Inspection on 30/11/06 for The Lodge Dovercourt

This inspection was carried out on 30th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Lodge Dovercourt 04/11/08

The Lodge Dovercourt 08/11/07

The Lodge Dovercourt 23/03/06

The Lodge Dovercourt 19/07/05

The Lodge Dovercourt 29/03/05

The Lodge Dovercourt 08/09/04

The Lodge Dovercourt 25/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Lodge - Dovercourt 16/18 Beach Road Dovercourt Harwich Essex CO12 3RP Lead Inspector Tim Thornton-Jones Key Unannounced Inspection 30th November 2006 09:00 The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 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 - Dovercourt DS0000017969.V317438.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 Adults 18-65. 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 - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge - Dovercourt Address 16/18 Beach Road Dovercourt Harwich Essex CO12 3RP 01255 503678 N\A thelodgecarehome@aol.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) Mrs Nowranee Sookun Mrs Nowranee Sookun Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) 23rd March 2006 Date of last inspection Brief Description of the Service: The Lodge is situated near the seafront at Dovercourt. The home changed its category of care from elderly people to people with learning disabilities in 2001. Prior to this it had been operating as a small home. Mrs. Sookun has remained the registered manager during the lifetimes of both registrations and has a background in nursing. The accommodation is comprised of a converted family home, with eight single rooms, one of which is on the ground floor. There is no lift. There are two bathrooms with toilets and additional separate toilets on the ground and first floor. Catering and laundry facilities are at the back of the house on the ground floor. Communal areas consist of a lounge and dining room. The dining room has patio doors opening up onto the rear garden, which is accessed via steps and is mainly laid to lawn with some flowerbeds. The small front garden is paved. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection confirmed that the weekly fees for this service were stated by the Registered Person to be £1000.00 to £1,200.00 per week. The arrangements for care planning were good and were able to reflect the complexity and challenge of service users accommodated. Access to the community and social and leisure opportunities were satisfactory and suitably balanced to take account of service user preferences and choices. Staff related standards were, however, poor with the exception of supervision, which met regulatory requirements. Recruitment practices, induction practices and some aspects to training require improvement. Overall the environment was domestic in style and comfortable with recent improvements to decoration. There are improvements required however to ensure the safety of service users and aspects to privacy and dignity. Record keeping was generally good and periodic checks to gas, electrical and fire safety systems were adequate. Quality assurance and monitoring remain below that required by regulation. Whilst some good improvements have been made since the previous inspection other matters remain below the required National Minimum Standard, some of which have remained outstanding and carried forward from previous inspection reports. What the service does well: What has improved since the last inspection? • • • Decoration to the rooms. Medicine administration. Staff supervision. DS0000017969.V317438.R01.S.doc Version 5.2 Page 6 The Lodge - Dovercourt 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. The summary of this inspection report can be made available in other formats on request. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • Service users do not benefit from information they need to make an informed choice about where to live. • Service users benefit from the homes practice regarding admission procedures. EVIDENCE: The Registered Person has produced an Information booklet/Statement of Purpose. The document is useful although does not contain all the information required by regulation and therefore requires amendment. The home was not able to produce a Service Users Guide for inspection. The available documentation did include a contract with a version set out in ‘widget’ symbol format, although was not completed in terms of service user detail, signed or dated. The Registered Person will need to produce a service users guide in accordance with regulatory requirements. The admission procedures in relation to one person who recently came to live at the home was good in that the information was comprehensive in terms of The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 9 the pre-admission information, which gave an informed basis on which to make a decision about the appropriateness of the admission. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the homes approach to care planning. • Service users are adequately supported to take risks as part of an independent lifestyle. • Service users are encouraged to make decisions with appropriate assistance. EVIDENCE: Four service users were being accommodated at the time of the fieldwork inspection visit. Two service user files were case tracked to ascertain the way in which the home manages the care process. