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Inspection on 18/06/08 for The Old Lodge Nursing Home

Also see our care home review for The Old Lodge Nursing Home for more information

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Good service.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The information about the home has been updated so people are more able to make an informed choice about whether they want to use the services of the home. New forms have been devised to ensure people receive a more thorough assessment before moving into the home, to reduce the risk of placement breakdown. The recording of care has improved so staff are more aware of peoples` needs. People have more to do in the day and more activities are offered. An activity coordinator had been employed and the recording of social care needs had improved, so social care was more person-centred. Since the last Inspection, among other items, new washing machine had been purchased. Staff confirmed that both washing machines were suitable for the laundering of soiled items. Staff are better trained to do their jobs and so people received care from a more skilled workforce.

What the care home could do better:

Staff need to record whether one or two tablets have been given each time when administering variable dose medication, so there is an accurate record of the medications people are receiving. There were still some gaps in the recruitment of staff, which means that people are not fully protected against potentially unsuitable workers. The induction, supervision and initial training that staff received also needed to be improved so that people were not exposed to poor care due to inexperienced and unsupervised workers. The ongoing management of health and safety within the home needs to be improved to ensure that day to day hazards arising are quickly identified and eliminated, so as to reduce the risk of accident to people living in the home.

CARE HOMES FOR OLDER PEOPLE Old Lodge, The Nursing Home Sandypits Lane Etwall Derby Derbyshire DE65 6JA Lead Inspector Helen Macukiewicz Unannounced Inspection 18th June 2008 09:00 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 Old Lodge, The Nursing Home DS0000002135.V366480.R02.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. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Lodge, The Nursing Home Address Sandypits Lane Etwall Derby Derbyshire DE65 6JA 01283 734612 01283 733067 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) Folcarn Limited Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (5) of places Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 40 Places for OP 5 Places for younger PD aged 50 years and over included in the total above 11th February 2008 Date of last inspection Brief Description of the Service: The Old Lodge is a detached house, which has been adapted and extended to provide nursing care for up to 40 people, aged 65 years and over. However, up to 5 of the bedrooms can accommodate disabled people, aged 50 years and over. The Home is situated in a rural position, approximately a mile from Etwall village centre. The village has several local shops and is on a bus route for Derby. The Old Lodge has 32 single and four double bedrooms across two floors. 10 of the bedrooms have en-suite facilities. Access to the first floor is by stairs or by a passenger lift. The Home has 2 lounges, a conservatory and dining room. The Home also has a well laid out garden. The range of weekly fees was between £550.00 and £650.00 per week. Extras to pay include private chiropody, dentist and optician. The Inspection reports are made available in the Managers’ office. The Manager provided this information during the Inspection. You can obtain further copies of the latest Inspection report by visiting www.csci.org Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This Inspection was unannounced and lasted 7.5 hours during one day. No pre-inspection questionnaires were received from people living in the home before this visit. Questionnaires were left at the home for people to complete afterwards. The Manager had completed a self-assessment of the home when we asked for it, and information from this was used to assess the outcomes of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service, their relatives and visiting professionals took place. Time was spent in discussion with the Manager and staff. Five peoples care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. What the service does well: What has improved since the last inspection? Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 6 The information about the home has been updated so people are more able to make an informed choice about whether they want to use the services of the home. New forms have been devised to ensure people receive a more thorough assessment before moving into the home, to reduce the risk of placement breakdown. The recording of care has improved so staff are more aware of peoples’ needs. People have more to do in the day and more activities are offered. An activity coordinator had been employed and the recording of social care needs had improved, so social care was more person-centred. Since the last Inspection, among other items, new washing machine had been purchased. Staff confirmed that both washing machines were suitable for the laundering of soiled items. Staff are better trained to do their jobs and so people received care from a more skilled workforce. 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. Old Lodge, The Nursing Home DS0000002135.V366480.R02.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 Old Lodge, The Nursing Home DS0000002135.V366480.