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Inspection on 15/11/07 for St Andrews Lodge Care Home

Also see our care home review for St Andrews Lodge Care Home for more information

This inspection was carried out on 15th November 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The environment at St. Andrews has been developed in a way that "brings the outside in." Each resident`s door has a number and doorknocker, the corridors each have street names and there is a row of mock shop fronts containing items to stimulate interest in those walking by them. The hairdressing room has been set out as a barber`s shop, complete with red and white pole. There is an authentic, wall-mounted pillarbox for mail, all designed to stimulate the residents` mental capabilities and interest as they walk around the home. The atmosphere is warm and welcoming and the interactions between staff, residents and their relatives, are supportive and respectful.The activities co-ordinators have developed an extensive activity programme for each of the units, based on the preferences and interests of the residents, which aims at supporting their individual leisure needs.

What has improved since the last inspection?

The recording of administering medications has improved, with all dosages signed and no gaps in the records, which helps maintain the protection of residents from any harm with medication. The home has introduced a sensory room, with water bubbles, lights, sounds and visual stimulation, with comfortable areas to relax and observe these, which help promote calmness in people who may be distressed or agitated.

What the care home could do better:

The acting manager has been in post since February 2007 and must apply for registration, as it is an offence under the Care Homes Regulations, to run a home as an unregistered manger. Equality and diversity of residents is valued and taken into consideration within many aspects of their daily lives, but continued development is needed in some care plans to identify individual religious and cultural diversity. Complaints received by the home should be dealt with in line with the home`s complaints procedure and the complainant notified, in writing, of the outcome of their complaint, to support the protection and welfare of residents. The Commission must be notified of all untoward incidents which occur at the home, and this must include any injury to or death of a resident, to help maintain the safety and security of the residents and monitor the quality of care you provide for them. All care staff at the home must undergo regular supervision, which includes their professional and personal development, as well as their care skills and competencies, to make sure residents receive care from skilled, competent staff, in a way which is safe and in accordance with their preferences.

