Inspection on 11/04/07 for The Lodge

This inspection was carried out on 11th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Lodge 18/08/09

The Lodge 02/12/08

The Lodge 09/01/08

The Lodge 19/04/06

The Lodge 05/07/05

The Lodge 28/04/05

The Lodge 04/10/04

The Lodge 17/05/04

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

CARE HOMES FOR OLDER PEOPLE The Lodge Watton Road Ashill Thetford Norfolk IP25 7AQ Lead Inspector Kim Patience Unannounced Inspection 11th April 2007 10:00 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 The Lodge DS0000027322.V337060.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. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Address Watton Road Ashill Thetford Norfolk IP25 7AQ 01760 440433 01760 440043 kaz1509@hotmail.com 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) Mr Kenneth John Squire Mrs Irene Margaret Squire Mrs Karen Syer Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: The Lodge is a residential home registered for 20 elderly people with Dementia. The home was originally a large detached family home, and it retains many of its original features. There is a large lawn at the front of the home which provides a good sitting area for residents, with smaller gardens at the side and rear. There is a car park at the front of the home. If nursing care is required it is provided by members of the District Nursing team. Any medical or specialist services are obtained via the GP. The home is situated on the outskirts of the village of Ashill, on the Swaffham to Watton Road (B1077). The fees charged at this home range from £393.00 - £450.00 per week. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took approximately 7 hours to complete. The manager, Karen Syer was present throughout the inspection and helpful in facilitating the process. During the visit, a tour of the building was completed, residents, relatives and staff were spoken with. Records relating to residents, staff and the running of the home were inspected and observations of daily life in the home were made. Nine resident surveys were returned to the Commission and the results along with any comments made have been incorporated in the report. What the service does well: What has improved since the last inspection? What they could do better: • The home must ensure that contracts are issued to all people who are using the service. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 6 • Care plans must be developed to include assessments of all needs including personal care and guidance as to how peoples needs should be met taking into account their choices and preferences. Resident’s files must be kept in accordance with the regulations. The home must ensure that all potential risks to residents safety are assessed and a plan of action to minimise risk must be written. People’s nutritional needs must be assessed. Medication management must be improved ensure the health safety and welfare of residents is protected. The home must ensure that each resident has a social care plan and that activities that meet the individual’s needs and expectations are provided. Residents must be offered a choice of meals and menus must be based on the needs, likes and dislikes of residents. The home must maintain records of individual’s dietary intake. Risk assessments must be completed on products stored in resident’s rooms and action taken to minimise risk. Risk assessments must be completed on the uncovered radiators and action taken to minimise risk. Staffing levels must be increased to ensure that people’s holistic needs are met. The manager must not appear on the rota as covering care shifts. Staff must be registered for NVQ training and the number of staff trained at this level must be increased. The manager must introduce a plan of formal supervision. • • • • • • • • • • • • • The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 8 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 The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. The home can provide sufficient evidence that people who use the service are provided with information that enables them to make an informed decision as to whether the home will meet their needs and expectations. However, this not consistent with the views of all people who live there. The home can also provide sufficient evidence that prospective users of the service have their needs assessed to determine that they can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure in respect of new admissions. People expressing an interest in living in the home are provided with a copy of the statement of purpose and service users guide, in addition to information about the facilities and services. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 10 Prospective users of the service and their relatives are invited to view the accommodation and sample the service. The manager completes a pre-admission assessment, which gives an account of their basic needs and preferences. A file relating to one new user of the service was assessed and there was evidence that the procedures had been followed. The pre-admission assessment was fairly thorough and contained some good person-centred information. The resident had been issued with a contract and terms of residence that they had signed in agreement. Nine resident surveys were returned to the Commission. Whilst all nine indicated that people were provided with sufficient information about the home prior to moving in, five indicated they were not provided with a contract. This was discussed with the manager who said that all residents were provided with a contract, however, sometimes the contract was issued by social services and in these cases the home does not issue one of their own. See requirements. The home does not provide intermediate care services. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. The home cannot demonstrate that the health, safety and wellbeing of people who use the service is promoted through care planning, health assessments and the safe management of medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents file were inspected and found to be generally well organised. The files inspected did not include a photograph of the resident and this is a requirement. See requirements. The home uses a care plan format, which is somewhat limiting, however provides a sound structure on which to assess people’s social and emotional needs. There was lots of information relating to life history, family, previous employment, interests and hobbies and likes and dislikes. In addition the files contained a strengths assessment records of daily activity. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 12 Some improvements are needed in care planning as the current care plans focus mainly on the social and emotional needs of each individual and omit to address the health and personal care needs people may have. Care plans state what the need is, but do not set out how the need should be met by staff, taking into account the persons choices and preferences. See requirements. Files contained a risk reduction programme, however, this was not completed in all cases. See requirements. The home does not have nutritional needs assessments nor care plans that address any nutritional needs people may have. See requirements. The home must also provide sufficient evidence that care plans and associated records are reviewed on a regular basis, as there does not appear to be any system of review currently. See requirements. The homes medication arrangements were inspected and the findings are as follows: Medicine storage Medicines are stored in locked cupboards in a small room allocated for this purpose. Controlled drugs are stored in a metal cabinet. The home has a trolley for transporting medicines around the home located in this room when not in use. Keys to medicines and the room were said to be held by authorised members of staff. A medicine refrigerator is also available in the room containing some medicines requiring storage at a low temperature. However, on the day of inspection the refrigerator was not in working order and awaiting repair. It is of concern that medicines requiring refrigeration including insulin have been stored at room temperatures for periods exceeding their maximum room temperature storage and may therefore now be unsafe for use. See requirements. Medicine administration The home uses a monitored dosage system (MDS) from which the majority of medicines are dispensed. There are also a number of other medicines that are dispensed from the original packaging. The home does not have resident-identifying photographs with the Medication Administration Records (MAR) and this would assist with safer administration. See recommendations. The lunch-time medicine round was observed in part and it was noted that when the care assistant took medicines to residents seated in the dining area The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 13 the trolley containing medicines was left unattended with the doors open in the corridor. During this time medicines could be accessed by residents and may pose a risk to their safety. See requirements. The management of medicines was assessed by inspecting the MAR charts, by conducting an audit of some medicines against the records held and by observation. There were a number of concerns arising from the inspection and audit as follows: • On entering the medicine room a vessel marked DB was seen to contain two tablets. The senior care assistant present was asked why they were there and she replied the medicines had been prepared for a resident at lunchtime who had refused to take them and she had intended to destroy them. On examination of the resident’s chart, it was found that the chart had been signed and it therefore appeared the medicines had been administered when they had not. • There were a number of other vessels marked with resident’s initials, which may indicate that medicines are potted up prior to administration and this is unsafe practice. However, there was no evidence of this during the inspection. Examination of MAR charts showed that there were some gaps when it cannot be determined if medicines have been given or not. There were some signatures crossed out and correction fluid had been used to delete some signatures. Some medicines could not be audited due to the lack of an effective audit trail and the home does not conduct internal audits of medicines. Medicines prescribed on a PRN (when required) basis were being given consistently. There were no care plans setting out the nonpharmacological intervention to be taken before giving the medicines and therefore the home could not justify the decision for giving the medicines on a regular basis. For instance one resident was prescribed Temazepam on a PRN basis but this was given each night. Another medicine Diazepam was prescribed three times a day PRN and this was given consistently. There were no records justifying the use of these medicines and therefore it is of concern that they may have been given inappropriately. Antibiotics prescribed for one resident showed that 21 were prescribed three times a day and while the chart showed 21 were administered the course was completed in nine days and not in the seven days in accordance with the prescription. Another resident prescribed antibiotics four