Inspection on 07/08/06 for South Lodge

This inspection was carried out on 7th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Lodge 12/01/06

South Lodge 21/07/05

South Lodge 02/02/05

South Lodge 16/08/04

South Lodge 11/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 South Lodge Susan Day Home Runnacleave Road Ilfracombe Devon EX34 8AQ Lead Inspector Victoria Stewart Key Unannounced Inspection 7th 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 Lodge DS0000022159.V298053.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 Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Lodge Address Susan Day Home Runnacleave Road Ilfracombe Devon EX34 8AQ 01271 862528 01271 862024 cherry@susanday.freeserve.co.uk 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) The Trustees Mrs Cherry Wild Care Home 33 Category(ies) of Dementia - over 65 years of age (33), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (33), Old age, not falling within any other category (33) South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: The Susan Day Home is a large voluntary-run home registered to provide care of up to 33 people over the age of 65 years, some of whom who may also have a dementia or mental health illness. The building is a three-storey Victorian villa situated in the Ilfracombe area of North Devon. Over the years it has had further extensions and adaptations to meet the needs of the people who live there. There is a lounge, dining room and two conservatories on the ground floor. Two further sitting rooms are sited on the first floor. All the private rooms are single and en-suite, apart from one room. Residents have access to all areas of the home by a modern, large passenger lift. The home has an attractive outside area, with a front garden and a choice of seating in different areas available, including a summerhouse. The home is centrally situated in Ilfracombe and is within a few minutes level walk from local the shops, the sea front and quay. The cost of care at the time of the inspection was within the range of £320 to £350 per week. Chiropody, hairdressing, personal toiletry items and newspapers/magazines are additional costs which are not included in the fees. The latest CSCI inspection report is displayed in the front entrance hall of the home, with further copies available from the home upon request. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned inspection programme for the year 2006/7 and took 6.5 hours for the inspector, Vickie Stewart, to complete. This inspection was unannounced, with the home having received prior notification that an inspection would take place within three months. The registered manager was on annual leave and therefore not present at this inspection. The head of care, officer in charge and care staff helped and assisted the inspector on the day. The home was full on the day of inspection and the inspector either spoke to or saw most of the residents and had lunch with three ladies. Prior to the inspection, a number of information surveys were sent out with an excellent return rate. Nine out of ten surveys sent to residents were returned; all seven surveys sent to relatives were returned and eleven out of twelve surveys sent to the home’s care staff were returned. The inspector also spoke with a health professional and two relatives on the day of inspection. This report is written with information gained from the pre-inspection questionnaire completed by the home, by talking with residents, relatives, staff and management, by looking at a selection of records (including resident files, staff files, medication records, quality assurance records, menus and health and safety records) by sampling the lunchtime meal and by undertaking a tour of the building. Lots of positive discussion took place during the inspection. The outcome of the inspection was fed back, discussed and agreed with the head of care of the home, prior to the inspector leaving. What the service does well: Prospective residents’ needs are assessed well, helping ensure that the home can meet the care needs of people who choose to live there. The home provides a high level of personal and health care to residents and involves other professionals when necessary. The home has a very friendly and homely atmosphere, with visitors welcome at all times. Residents’ families and friends remain part of residents’ lives and previous community contacts are encouraged. The home is extremely clean, well furnished and maintained to a high standard. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 6 The manager and management team have the knowledge and ability to ensure the home is run well and in the best interests of residents. Staff working at the home are well trained and motivated in their jobs and ensure that residents receive their care with privacy, dignity and respect at all times. Residents are involved in the running of the home and the service is monitored by various monitoring systems in place. Residents’ financial affairs are protected and a good complaints system is in place that enables residents to feel listened to. 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. South Lodge DS0000022159.V298053.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 Lodge DS0000022159.V298053.