Inspection on 02/05/06 for St Luke`s Lodge

This inspection was carried out on 2nd 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 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 11/01/07

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 Unannounced Inspection 2nd May 2006 10:25 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.V290740.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 Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 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 Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 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, six of 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 £425-460. There are no additional charges. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 2nd May 2006 between 10.25 and 15.50. A partial tour of the premises took place and care records were examined. The Registered Providers and three staff members were spoken with. Four service users also gave their views on the home. Some service users living in the home do not have the mental capacity to share their views regarding their care. Observations of care practices and interactions with staff members occurred in order to make judgements about the care that these service users received. There were no visitors present during the inspection. What the service does well: What has improved since the last inspection? There have been improvements in relation to the handling of medication. There is now clear information available detailing any allergies suffered by service users. All staff members have now received training in the protection of vulnerable adults. Staff members have also undertaken training including fire safety and infection control. There have been environmental and safety improvements including the redecoration of one bedroom, the placing of a window restrictor in another bedroom, the removal of an unpleasant odour in another bedroom, and the purchasing of a sluice. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 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. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 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.V290740.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. The arrangements for planning care are poor and do not serve to ensure that the health, personal and social care needs of people living in the home are met. The home does not provide intermediate care. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was no written assessment of need in place for the most recent service user to be admitted to the home. The Registered Provider said that the service user lived too far away from the home to obtain a needs assessment and that she had spoken to the service user’s family member on the telephone to get some information. There was a written ‘statement of need’ in place for another recent admission to the home. This had been obtained from the placing authority’s Care Management team. There was information in this document about the service user’s personal care and health needs, however, it St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 9 lacked detail about other aspects of the service user’s needs, such as social interests, religious needs and dietary preferences. It is of concern that the Registered Provider has not obtained detailed needs assessments for new service users. It is also of concern that the Registered Provider appears unaware of the importance of obtaining such information. New service users must only be admitted to the home on the basis of a full needs assessment undertaken by people trained to do so, and with the prospective service user, his/her representatives’ involvement. The Registered Providers cannot assure service users that their needs will be met in the home if they do not fully know what these needs are. A Requirement is made regarding this issue. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. National Minimum Standards 8 and 10 were assessed as being met at the last two inspections of the home and as there have been no changes regarding these Standards in the home, it remains that they are considered met. Service users have their needs detailed in a care plan so that staff members are clear about how needs should be met. However, as assessments of need are not always carried out, it is unclear whether service users have their needs fully met. There have been some improvements in handling medication, and in general, there are good arrangements for ensuring that the safe handling of medication protects service users. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans for the two most recent admissions were examined. The Registered Provider said that care plans had been drawn up in the first few weeks of the St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 11 service users arrival at the home. Both service users had a care plan that detailed how staff members should meet their health, personal and social care needs. Moving and handling risk assessments were in place. There was also information in care plans about how staff members should support service users to be independent. There were records detailing that care plans had been reviewed on a monthly basis and updated to reflect changing needs. Reviews of care indicated that the Registered Provider had consulted with service users, their relatives and health care professionals about the service users changing needs. One service user spoken with said that they were happy in the home and that the staff members were helpful. This service user said that they liked to get a newspaper each day and see their relative regularly out with the home. This information was clearly detailed in their care plan. One staff member spoken with was clear about this information. Whilst in general, care plans are good, Standard 7 is not considered fully met as care plans must be generated from a comprehensive assessment. It is not clear whether care plans fully detail service user’s needs, as some service user’s needs have not been fully assessed (Refer to Standard 3 of this report) Medication was noted to be stored securely in the home. Medication Administration Records were examined for the two most recent service users to be admitted to the home. These were up to date and in good order. The allergy sections on these Medication Administration Records had been filled in, in line with a Requirement made at the last inspection of the home. A number of the care staff team have recently undertaken training in ‘Care and Control of Medicines’ There were certificates to back this up. However, there remains a need for the Registered Providers to produce a list detailing the names of each staff member who has been trained, and is competent to handle medication. A repeat Requirement is made regarding this issue. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. National Minimum Standards 13 and 14 were assessed as being met at the last two inspections of the home and as there have been no changes regarding these Standards in the home, it remains that they are considered met. Service users receive a varied, wholesome and nutritional diet that meets their preferences, however, there is some poor practices regarding service users who require support to eat that do not promote their well being. Service users are consulted with about daily living; differing expectations and lifestyles are therefore catered for. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was music playing in the communal lounge and one service user was playing dominos with a staff member. Some users have a newspaper delivered to the home. One service user had a care plan that detailed the arrangements for them to practice their religion. Care records indicate that a number of service users receive regular visits from their friends and family members and that there are regular structured activities available. There was St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 13 information displayed on the home’s notice board detailing a range of activities to be held in the home. This notice board however, detailed that the month was April, when in fact the month was May. It is recommended that this information board is kept up to date. A number of service users living in the home have dementia and displaying inaccurate information is not helpful. There is a varied menu and meals are served in a pleasant dining area. There was positive feedback from service users spoken with about food in the home. One service user said that food was “very good”. There was a menu displayed in the lounge and a staff member said that there is always a choice of meals available. Some service users are provided with a diabetic diet. There are no service users from ethnic minority groups living in the home currently, however, specific cultural diets could be catered for following consultation with the Registered Provider. There was a good supply of fresh fruit and vegetables in the home. Staff members were available to provide support and assistance to service users during a mealtime. However, there were two service users who required to be supported to eat. Staff members stood whilst supporting these service users. This is not appropriate. Where service users require support to eat this should be done sensitively and discreetly. Staff members must be seated, and at eye level with the service users that they are feeding. A Requirement is made regarding this issue. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home has systems in place for dealing with service users and their family’s complaints. This ensures that service users and their family members know that their complaints will be taken seriously. There continues to be failures in the home’s staff recruitment procedures. They are not robust, and therefore people living in the home are not fully protected from abuse. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has a complaints procedure, which is made available in the Service User Guide, and on a notice board in the lounge. The Registered Provider said that no complaints have been made since the last inspection of the home. A procedure for responding to allegations of abuse was available in the home. Records indicate that a number of staff members have undergone training in the protection of vulnerable adults since the last inspection of the home. One staff member confirmed that they had received such training and was able to describe what they should do following an allegation of abuse. There were no records detailing that the most recent staff member to be employed in the home has undergone training in adult protection, however, this staff member confirmed that they had undergone such training. There must be records St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 15 detailing the training undertaken by each staff member in the home (Refer to Standard 30 of this report) There has been an ongoing failure by the Registered Providers to ensure that staff members are fully vetted before being employed to work in the home. This does not ensure that service users are fully protected (Refer to Standard 29 of this report) St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. In general, service users live in a comfortable, homely and clean environment. However, there are some shortfalls in this area, which do not fully promote the welfare of service users, nor provide safe and comfortable surroundings in which to live. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is a large detached property, situated on a quite road close Surbiton town centre. There is a car park at the front of the property, and a large, well maintained garden to the rear. There is a pleasant seating area in the garden. The communal areas of the home were homely and well decorated. There was a gardener and cleaner working on the day of this inspection. Records indicate that the London Fire and Emergency Planning Authority visited the home in May 2005, and it complied with their Regulations. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 17 A Requirement was made at the last inspection of the home regarding the need for one bedroom to be redecorated. This has now been done. A window restrictor has been fitted in one bedroom in line with another Requirement set at the last inspection. Generally, the home was clean and hygienic. There were cleaning schedules detailing that all areas of the home are cleaned regularly. There was one bedroom that had a strong smell of stale urine at the last inspection. This problem has now been rectified. However, there was another bedroom that had a strong smell of urine. The Registered Provider said that the flooring in this bedroom had recently been replaced to rectify this problem. This bedroom was viewed again at the end of the inspection, there was no unpleasant odour, however, the room had recently been sprayed with air freshener and therefore it was unclear whether this had ‘masked’ the unpleasant odour. This issue will be looked at during the next inspection of the home. Other areas of the home, including the communal lounge and corridors had a smell of stale urine. The exact source of this odour is unclear, however, it is strongly recommended that the Registered Providers take action to ensure that all areas of the home are fresh smelling. The Registered Providers have purchased a sluice for the home following a Requirement made at the last inspection. Five service user’s bedrooms were viewed. These provided furniture and fittings in line with National Minimum Standards. Bedrooms and been personalised. Two service users spoken with said that they were happy with their bedrooms. One double room was viewed. This had screening which would provide privacy for personal care. There remains a need to ensure that service user’s views about having a bedroom door key, and a locked storage space are recorded in their care plans. A recommendation regarding this is repeated. One bedroom had wallpaper that was peeling. This must be made good. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. There has been an ongoing failure to ensure that the procedures for the recruitment of staff are robust. Therefore, people living in the home are not fully protected from abuse. Some improvements have been made regarding staff training, however, the lack of a staff training and development programme does not ensure that staff members are not provided with skills necessary for meeting the needs of service users. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Registered Provider said that one care staff member has recently completed NVQ Level 2 in Care. She also stated that four care staff members have recently enrolled to undertake this training. The home does not currently comply with National Minimum Standard 28, which requires that at least 50 of the care staff team have an NVQ Level 2 in Care. Progress with staff training in this area will be looked at during the next inspection of the home. Four staff recruitment files were examined. There was insufficient information and documentation is two of these files. No written references had been obtained for one recently employed staff member. The Registered Provider was unable to say whether these had, or had not been obtained. There was no employment history, or records of induction training for this staff member. A St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 19 Criminal Records Bureau and Protection of Vulnerable Adults check had been obtained. There was no Criminal Records Bureau or Protection of Vulnerable Adults check in place for the most recent employee. There were also no records detailing that this staff member had received induction training. It is of serious concern that the Registered Providers have failed to obtain required pre recruitment checks on staff members before employing them to work in the home. This problem has been ongoing. Action must be taken to address this issue to avoid possible enforcement action. There has been some progress with staff training since the last inspection of the home. Records indicate that within the last six months staff members have received training sessions in infection control, fire safety, protection of vulnerable adults, basic food hygiene, podiatry and principles of care. One staff member spoken with said that they had attended a number of training sessions and there were records to back this up. However, there were no records detailing training for two staff members and the Registered Provider was unable to provide evidence that these staff members had received induction training. There must be a written training and development programme in place that is in line with ‘Skills for Care specifications. Each staff member must have an individual staff training profile detailing all training undertaken. Each care staff member must undergo an induction programme that includes training in moving and handling, health and safety, infection control, food hygiene, and the protection of vulnerable adults. Records must be available detailing all training undertaken by staff members and when refresher training is planned. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. There are poor arrangements for handling service user’s finances, which do not ensure that service users financial interests are safeguarded. There are poor arrangements for staff supervision and therefore staff members do not receive the support and guidance necessary for doing their jobs well. There are, in general, good arrangements for managing health and safety in the home, this ensures that the well being of service users is promoted and protected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 21 The home does not generally deal with service user’s money. However, money is held in the home for one service user. There was poor record keeping regarding this service user’s money. Records did not indicate clearly the amount of money that the service user had brought with them to the home and there were no receipts, or records detailing how their money had been spent. A Requirement is made regarding this issue. The Registered Provider said that she provides formal supervision to each staff member on a regular basis. Two staff members spoken with said that they received supervision. However, supervision records detailed that some staff members have not received formal supervision on a regular basis. Records indicate that one staff member had net received formal supervision since May 2005. Records for another staff member detailed that since the beginning of 2005, they had received formal supervision twice. Care staff should receive formal supervision at least six times a year; all other staff members should receive supervision on an ongoing basis. There were records detailing that all portable appliances in the home have been safety tested since the last inspection. Records available also detailed that safety checks have occurred on the home’s emergency lighting and fire detection systems and that fire drills have occurred. A risk assessment has been carried out in relation to fire safety in the building. There were records detailing that the home’s hoist has been safety tested and the lift has been serviced recently. There were up to date Landlord’s gas safety, and electrical installation certificates. Suitable insurance is in place. Suitable systems are in place for testing for legionella in the home and there is a contract in place for the collection of clinical waste. Standard 38 is not considered met, as there are poor arrangements for staff induction, and for staff training in safe working practices. (Refer to Standard 30 of this report) St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 X 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 2 X 2 St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1)(a)(b) (c)(d) 13 (2) Requirement The Registered Providers must not admit a service user into the home unless they have obtained, or undertaken a full assessment of need. The Registered Providers must ensure that there are records detailing the staff members who have received training in the safe handling of medication. Repeat Requirement. Timescale of 01/01/06 unmet. The Registered Providers must ensure that staff members are seated, and at eye level with any service user that they are feeding, unless a needs assessments says otherwise. The Registered Providers must ensure that all bedrooms are ‘reasonably’ decorated, and do not have peeling wallpaper. The Registered Provider must ensure that: 1. There are two written references, applied for directly St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 24 Timescale for action 01/06/06 2. OP9 01/07/06 3. OP15 12 (1)(a) 01/06/06 4. OP24 23 (2)(d) 01/08/06 5. OP29 2. 19 (b)(i) 01/06/06 by the home, for each staff member, prior to them commencing work in the home. 2. There is a Criminal Records Bureau and Protection of vulnerable adults check applied for directly by the home, for each staff member, prior to them commencing work in the home. Repeat Requirement. Timescales of 01/06/04, 01/01/05, 01/05/05 & 01/11/05 unmet 6. OP30 18 (c)(i) 19(1)(a) The Registered Provider must: 1. Implement a planned programme of training for all staff members. This must include foundation training that is in line with ‘Skills for Care’ specifications. 2. There is individual staff training profiles detailing when each staff member has undertaken training, including induction training. Repeat Requirement. Timescales of 01/06/04 and 01/01/05, 01/05/05 & 01/01/06 unmet. The Registered Providers must ensure that there is a written record in the home detailing: 1. All money deposited by a service user for safekeeping. 2. The date the money was deposited for safekeeping. 3. The purpose for which the money was used, including a receipt. 01/06/06 7. OP35 Schedule 4 17 (2) 01/06/06 St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 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. 4. Refer to Standard OP12 OP24 OP26 OP36 Good Practice Recommendations The Registered Providers should ensure that the notice board in the lounge is kept up to date. The Registered Providers should ensure that service user’s views about having a bedroom door key, and a locked storage space are recorded in their care plans. It is strongly recommended that the Registered Providers take action to ensure that there is not a smell of urine in any area of the home. The Registered Providers should ensure that care staff receive formal supervision at least six times a year, all other staff members should receive supervision on an ongoing basis. St Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Luke`s Lodge DS0000013399.V290740.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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