Inspection on 21/06/05 for Stanway Green Lodge

This inspection was carried out on 21st June 2005.

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

Stanway Green Lodge 17/10/07

Stanway Green Lodge 28/11/06

Stanway Green Lodge 31/01/06

Stanway Green Lodge 22/09/05

Stanway Green Lodge 19/10/04

Stanway Green Lodge 15/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Stanway Green Lodge Stanway Green Stanway Colchester, Essex CO3 5RA Lead Inspector Tim Thornton-Jones Unannounced 21/06/05 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 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. Stanway Green Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Stanway Green Lodge Address Stanway Green Stanway Colchester Essex CO3 5RA 01793 702663 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Laura Kanitkar Mrs C Shave, Acting Manager (Unregistered) Care Home 27 Category(ies) of Old age; not falling within any other category registration, with number (27) of places Stanway Green Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: A condition has been placed upon the registration that an application to register a suitably experienced and qualified Manager is recieved at the CSCI by 31st July 2005. Date of last inspection 19/10/04 Brief Description of the Service: Stanway Green Lodge is a care home registered to provide personal care and accommodation for 27 older people. The Registered Person is Ms L Kanitkar. Ms Kanitkar took over ownership of the home on 30th January 2004. There is a manager in post who, at the time of the inspection, had not undergone registration with the Comission for Social Care Inspection. A condition was attached to the registration that an application to register a manager was made within three months of the commencement of the homes Registration. This was consequently extended at the request of the Registered Person until 31st July 2005. Stanway Green Lodge is a two storey detached property, situated in a semirural location. Accommodation is offered on both floors, the upper floor being accessed via a passenger lift. Accommodation is offered in both single and double rooms, some of which have en suite facilities. There is a choice of communal facilities and a pleasant garden. Stanway Green Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis. At the time of arrival a senior care worker was in charge of the home. The Registered Person, Mrs L Kanitker, and Acting Manager, Ms C Shave, arrived at the home during the late morning. The methodology used consisted of a tour of the premises and discussion with the service users met. A case tracking approach was used to sample the way in which the service manages the care process. This included a review of selected care plans and associated information, records, policies and, direct and indirect observation of practice. National Minimum Standards inspected at the previous inspection concluded that the home was required to improve sixteen standards. At this inspection twenty-one National Minimum Standards require improvement. Of these twenty-one standards, thirteen have been carried forward from the previous inspection as continued to be unmet. Overall a total of twenty-eight standards were assessed. The seven standards found to be met represents a compliance level for this inspection of 25 , which is a poor outcome. The overall management of the home requires improvement. The report makes comment upon all aspects of the homes operation and it is noticeable that there are a higher proportion of concerns than achievements. However, there are some positive elements and the potential for improvement is evident. What the service does well: • • • • • The service presents as a spacious and well proportioned environment. Service users rooms are maintained in an individual and comfortable manner. The grounds are well maintained. Some of the practice observed by care workers was caring and reflective of good practice. Completion pre-admission assessment information. Stanway Green Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stanway Green Lodge Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Stanway Green Lodge Version 1.10 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 standard(s) 1, 3 & 4. • The homes documentation, in the form of Statement of Purpose and Service Users Guide, do not contain all of the information necessary to appropriately inform service users. Pre-admission assessment practices were adequate within the sample seen. The service was unable to fully show that service users and their representatives were aware that the service could meet their needs. • • EVIDENCE: The Statement of Purpose was examined and found to not contain a significant proportion of information required by National Minimum Standards and regulation. The Registered Person was advised to review the document in accordance with guidance specified within the relevant National Minimum Standards document. Stanway Green Lodge Version 1.10 Page 9 The Service Users Guide was also inspected and this document was also unable to demonstrate that the requirements were met as specified within National Minimum Standards and regulation. A case tracking approach was used to evaluate compliance with pre-admission assessment of service users’ needs. Based upon the sample taken the service was able to show that a summary of the Care Management assessment had been obtained in