Inspection on 28/11/06 for Stanway Green Lodge

This inspection was carried out on 28th November 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

Stanway Green Lodge 17/10/07

Stanway Green Lodge 31/01/06

Stanway Green Lodge 22/09/05

Stanway Green Lodge 21/06/05

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 Heath Road Stanway Green Colchester Essex CO3 0RA Lead Inspector Brian Bailey Key Unannounced Inspection 28 & 30 November & 15th December 2006 10.00a th th 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 Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanway Green Lodge Address Heath Road Stanway Green Colchester Essex CO3 0RA 01206 330780 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) Mrs Laura Kanitkar Mrs Ann Carey Barlow Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) The registered manager must complete the Registered Manager’s Award within 12 months from the date of this certificate 31st January 2006 Date of last inspection Brief Description of the Service: Stanway Lodge is a large detached property situated in a quiet semi rural area about three miles from Colchester. Laura Kanitkar owns the home and the registered manager is Anne Barlow. The home is currently registered for 27 older people who need residential care. This does not include care for any specific category of service, such as dementia. Accommodation consists of fourteen bedrooms on the ground floor, eight of which have en-suite WC facilities and ten on the first floor, three of which are shared rooms. There are two lounges and a large dining room. There are various bathing and WC facilities throughout the home and a passenger lift that provides access to the first floor. There are ample car parking facilities at the front of the house and wellestablished grounds. Access to the house and gardens is good. Patio areas are available at the rear of the house for service users to use. As at 28th November 2006, the owner advised that the fees for accommodation ranged from £367 to £405 per week. Items considered to be extra to the fees include private chiropody, hairdressing, toiletries and newspapers and are listed in the home’s service user guide, which is available from the home. CSCI inspection reports are also available from the home and on our website www.csci.org.uk. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Stanway Green Lodge was carried out on 28th and 30th November and 15th December 2006. This report is based on a range of information that has been accumulated from our inspection records, three site visits to the home, discussions and observations with service users, staff, the manager and visitors, questionnaires issued by CSCI and the records kept at the home. As part of this unannounced inspection, the quality of information given to people about the care home was looked at. Residents and relatives were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: What has improved since the last inspection? Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 6 The manager and owner have taken note of the requirements raised at the last inspection and introduced measures to ensure these are implemented. This has been largely successful, which has resulted in far fewer requirements being found necessary and that these are in the process of being addressed. A staff development programme has been introduced that identifies the training needs for each group of 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. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to have their needs assessed and an assurance that the service can meet them prior to moving into the home. The service does not offer intermediate care. EVIDENCE: The home’s statement of purpose and service user guide contains a wide range of information about the home, including its aims and objectives and the facilities offered. The manager said that these are provided to all prospective residents and that they planned to introduce an easy read summary version of the documents. Copies of these documents were seen in some bedrooms. A visiting relative confirmed the information had been provided prior to a relative’s admission to the home. Two residents spoken with were unable to remember whether they had been given information about the home. The Service User Guide had been amended to include the recommendations made at the last inspection. It is recommended that these documents are dated when they are revised to ensure the most up to date are available. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 9 Examples of the home’s statement of the terms and conditions were seen, which had been signed and dated by the individuals. These met the required National Minimum Standards and included those items considered to be extra to the fees. Three care files and daily records were looked at. These contained an assessment of need provided by the social worker, although one contained minimal information, and an initial assessment by the manager, which was said by senior staff to be the usual procedure. The manager was reminded that up to date and comprehensive assessments from the placing authority are essential to enable the manager to determine whether the needs of a prospective resident can be met. Residents are encouraged to visit the home to meet the staff and look at the facilities available whilst considering whether the home will be suitable. This is part of the admission process as stated in the home’s statement of purpose. Staff explained that the normal practice however is for relatives to visit. The last inspection highlighted that fact that some of the residents accommodated were showing a need for care related to increasing mental frailty. The manager and owner have recognised this and has resulted in a programme of training for staff in understanding and working with people with dementia. The manager was aware that this does not permit people to be admitted with dementia unless a variation of registration for this category is applied for and granted. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 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, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service People who use this service can expect to be treated with respect and have their health needs met. They can also expect to have a plan of care to help staff meet their needs but these require further development to ensure staff are totally familiar with each person’s wishes. EVIDENCE: The care plans of three residents were seen and these showed that many of the needs of each person had been identified and recorded. Helpful and positive discussions were held with the manager and owner regarding how the care plans can be developed further and made more person centred in order to meet the wishes of residents. Although the information available in the records is fairly comprehensive, there is a danger that staff will make assumptions about what’s wanted rather than trying to find out exactly the person’s wishes. Areas that were covered included mobility, personal hygiene, continence, nutrition, and communication, night needs and pressure area care. The files Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 11 had risk assessments for moving and handling and falls. All the care plans were regularly evaluated and signed by the staff member. The files included some life history work and a photograph of the resident. There were records of visits from and to GPs and community nurses and contact details of other health professionals involved in the care of the resident. Care practice was observed during the day and it was noted that staff knocked on doors. Residents were addressed respectfully and offered choices about where they wanted to sit. Shared bedrooms all had ceiling track curtains for privacy when delivering personal care. The home has a policy and procedure for the administration of medication, which was last reviewed in October 2006. A Monitored Dosage System for the administration of medication was in use. All medication was kept in a locked cupboard. The Medication Administration Record sheets seen were up to date and the record reflected the medication available in the blister packs. Staff had recorded the opening date on all packets and bottles of medication. The manager and the senior staff confirmed that only designated staff that have received appropriate training are permitted to administer medication. Training records were available to show that staff had been trained, which included a check of their competency to carryout the duties. Controlled drugs were recorded in a register, which contained two signatures. Unwanted medication is recorded and returned to the pharmacist and signed for. Residents’ care records showed that where possible, the manager had obtained the wishes of residents in relation to their care during illness and end of life preferences. It was evident from discussions with residents that they considered staff to be courteous and respectful of their right to privacy. Two residents spoken with said they were able to enjoy as much time as they liked in their rooms and generally had meals brought to them. This was never a problem for staff and they always knocked before entering, which helped them to feel they were living in their own flat. A resident stated on a comment card “staff are kind and thoughtful”. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to be encouraged to maintain contact with family and friends, to be offered meaningful activities and receive a balanced and varied diet. EVIDENCE: As indicated at the last inspection, a positive development at the home during the past year was the appointment of an activities coordinator. From observation and discussion with the coordinator and residents, it was clear that work has continued to progress to broaden the range of activities available. Records looked at show that from discussion with residents and/or relatives an understanding of people’s interests prior to living at the home has been gathered, and the social and emotional needs of each resident identified. Residents who prefer to keep their own company and not join in communal activities have been identified. Their wishes are being respected although staff are reminded and provided with some guidelines to ensure that these residents do not become too isolated. Residents are supported to attend religious services if they require. During the time spent at the home over both days, there was a lively atmosphere with activities taking place and on one occasion, residents were clearly enjoying themselves preparing for an outing in a mini bus. One Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 13 resident spoke of the pleasure that had been gained from having been taken out the previous day to a garden centre. Photographs were in evidence of residents participating in activities. The coordinator attended a course “provision of activities in a care setting” in March 06. Newsletters are produced and an analysis of resident participation in the various events is recorded to ensure that activities can be monitored and changed if necessary. External entertainers were present on the first of the unannounced visits. It is apparent that the coordinator is endeavouring to ensure that the provision of activities and stimulation is a shared task that cannot be achieved as effectively by one person working alone. From observation and discussion with residents, it was evident that people are enabled to make choices to the extent of their ability. Residents were sitting in the lounges, bedrooms and the entrance hall. Visited rooms showed that residents had been encouraged to personalise their rooms. Relatives spoken with confirmed that there were no restrictions on visiting times and they always felt