Inspection on 11/01/07 for St Luke`s Lodge

This inspection was carried out on 11th January 2007.

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

St Luke`s Lodge 01/07/08

St Luke`s Lodge 21/06/07

St Luke`s Lodge 02/05/06

St Luke`s Lodge 25/10/05

St Luke`s Lodge 30/11/04

St Luke`s Lodge 28/04/04

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

CARE HOMES FOR OLDER PEOPLE St Luke`s Lodge 7 Southborough Road Surbiton Surrey KT6 6JN Lead Inspector Diane Thackrah Key Unannounced Inspection 11th January 2007 10:45a 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 Luke`s Lodge DS0000013399.V327085.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 Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Luke`s Lodge Address 7 Southborough Road Surbiton Surrey KT6 6JN 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) 020 8399 2085 Mr Christie Kamalanathan Rajanayagam Mrs Annapoorani Rajanayagam Post Vacant Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2006 Brief Description of the Service: St Luke’s Lodge is registered with the Commission for Social Care Inspection to provided care to a maximum of seventeen people over the age of sixty-five, whom may have dementia. The home is a detached property situated in a conservation area. The home is owned and managed by Mr and Mrs Rajanayagam. Service users have access to shops, public transport and other local resources. Bedrooms are provided over three floors, all of which can be accessed by passenger lift. There is a large garden to the rear of the property. Parking spaces are available. Twenty-four hour care is provided. As well as care staff, the home employs a cook and activities coordinator. A copy of the home’s Service User Guide and Statement of Purpose can be obtained on request from the Registered Provider’s, as can a copy of the most recent Commission for Social Care Inspection, inspection report. Fees for the home at the time of writing range between £417.00 - £488.00. There are no additional charges. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 11th January 2007 between 10.45 and 15.20. A partial tour of the premises took place and care records were examined. Observations of care practices also occurred. The Registered Manager her son and two staff members were spoken with, as were two service users and one visitor. A number of service users do not have the mental capacity to share their views about the care that they receive. Observations of care practices and interactions with staff members occurred in order to gain an insight into the experiences of these service users. The views of three relatives and four General Practitioners have been received via comment cards. The views of these people will be reflected in this report. What the service does well: What has improved since the last inspection? One bedroom has been redecorated and the screening around one sink has been improved since the last inspection. The level of staff supervision has increased. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. (3 and 6) This judgement has been made using available evidence including a visit to this service. There are appropriate arrangements for obtaining information about the needs of service users before they move into the home, which ensures that staff members are clear about the needs of service users. The home does not provide intermediate care. EVIDENCE: The Registered Provider said that there have been no new admissions to the home since the last inspection and therefore needs assessment documentation was not examined during this inspection. Previous inspections of the home have found Standard three to be met. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. (7, 8, 9 and 10) This judgement has been made using available evidence including a visit to this service. In general, there are adequate arrangements for ensuring that service users have their health, personal and social care needs met. However, there remain some poor practice issues that put into question the quality of care provision in the home. EVIDENCE: Care plans for three service users were examined. These provided adequate information about how the needs of the service users should be met and there was documentation detailing that care plans had been reviewed monthly. Concerns were raised at the last inspection of the home regarding one service user whose needs assessment detailed that they were at risk of developing pressure sores, but their care plan did not address this. A Requirement made regarding the need for the home to address this issue immediately has not been met. The Registered Provider said that she had contacted the service user’s Care Manager regarding this issue, and that a District Nurse had visited the service user in the home to carry out a Waterlow, Pressure Sore Risk St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 10 Assessment. There were however, no care records detailing that these professionals had been contacted, or the outcome of the contact. This is poor practice. Records available detailed that this service user is no longer resident in the home; therefore, the Requirement relating to this issue has been removed. However, a Requirement is made regarding the need to keep accurate and up to date care records regarding each service user’s care. There were records detailing that the Registered Provider has ensured that service users have access to a range of health care professionals. Feedback from three General Practitioners who have visited the home recently was positive. One General Practitioner said that the staff members were warm and caring and gave good support to service users. A visitor said that they were satisfied with the health care that their relative received. However, it remains of concern that the service user mentioned above entered the home with a needs assessment that detailed that they were at risk of developing pressure sores, and this was not followed up. This area will be monitored closely. Four Medication Administration Records