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 11 The first file seen showed that the person had received a comprehensive assessment prior to and at the time of admission. The care planning arrangements were set out in a well planned and comprehensively documented manner. Decisions had been recorded to reflect the assessment of need and known needs and preferences prior to admission. The methodology used to ensure that the way in which carers undertake the support of the service user were clear and well documented. The ongoing progress notes were well written and objective. The carer’s action notes were attached to each decision within the plan for ease of reference. Various additional risk assessments were included within the plan linked to various activities. These are focussed to enable the activity to be undertaken safely. The plan records, in separate sections, all the necessary key aspects of care delivery, for example, various healthcare professionals. Medical reviews were all noted to have been recent. GP, physiotherapy and Social Worker visits and reviews were separately and well recorded within the plan. Other Primary Healthcare Services such a chiropodist, optician, dentist etc were well recorded and up to date. Separate recording was also noted regarding visits and arrangements for contact with family and friends. The record for the sample seen indicated frequent telephone calls and visits. Records of current medicines being taken were listed within the plan. These cross-referenced with records held as part of the medicine administration records. A separate social diary is maintained, which details daily events. The record shows that service users eat meals out, attend clubs, go shopping, swimming, walks etc. The level of service user consultation within the plan was evidently limited in view of the persons disability and range of communication, although their was evidence via observation that carers were communicating and using various opportunities to engage with service users and obtain consent/preference and create informed choices. The second sample care plan followed the same structure as the first in terms of the care planning layout and tools used, although the sample was significantly different in reflecting the needs, decision making, assessment material and planning. This shows an individual approach to care planning. The service user in this instance has severe autism and no verbal communication. The inspector was not able to obtain information from the person on this occasion although was able to make observations. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 12 Staff do utilise a structured approach and methods of communication as a technique. Records indicate that some progress with planned the care outcomes are being achieved. Overall, the methods and recording being used were comprehensive and well managed. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from peer and culturally appropriate activities. • Service users benefit from opportunities to engage with the local community. • Service users benefit from good links with family and friends. • Service users benefit from individual rights being recognised in their daily life. • Service users mainly benefit from the homes approach to meals provision. EVIDENCE: Some service users are supported to attend a day activity centre in Colchester, which offers a range of opportunities to develop self help and occupational skills. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 14 Service users do use aspects of the local community, including café, leisure facilities and shops. The home is located in a residential street among houses of similar size and design and as such the home enjoys a sense of community. The records held by the home demonstrate that good links have been established and maintained with family and friends, for example one service user has a calendar in their bedroom showing forthcoming dates of visits from relatives and weekends visiting them. The Manager discussed with the Inspector aspects of service users need for personal and intimate relationships and the actions toward supporting people appropriately with such matters. Service users have freedom of movement subject to assessment of risk specified within the care plan. It is difficult to ascertain the extent to which service users have agreed to restrictions, although the level of practice recorded, and observed, in interacting with service users supported the view that care staff do adequately consider service users behaviour and individual communication methods as an indicator of consent. The method and type of communication between carers and service users was appropriate and supportive. Carers use appropriate language, tone and volume. Meals that are planned are recorded within a bound book and form a ‘menu’, which is written on a daily basis in accordance with choice. The record indicated that the menu was varied and balanced. The record, however, falls short of being able to demonstrate that service users actually receive a balanced and appropriate diet on the basis that no individual records are compiled that comment upon whether the person actually ate the meal and in what quantity. A discussion between the Manager and the Inspector agreed a way forward to resolve this. Food stocks were not viewed on this occasion. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 20 & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • • Service users benefit from the way in which carers provide flexible support. Service users benefit from their physical and emotional needs being met. Service users mainly benefit from the medicine administration system. EVIDENCE: The case tracking sample of service users indicated that both were unable to maintain and administer their own medication due to their incapacity to safely maintain the dosage and frequency required. A ‘bottle to mouth’ system of medicine administration is used in the home. Care staff that administer medication have received training in administration, usage and side effects, although it was unclear whether an awarding body validated the training that staff had received. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 16 Based upon discussion with care staff and the review of relevant records, policies and procedures, carers do provide flexible and personal support in a way that follows sound professional principles and is reflective of ‘ordinary life’. The daily life in the home is flexible, although for some, in view of their disability, it is beneficial to them for some structure to be applied. This, where necessary, is detailed within the care plan for the individual and has been subject to appropriate risk assessment. Service users are appropriately assisted and guided with personal care and encouraged to do as much for them as possible. Choices, although for some, are ‘informed’ choices, are given from everyday matters such as choosing what to wear etc. One service user was supported to go to Ireland on an aircraft recently, which was an experience not tried before. All service users at the home have been assessed as being unsafe to administer their own medicines and practical consent for the home to undertake this task was not possible for the sample group seen due to capacity issues. Records indicate that the arrangements for personal medicines and access to treatment were satisfactory. The medicine administration system was viewed and found to be secure, well maintained and recorded. The home uses a ‘bottle to mouth’ system in individual containers as dispensed. The Manager was reminded to ensure that the date of commencement of medicines should be recorded on the administration record, if this is a different date from when the medicine was dispensed. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • Service users do not yet fully from the home procedures for safeguarding adults and the management of complaints. EVIDENCE: The home was in possession of the ‘Safeguarding Adults’ pack provided by Essex County Council. The Manager stated that the home has not needed to invoke safeguarding adults procedures during the period since the previous inspection. CSCI have received no referral during the same period. Not all staff employed at the home had received appropriate training in the protection of vulnerable adults from abuse. See staffing section. The service has a complaint procedure that meets with regulatory requirements. The manager confirmed that no complaints about the service have been received during the period since the previous inspection. CSCI are unaware of any complaints, concerns or allegations in respect of this service. A copy of the complaint procedure has been produced using ‘widget’ symbols for service users, although at the time of inspection was not readily displayed. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • Service Users mainly benefit from a homely and comfortable environment although are not fully protected from hazards (dining room) identified and aspects to privacy (bathroom). Service users benefit from a home that is clean and free from unpleasant odours. Service users benefit from a well furnished and decorated bedroom. EVIDENCE: A tour of the premises concluded that the rooms seen were decorated and furnished to a satisfactory level. Rooms occupied by service users were comfortable and personalised. The home uses a ‘total communication’ principle and in key areas within the building were ‘widget’ symbols, for example WC and bathroom to act as The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 19 prompts for service users. Additionally there was some attention to detail in service users rooms to assist service users to organise clothes, for example, symbols on cupboards and draws. In one bedroom the ‘morning routine’ was located in symbol format so that both the service user and assisting carer could follow a structured method. This was reiterated within the plan of care for the individual and demonstrates consistency. One bathroom was noted to have two windows facing the road, along which are other houses and public access. Whilst one window had obscured glass fitted and the other located at a higher level, neither had a curtain or blind fitted to maintain full privacy and modesty for service users. The manager was advised by the Inspector to consider an appropriate method to achieve improved privacy as a matter of priority. The communal areas were adequately furnished and decorated and no unpleasant odours were noted anywhere within the home. Some rooms have been redecorated since the previous inspection. The stair carpet is showing signs of wear and the registered person will need to plan for replacing this in due course. An electrical socket in the dining room requires attention as the fitting has a 20mm access hole located on the retaining box. This hole is large enough for a service user to push their finger or other material into the box in the area of live terminals and therefore presents as a serious risk. The Registered Person was advised to seek assistance from a qualified Electrician to rectify the problem immediately. No service users require mobility aids and therefore no additional equipment is currently necessary to be provided. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34, 35 & 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. • Service users do not fully benefit from the training provided to care staff. • Service users do not benefit from staff recruitment practice. • Service users benefit from carers who are regularly supervised. • Service users do not fully benefit from the amount of staff assessed as adequate to meet their needs. EVIDENCE: The manager, Mrs Sookun, has recently completed the City and Guilds Registered Managers Award (RMA) and has several years experience as a manager of a care home. Five care staff are employed and occasional agency carers are used. Whilst at present none of the five employed carers have a NVQ qualification at level 2, two carers are working toward this award and a further two carers have nursing qualifications. One has attained an RMN (Registered Mental Nurse) and another RMN and RGN (Registered General Nurse), however the home The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 21 does not provide nursing care although at present this fact is not specified within the Statement of Purpose, as required by regulation. The Manager confirmed that 250 care hours are required to support the four current service users at the home. Mrs Sookun further confirmed that 250 care hours are being deployed on average, although the ratio of care staff to service users varies according to when service users are away from the home either at day services or visiting relatives etc. No additional hours are calculated in respect of carers undertaking additional non-care related tasks such as cooking, cleaning or laundry, although the care plan indicates that service users do undertake some cleaning and catering with support from carers. The manager will need to ensure that the proportion of non-care hours are added to the requirement to support service users personal care needs to ensure appropriate deployment. The Manager stated that