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation and procedures ensure that people are admitted appropriately to the home and have the information they need to make an informed choice about moving there. EVIDENCE: The information about the home contained within the Statement of Purpose and Service Users Guides had been updated to reflect the current services offered by the home, including range of fees and extras. A copy was seen in the foyer and in each bedroom visited. People living in the home told us they had seen these documents and knew where they were kept. People told us they were satisfied with their admission to the home. One person told us ‘it’s one of the nicest places I’ve been to’. In response to the last Inspection requirements, the provider had stated that ‘pre-admission Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 9 documents of patients needs has been formulated and is being utilised’. Completed new pre-admission assessment forms were seen in care files and were able to support that people were admitted appropriately to the home. The new forms had been updated very recently to include identification of any cultural needs. Files also contained copies of Social Services and healthcare assessments and transfer information. Old Lodge, The Nursing Home DS0000002135.V366480.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the care they need and this is provided in a way that upholds their dignity. EVIDENCE: All care files contained an assessment of need and care plan. In response to the last Inspection requirements, the provider had stated that ‘all care plans have now been re-written’. It was clear that the manager and staff had invested a lot of time and effort into improving the recording of care needs. Care plans were relevant, detailed and reviewed and updated at regular intervals so that staff could easily see what care needs people had. New forms had been developed to show that people were involved in the planning of their care and that they were agreeing to care plans. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 11 Risk assessments in areas such as continence, falls, nutrition and skin care, among others were seen. These were detailed and had been updated and reviewed so people were not exposed to any unnecessary heath risks and staff could easily identify where people needed extra observation and support. People told us they could see the doctor at any time and had visits from the optician. They told us that staff cared for them well. Healthcare professionals were seen visiting people at the home such as occupational therapists. Care records also recorded visits from professionals and attendance at outpatients’ appointments. A visiting professional told us they had seen marked improvements in the nursing care provided by the home, and said that they also found care records to be well organised, which meant that information was easy to find. People told us that staff respected their privacy and upheld their dignity; relatives also confirmed this to be the case. Staff were observed knocking to request permission prior to entering peoples’ bedrooms. People living there also said this was routine practice. People who self-medicated had been provided with a place to store medications safely in their bedrooms. The recording of medicines given was good with the exception of 1 variable dose medication, where staff had not been recording whether one or two tablets had been given each time. There were no gaps in signing on the medication administration records which supported that people were getting the right medication at the right time. Storage of medicines was good. Old Lodge, The Nursing Home DS0000002135.V366480.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12-15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to lead a lifestyle of their choosing. EVIDENCE: There was evidence to support that there had been an effort to improve the social care that people received since the last Inspection. All care files that were seen had some form of assessment of social needs and likes/dislikes. A new form had been devised so that relatives could also record what people liked to do, and write a bit about the persons’ life and people who are important to them. One relative handed a completed sheet to the manager during the inspection and completed sheets were also seen in care files. One of the files contained a care plan for social needs based on their assessment. In the other two files, there were assessments but no care plans following on from this, which would help to ensure staff have a plan of social care to follow. In response to the last Inspection requirements, the provider had stated that questionnaires had been provided to residents and relatives to find out what Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 13 their social likes/dislikes were. Also that there were plans to employ an activities co-ordinator and that peoples’ preferences, including their preferred form of address was assessed by staff. This was all supported through the findings of this visit. People told us they had been on a trip to the garden centre in April, and that a trip to the zoo was being planned, at their request. People told us they would still like more to do during the day but did occupy themselves. One person told us there was a bingo session once a week, which they enjoyed. A relative also told us that Bingo was something people liked to take part in. A recent residents’ survey conducted by the manager had also highlighted that more activities were needed. An activities co-ordinator had been employed since the last Inspection, but was off long-term at the time of this visit. The manager said that an advert was in the paper to find a replacement. A record of all activities that people had participated in had been kept by the former activity co-ordinator and this supported that people were receiving more one to one support at that time. Talking newspapers/books were available for people, and one person was receiving Holy Communion. Relatives took another person out for the afternoon and others were receiving visitors at the home. People told us that their daily routine was flexible; they could choose what time they rose and went to bed. People who wanted to stay in their bedrooms were able to do so. Peoples’ preferred rising/retiring times were also stated in their care documentation, along with their preferred form of address, this helped to ensure care was more person-centred. People told us the food was ‘very good’. Staff assisted people to eat their meals in an unhurried manner and encouraged those with a poor appetite. There was a menu board in the dining area and staff were asking people what they would like to eat, from a choice of two main meal options. Alternatives were provided for those who wanted it. Although comments received during this visit were positive, a recent residents’ survey conducted by the manager identified that people wanted more choice within the menu. The manager said she was working with the cook to bring about the changes people had requested. This supported that people were able to make choices with regard to their daily life. Old Lodge, The Nursing Home DS0000002135.V366480.