respect of the service users accommodated. The case tracking approach was used to ascertain whether service users and their representatives were fully aware of whether the home they enter would have the capacity to meet their needs. The Inspection concluded that the information available did not demonstrate that the care practice was based upon current good practice and reflect relevant professional guidance. Stanway Green Lodge Version 1.10 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 standard(s) 7,8,9,10 & 11. • • • • The care planning arrangements sampled were maintained to ensure safe delivery of care practice. Healthcare practices require improvement. Arrangements for the administration of medication do not meet with adequate standards of practice. The practice associated with privacy and dignity was being maintained by some individual staff, although aspects of the service provision does not accord with dignified practice. Arrangements for ‘end of life’ issues were not reflective of good professional practice. not adequately • EVIDENCE: Care planning and healthcare arrangements were sampled. The overall structure of care planning documents had improved since the previous inspection, with various individual recording sheets in place. However, upon closer inspection it was noted for several that data had not been kept up to Stanway Green Lodge Version 1.10 Page 11 date. An example of this was personal care associated with nail cutting. Records showed this to be infrequent (in one record the gap between nail cutting for one individual was stated to be 8 months) and one example seen indicated that a visiting Chiropodist referred a healthcare matter to the District Nursing service. A further example was noted for one frail service user, who was visited as part of the inspection process, that requested a drink. The person in charge, having given the drink, confirmed that the service user was in need of regular fluid intake, due mainly because of the persons current state of health and particularly as the day was very warm. The acting manager was unable to ascertain how much fluid the service user had taken recently since no record was being kept. The person in charge stated she would ensure a record was held in the room immediately. However, it was unclear from the care plan what instructions care workers had been given to monitor the welfare of the service user. The care planning approach was not adequately comprehensive to enable care workers to be clear about individual care requirements and methods to be used in order to deliver consistent and planned care. There was little evidence available to demonstrate that care management arrangements at the home operated a key worker, or similar, arrangement. Each care plan seen showed that daily notes were being written. These varied in quality and objectivity. The majority of entries were not directly liked to care plan objectives or decisions taken and recorded, within the plan. None of the care plans sampled gave a clear indication that the service user was integral to the decision making and monitoring process. This lack of attention contributes to a lack of dignity and empowerment of those receiving the service. In one sample a hand written note at the top of a page within the plan stated “In case of hospitalisation family request no resuscitation if needed”. This was discussed with the acting manager who confirmed that the family had in fact made this request. The decision had not been part of a formal care review and no evidence of consultation with the service user, healthcare professionals or reflection of any good care practice was noted. The acting manager confirmed that the service user in question was able to express personal choice. All of the care plans sampled were unable to provide evidence of individual consultation or planned arrangements for ‘end of life’ choices or preferences. In a further example, a service user was noted to have either fallen, or had been found on the floor on eleven occasions in a sample period between Christmas 2004 and the end of April 2005. The plan did not provide any evidence that a review had taken place to ascertain the needs of the person or Stanway Green Lodge Version 1.10 Page 12 to realign the care strategy on a day to day basis to reduce or prevent these occurrences. The records seen showed that occurrences within the home had taken place that were required by Regulation to be reported to CSCI, but had not been. This is a matter that the Responsible Individual must address. The administration of medicines was reviewed by case tracking sample. The security arrangements were good and the administration record had been completed, however, the monitored dosage system used had not been without problems. The acting manager stated that errors had occurred, whereby medicines had run out, and that the cause of this had been due to difficulties at either the GP Surgery and/or Pharmacy. However, the overall management of the system was not reflective of good practice in that a number of ‘spare’ sets of medicines were located within the secure cupboard and were being used by the home if medicines had run out. No evidence was available to demonstrate that the home had thoroughly investigated the cause of the errors experienced or had taken appropriate steps to safeguard the continuity of prescribed medicines for service users. One medicine