times a day was supplied 28 on the 4/4/07, the charts showed 19 DS0000027322.V337060.R01.S.doc Version 5.2 Page 14 • • • • The Lodge had been given, 6 were refused and one remained in the pack. This indicates a deficit of 2 suggesting that the medicines were not given in accordance with the prescription. • • Some medicines remained in the MDS and on examination of the charts it appeared that the medicines had been given when they had not. One resident had been prescribed Warfarin and this medicine was printed on the chart but there were no signatures to indicate that medicines had been given. In one other case, the resident had been prescribed Warfarin as directed, however there was nothing to indicate what dose was being given. Another resident was prescribed Sodium Valproate in tablet form, which was later changed to liquid form. Both appeared on the chart and both medicines were available in the cupboards. There was nothing on the chart to indicate one has been discontinued and this is unsafe. One resident was prescribed a Beconase spray, yet the chart was not signed to say it had been administered. When the manager was questioned, she said that the resident kept the spray in his pocket and used it when he wanted. There was no risk assessment or care plan for the self-administration of medicines in this case. Another resident was seen to have a number of inhalers in their room without risk assessment in place. • • The above are points are some of the numerous examples that indicate the home do not manage medicines in a way that promotes the health, safety and welfare of residents –see requirements and recommendations. In addition, the manager stated that not all staff have received accredited training in the safe management and administration of medicines. See requirements. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. The home cannot fully demonstrate that the service provided meets the expectations and preferences of residents. It also cannot demonstrate that choice and control is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As mentioned in standard 7, the home assesses resident’s social and emotional needs adequately. However, the information is not transferred to care plans that set out the need and how it should be met. The home gathers lots of information about people’s life history and family and there is evidence that person centred activities are promoted. For instance one resident worked as a farmer and enjoys being outdoors. He has a small-scale model horse and cart in the garden and this stimulates conversation about his past. Other residents are involved in the activities of daily living such as folding laundry and setting tables for lunch. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 16 There is a plan of activities, which shows some group activities and some individual activities. Of the nine resident surveys returned to the Commission, two stated that activities were always available, five indicated that they are usually available and two indicated sometimes. Some comments were made by relatives, one stated that ‘mother needs support with activities and this is not always possible’ ‘being profoundly deaf makes it difficult to be part of what is going on’ ‘the Lodge tries to involve mother in activity and usually succeeds, where I don’t’. The results of the survey show that the home needs to make some improvement to the provision of activity. See requirements. On the day of inspection, it was warm and sunny, the doors to the home were open and people had free access in and out of the building into the grounds. Whilst the grounds are yet to be developed, most residents clearly enjoyed being outside sitting on the benches and walking around. Staff were also outside supporting residents. It was good to see residents walking in and out of the home as they wished and is an unusual sight in most care homes. Meals and mealtimes were assessed and the findings are as follows: Lunch was served in the main dining room, where most residents preferred to eat. Tables were nicely laid out with cutlery, paper napkins and flowers on the table. Meals were served ready plated and residents were not offered any choices of food or drink. The food looked appetising and residents appeared to enjoy the meal. See requirements. There was only one member of staff on duty in the dining area and she was being assisted by the cook who was serving meals. However, a number of people needed some prompting or assistance with their meals and the support was not readily available. Subsequently, those that did not eat their meal were not offered anything else and staff did not seem to understand that their cognitive impairment may affect their ability to coordinate thinking and physical movement to good effect, hence the need for some prompting. See requirements. The cook was spoken with and menus were discussed. The cook draws up the menus based on what she thinks residents will like, although she does sometimes sit with people and ask what they like. The meals are all home cooked and appear to be nutritious and well balanced. However, the home needs to take into account people’s choices and preferences in relation to food and this should arise from assessing people’s nutritional needs. The home should also find a way of providing a choice of meals, perhaps by producing The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 17 pictures of plated food and asking people to indicate what they like to eat. See requirements One resident required a liquidised meal and the meal was pureed all together in one bowl. Residents should be given the opportunity to experience the various tastes and textures of food and it should always be pureed in separate portions. See requirements. The home does not retain records of individual’s dietary intake and this is required. See requirements. One relative and resident spoken with said that the food was always good and they enjoyed the meals. Resident surveys showed that six people indicated that the food was always good, with one comment saying that it is excellent. Two people indicated that the food is usually good and one said sometimes, with a comment saying improvements need to be made to the food offered at teatime, as it is not always suitable. During the inspection, visitors were seen to come in and out of the home without restriction. Relatives were spoken with and were happy with the service provided, saying the staff were very kind and welcoming. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home can provide sufficient evidence that they have systems in place to ensure the protection of residents and that peoples concerns are listen to and taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure in relation to complaints that is publicised in the service users guide and posted in the reception area of the home. The manager said she hasn’t received any complaints since the last inspection and that the home has a complaint log in place to record any complaints made. Eight of the residents surveys returned indicated that people know how to make a complaint, one stated they did not. In respect of adult protection, the home has not had any adult protection concerns and all staff are trained in the protection of vulnerable adults. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. The home provides fair accommodation and maintains a reasonable standard of cleanliness. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has two communal lounges and a separate dining room. One of the lounges has been re-carpeted and new chairs have been purchased. Both lounges now look comfortable and homely. The dining room was nicely laid out and again very homely. There is lino flooring, which is easy to keep clean but not domestic in character and can make the room appear institutional. The home must start to consider how they can make the environment more enabling for people with dementia. While some improvements have been made The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 20 such as sign-posting this needs to be developed so that residents who are unable to understand text are provided with an alternative such as pictures. Additionally, the home could look at the effective use of colour and placing items that aid memory and recall on bedroom doors to assist with orientation. During a tour of the premises it was noted that products that are potentially harmful if misused were seen in residents rooms. The home had not assessed the level of risk to the resident or others and this is a requirement. See requirements. It was also noted that there were a number of radiators that were hot to touch and in areas that could expose people to the risk of burns if there is prolonged contact with the surface. The home must ensure that all radiators are risk assessed and action taken to minimise the risk of harm. See requirements. In general the home was clean and tidy with no apparent odours detected on the day. However, a survey returned by a visiting professional stated that there were concerns about continence management as the home often smelt. Of the nine resident surveys returned to the Commission, six indicated that the standards of cleanliness were always good and three indicated that they were usually good. Work on the gardens and other external area is progressing well. The home plans to involve the residents in landscaping the gardens and planting shrubs. Work needs to continue to ensure that the home provides a safe pleasant outdoor space. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. The home cannot demonstrate that there are sufficient numbers of trained and competent staff to meet people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the home was providing accommodation and services to 16 people, all with a diagnosis of dementia. All of the nine resident surveys indicated that people always have their needs met and staff were always/usually available when needed. However, staff rotas show that staffing levels are at the minimum with two care assistants on duty per shift. The manager is working many shifts to make sure peoples needs are met, leaving little time to fulfil her role as manager. This must stop and the manager must not be included in the staffing rotas. See requirements. The home has an annual training and development plan that shows all mandatory training is provided in addition to specialist training such as dementia awareness. However, as mentioned in standard 9, at least one member of staff administering medication had not been trained to do so. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 22 There are only three members of staff who are currently trained at NVQ level or above. The home needs to ensure that staff are provided with NVQ training as they are currently not achieving the workforce training targets. See requirements. New staff files were inspected and no issues of concern arose. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is poor. The home cannot provide sufficient evidence that the home has robust management systems in place to protect the health and welfare of people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager who shows commitment to providing good care for people who use the service. The manager has completed ongoing training relating to her management role and she is currently undertaking a course in advanced dementia studies with the university of Bradford. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 24 This inspection has identified a number of key areas that need to be improved and the manager must withdraw from hands-on care and concentrate on the management issues. See requirements. The manager has recently introduced a quality assurance system, which includes stakeholder surveys. The quality assurance system will be implemented throughout the year and when completed the results will be published in a report. Progress will be assessed at the next inspection. The home does not hold any money for residents and therefore standard 35 is not applicable. Staff supervision was discussed with the manager who said that no formal plan of supervision has been introduced as yet. Staff team meetings have been taking place and the manager has an open door policy so staff can discuss any issues or concerns. However, staff must be provided with formal one to one supervision. See requirements. Health and safety records were checked in brief and no issues were identified apart from those already highlighted in this report. The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 5(1)(c) Requirement All people using the service must be issued with a contract so that there is some formal agreement about the facilities and services provided. Residents files must be kept in accordance with the regulations and include a photograph of the resident for identification purposes. Care plans must be developed so that all needs are assessed and staff are provided with clear guidance as to how needs should be met taking into account peoples choices and preferences. Care plans must be reviewed monthly to ensure that they reflect any changes in need. Individual risk assessments must be completed to ensure the risk of harm is identified and minimised. Nutritional needs assessments must be completed to ensure that people’s nutritional needs are met appropriately. People who use the service must have medicines that require DS0000027322.V337060.R01.S.doc Timescale for action 01/06/07 2 OP7 17(1)(a) schedule 3 point 2 15(1)(a) 02/07/07 3 OP7 02/07/07 4 5 OP7 OP8 15(1)(a) 13(4) 02/07/07 02/07/07 6 OP8 12(1)(a) 02/07/07 7 OP9 13(2) 01/06/07 The Lodge Version 5.2 Page 27 refrigeration stored appropriately within the accepted temperature range to safeguard peoples health and welfare. 8 OP9 13(2) People who use the service must be protected by safe and secure storage of medicines at all times to safeguard their health and welfare. People who use the service must have medicines administered by staff following safe procedures to safeguard peoples health and welfare People who use the service must have medicines administered in line with prescribed instructions at all times and this can be evidenced by records accounting for medicines. People who use the service must be administered medicines prescribed on a PRN (as required) basis in line with clear written guidance on their use and only when clinically justified. People who use the service and who self-manage medicines must have a risk assessment conducted on a regular basis to ensure they are administering medicines safely and their health and welfare is safeguarded. People who use the service must be administered medicines safely by staff considering full and accurate MAR charts with clear dose directions for all medicines to safeguard peoples health and welfare. People who use the service must have medicines administered by staff who have received training and are assessed as competent DS0000027322.V337060.R01.S.doc 01/06/07 9 OP9 13(2) 01/06/07 10 OP9 13(2) 01/06/07 11 OP9 13(2) 01/06/07 12 OP9 14 01/06/07 13 OP9 13(2) 01/06/07 14 OP9 18(1)(c) 01/06/07 The Lodge Version 5.2 Page 28 15 OP15 12(2)&(3) 16 OP15 17(2)sche dule 4.13 16(2)(i) 17 OP15 18 OP19 13(4) 19 OP19 13(4) 20 OP27 18(1) 21 OP30 18(1c) 22 OP36 18(2) to undertake medication related tasks to safeguard people’s health and welfare. People who use the service must be provided with a choice in respect of meals and offered alternatives. The home must maintain records of individual’s dietary intake so that it can be determined whether the diet is satisfactory. Liquidised food should be prepared and served in separate portions to give people the opportunity to experience various taste and texture and promote dining that is consistent with previous experiences. Risk assessments must be completed on products stored in residents rooms to safeguard their health and welfare. Risk assessments must be completed on the uncovered radiators to safeguard the health and welfare of people who use the service. The number of staff on duty per shift must be increased and the manager must not be included in the care hours. Staff must complete NVQ training to ensure they are appropriately qualified and competent carers. Staff must be provided with appropriate supervision in order to promote good practice for the benefit of people who use the service. 02/07/07 02/07/07 02/07/07 02/07/07 02/07/07 01/06/07 03/09/07 02/07/07 The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 29 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 OP9 Good Practice Recommendations It is recommended that regular and frequent audits of medication and their records are conducted by a senior member of staff to promptly identify discrepancies arising and take remedial action. It is recommended that resident-identifying photographs are used alongside MAR charts to assist in safe medicine administration. 2 OP9 The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Lodge DS0000027322.V337060.R01.S.doc Version 5.2 Page 31 - 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!