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are kept safe through effective complaints and safeguarding policy and procedures. EVIDENCE: There have been no complaints about the service raised with us since the last Inspection. No complaints had been received by the home either. The manager had developed some new forms to record any issues raised on. These were kept on a notice board in the main corridor so people could take one when they wanted. The complaint procedure was also on display in another part of the corridor. This needed updating and was not very accessible, being written in small type and displayed at a high level. It was suggested to the manager that the procedure and forms be displayed together, and that the procedure be amended so it was easier to read. Despite this, people told us they had no complaints and knew who to approach should they need to raise any issues. People told us they were confident the manager would sort any issues out. One relative told us they had ‘never had any complaints’. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 15 In response to the last Inspection requirements, the manager had stated that the complaints procedure had been included in the information about the home (service user guide). She also said that staff had attended safeguarding training in April. The updated service user guide was seen, and was available in peoples’ bedrooms. This included the relevant contact points for complaints to be raised outside the home. Staff told us that most had attended safeguarding training. Although not directly involved in peoples’ care, there were 5 ancillary staff who still needed safeguarding training. The manager was waiting for two new members of staff to commence employment then said she would be sending all remaining staff on the next available safeguarding course. Certificates were available to support the training received by the rest of the staff. There had been 1 safeguarding issue ongoing at the time of the last Inspection. However, this had been concluded. The owner and manager had co-operated fully with Social Services and us in resolving the issues. Safeguarding procedures had been acquired since the last Inspection and were on display in the managers’ office. Some people required bed rails on their beds to keep them safe. In all but one file consent had been obtained for their use. The manager confirmed she was waiting for a relative to visit so that consent for the remaining person could be gained. The manager had received information about the Mental Capacity Act and had requested some forms to be sent to the home so staff could record decisions people made, more in line with the requirements of the Mental Capacity Act. The manager had also obtained a form to enable staff to fully assess the safety of bed rails, and to improve the information provided before asking for consent. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The environment of the home is well maintained and is suited to the needs of the people who live there. EVIDENCE: Most areas of the home were clean, tidy and in a good state of repair. In the managers’ pre-inspection quality assurance document she recorded that ‘new carpets have been provided in a number of bedrooms, new furniture in bedrooms and new display boards’. She also recorded that the dining room was planned for redecoration and new furniture. One bedroom contained a strong urine odour; the carpet and a chair needed replacing/thorough cleaning. The manager and provider confirmed that the ensuite carpet had already been replaced in that room and that a new carpet Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 17 shampooer had been purchased. They were considering purchasing an alternative chair/floor covering and could demonstrate that they were actively trying to address this area of need. Since the last Inspection, a new washing machine had been purchased. Staff confirmed that both washing machines were suitable for the laundering of soiled items. One person told us ‘the laundry is very good- excellent’. A relative said the laundry service was ‘very good’. There was equipment available for the cleaning of the home and maintenance of infection control. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 18 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): Standards 27-30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are cared for by sufficient numbers of well-trained staff. However, gaps in recruitment means their wellbeing is not fully safeguarded. EVIDENCE: Staffing rotas showed there were 2 nurses and 5 care staff during the morning, 1 nurse and 5 care staff during the evening and 1 nurse and 2 care staff at night. The manager worked 5 days/week in addition to these staffing numbers. Existing staff covered gaps due to training/sickness so people were receiving care from people they knew. People told us they were happy with the care staff provided. Comments included ‘they check on you at night’, ‘staff are very good – very helpful’ and ‘staff try their very best’. More than half of the total number of staff had National Vocation Qualifications in care subjects at level 2 or above. The manager said she aimed to get all staff trained. In response to the last Inspection requirements, the manager had stated that ‘systems in place for references and checks before commencement of any employment. Induction programmes given to every new member of staff’. However, a check of recruitment procedures showed that there were still some Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 19 gaps in procedure. All staff files seen supported they had CRB and POVA first checks before commencing employment. However, the following information was missing from the files:• • • • One had no written verification of the reason why they had ceased working with vulnerable adults. Two had no full employment history prior to entering the UK. Two had