being taken by a service user, due to the nature of medical condition, needed the dosage and frequency of the medicine to be changed, but remained dispensed as part of the monitored dosage system, issued on a twenty-eight day cycle. The acting manager was recommended to request from the service user’s GP to withdraw the medicine dispensing from the Monitored Dosage System in favour of individual bottles to maximise flexibility and convienence for the service user. Overall, there was a contrast between the interface of care workers and service users, several examples of which were observed to be sensitive and supportive in approach, and the care management arrangements. Service users spoken with expressed satisfaction and were of a positive and happy demeanour. Some service users discreetly observed, however, were either mentally and or physically frail, or less able to express their preferences and choices. For this latter group the construction of the plan of care is particularly important, and in the absence of a comprehensive approach, staff tended to rely on their own professional and caring intuition rather than being directed by a thorough, clear, well planned, individual and agreed care plan. In view of the number and degree of service users’ needs, the current arrangements were not adequate and improvements will need to be made. Stanway Green Lodge Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 • • • Social Activities were limited. Whilst there was no restriction regarding visiting for relatives, the quality of communication between the home and relatives could improve. The midday meal was wholesome and presented in a satisfactory way. EVIDENCE: At the time of inspection hymns were being sung in one of the sitting rooms and appeared to be enjoyed by those participating. Overall, however, the strategy for identifying and updating social and leisure interests, and the maintenance of a programme to meet these needs is not adequately developed. The home has statements to support the position that relatives and visitors are welcome. To fully engage with the quality of relationships between the home and service users’ families and friends, the culture of the service must be capable of supporting relatives appropriately by providing clear and informative assurance of their relative’s welfare. The inspection concluded that this aspect was not adequately developed. See section ‘Complaints and Protection’. Stanway Green Lodge Version 1.10 Page 14 This inspection did not visit the kitchen area or look at nutrition records other than information held within the care plans of the sample group. However, the midday meal was adequate and service users who expressed a view stated they were happy with food provision. Stanway Green Lodge Version 1.10 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 • • Arrangements for responding to complaints were adequate. The arrangements within the home to safeguard service users’ welfare and protection from abuse is well defined in structure, but not in practice. EVIDENCE: The home has a procedure for managing complaints made in respect of the service. The policy and practice procedure met with National Minimum Standards. The home had not investigated complaints during the period since the previous inspection. A few days before this inspection CSCI received a letter alleging a range of poor practices and abuse of service users, and illegal employment practices by the home. The letter was anonymous. The Registered Person was shown the letter and refuted the allegations. The inspection did not uphold, as far as practicable to investigate the matters alleged, any of the allegations made, since the details provided were inadequate to proceed with a suitable investigation. Two further complaints were received at the time of the inspection from two separate sources, one had preserved identity. These matters are being investigated separately from the inspection, although some of the issues were covered as part of the inspection process and will be used to inform the outcome of the complaint. Stanway Green Lodge Version 1.10 Page 16 The inspection did not conclude that the service was abusive in practice and, as previously stated within this report, some of the practice observed was well delivered. The care management arrangements, however, remain underdeveloped in terms of current thinking regarding the care of older persons. The service is not adequately reflective of the best professional practice. Some examples of this have been highlighted within this report. The conclusion is that the overall practice of the home will need to develop further to ensure the protection of service users from the consequences of some aspects of current practice. This will be referred to further in the section of this report regarding staffing. Stanway Green Lodge Version 1.10 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,24, 25 & 26 • • • • • The building and grounds meet with service notwithstanding the matters highlighted below. users’ needs, The bathing and WC facilities do not meet with service users’ needs. Individual bedrooms were well decorated, furnished and comfortable. The communal areas were less well maintained. The health and safety of service users was not being adequately maintained. Communal areas and service users bedrooms visited were clean with no unpleasant odours noted. The laundry