Inspection on 02/02/06 for St Mary`s Lodge

This inspection was carried out on 2nd February 2006.

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

The inspector 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 Mary`s Lodge 17/11/09

St Mary`s Lodge 29/09/09

St Mary`s Lodge 01/05/08

St Mary`s Lodge 02/10/07

St Mary`s Lodge 20/11/06

St Mary`s Lodge 11/08/05

St Mary`s Lodge 11/11/04

St Mary`s Lodge 17/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Lodge 81-83 Cheam Road Sutton Surrey SM1 2BD Lead Inspector David Pennells Unannounced Inspection 2nd February 2006 4:50pm 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 Mary`s Lodge DS0000007144.V281575.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 Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s Lodge Address 81-83 Cheam Road Sutton Surrey SM1 2BD 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 8661 6215 020 8661 6215 Mr Jugdutt Dudhee Mrs Marietta Dudhee Mr Jugdutt Dudhee Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 11th August 2005 Brief Description of the Service: St Mary’s Lodge is situated within walking distance of Sutton town centre, which provides a wide range of transport links, commercial, shopping, entertainment and recreational facilities. The home is a substantial property created from the joining together of two large Edwardian family houses, with two wings of accommodation to the rear subsequently being added. The accommodation is laid out over three main floors, access to which is provided by a passenger lift and stairs; there are, however, many areas of the home that are only accessible by varying numbers of steps and the two sides of the home at ground level are also separated by a step. The home provides thirty single and five double-occupancy bedrooms. Communal space is generous and homely in character, being provided in a range of varying lounge / dining areas throughout the ground floor. The home is registered to provide accommodation and care to 40 older people, 20 of these places now falling within the category of ‘people over 65 with dementia’. This formula was adjusted last year to reflect the number of service users who actually do have a form of dementia: previous to this, the home had only registered ten out of the forty beds to accommodate people with dementia or a related condition. This ‘mix’ continues present a challenge to the home as it supports those who are mentally sound - alongside those service users with failing memory / mental ability. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit covered the home’s daily life from just before teatime (4.50pm) through to the mid-evening - the inspector leaving the home at approximately 8.00pm. During his stay, he was able to meet with the manager / proprietor and his wife - Mr & Mrs Dudhee, to tour the premises and to meet with and chat with many service users and most of the staff on duty. It was good to see that the day was far from over immediately after tea / supper was finished; the majority of service users staying up and watching TV up until 8.00pm and well beyond. The inspector is grateful to service users, staff and the proprietors for the welcome, cooperation and hospitality shown during the inspection visit. What the service does well: What has improved since the last inspection? The proprietor continues to make progress in addressing the requirements and recommendations set at the last inspection; the number of the former dropping from twelve to seven and the latter from eleven to four. The undersize double occupancy bedroom has been adjusted to ensure it now meets minimum standards; call bells have been made more available in communal toilets and bathrooms. Water supplies throughout the home have been inspected and cleaned in accordance with best practice guidelines. Documentation regarding service users’ ‘last wishes’ has been worked on, and staff files have improved - reflecting the home’s stronger focus on ensuring St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 6 that all necessary checks are fully undertaken by the home prior to employment of such staff. 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 Mary`s Lodge DS0000007144.V281575.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 Mary`s Lodge DS0000007144.V281575.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): none inspected at this visit. Service users can rely on needs being full assessed before being admitted to the home, and a care plan being put in place to address identified areas of need thus ensuring appropriate individual care being provided. EVIDENCE: The above judgement statement covers key standard 3 - which was reviewed at the last inspection visit and found ‘met’. The statement is reiterated for the reader’s information. At the time of the inspection visit, there were four vacancies at the home; two admissions were due in the following week. The home does not provide ‘intermediate care’, so Standard 6 is not applicable. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11. Service users needs are fully assessed using a plan of care that then guides staff members to provide an individualised service, including meeting their broad health care needs, the administration of medicines and general social care. A heightened awareness of the detail of care plans by staff would benefit service users through a more consistent approach to the individual. Medication administration is appropriately managed and properly recorded and stored, though the location of district nursing supplies storage could be improved. Service users can generally rely on staff to provide sensitive personal care – though guidance to staff in aspects of dignified management of care is recommended. Certain daily personal care activities need reviewing and monitoring by the management to ensure clear 1:1 personal care services are provided in the privacy of their own rooms (rather than in communal spaces) to maintain service user’s self-esteem and pride. Service users can rely on appropriate care at the point of severe illness / death; the gathering of details concerning a service user’s - or their advocate’s / representative’s “final wishes” is now recorded on the individual care plan. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 10 EVIDENCE: All standards were inspected at the last inspection visit and all were found ‘met’ excepting the last standard (11); the first three statements are reiterated from the last report. The final statement can now confirm that the proprietor has collated sufficient information to guarantee that a service user and their loved-ones / representatives would be supported should the service users be taken seriously ill or pass away. Such information is collated at the point of new admissions to the home. Mr Dudhee has ensured that the information is now kept on each care plan - in order that all such support can be given. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Service users can expect to engage with social and recreational activities suited to their preferences. Spiritual needs are identified and met through contact with local church ministers/congregations. Relatives and friends can expect to be welcomed at the home and service users are encouraged to maintain contacts with links outside the home. Service users can expect to be appropriately helped to exercise choice and, where appropriate and safe, control over their lives. Service users can expect to receive a wholesome and nutritious diet provided by the home, with special needs generally recognised and catered for. EVIDENCE: Three of the four standards above were inspected at the last inspection visit and found ‘met’. Standard 14 was not reviewed - so was assessed at this visit and was found ‘met’. The third judgement statement above reflects this new assessment, with the other three statements being reiterated from the last inspection report. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 12 Standard 14 explores issues relating to: managing financial affairs, advocacy, respecting of the right to personal possessions, and enabling access to information kept concerning a service user. A number of service users still have some control over their own affairs; this is encouraged, where appropriate and assessed on admission to the home. Obviously - especially in regard to service users with dementia - relatives or advocates / solicitors or local authority personnel are often heavily involved. The inspector noted advertisements for local advocacy services in the front hallway of the home, where service users and their relatives often pass. Permission is positively given to service users who wish to bring in items of furniture or other familiar items when entering the home; the only proviso is that these items be safe from the point-of-view of fire and soundness. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Service users can be confident that the home will deal with complaints appropriately; information about the complaints procedure is readily available to all who may wish to express an opinion about the service. Service users can be assured that the processes in the home wil protect them from potential abuse by staff or others. EVIDENCE: Key standard 16 was inspected at the last visit and found ‘met’. The first judgement statement is reiterated from this assessment. Key standard 18 was inspected at this visit and found ‘met’. The home has an Adult Protection policy and the proprietor was able to produce a copy of the 2005 revised local authority (LB Sutton) Adult Protection policy and procedure. Staff members are all now thoroughly vetted and recruitment assures that nobody starts at the home until their credentials with regard to the Criminal Records Bureau and the Protection of Vulnerable Adults Register have been checked. The proprietor confirmed he was conversant with the procedure for referral of staff to the Vulnerable Adults ‘List’ - if this became necessary. The home’s policies and procedures - created by a reputable company - cover all essential areas of guidance, including physical intervention, service user’s finances, insurance and such issues as gifts gratuities and bequests. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 14 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): 22, 23, 25 & 26. Service users can expect to live in a clean and well-maintained environment. Those service users with dementia, especially, would benefit by increased signage and other aids to promote their independence / orientation. Communal lounge and dining facilities are homely, warm and generally comfortable; toilets and bathrooms are suitable to service users with emergency call bell provision now being appropriately provided. Service users’ own bedrooms are distinctively different, and offer scope for the personalisation that the home encourages. Bedrooms are both safe and comfortable, meeting each individual’s needs with all basic amenities provided. EVIDENCE: The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. The proprietors provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 15 The home more recently redecorated one of the lounges in a distinctive colour the ‘blue room’ – to ‘anchor’ / orientate service users in their familiar environment. There continues, however, to be a need to ensure that the house further develops a culture of being well ‘sign-posted’ for service users – more especially those with dementia - but also both those who are relatively competent, to ensure that all are as assisted in being oriented in time and place. This should include orientation boards, calendars, clear-faced clocks, and directional signage - especially for