during a 12 month period. 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 the service. The home has mix of staff that has a range of skills and there were sufficient numbers of staff on duty to meet the needs of service users. Staff morale was good and service users benefit from a staff team that has had sufficient training to meet the needs of service users and are competent and qualified. The homes recruitment policy and practice supports and protects service users. EVIDENCE: The homes rota showed that the home employs a total of 13 qualified nurses and 41 care staff, in addition there are domestic staff employed at the home. From 8am to 8pm there are 2 trained nurses and 11 care staff on duty and there is also a student nurse and an adaptation nurse on duty in addition to the normal staff. Between 8pm and 8am there are 2 trained nurse staff and 6 care staff. The homes manager and her deputy work in addition to the rotered staff. There are 2 domestic staff on duty 8am – 3pm seven days a week and there is a domestic staff member employed on Tuesdays and Thursdays 7 – 12Am who’s job is to deep clean carpets. There is 1 laundry staff member on duty 8am – 4pm 7 days per week and additional laundry staff help out between 12 – 3pm 2 days per week. There is dedicated kitchen staff and cooks work 7 – 3 seven days per week and kitchen assistant’s work 8 – 3 seven days a week. There are teatime cooks who work 4 – 6 seven days per South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 20 week. The home has bank staff that cover for sickness and holidays and the home has a waiting list for staff that would like to work at the home. The home has 14 staff that has already obtained their NVQIII qualification and there were job descriptions for staff and these gave details of individual roles and responsibilities. Recruitment records were seen for 5 staff members all had appropriate documentation including 2 x refs, photo, passport, birth certificate PIN numbers for Nurse’s and application forms, there were work permits where appropriate. There was one discrepancy on the application form for one staff member and this was discussed with the homes manager who said that she would speak with the staff member concerned before she commenced her next shift, she will report back her findings to the CSCI. Training records showed that all staff have completed an induction and the new induction pack for staff includes, job description, company rules, general work rules, abuse policy, bullying policy, day routine, night routine, basic care plan information General Social Care Council Codes of Practice and Induction work books. The home has in house trainers with appropriate qualifications and there are 2 members of staff who are trained to conduct manual handling training, the training plan for 2006 shows that training is planned in essential care, moving and handling, fire training, adult protection training, food hygiene, skin care, infection control, challenging behaviour, podiatry care, care of dying patients, dementia care, epilepsy training, first aid, diabetes, foundation health care and teaching and assessing. South Africa Lodge Nursing Home DS0000011473.V306052.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. The manager is experienced and there is clear leadership. The home has a quality assurance monitoring system to obtain the view of service users at the home. Service users financial interests are safeguarded by the home financial procedures and staff are appropriately supervised. The health safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager of the home is an experienced manager and she has an effective deputy who has completed the registered managers award and who helps in the day-to-day running of the home. The home also has a dedicated administrator who is responsible for the domestic staff and who also helps to ensure that required records are kept and are up to date. Staff spoken to said that the manager was very approachable and were confident in her abilities South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 22 The home has an effective quality assurance system in place and relatives and relevant others are sent questionnaires to ascertain how the home is meeting the needs of service users, the results of questionnaires sent out in January 2006 show that 50 surveys were sent out and 27 received back, evaluation of questions showed that of the 9 questions asked there was 100 positive feedback from 8 of the 9 questions on the question “overall how do you rate the quality of care your relatives receives” replies were: excellent 70 , good 30 . There were also 10 questionnaires received back from visiting professionals e.g. GP’s, Health Visitors and Care Managers and all were very positive about the home. The home is corporate appointee for 3 service users and accounts are held in the name of each individual, there are comprehensive records and these are audited independently. The home also keeps some spending money for 2 service users and this money is kept separately in the safe with appropriate records and receipts kept. The inspector checked the balances of 2 service users and these were found to be correct. Staff files inspected showed that staff received supervision 6 times per year in accordance with the National Minimum Standards. The fire logbook was inspected and this confirmed that all relevant training, and testing is carried out. Private electrical equipment was due to be tested on 20/9/06, fixed electrical wiring was last tested on 2002 in the new wing and 2005 in the older part of the home, the approved gas safety engineer called in June 2006, and the passenger lift was tested in July 2006, the hoists and lifting equipment was being tested by an approved engineer on the day the inspection took place. South Africa Lodge Nursing Home DS0000011473.V306052.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 N/A 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 24 No 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 OP7 Regulation 15 Requirement Care plans must be amended to ensure that there is clear information for staff so that they have all the information they need to give the right support for service users Timescale for action 30/10/06 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 OP9 Good Practice Recommendations It is a recommended that the home discuss with those service users GP’s who are diabetic to obtain clear information on each service users individual “normal blood glucose Range” and then provide clear instructions for staff on what action they should take for each individual should their blood sugar fall outside their normal range. South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 South Africa Lodge Nursing Home DS0000011473.V306052.R01.S.doc Version 5.2 Page 26 - 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!