Inspection on 12/03/08 for South Moor Lodge Care Home

This inspection was carried out on 12th March 2008.

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 but made no statutory requirements on the home.

Other inspections for this house

South Moor Lodge Care Home 30/03/09

South Moor Lodge Care Home 20/02/07

South Moor Lodge Care Home 20/10/06

South Moor Lodge Care Home 05/01/06

South Moor Lodge Care Home 28/09/05

South Moor Lodge Care Home 22/03/05

South Moor Lodge Care Home 23/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE South Moor Lodge Care Home South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD Lead Inspector Mary O`Loughlin Unannounced Inspection 12th March 2008 09:30 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 Moor Lodge Care Home DS0000008788.V360809.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 Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Moor Lodge Care Home Address South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD 01427 891204 01427 891504 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) Mrs Christine Mary Clayton Mr Frank Clayton Ms Roseanne Livermore Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered providers may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: Old Age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 40 20th February 2007 2. Date of last inspection Brief Description of the Service: South Moor Lodge is a residential home providing personal care to 40 older people and those who may suffer from Dementia. An extension has been built in 2007 attached to the main building. This extension is on two floors. It includes 11 bedrooms, a small lounge, a sensory room and a new bathroom. The home has a very a large paved courtyard. The manager explained that this area was used for barbecues and fetes. There was a large metal gate that when closed made the area secure. Mr and Mrs Clayton who are active in all parts of service provision own the home. Mrs Clayton works as carer at the home in the home and Mr Clayton is closely involved in the building and maintenance of the home. The home is an adapted cottage style house set in extensive grounds. All service users have single bedrooms with en-suite facilities sited on two floors with access by stairs, a stair lift and a lift. Some of the ground floor rooms have patio doors onto the garden. The patio area at the front of the building is secure and there is a car park to the front of the building. The range of fees are: £290.00 to £400.00 per week. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One inspector conducted the unannounced visit over 5hours. The main method of inspection used was called ‘case tracking’ which involved selecting two residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The registered manager, and members of staff were spoken with as part of this visit. Documents were read as part of this visit and medication management was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken which included a sample of resident’s bedrooms, to make sure that the environment is safe and providing appropriate aids. A review of all the information we have received about the home and the previous requirements that were set at the last inspection was considered in planning this visit and this helped decide what areas were looked at. A range of additional information was used to determine the outcome of this visit, including information provided by service users, representatives of service users and staff within our pre-inspection surveys. The manager returned her Annual Quality Assurance Assessment, referred to in this report as (AQAA), this provided good information on the services provided. The quality rating for this service is 1 star this means the people who use this service experience adequate quality outcomes. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? An extension has been built attached to the main building. This extension is on two floors. It includes 11 bedrooms, a small lounge, a sensory room and a new bathroom. Menus have changed in response to requests from service users. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-3-6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The practice of ensuring that all prospective residents including those that selffund receive a thorough assessment as required is inconsistent and records are not comprehensively completed to ensure that all aspects of the service users health and welfare are taken into account. Intermediate care is not provided at the home. EVIDENCE: Since the increase in numbers in December 2007 to 40 places the home have produced a revised statement of purpose and service user guide, which was assessed by our registration team as providing prospective service users with information they need to make an informed choice about where to live. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 10 The responses to our recent surveys suggested that 7 out of 9 people felt they had been provided with sufficient information prior to admission. We looked at the records of 2 recently admitted service users and found that the process of assessing service users prior to admission is insufficiently documented and does not meet the required standard, the manager told us that she always discusses the needs of each prospective service user but has not always completed the written records, which could be a potential risk to service users if their needs are not fully taken into account. We also found that service users are not informed in writing that following an assessment the home can meet their needs. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-8-9-10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to healthcare and remedial services. The health care needs of service users unable to leave the home are managed by visits from local health care services. Residents have the aids and equipment they need and these are well maintained to support them in daily living. There are shortfalls in the care plans and medicine management systems that do not fully safeguard the service users health and wellbeing. EVIDENCE: We surveyed some of the service users and their representatives before this inspection and found a high level of satisfaction with the care they were receiving. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 12 100 of service users surveyed said that staff listened to them and acted on what they said. 80 of relatives surveyed said that the home always provide the care and support to their relative that they had expected or agreed. 80 of care staff surveyed said the ways of passing information about service users between the staff usually worked well. Relative comment; “We have total confidence in the way Mum is cared for, staff are understanding and caring in their approach and always prepared to discuss any aspect of care with family and friends.” To support these findings we looked at three care plans, the written recorded information about the needs of service users was not fully comprehensive and there were shortfalls in assessing risks such as Falls, Nutrition and Pressure sores. In practice we saw good examples of the care service users receive to manage their health with regard to nutrition and pressure sore risks. Service users had access to external professionals such as the District Nurse and General Practitioner and any equipment necessary to support their conditions. Staff recorded the times of turning service users who were prone to pressure sore development and ensured a consistent application of care, which protected them from any skin damage. In all three cases daily records were completed which recorded events and how these were dealt with. The records did not tell us whether the service users were consulted on the care plans as no signatures or record of who had been involved was held. The care plans were not sufficient to ensure that staff were fully informed of all aspects of the service users health, personal and social care needs, and evidence from staff surveys said that “sometimes we are told conflicting information about changes with a service users health and this is not recorded in a detailed way to help us support or care for them” We looked at how medicines were managed and found that there were some shortfalls and that they do not always follow safe practice guidelines. Medicines were stored safely and generally recorded into the home as required, however for those service users that were recently admitted there was no record of the medicines that they had brought into the home and the South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 13 hand written medicine record sheets had not been signed and witnessed to reduce any error. The medicine policies were looked at and did not show evidence of up to date review in line with current good practice guidance. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-13-14-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have the opportunity to develop and maintain important personal and family relationships EVIDENCE: There has been consistent evidence that service users are provided with a range of activities that meets with their social expectations and needs. We found that there are suitable activities provided and attempts to provide a service that is as individual as possible, using its staff and resources effectively. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 15 The AQAA gave us information that residents are consulted on how the home can work to provide them with a flexible lifestyle, the home has listened to their views and has made some changes to the events provided. 80 of the service users we asked about activities said that they were usually offered the opportunity to take part in activities that the home had provided. 100 of the representatives of service users said they were kept up to date with important issues affecting their friend or relative. During this inspection a coffee morning was taking place and friends and relatives were visiting the home. Service users were able to go out with their friends and staff were seen to support this. During the afternoon a church service was being given by the local minister, an event that takes place regularly for those people unable to attend church. The information within the AQAA told us that the manager recognises and works towards equality and diversity for all service users in respect of age, gender, religion, and culture. 90 of the service users we surveyed said they were always happy with the meals provided at the home. Only one person said they would like more choices. The information we received within the AQAA shows us that the manager has had meetings with the service users and menus have been changed as a result, which shows that they are listening, and acting on the choices and preferences of the service users. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16-19 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and acted upon promptly. The present lack of recording and risk assessing new problems for service users who lack capacity to safeguard themselves does not fully protect their health, safety and welfare. EVIDENCE: From the registration site visit in December 2007 and from previous inspections the evidence shows that the home has a suitable complaints procedure in place. From our recent surveys it was clear that service users and relatives knew how to make a complaint, 100 of the service users said they knew who to speak to if they were unhappy. We have not received any complaints about the service in the last 12 months. The manager told us within the AQAA that they had addressed 2 complaints in the previous 12 months within the appropriate timescales. Residents told us they felt safe and cared for. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 17 We looked at the procedures within the home for staff to follow in the event of service users suffering abuse, the staff have access to procedures but these are now out of date and the newly revised Safeguarding Adults Procedures need to be obtained to ensure staff respond appropriately to any suspicion of abuse. Staff training records indicated that some had received training in Safeguarding Adults but this was in 2005 and needs to be reviewed to ensure that they are aware of their responsibilities in line with the new policies and provide a consistent approach in practice. Staff have also received training in managing challenging behaviour in 2008 to ensure they respond appropriately to any incidents of aggression. One care plan seen through case tracking told us that there was insufficient assessment of risk for a service user that was unable to maintain their own safety if they wandered from the home. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The living environment is appropriate for the particular lifestyle and needs of the service users and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. EVIDENCE: A pre-registration site visit to the service took place 12 December 2007. The manager and the providers Mr and Mrs Clayton were present. A tour of the building was undertaken. This showed the following: An extension has been built attached to the main building. This extension is on two floors. It includes 11 bedrooms, a small lounge, a sensory room and a new bathroom. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 19 There were 11 additional bedrooms, five on the first floor and six on the ground floor. The bedrooms were above the required national minimum standard regarding space. They had relevant furniture and fittings in place including low surface temperature radiators, 2 Call systems to allow for movement around the room of the bed, TV aerial, and three double electrical sockets. Each room was ensuite with a shower, toilet and sink. The showers were thermostatically controlled for safety, window restrictors were on all first floor windows. A building officer completion certificate was seen. Contact was made with the building Officer during the site visit that was able to confirm that the certificate included confirmation of compliance with safe fire procedures. This inspection found that the environment was very clean and well maintained. The smoking area was compliant with Department of Health guidelines on smoking in residential homes. The residents that smoke have a risk assessment performed and evidence of this was seen following the requirement at the last inspection. The number of cleaning and laundry staff has increased as recommended and the manager said it has improved the cleanliness of the building. The manager said they send water samples each year to ensure that water was safe from contamination and storage was compliant with Legionella, these were not checked. The manager does not have the Department of Health Essential Steps Guidance for the infection control management in care homes, she was advised to obtain this and audit the homes practice South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas take into account the needs and routines of the people using the service, however the lack of providing cover in times of absences is stretching the service and does not allow the management of the home sufficient time to undertake their own responsibilities. EVIDENCE: The home has recently increased its size to 40 beds of which up to 8 people are accommodated who suffer from Dementia, the manager said they do not intend to increase this number regardless of the registration allowing them to. Spread over three wings the staff are deployed to work in different areas and in different numbers to meet the needs of the service users. The duty records were seen and confirm that there are care staff, catering, laundry and cleaning staff employed on a daily basis. The manager and senior care were on duty during the inspection and I discussed the recent concern about staffing numbers that we had received in January 2008. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 21 The manager agreed that they are at times struggling to meet desired levels of care staff due to sickness or holidays. She told me that regular staff have covered many shifts but have become tired as a result and reluctant to keep working extra hours. This has meant that the manager and senior care have covered most of the shortfalls, caring or catering hours. The manager said the home does not use temporary or agency staff. Recruitment drives have improved the staffing situation recently; a second cook and some care staff have been employed. The staff responses to our recent survey suggest that 90 felt they would do better if they had relief staff to cover holidays and absences. Relatives survey responses - 3 out of 8 said that things could be improved by providing more staff but 100 felt needs were being met. Recruitment procedure checks identified safe practice in obtaining 2 references and Criminal Record Disclosure for all staff prior to commencing employment. The manager did not have a single point of reference for what staff had done what training and said that she is going to develop a training matrix on the computer given the time. The AQAA told us that 80 of the care staff are trained to level 2 NVQ in care which shows that service users are in safe hands at all times. The pre-registration site visit in December 2007 showed us that staff have undertaken a distance-learning course in Dementia Care, which provides them with suitable skills to provide good care for people with this type of illness. The staff also receive a suitable induction to ensure they are competent to undertake care duties. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a qualified and competent manager in place who works hard to ensure the home is run in the best interests of the service users. The lack of sufficient administration time has allowed shortfalls to develop in the completion of appropriate records and the review of procedures in line with current good practice which does not ensure that service users receive appropriate care at all times. EVIDENCE: The manager is registered with us and as such has been assessed as having the required qualifications and experience and is competent to run the home. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 23 The AQAA we received contains clear, relevant information that is supported by a range of evidence. The AQAA lets us know about changes they have made and where they still need to make improvements. The manager demonstrates through discussion with us and within the AQAA that she understands person centred planning and thinking but she has little time to implement good care planning, she is trying to work towards introducing a new care planning system but this could take considerable time as she has no administrative support and has needed to cover other staff absences. Our records indicate that since the increase in the numbers and needs of the service users accommodated there has been no change to the allocated administration time, this now appears to be having an impact on the service as the manager is having difficulty in meeting her responsibilities with record keeping. There are also no suitable arrangements in place to provide cover for staff absences which is also impacting on management time as the manager and her senior carer fill the duties of absent staff. The manager trains and develops staff that are generally competent and knowledgeable to care for the residents. The service focuses on the individual, takes account of equality and diversity issues, and generally works in partnership with families or close friends, as appropriate, and professionals. The home has a statement of purpose that sets out the aims and objectives of the service. The registered provider lives on the premises and is in the home daily. Service users and families are surveyed by the home to encourage their suggestions for improvement and the manager demonstrates within the AQAA that their suggestions are listened to and acted upon, such as improving the social activities. Training records for staff were difficult to follow. There was no system (training matrix) of ensuring that staff training was sufficiently organised to ensure that updates were provided for all staff within the appropriate timescale. The manager said within the AQAA that the staff require Equality and Diversity training. Policies and procedures showed shortfalls in areas such as medicine management as identified in standard 9 of this report. Safeguarding procedures required updating. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 24 Infection control procedures require updating to reflect the “Department of Health’s guidance on “Essential Steps” for infection control in care homes” Care plans were not comprehensively completed and did not identify consultation. There were no records of limitations agreed with the service user as to their freedom of choice, liberty and movement. (See standard 19) The fire records were seen and show compliance with the safe management of risk. The manager does not have access to the Internet and has not accessed our website where she could obtain up to date guidance as legislation changes or good practice guidance is issued. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 4 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 2 X 3 X 3 X 1 3 South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement You must ensure that each prospective service user receives an assessment in line with Standard 3.3 and that they are informed in writing that the home is able to meet their needs prior to agreeing admission. The Registered person must ensure that care plans are developed and identify all the needs of the service users in sufficient detail to enable staff to provide comprehensive care. This requirement is outstanding from 23/04/07 and the time scale has been extended. The registered person must ensure that risk assessments on all identified risks are completed to ensure staff are aware of action to be taken. This requirement is outstanding from 23/04/07 and the time scale has been extended. Timescale for action 30/04/08 2. OP7 15 31/05/08 3. OP8 13 (4) (c) 31/05/08 South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 27 4. OP9 13 You must ensure that all medicines coming into the home are recorded to provide a suitable audit trail. All hand written medicines must be signed and witnessed. Medicine policies must be updated to reflect the current guidance and best practice. You must ensure that staff have access to and are trained in the revised safeguarding adults procedures. You must ensure that a record is held of any incident in the care home that is detrimental to the health and welfare of a service user. When risks are identified that a service user may wander away from the home there must be a record of what actions are taken to manage the risk and any limitations as to the person’s liberty, freedom of movement or power to make decisions. You must ensure that at all times there is sufficient staff on duty to meet the needs of the service users and enable the manager to take responsibility for fulfilling her duties. You must ensure that records required by regulation are maintained up to date and accurate. Review 1. Safeguarding Adults policy 2. Infection control policy 3. Missing person’s policy 4. Restraint Policy 5. Medication Policy 6. Care Planning and risk assessments for fall, nutrition, and pressure sore risk. DS0000008788.V360809.R01.S.doc 30/04/08 5. OP18 13 30/07/08 6. OP18 Schedule 3 30/05/08 7. OP31 18 30/05/08 8. OP37 17 30/06/08 South Moor Lodge Care Home Version 5.2 Page 28 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 OP27 OP30 Good Practice Recommendations Implement a training matrix that will enable a clear picture of training needs of the staff. Provide Equality and Diversity training for staff. South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Moor Lodge Care Home DS0000008788.V360809.R01.S.doc Version 5.2 Page 30 - 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!