area, however, was in need of improvement. Stanway Green Lodge Version 1.10 Page 18 EVIDENCE: The building is adequately proportioned, private, quiet and the grounds are well maintained. The inspection of the home included a tour of the building during which all communal rooms and several of the bedrooms were visited. There were a number of decoration improvements to be made, to repair cracks in walls and other marks. One bedroom visited had a broken electrical ceiling rose, which had part of the fitting damaged, exposing what appeared to be a live conductive part. An immediate requirements notice was issued to make this damaged fitting safe until a permanent repair could be made. Two of the toilets visited did not have adequate facilities. One had no toilet tissue holder fitted; the other had a toilet tissue holder fitted out of reach from the floor unit. This was pointed out at the previous inspection and it was disappointing to note that the holder had not been moved. The carpet in one bathroom was in need of cleaning and repair or replacement. One bedroom visited had a number of powered appliances. Electrical socket outlets had a number of multi plug extensions fitted to support the supply for the appliances. It is recommended to ensure that the supply arrangement in this room is properly assessed by a competent Electrician to ensure that the use of electrical accessories of this type do not present as a risk to the service user. Where such a risk is considered, further electrical socket outlets should be installed. The home pre-existed the current legislation of the Care Standards Act 2000 and under arrangements the bathing and WC facilities, specified as compliant as at March 31st 2002, must be maintained providing this level meets with the needs of service users. This inspection found that one bathroom was not used as it could not be used in conjunction with mobility equipment. On this basis the home’s facilities are not adequate. Access and exit doors are required to be risk assessed as some had a step down immediately after the doorstep. The accident book showed an entry that one service user had fallen, having attempted to leave the building by this exit. Entry and exit doors are required to be suitable for use by service users, therefore, all should be made safe by ensuring that they are ground level equivalent or appropriately ramped. The laundry was visited and noted to be in need of cleaning. The management arrangements for the laundry will require review since it was noticed that Stanway Green Lodge Version 1.10 Page 19 soiled laundry was stacked in a way that placed them inches away from clean hanging clothes. Some of the soiled items were on the floor. Stanway Green Lodge Version 1.10 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 to 30 • • • • The number of staff deployed requires review. Care workers do not have a full range of skills to ensure that service users needs are identified and met at all times. The recruitment practice of the home does not meet regulatory requirements. For the most part the care workers are trained in general terms but not all skills are maintained to meet service user needs. EVIDENCE: The service has used a staff/service user ratio calculation based upon a method recommended by the Department of Health. This was last assessed during March 2005 and specified that 599.33 care worker hours were required to meet service users’ needs. The staff roster at the time of inspection indicated that 552 hours were being deployed throughout the waking day. The Acting Manager stated that the dependency level and numbers of staff had changed since the most recent ratio assessment in March 2005 and therefore the assessment was required to be undertaken again, against current numbers and needs of service users. At the time of inspection at least 50 of care workers had attained a National Vocational Training award to at least level 2. This is a positive development. Stanway Green Lodge Version 1.10 Page 21 The recruitment of staff did not meet with National Minimum Standards or regulatory requirements. From a sample of five care workers, four did not have a current Criminal Records Bureau (CRB) check certificate in place. One care worker had only one reference and no health declaration in place. This practice is not acceptable to maintain appropriate levels of safety for service users. The staff did not have an individual training and development assessment and profile. Stanway Green Lodge Version 1.10 Page 22 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36,37 & 38 • • The current management arrangements are not adequate. The care outcomes are in keeping with the numbers, experience, knowledge and skills of care workers. The quality assurance approach does not meet requirements. Financial arrangements for service users were not fully adequate. Staff supervisory arrangements were not undertaken in a satisfactory way. Record keeping was variable in quality. There were some health and safety matters to be resolved. • • • • Stanway Green Lodge Version 1.10 Page 23 EVIDENCE: The home has been without a Registered Manager since the current owners have been registered. The Acting Manager has been in post for an established period. The home has a current requirement to apply to register a competent and experienced manager by 31st July 2005. The home’s quality assurance approach remains outside of the