were examined and these were in good order. The medication for one service user was found to be in stock and stored appropriately. Previous inspections of the home have highlighted that staff members are competent in respecting service users, and in upholding their dignity. Some staff members were noted to demonstrate patience and consideration with service users throughout the cause of this inspection. One staff member spoken with said that they had received some training about dignity and was able to give an example of how they would uphold the dignity of service users in the cause of their duties. One incident was observed during this inspection where a service user’s wishes were not respected, and their dignity not upheld. This issue has been reported to the local authority in order for it to be investigated under their protection of vulnerable adults procedures. It was further concerning that one service user’s bed had been made up with a pillowcase that had a large (what appeared to be) dried blood stain on it. A Requirement is made regarding this issue. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate. (12, 13, 14 and 15) This judgement has been made using available evidence including a visit to this service. There continues to be an activities programme and wholesome and enjoyable meals are provided. However, there is a need for some improvements in order to ensure that service user’s differing expectations and lifestyles are well catered for. EVIDENCE: Service users, in general appeared to enjoy the meal served during this inspection. There was no choice of meal, however, the cook said that all service users had been consulted with and were happy with the main meal on offer. One staff member was noted to mash together each food item on a plate before feeding this to a service user. This meal did not appear appetizing. When a service user requires a soft diet, each element of their meal should be softened separately in order that they are able to appreciate the individual tastes of the food, unless the service user specifically requests otherwise. There were no structured activities occurring in the home during the morning. Service users sat in the main lounge. Some service users were watching St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 12 television in the afternoon and the hairdresser visited some. There was a notice board in the lounge detailing that structured activities occur daily and there continues to be part time activities organiser employed to work in the home. One visitor said that there were usually some activities happening in the home. There was feedback from another visitor that, despite there being a large, well maintained garden, their relative was rarely supported to use it. It is recommended that increased opportunities be made for supporting service users to use the garden and to go on outings out with the home. Feedback from the majority of visitors was that they were made to feel welcome in the home, and encouraged to visit. One visitor said that they had been well supported by the owners, who were often available to answer any questions that they had. However, another visitor said that they had found the owners to be unhelpful in answering their questions. A large number of service users have a limited capacity to make decisions. The Registered Provider said that she maintains close contact with service user’s relatives and friends in order to support service users to exercise choice. Five bedrooms seen during this inspection had been personalised with the service user’s possessions and the Registered Provider said that service users could bring any personal items with them. However, some of the bedrooms appeared bear, and had very few personal items. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is poor. (16 and 18) This judgement has been made using available evidence including a visit to this service. There is a system in place for the effective handling of complaints. Service users and their relatives therefore know that their concerns will be acted upon. There are poor arrangements in place for handling allegations and instances of abuse. These must be improved to ensure that users will be protected from harm. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a concern may be raised with the Commission for Social Care Inspection. Feedback from three relatives indicated that they had been made aware of the home’s complaints policies and procedures. The Registered Provider said that no complaints have been made to the home since the last inspection. During this inspection one staff member was observed to engage in practice that is deemed abusive by the writer of this report. This issue has been reported to the local authority in order for it to be investigated under their protection of vulnerable adults procedures. It is of serious concern that the Registered Provider demonstrated a very poor understanding of the home’s own adult abuse policy, and the local, multi agency policy and procedures St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 14 following this incident. The staff member responsible for the alleged abusive behaviour was not suspended from duty, in line with the homes own policy, but was asked to carry out the same activity with a second service user. Also, the Registered Provider did not demonstrate a clear understanding of her responsibility for reporting this incident to the local authority. The Registered Provider must attend training provided by the local authority (Royal Borough of Kingston Upon Thames) in responding to allegations of abuse. A second incident, reported in late 2006, was investigated under Royal Borough of Kingston Upon Thames, protection of vulnerable adults procedures. This incident was found to be unsubstantiated, and no further action taken. It is of concern that the writer, on arrival at the home, was welcomed in by a staff member, without identification being checked. The staff member in fact said that it was not necessary for them to see identification, when offered it. Staff members must be more vigilant about allowing people into the home in order to ensure that the well being of service users is protected. A Requirement is made in relation to this issue. The home is further failing to protect service users by its on going failure to ensure that each staff member is thoroughly vetted before commencing employment. This issue is dealt with in Standard 29 of this report. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. (19, 24 and 26) This judgement has been made using available evidence including a visit to this service. The home is, in general, maintained, decorated and furnished to an adequate standard. However, there is a need for a number of environmental improvements to ensure that comfort, health and safety is maintained. EVIDENCE: Previous inspections of the home have found it to comply with the requirements of the London Fire and Emergency Planning Authority and Environmental Health department and there have been no changes. One bedroom has been redecorated since the last inspection of the home; however, it is of concern that the Registered Providers have failed to comply with a Requirement made at the last inspection of the home, regarding the need for environmental improvements in another bedroom. One bedroom on the ground floor still has chipped and yellowing paintwork. This creates a poor environment. The Requirement made regarding this issue is repeated. The screening around one sink has been improved since the last inspection. There St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 16 remains an unpleasant smell of urine in the communal lounge, despite a Requirement being made regarding this issue at the last inspection of the home. The Registered Providers must identify the cause of this odour and eliminate it from the home. It is not acceptable for service users to spend their days experiencing this odour. There remains a need to create a more homely atmosphere in a number of bedrooms. Some bedrooms seen had few personal possessions or homely touches. There is lino flooring in most bedrooms, which adds to this lack of homeliness. Much of the furniture seen in bedrooms was worn and mismatched. Recommendations are made regarding these issues. It was disappointing to note that, of four commodes seen, all were poorly washed and were stained with faeces. Commodes must be thoroughly washed after use. One commode seen was very rusty and had potential for scraping the skin of a user. This was removed from the home when pointed out as a hazard during this inspection; however, it is of concern that this was not spotted as a hazard prior to this inspection. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 17 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 poor. (27, 28, 29 and 30) This judgement has been made using available evidence including a visit to this service. Staff members are provided in sufficient numbers; however, it remains that the procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. The staff training and development programme remains inadequate for ensuring that the staff members are able to fully meet the needs of service users. EVIDENCE: The number of care staff members detailed in staffing rotas appears to be adequate, and in line with the needs of the current service user group. Three relatives surveyed said that they believed that there are sufficient staff members on duty in the home. Four new staff members have been employed to work in the home since the last inspection. In general, necessary pre recruitments checks have been carried out for these staff members prior to them commencing work and there were records detailing that each of these staff members have undergone induction training. However, application forms had not been completed fully and lacked details about the staff member’s employment history. A Requirement is made regarding this issue. Also, at the last, inspection of the home it was noted that one staff member had been employed without up to St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 18 date references being obtained. It is of concern that the Registered Providers have made no efforts to obtain references retrospectively, as required and despite a Statutory Enforcement Requirement being issued to the home regarding this. Three staff members are trained at NVQ Level 2 in Care and a further three staff members are currently undertaking this qualification. Once this training is completed, the home will have over 50 of the care staff team trained at this level. However, it is of concern that the home has failed to comply with a Statutory Enforcement Notice, issued by the Commission regarding the need to implement a programme of foundation training for staff members. The Registered Provider did however state that this would now be done as a matter of priority and documentation regarding ‘Skills for Care’ foundation training was made available by the end of this inspection. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 19 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. (31, 33, 35, 36 and 38) This judgement has been made using available evidence including a visit to this service. There have been one area of improvement, however, there are a number of concerns regarding the well-being and health and safety of service users. Improvements must be made in order to ensure that the home is run in the best interests of service users. EVIDENCE: The Registered Providers remain in day-to-day control of the home. There was mixed feedback about the Registered Providers. One visitor said that they had been well supported by the owners, who were often available to answer any questions that they had. However, another visitor said that they had found the owners to be unhelpful in answering their questions. Feedback from a number of General Practitioners who visit the home was that the home is well run. The St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 20 Registered Provider was observed