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Inspection on 09/05/06 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 9th May 2006.

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 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 outcomes for the residents at the home are that they are cared for in a structured environment, which provides opportunity to socialise and undertake activities according to their preference. The staff team have the skills and experience necessary to provide suitable care and assessment of the residents. There is a quality assurance system that actively encourages participation from relatives and comments are acted upon to improve the service.

What has improved since the last inspection?

There has been continuous improvement in the care planning and the care delivery.

What the care home could do better:

The acting manager must apply to register with the Commission for Social Care Inspection. The arrangements around admission assessments must be more robust to ensure that all information received is used to formulate a care plan ensuring that all aspects of the residents needs have been considered before admission.St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 7The Nurse drawing up the care plans must document who was involved in the care planning, wherever possible having the plans signed. New staff coming on duty must receive a more in depth history of the new residents to ensure that the resident receives the care that has been planned for them as an individual, and opportunities must be made for them to read the care plans. The system of recording daily events within the evaluation record sheets must be clarified to ensure that staff complete a full review as required and alter the care plan to reflect any changes. The routine tasks such as wheelchair transfers must be considered, residents should not be seated directly onto the canvass at any time, the cushions provided with the wheelchair should be with the chair. Methods of communication are generally reliant upon staff passing information on at Handover periods, if records of the residents diet, fluid balance or positional changes are not held then new staff coming on duty will not have a clear record of events on which they can make an appropriate judgement. The resident may not receive the care and attention they need. The female residents must be dressed in tights or stockings if this is their preference. More consideration must be given to maintaining the dignity of these residents when they are unable to protect themselves. The care plans should have some reference to how the resident is going to obtain clothing and on what basis. If the home is managing their affairs, efforts to ensure they receive new clothing should be made or referral to external advocates who will undertake this should be made. There must be more consideration and recording of the equality and diversity of the residents needs, providing reference to cultural or dietary preferences in the plans. When the pharmacy inspection has taken place there should be a record of the actions taken by the home to ensure that all recommendations are acted upon to improve the service. The bathroom 1.10 requires repair to ensure residents are not injured from the broken bath side. The shower room must have a drain cover fitted.

CARE HOMES FOR OLDER PEOPLE St Andrews Lodge Care Home Riber Crescent Basford Nottingham NG5 1LP Lead Inspector Mary O`Loughlin Key Unannounced Inspection 9th May 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 St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 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.V288463.R01.S.doc Version 5.1 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 Trinity Care Ltd Mrs Gillian Margaret Bell Care Home 80 Category(ies) of Dementia (80), Mental disorder, excluding registration, with number learning disability or dementia (80) of places St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Out of the total number of beds up to 10 beds can be used for service users aged between 50 & 65 years Service Users shall be within categories DE (80), or MD (80). Date of last inspection 8th November 2005 Brief Description of the Service: Trinity Care Ltd, the registered provider, had a contract with the Health Authority to accommodate people that are in need of continuing care. The contract is currently under review. 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 units, Garden and Assisi. Sited in an established residential area the home had sufficient car parking and a well maintained garden. All areas of the home were accessible to service users. The fee range is from £339.00 to £589.00 per week including the nurse determination fee. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report was produced following a visit to the home on 9th May 2006 over 6.5hrs. A range of information was used to inform the report including the visit; records of recent complaints and adult protection investigations, notifiable incidents, the providers own visit reports and the report from the supplying pharmacist after their inspection in April 2006. The residents were unable to give a clear account of their lives at the home and there were no visitor’s comments to include. The main method of inspection was to case track 5 residents, this means their care plan was looked at and the care they received assessed to ensure they were receiving appropriate care. Direct observation of the residents, how they appeared and how they were cared for provided further information. 6 Staff were spoken with, including the acting manager. The operations manager was also at the home to provide training and gave assistance with the inspection visit. The home has provided continuing care in contract with the health authority for some years. This contract has now ceased and the remaining residents are receiving an assessment of their needs to allow for appropriate protection of their rights and choices in future care. The registered provider has now commenced admitting people that are not under this continuing care service. This has involved setting up policies within the home to ensure that these residents receive appropriate support that is not part of the continuing care arrangements. During these changes the residents that are accommodated are having their needs assessed and wherever possible they are being transferred to the appropriate unit of the home that can more readily and safely care for their needs. Assisi unit was the focus of this inspection, the present residents are mainly those that have complex problems and may exhibit difficult behaviours. Adjacent to Assisi unit is Robin suite, this accommodates people that do not require nursing and is separated by a locked door. The Robin suite has a dedicated staff team. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 6 Assisi unit is managed in the best interests of the residents and they do receive care and support from external professionals to monitor their complex needs. The staff are trained in the special needs of these residents to ensure that all difficult behaviours are dealt with appropriately. What the service does well: What has improved since the last inspection? What they could do better: The acting manager must apply to register with the Commission for Social Care Inspection. The arrangements around admission assessments must be more robust to ensure that all information received is used to formulate a care plan ensuring that all aspects of the residents needs have been considered before admission. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 7 The Nurse drawing up the care plans must document who was involved in the care planning, wherever possible having the plans signed. New staff coming on duty must receive a more in depth history of the new residents to ensure that the resident receives the care that has been planned for them as an individual, and opportunities must be made for them to read the care plans. The system of recording daily events within the evaluation record sheets must be clarified to ensure that staff complete a full review as required and alter the care plan to reflect any changes. The routine tasks such as wheelchair transfers must be considered, residents should not be seated directly onto the canvass at any time, the cushions provided with the wheelchair should be with the chair. Methods of communication are generally reliant upon staff passing information on at Handover periods, if records of the residents diet, fluid balance or positional changes are not held then new staff coming on duty will not have a clear record of events on which they can make an appropriate judgement. The resident may not receive the care and attention they need. The female residents must be dressed in tights or stockings if this is their preference. More consideration must be given to maintaining the dignity of these residents when they are unable to protect themselves. The care plans should have some reference to how the resident is going to obtain clothing and on what basis. If the home is managing their affairs, efforts to ensure they receive new clothing should be made or referral to external advocates who will undertake this should be made. There must be more consideration and recording of the equality and diversity of the residents needs, providing reference to cultural or dietary preferences in the plans. When the pharmacy inspection has taken place there should be a record of the actions taken by the home to ensure that all recommendations are acted upon to improve the service. The bathroom 1.10 requires repair to ensure residents are not injured from the broken bath side. The shower room must have a drain cover fitted. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 8 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. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 9 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.V288463.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3-6 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents receive a full assessment of their needs and will know prior to entering the home that identified needs will be met. Intermediate care is not provided. EVIDENCE: The records of two residents who had recently been admitted to the home were examined to ensure continued compliance with the standard since the last inspection. One resident had been admitted following an assessment by a qualified nurse at the home, which included all the required information within the National St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 11 Minimum Standards to ensure that all aspects of their health and personal care could be met by the home. The staff had also obtained an assessment from the specialists involved in the persons care, however some information within this document was not used to inform the persons care plan which would have been valuable in giving staff a knowledge of the recent history and risks identified prior to the placement at the home. A second person had been admitted in an emergency within the previous 24hrs and staff were obtaining information form the external specialists involved in the persons care to provide them with the most up to date knowledge of the residents health needs. Intermediate care is not provided. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 12 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 adequate. This Judgement is made using available evidence including a visit to this service. The health and personal care which a resident receives may not be based on their individual needs. Residents are protected by the home’s policies and procedures for dealing with medicines. The arrangements for personal care do not always ensure that the residents dignity is respected at all times. EVIDENCE: The care plans of five residents demonstrated that they had had their health, personal and social care needs assessed at the point of admission and then at St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 13 least monthly or as their conditions changed. The plans contained in depth information on how to meet the needs of the residents. The plans seen did not demonstrate who had been involved in the care planning as there was no evidence of a signature or in some cases a date. The care planning of four residents showed that they had complex needs, all of which were assessed and monitored appropriately. However not all information contained within daily records was used to update the care plans ensuring they were appropriate. One resident had been unable to eat and had been weighed monthly, receiving diet supplements to ensure they had the necessary nutrition. There was guidance being provided from the dietician for those that required this specialist referral. Residents were assessed for their pressure sore risk and staff ensured that the appropriate equipment was in use both on the person’s bed and in the seating. There was a lack of attention to ensuring that when transferring residents in a wheelchair that they were seated on