CARE HOMES FOR OLDER PEOPLE St Andrews Lodge Care Home Riber Crescent Basford Nottingham NG5 1LP Lead Inspector Lee West Unannounced Inspection 15th November 2007 13:00p 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 St Andrews Lodge Care Home DS0000026472.V354447.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. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews Lodge Care Home Address Riber Crescent Basford Nottingham NG5 1LP 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) 0115 9245467 0115 9245485 slodge@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Health Care Trinity Care Limited *** Vacant *** Care Home 80 Category(ies) of Dementia - over 65 years of age (80), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (80) St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling under category MD(E) Mental Disorder older people over 65 years (excluding Learning Disability or Dementia) or DE(E) Dementia shall be admitted to St Andrews Lodge when there are already 80 persons of these categories/combined categories accommodated in the home To admit into St Andrews Lodge one named service user aged 45 years under category DE To admit into St Andrews Lodge one named service user aged 40 years under category DE To admit into St Andrews Lodge 10 service users aged between 50 65 years under category DE The maximum number of persons to be accommodated within St Andrews Lodge is 80 8th March 2007 2. 3. 4. 5. Date of last inspection Brief Description of the Service: St. Andrews Lodge provides nursing care for 80 older people with Mental Illness and for those with Dementia. The registration allows for up to 10 people between the ages of 50- 65yrs to be accommodated. The home is split into two separate nursing units, Garden and Assisi, and a residential care unit, Robin. Sited in an established residential area the home has sufficient car parking and a well maintained garden. All areas of the home were accessible to service users. The fee range is from £326.56 for residential care to £588.50 per week, including the nurse determination fee. The Registration Certificate is prominently displayed in the entrance area of the home, together with copies of the service user guide and daily menus. St Andrews Lodge Care Home DS0000026472.V354447.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 is upon outcomes for people 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. This inspection was unannounced and involved one inspector. The main method of inspection used is “case tracking”, which involves selecting five residents and looking at the quality of the care they receive by speaking with them, observation, reading their records, and asking staff about their needs. Five members of staff and four visitors were also interviewed. Due to the complex needs of some residents, who had difficulty with communication, time was spent with them in the lounge areas observing their interactions with staff and visitors. Documents, including care plans, medication administration records and financial records were inspected to help form an opinion about the health, safety and welfare of residents at the home Information supplied to the commission by the manager, on the Annual Quality Assessment, with information received by the Commission about the home, since the last inspection, were also considered, and helped the decision of which areas to focus on. What the service does well: The environment at St. Andrews has been developed in a way that “brings the outside in.” Each resident’s door has a number and doorknocker, the corridors each have street names and there is a row of mock shop fronts containing items to stimulate interest in those walking by them. The hairdressing room has been set out as a barber’s shop, complete with red and white pole. There is an authentic, wall-mounted pillarbox for mail, all designed to stimulate the residents’ mental capabilities and interest as they walk around the home. The atmosphere is warm and welcoming and the interactions between staff, residents and their relatives, are supportive and respectful. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 6 The activities co-ordinators have developed an extensive activity programme for each of the units, based on the preferences and interests of the residents, which aims at supporting their individual leisure needs. 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 St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Andrews Lodge Care Home DS0000026472.V354447.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 St Andrews Lodge Care Home DS0000026472.V354447.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, 4, 5, 6, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The completion of a full needs assessment with prospective residents helps to confirm the home can meet their needs and information in the service user guide, helps the resident to understand what they can expect and make their decision about the home. EVIDENCE: The service user guide contained useful information about the home and its facilities, written in plain language. Copies of the guide were displayed in the reception area of the home. People making the decision about coming into the home had opportunities, with their relatives, to make visits and one resident who was being admitted during the inspection visit said this had happened and that the visits helped in making the decision. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 10 “Other homes had been tried, but I liked the atmosphere in this one,” the resident commented. The records case tracked contained evidence of pre-admission assessments, which were thorough and identified care needs, but some did not identify any of the individual’s personal preferences, interests and hobbies. This led to care plans that dealt with the physical needs, but not the mental, religious or cultural needs being addressed. Intermediate care was not being provided to anyone at this time. St Andrews Lodge Care Home DS0000026472.V354447.