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): 2, 3, 4 & 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service There is a good admission process at the home, meaning that residents can be assured that the home can meet their needs Residents have a good understanding of the terms and conditions of the home EVIDENCE: Three residents’ files were looked at, including the most newly admitted resident to the home. All these files contained a pre-admission assessment of care carried out by a suitable professional – this contained enough information to enable a plan of care to be started. When the home assesses a prospective resident, care is always given to considering the residents already living at the home and whether the new person will settle in with them. All files seen contained a signed contract and acceptance of terms and conditions. Resident surveys confirmed that they felt that they had received enough information about the home so that they could decide whether to live there or South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 9 not. Residents are encouraged to come and see if they like the home before they move in and this length of time may vary from a few hours, include a meal or last over a period of one week. One resident told the inspector she had initially come for a two week trial but liked it and decided to stay; one said she choose the home with her relatives and one other said a trial visit was offered but not needed as “if you have to go in to care, there is nowhere else better”. One further resident confirmed she had had a tour of the home and met the staff before she decided to live there. Staff at the home receive lots of training and have the necessary skills and experience to meet the residents’ needs. The home ensures it meets the diverse needs of people from different backgrounds for example it caters for the different residents’ cultures and beliefs. South Lodge DS0000022159.V298053.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 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 this service. Residents benefit from staff planning and delivering a high standard of health and personal care Medication is well managed with clear systems in place promoting good health, but improvements must be made to ensure that residents are fully protected Staff ensure that residents are treated with respect, privacy and dignity at all times EVIDENCE: Three residents’ files were selected and their care plans looked at. All of these showed an individual plan of care which contained all the information required and included suitable risk assessments and specialist advice where necessary, for example one resident who was an insulin dependant diabetic had a separate plan specifically showing staff how manage this condition. Residents also have an individual profile completed, which includes brief summary of relevant personal, medical and social history details. For those residents that South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 11 self medicate, suitable assessments and reviews were seen. Good practice was seen of information regarding residents’ leisure and social interests – residents and/or relatives are encouraged to be part of the care planning process - one care plan had been completed by a relative who had written down the previous social history and interests of the resident. Two files contained details of the residents’ wishes on death and one contained a ‘client transfer to hospital’ details which, in the event of the resident being admitted to hospital, explained the care needed for this particular resident to pass on to other professionals. All care plans showed evidence of regular monthly review, with six monthly reviews carried out by a member of senior staff and the resident and/or their relative. All residents seen on the day of inspection appeared to be having their needs well met, this included several residents with high dependency needs. Those residents spoken with confirmed that they were well looked after. One resident survey said, “I always have the support and care I need. One only has to ask and someone will come to you soon”. The home is in the process of transferring on to electronic records, which will make the retrieving of information quicker and easier for staff to access. Specialist professionals are contacted when necessary - one health care professional said that there was good communication between the home, that suitable referrals were made and that she considered the home provides “good” care, for example one resident who has been nursed in bed for some time does not have any problems with pressure areas. When residents have a doctor, hospital or dentist visit etc a member of staff always accompanies them. The systems relating to the medication process were looked. Boots supply the home with a monitored dosage system and regularly audit the service and gives guidance to the home. The recording, storage, handling, administration and disposal of medicines was generally satisfactory with the exception of two issues – the inspector saw that one resident’s medication had been “potted up” and there was an error in the recording/quantity held of the controlled drugs belonging to another resident. Ways to resolve and prevent re-occurrence were discussed on the day of inspection and the home took immediate action by contacting the Boots community pharmacist for the proper guidance. Staff explained to the inspector how they meet the privacy and dignity needs of residents - this was observed on the day of inspection and residents confirmed that staff always treated them with respect. South Lodge DS0000022159.V298053.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 this service. Residents are able to exercise choice and control in their day-to-day lives The home offers a programme of social, leisure and recreational activities that residents enjoy The home provides a welcoming and friendly approach to relatives and visitors Meals are well presented and served in a congenial setting, but the food served may not always offer both choice and variety of food EVIDENCE: The home has an activities organiser and programme which gives residents 20 hours of recreational, social and leisure interests for residents at the home. These activities can involve several residents or be on a one-to-one basis. Residents confirmed that the home provides interesting activities but that sometimes they do not want to take part – some comments included “I join in some things, but am too old and tired to do it all” and “I don’t join in everything, but the staff always asks me to join in”. Last week, the home had its annual fete/open day where monies raised are used for the residents’ fund. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 13 Relatives, staff and some residents took part in the day and enjoyed themselves. The home has strong links with the local community and has been a home in Ilfracombe for many years. Many of the residents walk into town, take part in the local clubs (such as luncheon and bridge) or go shopping. One exIlfracombe resident has many “locals” visiting. Relatives confirmed that they are made welcome at all times and are kept informed of any important matters. Residents confirmed that they have choice in their lives for example they can get up and go to bed when they like and can eat in their rooms. Two residents said the home was “just like a hotel” and we can “come and go as we please”. Meals are taken in the newly decorated dining room which is now a welcoming and light room for residents to eat in. No menu is displayed in the home and several residents spoken with said that they it would help if they knew what was for lunch - this has been ordered the day before. The home provides a proper choice of meal on a Tuesday, Thursday and Saturday. No formal choice is offered on the other days but staff said that an alternative could be offered if requested. Menus show that the teatime meal has a very limited choice with “bun round and madeleines” as one Thursday tea. The inspector felt that these menus did not perhaps reflect the food that is being served at the home as some residents confirmed that the food was “very nice and varied”, “good choice of menu and good quality” and “the food I get is excellent”. However, four surveys said they only ‘usually’ like the meals at the home. Fish is served on a Friday and one resident in a questionnaire said that she “only picks at it” as she does not like fish and no alternative is offered. The inspector shared lunch with three residents when cold meat, coleslaw, beetroot, onions and new potatoes were served with a peach flan for dessert. The inspector was told that a ‘cold’ lunch is always served on a Monday. One resident who did not want this meal was given a fried egg instead. Some residents needed assistance to eat their lunchtime meal - care staff were seen to do this in a dignified and unhurried manner. The cook keeps a suitable record of temperatures of food and equipment but does not routinely record food served at breakfast – the inspector was told that at least one resident has a fried breakfast. The home has a three-week menu which is changed for summer and winter. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. The home has a good complaints system which ensures that residents and relatives are able to express their views and be listened to Residents are protected from abuse by staff who understand the principles of adult protection, have attended the necessary training and are aware of the procedures to take EVIDENCE: No complaints have been received by the CSCI since the last inspection. The home has a complaints system and residents, staff and relatives confirmed in their surveys that they knew how this worked but had not made a recent complaint. Residents were extremely complimentary of the home and had only good things to say about the home on the day of inspection for example “if all residential homes were like Susan Day, no-one would have to fear being in care” and “if you can’t live by yourself, it’s the best place”. The inspector looked at the complaints book and one complaint had recently been investigated. The home is very good at knowing their residents well and resolving any issues before they become complaints. This was indirectly observed during the inspection. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 15 Staff have professional training in the Protection of Vulnerable Adults and those spoken with had a good understanding of the principles of abuse and knew the procedures to take. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service Residents benefit from living in an environment that is homely, well furnished and maintained to a high standard EVIDENCE: The home is exceptionally clean and maintained to a high standard, whilst still having a homely and welcoming atmosphere. Residents stated in their surveys that the home was “kept spotlessly clean always”, “the home is spotlessly clean – home from home” and “excellent cleaners and standard of cleaning”. During the inspection, four residents wanted to make a point of telling the inspector that they felt the home was extremely clean and well kept. One relative commented that the cleanliness of the home was one of the reasons Susan Day was chosen for their relative to live. Three domestics work daily to ensure the home is kept clean and attractive for residents. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 17 Since the last inspection, the dining room has been completely refurbished. Residents’ private rooms are personalised and individually decorated with sentimental items of furniture and possessions brought in to make the rooms homely. On the day of inspection, the home was having cavity wall insulation installed to make the home warmer for the residents in winter. The garden is extremely well maintained and looked after – one resident enjoys pruning and tending to the flowers and shrubs on a daily basis. Hanging baskets, flowerbeds, shrubs, lawn and a central water feature make the garden attractive and residents told the inspector that they enjoy sitting there. A variety of seating areas are available, both in the sun and the shade, and a summerhouse fitted with patio furniture makes a welcoming area for residents to meet and chat. All areas of the home are accessible by the lift. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality is this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a happy, caring and permanent staff group who are employed in sufficient numbers with the necessary training to allow them to do their jobs well The staff recruitment procedures are generally good, but are not always consistent to protect residents living at the home EVIDENCE: On the day of inspection, the home had the head of care, an officer in charge, four care staff, three domestics, one cook and one kitchen assistant on duty to care for 33 residents. The home is sufficiently staffed to meet all the residents’ needs well and are a happy, motivated and caring staff group. The majority of staff have worked at the home for many years. Residents were very complimentary of the staff and comments such as “staff are always ready to listen to any problems I have”, “very good care staff” and “staff are caring and carry out their duties in a professional manner”. Staff surveys commented that they felt well trained to do their jobs and are supported by senior staff. Training is promoted in the home and staff spoken South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 19 with demonstrated to the inspector the varied courses they had attended. Regular staff meetings are held which staff felt were useful. The majority of care staff have either NVQ 2 or 3 and three senior members of staff have achieved the Registered Manager’s Award and NVQ Level 4. Three staff files were looked at. Two of these contained all the information required but the inspector noted that a temporary member of ancillary staff had been employed without the necessary pre-employment information; for example, no references had been gained and no personal details were held on file – however this member of staff had received a Protection of Vulnerable Adults check and was working under direct supervision with minimal resident contact. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff receive clear leadership and guidance by the management team Residents are involved in the running of the home, with evidence that their views are sought Systems are in place to ensure that residents’ personal monies are correctly managed The health and safety practices in the home ensure that there is a suitable environment for residents to live in EVIDENCE: South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 21 The manager has worked at the home for many years and is suitably experienced, qualified and skilled with the appropriate qualifications. She is assisted by a head of care, who is responsible for the care practices in the home and an officer in charge then takes responsibility for the day to day running of the home and supervision of care staff. Staff described the management of the home as “very friendly and open”, “the home is run very smoothly which is put down to good management” and “it is a very well run care home that always puts the service users needs before financial gain”. One said that it was appreciated that the management include the staff in any major decisions about the home. Staff spoken with told the inspector how much they liked working at the home and are “pleased to come to work” and “it’s a lovely place to work”. The home carries out regular questionnaires to residents and relatives to monitor the quality of the service. The inspector saw the latest ones and noted that the small number of negative comments received had been acted upon. Regular resident meetings are held and minutes taken. A member of the management committee visits the home on a monthly basis to carry out a monitoring visit. This committee meet regularly at the home and are actively involved in its management. The Annual General Meeting was recently held. The inspector was told that the manager has done further work on monitoring the quality assurance of the home, but evidence of this was not seen. Three randomly selected monies held by the home on behalf of residents were selected and looked at. These were satisfactory and good records held. All statutory training for staff was up to date (including fire and manual handling). All equipment used in the home is serviced and maintained as necessary. Fire records were looked at and these were found to be well-kept and up to date with records of staff that have attended the fire training held. South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13, 2 Timescale for action The registered person shall make 15/08/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. With regard to: • Ensuring that the recording, administration, dispensing and administration of all drugs, in this case particularly controlled drugs, is managed appropriately • Ensuring that resident’s medication is not “potted up” or secondary dispensed and a system devised to prevent this happening Requirement South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 24 2. OP29 19 (1) a, b Schedule 2 The registered person shall not employ a person to work at the care home unless all the necessary information contained with Schedule 2 is obtained. With regard to: • Ensuring that two satisfactory references, a completed application form and full personal details are obtained on each employee and held on file 08/09/06 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. 2. Refer to Standard OP15 OP15 Good Practice Recommendations It is recommended that the choice of food served is reviewed with a daily choice offered. Menus should reflect the actual food available It is recommended that a system is developed to show residents what they will be having to eat that day South Lodge DS0000022159.V298053.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Lodge DS0000022159.V298053.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!