she spends approximately 25 of her time as a carer with the remaining time managing the home. Three staff files were examined at random. The first indicated that recruitment practices were adequate with the exception of a gap in the employee’s previous employment. All other recruitment checks were satisfactory. The person was recruited in September 06 but has not been subject to an induction procedure following ‘Skills for Care’ guidelines. Two further staff files were checked and were noted not to have a current Criminal Record Bureau (CRB) check. The Manager stated that the two staff in question had been recruited via an agency from overseas. A Police check had been undertaken from the person’s country of origin by the agency, however, none had been undertaken in the UK. One of the two carers had no references. All other recruitment checks had been completed. Neither staff were following a ‘Skills for Care’ induction process. No evidence was available to indicate that staff have been given copies of the codes of practice set by the General Social Care Council GSCC. The manager has not yet undertaken an assessment for the staff team as a whole or an impact assessment to ascertain the experience and skills requirements of carers. Each staff member should have an individual training and development profile. This was not evident. A list of training that staff had undertaken was available. This indicated that some training had been provided, including the Learning Disability Award Framework LDAF, which is positive. The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 22 From the sample files seen, staff had received suitable and appropriate training although in the absence of an appropriate assessment of training needs, the suitability of this is difficult to appropriately assess. All staff require training associated with safeguarding adults. The manager had undertaken supervision in an appropriate manner and at suitable intervals The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 39 & 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. • • • Service users benefit from the home being managed by an experienced and qualified person. Service users do not yet benefit from the homes approach to quality assurance. Service users generally benefit from the homes environment being safe with the exception of one specific matter. EVIDENCE: The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 24 The Manager has several years experience of managing care homes and has recently qualified by achieving the Registered Managers Award, validated by City and Guilds. The quality assurance and monitoring system is developing in that questionnaires have been sent to all stakeholders and been returned. The manager has yet to analyse the data and to formulate the results to drive forward improvement plans. This was fully discussed with the Manager. This is a matter that has been outstanding for some considerable time and as such the outcome standard is considered poor. CSCI had sent out questionnaires via the service to relatives and healthcare professionals. Of those returned, all were supportive of the home. A health and safety matter was raised with the manager, in that an electric power socket located within the dining room was noted to have a 20mm hole to the side of the box. This presents as a hazard since it would be possible to place a finger or other debris in the hole where live terminals are located. The manager was advised to address this matter as an urgent priority. Other health and safety checks were reviewed. Portable electrical appliance check and fire system check was carried out by contractors in October 2006. The last fire drill was recorded to have taken place on 25th June 2006. Contractors undertook a gas safety check and emergency lighting check during November 2006. The Lodge - Dovercourt DS0000017969.V317438.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 Adults 18-65 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 1 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 3 3 X 2 X X 1 X The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 26 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 YA1 Timescale for action 4,5 & 6 The Registered Person must 09/01/07 ensure that the Statement of Purpose and Service User Guide meets with regulatory requirements and reviewed. 13(6). The Registered Person must 09/01/07 ensure that the hope operates an adequate approach to safeguarding adults, including the training of staff. 13(4)(a)(c). The Registered Person must 19/12/06 12(4)(a). ensure that the environment is free from hazards to the safety and welfare of service users and ensures adequate privacy. 13(4)(a)(c). The Registered Person must 19/12/06 maintain bathrooms in a manner that preserves privacy and dignity of service users. 19(1)(a)(b). The Registered Person must 09/01/07 19(4)(b)(i). ensure that recruitment 19(5)(b). practices are in accordance with regulatory requirements. 18(1)(a). The registered manager must 09/01/07 18(1)(c)(i) ensure that staff training and development programme meets sector scales council workforce training targets and ensures staff fulfil the aims of the home to meet the changing needs of DS0000017969.V317438.R01.S.doc Version 5.2 Page 27 Regulation Requirement 2 YA23 3 YA24 4 YA27 5 YA34 6. YA35 YA32 The Lodge - Dovercourt 7. YA39 24(1-5) 8 YA42 13(4)(a to c) the service users as advised. This would include national vocational qualification training for staff and appropriate induction. This is a repeat requrement since 2002. The registered person must put 09/01/07 in place a quality assurance system based on seeking the views of service users and other stakeholders in the home. This standard was not assessed at this visit and is therefore carried forward to the next inspection. This is a repeat requirement. The Registered Person must 19/12/06 ensure that adequate checks are made to the premises to ensure that all spaces are fit to be used by service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Lodge - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 - Dovercourt DS0000017969.V317438.R01.S.doc Version 5.2 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!