a cushion and not onto the chair canvass. Recent concerns expressed in complaints have been around the personal care that residents receive, with particular regard to the care of peoples nails and clothing. The residents seen during this visit all appeared clean and had well-manicured nails, one resident proudly showed me her varnished nails. The manager confirmed that staff had received training as a result of the complaint and that nail kits had been purchased and distributed to the unit. 7 out of 10 female residents were not wearing tights or stockings; other females were dressed in socks. This is not appropriate nor does it maintain the persons dignity. There was no record of their preference in this area. Personal clothing appeared of a good standard in general, aprons were in use at mealtimes to protect clothing. For those residents unable to manage own finances and for whom the home safeguards their funds, there was insufficient evidence that clothing was purchased or that the staff had considered who was responsible for those within the records. Good person centred planning would ensure that the staff considered all aspects of the persons needs. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 14 The staff team provided residents with opportunity to use the toilet before the lunchtime meal. The residents were not offered the toilet until 2hrs later when afternoon staff came on duty. Residents were observed to have been incontinent during this time. Afternoon staff had no record of positional changes, intake and output or toileting times for any of the residents and this could not ensure that any problems would be addressed within a safe timescale or the promotion of their comfort and dignity. Staff coming on duty received a handover from the qualified nurse which did not provide them with sufficient information for the newly admitted residents which would ensure that they received a more person centred care rather than a task orientated service. Appropriate management of the recording, administration and safekeeping of medicines is in place. The recent Pharmacy inspection report recommended that some areas required improvement. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 15 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 is made using available evidence including a visit to this service. Residents experience a life style that satisfies their needs and are enabled to exercise as much control of their lives as they are capable of. Contact with relatives and friends is supported for residents. Wherever possible the residents preferences are considered to enable them to have control over their lives. Residents receive appropriate management of their nutritional requirements. EVIDENCE: Activities workers were seen with residents, sharing conversation and playing games. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 16 Residents are all assessed for their interests and preferences which then informs a care plan on working and playing. The opporunities available were suitable for the residents needs. There is evidence that relatives are encouraged to remain involved and residents are supported to maintain contact with friends and loved ones. There is a private room where relatives are able to visit and staff support the resident to the room if they wish. Church services are held monthly and dates are displayed. Relatives attend meetings at the home and are able to inform changes in the practices as a result. Cultural needs for those within ethnic minorities was not addressed within the one resident case tracked. The meals were nicely presented and staff supported people appropriately. There was a lack of clarity between staff regarding different special diets which did not ensure that the resident would receive an appropriate diet. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents and their relatives can be confident that their complaints will be listened to,taken seriously and acted upon. There are robust systems in place to protect vulnerable residents from abuse. EVIDENCE: The records of complaints over the last 6 months demonstrate that the home had addresssed 3 complaints and had done so within the required timescale. The outcomes of each complaint had informed the practices at the home and staff had received training in any areas that were indicated from the investigations. The Acting manager is familiar with the local procedures for investigating incidents under the Vulnerable Adults Procedure. There have been 2 Adult Protection referrals over the last 6 months, one not substantiated and the second ongoing. The records of relatives meetings show that opportunities are in place for people to raise concerns or make constructive suggestions, records indicated St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 18 that from these meetings, changes in the homes policy and practice takes place. Staff also have regular meetings and confirmed that they felt able to raise any concerns or make suggestions to improve practices at the home. Staff have received training in Adult Protection issues, and dealing with difficult behaviours to ensure that any aggression physical or verbal is understood and dealt with appropriately. Policies and practices regarding the safe keeping of residents monies and financial affairs ensure their safety. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. The home is suitable and safely maintained in the interests of the residents. Residents can be assured that suitable infection control policies and procedures are in place. EVIDENCE: The home was warm and clean. The fire system is maintained appropriately with risk assesments compliant with the Fire Authority. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 20 There are no outstanding issues from the Environmental Health Office that the Commission is made aware of. The home has three units all locked with key pads to ensure residents safety. The main entrance is staffed by one person during office hours. CCTV operates outside of the home for external security. The home has a routine maintenance programme and the homes handyman provides daily support. The grounds are attractive, recent relatives meetings have informed the owners of untidy areas that are in the process of being tidied up. There are systems in place to control infection, staff are provided with training and personal protection to undertake safe practices and control any spread of infection. The laundry system provides safe washing temperatures that control any infection. There is a clinical waste collection in place in line with legislation. One bathroom 1.10 was in need of repair to the external moulding and a replacement shower attachment. A recent complaint was received by the home regarding the loss of jewellery in a shower drain that had no cover. This cover was not in place at this time and would not ensure that the problem would not recur. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-28-29-30 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents needs are met by a staff team, sufficient in numbers and suitably trained. The recruitment policy ensures that residents are protected from staff that may be unsuitable to work with vulnerable adults. EVIDENCE: Duty records show that qualified and care staff are employed in sufficient numbers. The environment was well maintained demonstrating that there was sufficient domestic staff employed. The manager confirmed that 55 of the care staff ratio have an NVQ qualification. Three staff files examined show that the home continues to undertake safe recruitment practices ensuring the protection of the residents. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 22 Staff files and staff questioned confirm that the home ensures all staff receive induction training to National standards. Foundation training is in place. Training and development is included within staff supervision files to ensure that staff have access to at least three days training a year. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 23 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 adequate. This Judgement is made using available evidence including a visit to this service. The home has an acting manager in place who is not registered with the Commission. The quality assurance system in place ensures that the home is run in the best interests of the residents. Residents financial interests are safeguarded. Suitable health and safety systems in place ensure the safety of the residents. EVIDENCE: St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 24 There is an acting manager in place who has completed three months in post and is now considering registering with the Commission. The acting manager must address this issue to avoid enforcement action. There are clear lines of accountability and access to the operations manager to support the acting manager. There is an effective quality assurance system in place that actively seeks the views of all those involved in the home and it was evidenced that these views are considered and used to inform the homes development, improving the outcomes for the residents. 2 residents that were case tracked were unable to manage their own finances. The homes administrator undertakes the task of ensuring all monies related to these residents is appropriately managed. The statements of these residents bank accounts show that they are appropriately managed with records of all incoming and outgoing payments. One resident with excessive funds was referred to the Court of Protection which is good practice. The home provides safe working practices including; safe moving and handling, fire safety, first aid and food hygiene. Records and statements demonstrated that staff receive training in all areas of health and safety. New staff are included within health and safety meetings and minutes of these were seen. Chemicals are stored safely, electrical equipment safely maintained and water systems appropriately regulated to ensure residents are protected. There is a written statement of policy, which ensures compliance with relevant legislation in health and safety. The fire system is checked weekly. Accidents are recorded. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 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 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 X 3 St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 26 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. Standard Regulation Requirement Timescale for action 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 3 Refer to Standard OP3 OP7 OP8 Good Practice Recommendations Ensure that prior to agreeing admission that all documents received from specialists involved are considered and information is used to inform the home’s own care plan. Wherever possible the care plans should be signed by the people involved, the resident and or their relative and dated. Ensure that if evaluation records are being used to record daily events that these records are used to change the original plan to ensure that the plan reflects the current needs of the resident. Ensure that residents are seated on a cushion when transferred in wheelchairs and not the seated directly onto the canvass. Provide a safer system of communicating special diets to ensure all staff are aware of each residents dietary needs. Ensure that female residents are dressed appropriately with tights or stockings. DS0000026472.V288463.R01.S.doc Version 5.1 Page 27 4 5 6 OP8 OP8 OP8 St Andrews Lodge Care Home 7 8 9 10 11 OP8 OP8 OP8 OP9 OP10 12 13 14 15 16 17 OP12 OP15 OP19 OP19 OP19 OP31 Ensure records are completed of the diet, fluid balance and positional changes for those residents requiring this. Ensure that care delivery is person centred and more appropriate management of the needs of residents who may be incontinent is in place. Ensure that staff are fully informed of all aspects of the care for newly admitted residents. Provide evidence of the action taken to address the recommendations made from the pharmacy inspection of 26/04/06. Provide some reference to who is responsible for providing and purchasing clothing and how often this is to be addressed within the plans of those people that the home manage the personal finances for and who are unable to manage their own affairs. Ensure that the cultural needs of residents are addressed within the care plans. Improve upon the system of informing the kitchen staff of special diets to ensure they are fully informed at all times. Ensure that the external grounds are safely maintained. Repair Bath 1.10 and replace the shower attachment. Replace the drain cover to the shower room on Assisi Unit. The acting manager must register with the Commission for Social Care Inspection, as it is an offence to carry on a care home without a registered manager. St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 St Andrews Lodge Care Home DS0000026472.V288463.R01.S.doc Version 5.1 Page 29 - 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. 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