to respond well, in general, to the needs of service users throughout this inspection. Concerns have been raised at this, and previous inspections regarding the Registered Provider’s ability and willingness to address Requirements and recommendations made during inspections, all of which focus on ensuring the well being of service users and improving their daily lives. During this inspection, the Registered Provider demonstrated a poor awareness of adult protection policy and procedures and a Requirement has been made regarding this. The Registered Provider said that there is an informal system of quality control in the home, were by service users and their relatives are consulted regularly. There was documentation detailing that there is an ongoing programme of redecoration in the home. There is a need to carry out regular checks on quality in the home, particular in view of the fact that a large number of Requirements have been made during this inspection regarding poor quality issues in the home. The Registered Provider said that the home no longer provides a service of holding money for service users. Any money needed on a day to day basis is loaned to service users, and their family members are then invoiced for this. It was positive to note that a Requirement made about the need for an increased frequency of supervision has been met. Records were available detailing that four staff members have received formal supervision on a bimonthly basis. Staff members spoken with confirmed that they were provided with supervision. Health and safety checks were not examined in detail during this inspection. Pervious inspections of the home have found these to be in good order. Standard 38 is not fully met due to failures by the home to carry out good recruitment practices and foundation training; and, poor hygiene practices. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X 1 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X N/A 3 X 2 St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 12 (1)(a) 13 (1)(b) Requirement Timescale for action 01/02/07 2. OP10 12 (1)(a) 16 (2)(e) 3. OP15 12 (1)(a) 16 (2)(i) 4. OP18 12 (1)(a) The Registered Provider must ensure that there are accurate and up to date care records in place for each service user. These must detail any contact with health and social care professionals, and the outcome of the contact. The Registered Provider must 01/02/07 ensure that service users have clean bed linen at all times. (i.e. not stained/dirty pillow cases) The Registered Provider must 01/02/07 ensure that (in cases were a service user requires a soft/purred diet) each element of their meal is softened/purred separately in order that they are able to appreciate the individual tastes of the foods that they enjoy. The Registered Provider must: 11/03/07 1. Ensure that all relevant policies and procedures are adhered to when an allegation of abuse is made. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 23 5. OP18 12 (1)(a) 6. OP18 23 (2)(d) 7. OP24 12 (1)(a) 23 (2)(c) 23 (2)(d) 8. OP26 9. 10. OP26 OP29 12 (1)(a) 16 (2)(j) 19 (1)(a) 2. Attend training provided by the local authority (Royal Borough of Kingston Upon Thames) in responding to allegations of abuse. The Registered Provider must ensure that staff members are clear about the home’s policy on welcoming visitors into the home. (i.e. checking identification documentation and accompanying them to the desired location) The Registered Provider must ensure that all bedrooms are ‘reasonably’ decorated, and do not have chipped and yellowing paint. Repeat Requirement. Timescale of 01/12/06 unmet. The Registered Provider must ensure that old and rusty commodes are not used in the home. The Registered Provider must ensure that there is not a smell of urine in the communal lounge, or any other areas of the home. Repeat Requirement. Timescale of 01/12/06 unmet. The Registered Provider must ensure that commodes are thoroughly washed after use. The Registered Provider must ensure that there are two written references, applied for directly by the home, for each staff member, prior to them commencing work in the home. Written references must be obtained retrospectively for any staff member working in the home with out references. Repeat Requirement. 11/01/07 01/02/07 01/02/07 01/02/07 01/02/07 01/02/07 St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 24 Timescales of 01/06/04, 01/01/05, 01/05/05, 01/11/05, 01/06/06 and 11/01/07 unmet. Statutory Requirement issued on 14/12/06 unmet. The Registered Provider must 01/02/07 obtain a written record of each new staff member’s employment history, prior to them commencing work in the home. The Registered Provider must 01/02/07 implement a planned programme of training for all staff members. This must include foundation training that is in line with ‘Skills for Care’ specifications. Repeat Requirement. Timescales of 01/06/04 and 01/01/05, 01/05/05, 01/01/06, 01/06/06 and 11/01/07 unmet. Statutory Requirement issued on 14/12/06 unmet. The Registered Provider must 01/03/07 ensure that a system of quality control is implemented in the home. (i.e. at least monthly checks on the premises, records and views of stakeholders) 11. OP29 19 (1)(a) 12. OP30 18 (1)(c)(i) 19(1)(a) 13. OP33 26 St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 25 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 OP12 OP24 OP24 Good Practice Recommendations It is recommended that increased opportunities be made for supporting service users to use the garden and go on outings out with the home. It is recommended that action be taken to ensure that all bedrooms in the home are homely in appearance. It is strongly recommended that any worn, and mismatched furniture in bedrooms be replaced with matching, higher quality furniture. St Luke`s Lodge DS0000013399.V327085.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Luke`s Lodge DS0000013399.V327085.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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