welcome. Two residents spoken with said they prefer and had chosen to take their meals in their own rooms, which does not present a problem for the staff. Meal trays were observed being taken to several bedrooms. One resident spoken with said they liked to have their meals in their room and be able to watch their own television in private, which made it feel like living in their own flat. The food was well-presented and appetising in appearance and residents were not hurried to finish their meal. Staff were observed to sit with residents that required some assistance. The dining tables were well laid out and cold drinks were provided. The menus showed that a choice was available, which was observed on the days of inspection. Residents spoken with said that they enjoyed the meals provided and the opportunity to have a choice. One resident stated on a comment card “the food is very good and well presented. I enjoy the meals very much”. Adequate food stocks were available. Not all staff had received basic food hygiene training, which is a requirement, (see Management and Administration section re health & safety) Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to have any complaints taken seriously and investigated, although they are potentially at risk unless all staff have received the appropriate training relating to protection from abuse. EVIDENCE: The home has a complaints procedure that is clearly detailed in the home’s statement of purpose and service user guide. The manager was aware of the need to make one amendment in relation to advice given to complainants about CSCI. The home keeps a log of all complaints and compliments regardless of the nature of the issue raised. One relative stated on a comment card returned to CSCI that they were unaware of the complaints procedure. Although the home has policies and procedures in place to protect service users from abuse, the training log shows that some staff have not been provided with the required training. This is essential as service users are potentially at risk unless staff are fully conversant with what constitutes abuse. The manager stated that these staff will attend training in January and February 2007, which has been booked. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 -26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service People who use this service can expect to live in a clean, comfortable home although there are some areas that require redecoration and for some items of bedroom furniture to be replaced EVIDENCE: Stanway Green Lodge is a large detached property that has been adapted to meet the needs of older people. The building is well maintained and decorated and furnished to a reasonable standard although there are a few areas in need of some improvement and redecoration. A partial tour of the building was carried out that included the kitchen, laundry, lounges and dining room, bathrooms and several bedrooms. All were clean and tidy and odour control was effective. One resident stated, “The home is always fresh and clean, no complaints”. A number of the residents’ bedrooms seen were well furnished and decorated although some were looking rather dated in appearance and need brightening up. Some lampshades above beds Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 16 should be replaced with a shade of a different design to avoid residents having to look at a bright bulb when in bed. Many of the bedrooms had been personalised with resident’s own possessions. Three residents spoken to said that they were very satisfied with their rooms, they were comfortable and liked being able to have some of their own possessions with them. The grounds were well maintained considering the time of year. Access at the front door and from a lounge to the garden is good. There is a small step leading from the dining room to the garden, which is a potential hazard and means that some residents would not be able to access the garden independently from this door onto the ramp. A risk assessment must be completed to minimize the risk of an accident. As an interim measure it was suggested to the manager that the step should be highlighted in some way to ensure it is brought to people’s attention when they are leaving the dining room to go into the garden. Car parking facilities and access to the home using public transport is good. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service People who use this service can expect to be supported by experienced and correctly recruited and trained staff. EVIDENCE: The service uses a staff to service user ratio calculation method recommended by the Department of Health. This was inspected and the ratios were in accord with the staff roster. The home employs separate cleaning and catering staff. Two relatives have commented that in their view there are not always sufficient staff on duty. A training matrix/record log was made available that showed the training courses attended by staff. There were some gaps where staff had not yet been provided with ‘statutory’ training such as moving and handling, food hygiene and first aid. The manager did explain that these staff had only recently been employed and that training was planned for them. The owner and manager were to attend a train the trainer’s course in early December 06, which will enable them to respond and provide training to staff more effectively. Since the last inspection, the owner has assessed the training needs for each type of job at the home and identified the training that has to be provided and the degree of priority that must be given. The training listed for each role includes the statutory requirements such as health & safety as well as training specifically for those caring for older people. Several staff spoke of a training course on dementia that they are currently working on, Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 18 which