rooms such as toilets, etc. At the last inspection visit, double bedroom no 29 was declared - and was confirmed - as being less than 16 square metres in size – the absolute minimum for double occupancy rooms. The proprietors have now removed to chimneystack brickwork to increase the size of the room - now declaring in to meet the minimum national standards. The inspector did not measure this room. The home has a wide range of bathrooms and toilets all now having been ‘revisited’ by the proprietor - regarding call bell points being situated where they are of use to service users when in the bath or on / by the toilet; extension leads have been appropriately provided. The inspector explained to the proprietor that minimally weekly checks must be regularly undertaken for all essential health & safety checks throughout the home; both the fire alarm testing and checks at each bath and shower outlet had not been undertaken in the two weeks prior to the inspection visit. The latter check is designed to see what absolute maximum temperature of hot water can be drawn from the tap - in order that it can be confirmed that the thermostatic mixer valves are fully operational. Staff do, apparently, check and record the temperature of bath water when bathing a service user (which is commendable) - but the risk of scalding / burns (which can occur in unusual situations) can only be properly avoided when valves are properly and regularly monitored. There is an extensive secure back garden – leading from a number of points at the rear of the house. There is a concrete patio area with a couple of garden benches that is accessed through well support-railed pathways. The garden, with a few rose bushes and shrubs, did not has not received a lot of attention, especially throughout the winter months; this area should be developed into a far more attractive - and functional - area for the benefit of service users. Bathing equipment - such as bath seats and non-slip mats were noted to be heavily scaled and not as scrupulously clean as they could; this must be a priority for both cleaning and care staff - to make the bathing experience as pleasant as possible, and to prevent any risk of cross-infection. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 16 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): 29 & 30. Staffing is provided in sufficient numbers to ensure that the needs of the service users are met at all times, with the skills mix and training providing for appropriate care giving and safe practices within the home. The home’s recruitment practices ensure generally that service users are protected from abuse, though the home must ‘keep up’ with current best practice – relating to checking references and particularly with regard to CRB (Criminal Records Bureau) checks and the PoVA (Protection of Vulnerable Adults) procedures. Induction of staff is also in need of ‘tightening up’. EVIDENCE: Staffing at the home is provided at a level of a proprietor and a minimum of six care staff on duty at any time from 7.00am to 10.00pm. Adequate handover times are provided. Night Care staff members are provided at a level of three staff on site - with Mr and Mrs Dudhee, the proprietors asleep, but on call, in their property next door to the home. Cleaning staff members are provided on a daily basis from 7.00am to 3.00pm. Staffing in the kitchen has been increased to provide a worker from 3.00pm to 7pm each day to ensure that a staff member other than a carer addresses suppers and the consequential washing up every night. The home has now been undertaking a Criminal Records Bureau and PoVA check for every new staff member - at the point of his or her engagement. This was evidenced by a random check of new staff members’ files. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 17 An excellent new booklet concerning: ‘Insight into Dementia’ has been introduced by the proprietor - expressing the home’s commitment to quality dementia care services. Induction booklets examined at random for newer staff members were examined and still found to be wanting: more than one had only the staff member’s signature in all the boxes with no supporting dates, detail or countersignatures of the inductor. The proprietor relies heavily on the induction booklets to evidence initial engagement with the policies and procedures of the home; this was clearly still failing. Other, more long-term staff members had signed a statement at the rear of the procedures manual to state that they had read this whole vast volume – without being specific. The home has been previously required to ensure that staff signed their name and a date against an index of the individual procedures and policies – effectively, therefore, acquiescing to each individual document’s instruction. The staff then are ‘signed up’ – through this signature process - to the furthering the conduct of the home as the proprietors would require it. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 18 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): 33, 37 & 38. The home is managed and run by a competent manager and deputy manager, being the registered provider. Service users can be - and are - confident in the attention to the service provided at the home by the managers. The ethos and leadership at the home is clearly expressed by the engagement of the management with staff and the listening ear provided to the opinions of service users and stakeholders. The proprietor’s approach to monetary issues at the home ensures the protection of services users’ financial interests – thus providing protection especially to those who cannot manage their own affairs any longer. Record keeping and the existence of policies and procedures seeks to ensure the best interests of service users, though greater attention should be paid to ensuring that staff fully ‘sign up’ to the approach of the home. With one or two exceptions, the service is maintained in a safe and appropriate way thus providing protection for all service users at the home. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 19 EVIDENCE: Standard 33 was discussed with the proprietor and found ‘met’ on this occasion; the proprietor assured the inspector that surveys were being sent out to service users’ relatives / visitors and exit interviews were also being introduced to monitor the feeling of consumers at a point of leaving the home. Action / review planning was all [part of the Registered manager’s award which Mr Dudhee had undertaken alongside his CMS qualification. The general feeling within the home was warm and congenial; both staff and management were open and communicative and little sense of anxiety was apparent with service users. Both proprietors were again welcoming, warm and open in their dealings with the inspector. Mr Dudhee received his CMS certificate in November 2004. He is currently aiming to complete his NVQ ‘A1’ Assessor’s Course by June 2006. He has a sense of direction and leadership. His partner, Mrs Dudhee, is also clearly capable of handling issues at a higher level; she is finishing her NVQ at level 3 in Care. She can capably handle meetings (such as service user’s reviews) when necessary. The proprietor has worked to a five-year business plan that guides the spending and development of the home (used as part of the RMA training Course). The proprietor assured the inspector that there is no question that the home is financially viable; occupancy has been maintained reasonably well; mostly the home is close to 100 occupancy. The home is generally well maintained - and the proprietor again produced large swathes of papers to prove maintenance contracts and similar were in place. Evidence of the water system’s recent servicing by the plumber was requested. Water samples had also been sent away for analysis. The proprietor was again advised to have a ‘good clear out’ – archiving the many previous years’ documentation, and ordering more clearly the present year or so’s papers. Fire records should also be fully moved in to the new record file book seen at the time of the inspection – and the old collapsing record book carefully archived. One area of absence in maintenance issues was the checking of the water heating and cold water supply systems with regard to contamination by Legionella organisms. The proprietor is required to ensure a competent examination and maintenance check of this entire area. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X 2 3 X 2 2 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 2 St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 21 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 OP22 Regulation 23(1) & 23(2) Requirement A clearly thought-through and research-based approach to the décor and signage in the home must be universally implemented in order to support and guide particularly the service user group who have dementia. Timescale of 30.04.05 & 30.09.05 not fully met. Timescale for action 15/04/06 2. OP25 13(4) Regular checks of the maximum 02/02/06 temperature outflow from hot water taps must be undertaken, with specific records of each test kept. Timescales of 18.05.04, 11.11.04 & 11.08.05 not met. Fire alarm testing must be rigorously undertaken on a weekly basis - with no weeks neglected. Bathing equipment - such as bath seats, non-slip mats must be kept scrupulously clean to prevent any risk of crossinfection. 02/02/06 3. OP38 23(4) 4. OP26 23(2)(d) 15/04/06 St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 22 5. OP30 17(2) Training records - such as induction booklets - must be properly completed to evidence sufficient attention has been shown to this vital area of introducing new staff in the home and its procedures. Timescale of 30.09.05 not met. Policies and procedures must be indexed and staff must sign to confirm that they have read all relevant documents individually signing and dating against such an indexed format (30 & 38). Timescales of 30.10.04, 30.04.05 & 30.09.05 not met. Evidence of the checking by the plumber of the homes water supply systems - in line with the Code of Practice on the Prevention of Legionella including inspection of storage tanks, checking and flushing of pipes, etc. (where necessary) must be evidenced to the Commission. 15/04/06 6. OP30 18(1) 15/04/06 7. OP38 13(4) & 23(2) 15/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations That service user plans - or summaries of the salient actions / goals in bullet point form - should be located closer to the day-to-day notes to ensure consistency of approach and to guide record keeping. St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 23 2. OP8 That the home should adopt a system of working with all residents in Life History / Life Story books - creating scrap books concerning their past individual life, leading up to the present day - and involving relatives and friends seeking to build up / restore self-esteem for the individual. That the rear garden area is reviewed and made more accessible and attractive to encourage the movement of service users outside and to encourage appropriate and beneficial exposure to sunlight. That the management of records / including maintenance documents - and especially the fire precaution records book - should be thinned out - with an ordered process of archiving undertaken - and current papers / books properly ordered to facilitate ease of access. 3. OP19 4. OP37 St Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 24 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 Mary`s Lodge DS0000007144.V281575.R01.S.doc Version 5.1 Page 25 - 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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