consultative culture that is required to ensure that service users’ wishes and feelings are integral to the care planning process and the achievement of positive service outcomes. Service users must be appropriately consulted about the service they receive and how best to ensure that it is delivered in a safe and effective way. The financial records for service users could not be accessed at the start of this inspection, as the Acting Manager and Registered Person were not on site. When access was possible a sample was taken and the daily balances and record sheets balanced. However, there were some minor discrepancies such as entries written incorrectly and no explanation for one expenditure. The structure of staff supervision was satisfactory, although the Acting Manager was unable to demonstrate that the frequency of supervision of staff met with National Minimum Standards. Some record keeping was found to be satisfactory, although essential documents such as the service users’ care plans, Statement of Purpose and Service Users Guide did not meet requirements. Health and safety issues have been raised elsewhere within this report and include the damaged light fitting, condition of laundry, bathroom flooring, and ground floor equivalent exits etc. Stanway Green Lodge Version 1.10 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 2 x x 3 1 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 1 x 2 x 3 2 2 2 Stanway Green Lodge Version 1.10 Page 25 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4,5,6 Requirement Timescale for action 30/07/05 2. 4 3. 7 4. 9 5. 10 6. 11 7. 12 The Registered Person must ensure that the Statement of Purpose and Service Users Guide are available and in accordance with regulatory requirements. 12(1b),15 The Registered Person must ,16,19,23, ensure that the service has the 24 full capacity to meet service users needs. 13,14,15 The Registered Person must ensure that service user assessments are maintained and that each service user has a comprehensive plan of care. 13(2) The Registered Person must ensure that the system for the safe administration of medicines is maintained. 12(4a) The Registered Person must ensure that the home is conducted to ensure the dignity of service users. 14(1c) The Registered Person must 15(1d) ensure that service users are consulted regarding the assessment of individual needs. 16(2m,n) The Registered Person must make suitable provision to consult with service users about social and leisure interests and a programme of activities. Version 1.10 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 Stanway Green Lodge Page 26 8. 13 16(2m) 9. 18 13(6) 10. 19 & 25 23(2d,j,p) , 23(2c), 23(2j) 11. 21 12. 26 23(2d) 13. 27 18(1a),18 (1c)(i), 18(4) 14. 29 19 15. 30 13(6), 18(1c)(i) 16. 31 9(1), 8(1) 17. 33 24 The Registered Person must ensure that service users are enabled to maintain contact with family taking consideration of their needs. The Registered Person must ensure that service users are prevented from being harmed or being placed at risk from harm. The Registered Person must ensure that the home is subject to regular and suitable maintenance. The Registered Person must ensure that baths and showers fitted are approriate for the needs of service users. The Registered Person must ensure that all parts of the home are kept clean. This refers specifically to the laundry. The Registered Person must ensure that at all times suitably qualified, competent and experienced persons are working at the home in numbers appropriate for the welfare of service users. The Registered Person must not employ a person to work at the care home unless the person is fit to work at the care home. The Registered Person must ensure that persons employed at the home receive appropriate training for the work they are to perform. The Registered Person must appoint a Manager who has the qualifications, skills and experience necessary for managing the care home. The Registered Person must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. Version 1.10 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 30/07/05 Stanway Green Lodge Page 27 18. 36 18(2) 19. 20. 37 38 17(1) 13(4a) The Registered Person must ensure that persons working at the care home are appropriately supervised. The Registered Person must maintain records in the home required by regulation. The Registered Person must make arrangements for all parts of the home to which the service users have access to be, so far as reasonably practicable, free from hazards to their safety. 30/07/05 30/07/05 30/07/05 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 31 Good Practice Recommendations The Registered Person is recommeded to ensure that a Manager is employed who has achieved National Vovational Qualification level 4 in both care and Management by 31st December 2005. The Registered Person is recommended to improve information to care workers on the side effects of medicines taken by service users. The Registered Person is recommended to seek the services of a competent person who has specialist knowledge of the service user group to assess the premises and any adaptations required. 2. 3. 9 22 Stanway Green Lodge Version 1.10 Page 28 Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester CO1 1RJ 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 Stanway Green Lodge Version 1.10 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!