no statement as to their mental/physical health. One had no record of qualifications. The need to ensure proper checks on staff, and ensure that people are not exposed to unsuitable workers was a requirement of the last Inspection that has not been met. There had been clear investment in staff training since the last Inspection. Therefore people were receiving care from staff who were better qualified to meet their needs. Staff told us they had been on courses in subjects such as venepuncture, palliative care, infection control, as well as attending mandatory training in subjects such as health and safety and fire safety. Some dementia training was taking place on the week of the inspection. There were certificates to support the training received in a file. The manager said she wanted to put all certificates in individual staff files, and was going to devise a training matrix so she identify any gaps in training at a glance. At the time of this visit there was a basic induction checklist in use and no foundation training programme apart from National Vocational Qualifications, which not all staff had achieved. The manager had obtained both a comprehensive induction and foundation training pack from skills for care and intended to start using these for all staff, including those already employed. This would ensure better safeguards for people against staff who were inexperienced. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the people who live there but gaps in the management of health and safety has the potential to put people at risk. EVIDENCE: The manager had been in post since January 2008. She is a qualified nurse with management experience in a clinical setting. She had yet to apply to be registered with us. She said she intended to commence her Registered Managers Award in September 2008. She had made links with nurses and managers in other care homes to further her knowledge of the care setting and to gain some clinical support. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 21 Since the last Inspection the manager had given out questionnaires to people living in the home and their relatives to establish their satisfaction with the service. Completed surveys had been returned. The manager and provider had also completed a self-assessment for us, which enabled them both to review the service and identify where improvements were needed. In this document the manager had recorded that ‘I am in the process of forming a relatives forum to ensure satisfaction and effective communication’. Systems for the handling of peoples’ personal allowances had improved and money was being kept individually so people were better protected. The manager had provided some direct supervision of staff, through observations of their practice. There was a notice in the office to inform staff that appraisal and supervisions would be commencing shortly. The manager confirmed that she would start with qualified staff, who would then in turn supervise care staff. The manager said that delays in starting appraisals had been due to the fact that there was no deputy manager, but this post was being advertised. The need to ensure staff were appropriately supervised so poor practice is quickly dealt with and training needs identified, was a requirement of the last Inspection that has not been fully met. Up to date risk assessments were contained within a file in the office. Hazards identified during the last Inspection had been risk-assessed and new signage was on display. During the Inspection it was noted that for the third consecutive Inspection a first floor window restrictor was not in place, despite one being provided at the time of the last 2 Inspections. This created a potential risk to people moving around in that area. The provider said this had occurred due to very recent maintenance outside the window. Again, a restrictor was provided at the time of this Inspection. The manager and provider said they would look at ways to ensure better ongoing management of health and safety within the home. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 23 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 OP29 Regulation 19 and schedule 2 Requirement Staff must not be employed by the home until all recruitment checks required by regulation 19 and schedule 2 have been acquired. To ensure people are not exposed to potentially unsuitable workers. Previous timescale of 29/02/08 not met. 2. OP36 18(2) All staff working in the home must be appropriately supervised so poor practice is quickly dealt with and training needs identified. Previous timescale of 30/04/08 not met. 3. OP38 13 (4)(c) There must be systems in place to ensure ongoing health and safety management within the environment so that people are kept safe and free from unnecessary hazards to their health. 31/08/08 31/08/08 Timescale for action 31/08/08 Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 24 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. 2. 3. 4. 5. 6. 7. 13. Refer to Standard OP9 OP12 OP16 OP18 OP19 OP30 OP31 OP38 Good Practice Recommendations Staff should record whether one or two tablets are given each time, for variable dose medications to ensure there is an accurate record of medications given. Care plans should follow on from social assessments, which would help to ensure staff have a plan of social care to follow. The complaint procedure and forms should be displayed together, and the procedure should be amended so it is easier to read. All staff, including ancillary, should attend safeguarding training to ensure better protection of people living in the home. Further action should be taken to reduce unpleasant odour in the bedroom identified during the inspection, to ensure the dignity of the occupant. Staff should receive comprehensive induction and training to ensure better safeguards for people against staff who were inexperienced. The Manager should register with the Commission for Social Care Inspection. There should be a system in place for regularly checking window restrictors. Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Old Lodge, The Nursing Home DS0000002135.V366480.R02.S.doc Version 5.2 Page 26 - 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. 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