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 good This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and their privacy is upheld, their care needs are identified in individual care plans and actions set out to meet these needs. EVIDENCE: Five residents’ files were case tracked. These contained records of assessments, including moving and handling, nutritional needs, pressure area care. One contained identification of some mental health needs and how to deal with them. Daily records were kept, which helped with monitoring of the continuity of care provided. Residents spoken with said they were satisfied with the care at the home, and that the staff were, “lovely and always helpful.” St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 12 One relative said, “When I go home I feel my relative is getting the best help there is.” Some of the residents were not able to respond verbally, so their interactions with the staff were observed and found to be positive and supportive of the residents’ well-being. Staff were observed responding quickly, when residents being nursed in bed used their nurse call alarm. Also, those who were being nursed in bed had, at their choice, their doors open onto the corridor, to help them see people going by their rooms, and to be able to speak with people. One resident being nursed in bed said, “I feel I can catch someone’s attention with the door open, and I can see and hear people, so don’t feel so alone.” Staff said they used the care plans to make sure they give the help that’s needed, and, “make sure residents still do things for themselves that they can.” They were also able to discuss how they supported the residents, and their individual needs, but were not clear about their religious and cultural needs. Medication policies and practices were in place and records of those case tracked were seen, with the Medication Administration Records accurately completed, and no gaps seen. Medicines were stored securely and records were seen of medicines coming into the home, or returned to the pharmacy. There were no residents at this time who self-administer medication, due to the complexity of their needs. Staff were giving residents’ medication at lunchtime, and this was observed to be in a safe manner, with staff making sure residents had taken their medication before signing the records, to protect residents from harm. Staff were observed knocking on the doors before going into a resident’s room and their interactions were gentle and respectful. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Sufficient staff resources are provided to allow time for activities and stimulation. Family and friends are made welcome and included whenever they visit the home. EVIDENCE: Three activities co-ordinators have developed an activities programme for each of the units, Garden, Assisi and Robin. The activities were group and one to one, starting with one to one interactions at breakfast, with group activities, including table games, music and dance, arts and craft and baking during the days, Monday to Friday, in each area, until late afternoon. Some residents have developed relationships with other residents in the home and others have been supported by staff to maintain relationships they had with people before they came to the home. The co-ordinators explained how they created their programme from their discussions with residents and assessment of their interests, hobbies and history of their lives, and records of these were seen. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 14 Light therapy in the newly designed sensory room was also programmed. The co-ordinators said this had become a valuable resource, as it had a very calming effect on residents who had become distressed, or agitated and that, “its sometimes difficult to get residents to leave the room, because it is so relaxing and calming.” During the visit the co-ordinators and care staff were observed in the large lounge area, interacting with the residents. There was cheerful chatter between them all, and relatives who were visiting were included. Residents were in groups, some were wandering around the corridors and communal rooms and were seen to be touching art work, specially designed to encourage interest. Relatives were invited to Christmas activities, which included a special lunch served in the home and activities “Dates for Diary” showed a varied selection of entertainments inside and outside the home, which residents and visitors could attend. One visitor spoken with said, “the girls try hard to help us all have fun.” During this visit there was entertainment, a musician with a keyboard, and residents and staff were observed dancing and singing to the music. Staff were encouraging residents who had difficult mobility to be included, by making sure chairs were turned round, or pushed nearer the entertainer. Residents said they enjoyed the food, which looked nutritious and appetising and that there were always choices available if they didn’t like what was being offered. The meals were served in a pleasant dining area, but residents could eat where they chose and special arrangements were made for privacy for residents who wished to eat with their relatives. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place, available to anyone, but staff do not always follow this, which may lead to dissatisfaction from complainants. Residents are protected by staff who are aware of their roles in safeguarding adults. EVIDENCE: There was a complaints procedure in place, but records did not show the outcomes, actions taken, and responses of any complainant. Residents said they would speak to the staff if there were any problems, or complaints, but also that they felt safe with the staff who are, “very caring and do their best.” There had been a complaint from a healthcare professional, which identified specific areas of concern about monitoring and recording risk assessments for individual residents. Although the Annual Quality Assurance Assessment stated, “all complaints are recorded and responded to within a 28 day period,” no evidence was seen that this had been followed. Records showed action had been taken, with risks being identified and put into the care plans, but there was no evidence of a response and outcome to the complainant. The operations manager said the complainant had been spoken with about the St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 16 complaint, and had since visited the home a number of times, and was satisfied, but there was nothing recorded to reflect this. Staff said they had received training in safeguarding adults and were able to describe their role in this area. Policies for safeguarding adults were in place and up to date. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 25, 26, Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The environment is well-maintained, providing a safe place to live, with communal areas which encourage small clusters of people to meet together. Residents’ bedrooms are personalised with their own possessions and all areas are clean and smell fresh, encouraging a feeling of well-being for the residents. EVIDENCE: The home has continued with the programme of improvements to the environment and all areas of the home were clean, pleasant and hygienic. There were different artwork and wall decorations on each of the corridors, its own street name sign, with residents’ front doors along each side of the corridor, painted in striking, primary colours. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 18 Bedroom doors all had door knockers and letter plates, reminiscent of a proper front door, painted in the primary colour of their choice, this helped them to identify their own private and individual room. There were intricate and interesting murals from floor to ceiling in the bathrooms, corridors and entrances to each area, with designs to reflect the name of the house. Assisi had murals with animals and Garden had flowers and a scarecrow. A red and white pole outside the door identified the hairdresser’s, with sign writing and pictures on the walls like any hairdressing salon. Two residents were observed having their hair dressed, and their interactions with the hairdresser were positive and cheerful. There was also a corridor of shop frontages, which contained interesting bottles, boxes and other articles in their mock windows, to stimulate residents’ interest in their surroundings. People were observed walking along this area and stopping to look into the windows. Furnishings around the home were comfortable, with chairs in small groups in different areas of the lounge, people were observed interacting within their groups. Visitors spoken with said they found the home much more pleasant now, and they said they felt the efforts made to improve the environment had a positive effect on their relatives. One said, “it gives us somewhere to walk and something of interest to see, especially in winter when its really too cold to go out.” Residents spoken with said they were satisfied with their own rooms, and had their own possessions around them, particularly photographs and ornaments, which they said reminded them of their family. Recently a sensory room had been developed, to support people with agitation and distress. This room had extensive light therapy, bubble tubes, a calm atmosphere, comfortable cushioned seating area and sounds and visual displays to provide a calming environment. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by staff who are competent to do their jobs, in sufficient numbers and who are recruited after their suitability has been confirmed, to ensure all residents are safely cared for. EVIDENCE: Recruitment policies were being followed. The staff files case tracked contained records of Criminal Records Bureau checks, professional references and personal identification. The staff records were well organised and the information easily accessible. Copies of training certificates were in the staff files, including infection control awareness and dementia awareness, care, cause, relief and prevention of pressure sores. Staff said they had received induction training and some had achieved the National Vocational Qualification at level 2 or 3, with some working towards this. The duty rota showed sufficient staff on duty to meet the needs of the residents, but staff said, there were still times when they were very busy, St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 20 particularly at meal times when a number of residents needed help with their meals and drinks. The activities co-ordinators were observed helping residents, during the early afternoon, with hot drinks brought round to each group, encouraging them to drink and also interacting with residents who had difficulty with verbal communication, which increased their well-being. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager has a good understanding of the importance of good outcomes for people who use the service, and works continuously to improve the quality of life for residents, but being unregistered is working contrary to the Regulations. EVIDENCE: Although the home is run in a way which puts the residents’ interests first, as evidenced in the improvements in the well-being of the residents observed and spoken with, the manager has been in post since January 2007, and has still not applied to the Commission for registered manager status, contrary to the regulations. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 22 Records of residents’ personal allowances were checked and balanced with the accounting sheet. Relatives spoken with said they were satisfied their relative’s money was safely taken care of by the manager and they were able to have their own money whenever they wanted it. There was no evidence of staff supervision having taken place and the manager said there had not been any for some time and the last supervision was a group session in September. Staff spoken with also said they had not had any supervision for, “quite a while.” Without supervision, the manager cannot monitor the strengths, training needs, or personal development needs of the home’s staff, which has the potential of leading to a less competent team and lowering of standards of care. During the summer, a number of incidents that should have been reported to the Commission as notification of untoward incidents, were not. These incidents were notified by another health professional who was concerned. Other incidents have been reported “retrospectively.” This practice impacts on the safety of residents, as the reasons for the incidents, or potential problems, could not be identified or used to support improvements in care. The Annual Quality Assurance Assessment sent to the Commission provided evidence of dates of maintenance and servicing, fire system testing and other health and safety checks to maintain the safety of residents and staff and records were seen during the visit to support this information. Evaluation of the residents’ survey carried out in August was seen. One area surveyed was, “are you able to choose when you get up or go to bed?” Residents had responded yes, but the care plans did not contain any information about preferred times to get up or go to bed, which indicates the evaluation had not led to any changes in care planning, reducing the effectiveness of resident surveys as a quality tool. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 x 18 3 4 X X X 3 3 3 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 2 2 3 St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 22(3) Requirement You must make sure all complaints are investigated fully in accordance with the home’s policy and that the complainant is informed of any action to be taken in response to the complaint to support the protection and welfare of residents. You must make an application to the Commission to become the registered manager of the home to comply with the Care Homes Regulations. You must notify the Commission, without delay, of any death, serious injury, serious illness, or other untoward incident, which occurs, to enable monitoring of protection of residents and effectiveness of actions you have taken in response to the incidents. You must make sure people working at the home are regularly supervised to cover all aspects of their practice and personal development needs to DS0000026472.V354447.R01.S.doc Timescale for action 30/03/08 2. OP31 9(1) 28/02/08 3. OP37 37(1) 28/02/08 4. OP36 18(2) 30/03/08 St Andrews Lodge Care Home Version 5.2 Page 25 support a skilled and well managed workforce for a positive outcome for residents. 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 OP4 Good Practice Recommendations You should ensure individual care planning takes into consideration the religious and cultural needs of the resident, to support their needs and enable them to maintain their individuality. St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 St Andrews Lodge Care Home DS0000026472.V354447.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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