is proving to be quite demanding. From observation and discussions with the manager and staff, training has been given a higher priority than previously. Staff recruitment was sampled using three staff files at random. These contained the required information such as application form, two written references, photograph, Criminal Record Bureau (CRB) disclosure checks, induction training, supervision records and a job description. These files were kept in a locked cabinet to ensure confidentiality is maintained. The manager stated that of the 13 care staff employed, 5 had a National Vocational Qualification (NVQ) at level 2 and 2 staff had a NVQ level 3, which means the home had achieved the minimum target of 50 of care staff having obtained the qualification. Not every staff member’s training records were looked at to verify this. Records did show that staff employed since the managers appointment in 2005 had received appropriate induction training. Staff spoken with had mixed views about the home. Two people expressed a sense of frustration that the manager and owner spend too long in the office, and another person did not consider there had been sufficient staff meetings. Records did show however there had been frequent meetings between different groups of staff throughout 2006. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from having an experienced manager and owner who have made progress during the past year and are taking positive action to continue to raise standards. Residents are potentially at risk unless all staff have received the statutory Health & Safety training. The Quality Assurance system has to be introduced to ensure that all residents are given a voice about how the services are provided. EVIDENCE: The registered manager, Ann Barlow, has completed the Registered Managers Award (RMA) and as at November 06 was awaiting confirmation and a certificate. The manager must provide CSCI with a copy at the first opportunity to enable the home’s certificate of registration to be amended. The home’s owner, Laura Kanitkar, is also attending a RMA qualification course of study, which is nearing completion. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 20 Records of three staff files were checked and these showed that the home is operating a staff supervision system and that the frequency of 5 to 6 sessions per year was being maintained. The home’s Quality Assurance system had still not been launched although a series of questionnaires had been produced for issuing to residents, relatives and other people with an interest in the home. This has now been delayed until early 2007 in view of survey forms having been issued by CSCI during December 2006. Twelve comment cards returned to CSCI during December 2006 from relatives and residents indicate a good level of satisfaction with the services provided. Examples of comments are; resident, “I am very happy here, I’m warm and comfortable and feel at ease with everyone”. Relative, “The staff are wonderful”. The only reservation to be expressed was by two relatives who felt that there are occasions when there are too few staff on duty. Residents’ finances held for safekeeping were not checked on this occasion, however, this standard was assessed in January 2006 and was found to be secure, accessible and adequately recorded. The registered owner carries out Regulation 26 monthly audits. The reports show that checks are made on a range of topics in order to gauge the quality of the service being provided; these contained recommendations for the manager and staff to discuss or implement. Records noted at the previous inspection as requiring attention were checked and are considered to now meet the required standard. Records show that the servicing of equipment and systems under Health & Safety were up to date and are being maintained appropriately. As already stated under “staffing” some staff have not received the required ‘statutory’ training such as moving and handling, food hygiene and first aid. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 OP4 Regulation 14 Requirement The Registered Person must ensure that comprehensive and up to date assessments of need are obtained for all prospective service users. Timescale for action 01/02/07 2 OP7 12, 14, 15 The Registered Person must 30/03/07 continue to develop care plans to ensure that service users’ health, personal and social care needs and aspirations are detailed and provided with clear guidance as to how these are to be met. 13 The Registered Person must ensure that all staff are trained in the protection of service users from abuse. This is a repeat requirement. The Registered Person must ensure that all service user bedrooms are decorated to a good standard and more appropriate lampshades provided. 28/02/07 3 OP18 OP30 4 OP19 23,24 30/05/07 Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 23 5 OP20 23,24 The Registered Person must ensure that the step at the exit door in the dining room is risk assessed and measures taken to minimise the risk of an accident. The Registered Person must ensure that the quality assurance survey forms are issued and an analysis of the feedback is provided to service users and CSCI. 01/02/07 6 OP33 24 01/04/07 7 OP38 OP30 13,16, 23, The registered person must 24 provide staff with basic health and safety training such as moving and handling, first aid and food hygiene. 01/02/07 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 OP1 Good Practice Recommendations It is recommended that the statement of purpose and the service user guide are dated when changes are made. Stanway Green Lodge DS0000053190.V312755.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex 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 DS0000053190.V312755.R01.S.doc Version 5.2 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. 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!