Inspection on 21/08/06 for Thetford Lodge

This inspection was carried out on 21st August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thetford Lodge 19/07/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Thetford Lodge 16 Thetford Road New Malden Surrey KT3 5DT Lead Inspector Diane Thackrah Key Unannounced Inspection 21st August 2006 10:45a 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 Thetford Lodge DS0000065234.V307706.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. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thetford Lodge Address 16 Thetford Road New Malden Surrey KT3 5DT 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) 020 8942 6049 020 8942 6049 CHD (Care Homes) Ltd Mrs Sue Martin Care Home 17 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (13) of places Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: Thetford Lodge is situated in a residential street in New Malden, a short walk from the high street. The home is a converted house with fifteen single, and one double, bedrooms. Accommodation is provided on the ground and first floor. The first floor is accessible by stairs and a chair lift. There is a modest garden to the side of the home and parking is available. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Manager. Fees for the home at the time of writing are between £400.00 - £500.00 per week and there are no additional charges. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 21st August 2006 between 10.45 and 15.35. A partial tour of the premises took place and care records were examined. Observations of care practices also occurred. The Registered Manager and three staff members were spoken with, as were seven service users and one visitor. The views of two relatives and three general practitioners have been received via comment cards. The views of these people will be reflected in this report. What the service does well: This is, in general, a well run home were service users have their needs well met. The majority of feedback received about the home was positive. One professional said that they had noticed recent improvements in the home. Two visitors said that there were always sufficient staff members on duty, and one said that that their relative received “good care” One service user spoken with said “I like it here, we’re well looked after” Another service user said “they keep my bedroom tidy and mostly knock before entering” There are good arrangements for ensuring that service user’s needs are assessed prior to them moving into the home and service users and their representatives are consulted with about the care to be provided on an ongoing basis. Service users, in general, have their health needs met well and are protected by good practice in handling medication. There are good arrangements for handling complaints and allegations of abuse. There are also good arrangements for ensuring that service users live a fulfilling lifestyle, in accordance with their wishes. Structured activities are provided daily and there are opportunities for service users to relax and spend time with their family members and friends. The home is comfortable, clean and generally well maintained and there the grounds of the home offer a pleasant space to relax. Staff members are supplied in sufficient numbers and there is staff training in safe working practices. All staff members are thoroughly vetted, offering a good level of protection to service users. There is a quality assurance system that takes into account the views of those using the service. Health and safety is, in general, taken seriously. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Six Requirements have been made following this inspection. Whilst it is recognised that, in general, care planning in the home is good, there is a need to ensure that care plans provide further detail about service user’s needs in relation to moving and handling. Also, there is a need to ensure that care plans are signed by service users or their representatives in order to indicate their involvement in the care planning process. Concerns have been raised about the poor arrangements for fire safety in the home. Two fire doors were obstructed at the time of this inspection and there has been a recent failure to ensure that the fire alarm is safety tested on a regular basis, and that fire drills occur. There is currently no business and development plan for the home and there is a need to ensure that at least 50 of the current care staff team are qualified at NVQ Level 2 in Care. A recommendation has been made regarding the need to implement a good practice recommendation made by the Primary Care Trust Pharmacist inspector. A second recommendation has been made regarding the need to remove an inappropriately placed sign in the home. Please contact the provider for advice of actions taken in response to this Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thetford Lodge DS0000065234.V307706.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 Thetford Lodge DS0000065234.V307706.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. There remain appropriate arrangements for obtaining information about the needs of service users before they move into the home, which allow these needs to be met. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Assessment information was examined for the two most recent admissions. Assessments included a social history, risk assessments and details about the service user’s personal and health care needs. Needs Assessments have been obtained through Care Management arrangements. There were also medical reports that had been obtained from the service user’s General Practitioner. There was documentation detailing that service users and some family members are fully involved in this process. The Registered Manager said that Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 10 she had visited each of these service users in their own homes prior to them moving into the home and carried out an assessment of need. Thetford Lodge DS0000065234.V307706.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. There are, in general, good arrangements for ensuring that service users have their health, social and personal care needs well met, however, improvements must be made to the risk assessment process in order to ensure that all staff members are clear about how they should address service user’s needs. There are good arrangements for ensuring that medication is handled safely and an emphasis is placed on protecting the dignity, and respecting the privacy of service users. This ensures that the well being of service users is protected. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans for the two most recent admissions were examined. Both care plans contained information about the service user’s personal, health and social care needs and how staff members should address these needs. It was positive to note that care plans detailed how staff members should support service users to retain a degree of independence. However, risk assessments in relation to moving and handling were not present in either of the files Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 12 examined. The Registered Manager said that these were complied within the first three months of a service users living in the home. Risk assessments is relation to moving and handling must be obtained prior to a service user moving into the home, and form part of the care plan. The Registered Manager stressed that she had consulted with each service user and their family member regarding the plan of care, and there where records to back this up. However, the service users, or their representative had signed neither of the care plans seen. Requirements are made regarding these issues. Care records seen detailed that service users have access to a range of health care professionals and that the home is proactive in arranging health care appointments. Two social care professionals were visiting service users in the home at the time of this inspection. There were records detailing that service users are registered with a general practitioner, have their weight monitored regularly and see opticians and dentists as necessary. One service user spoken with said that they received good support from the staff members with their health needs, and felt confident that health appointments would be arranged for them as necessary. The Registered Manager said that there is no one in the home who has a pressure sore. There was positive feedback about the home from three visiting general practitioners. One General Practitioner commented that they had noted “enormous improvements” in the home recently. There are policies and procedures in place for ensuring that medication is handled safely. These have been reviewed since the last inspection of the home and are now more ‘user friendly’ Medication Administration Records examined for the two most recent admissions were accurate and up to date and corresponded with medication available. Requirements made about poor handling of medication at the last inspection of the home have been met. One senior staff member confirmed that they had received training in the safe handling of medication. This staff member demonstrated a good awareness of their responsibilities for handling medication safely. All medication was noted to be stored securely at the time of this inspection. Facilities are available for handling controlled medication. Some service users maintain responsibility for their own medication. There was documentation detailing that the local Primary Health Care pharmacist carried out an inspection of medication in the home in February 2006. Medication, in general was found to be in good order. Three recommendations were made as a result of the inspection. The Registered Manager has addressed two of these recommendations. It is strongly recommended that the remaining recommendation be addressed. There were records detailing that the Registered Manager carries out weekly audits of the medication systems in the home. Staff members were observed to treat service users with respect and to uphold their dignity during this inspection. Staff members knocked, and waited for a response before entering service user’s bedrooms. One service user said that this was usual. Staff members were noted to consult with service users Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 13 appropriately and all service users spoken with said that they were happy with the care that they received from staff members. One service user said, “I can not thank the staff members enough for what they do for me” Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. There continues to be a varied activities programme and wholesome and enjoyable meals are provided; therefore differing expectations and lifestyles are well catered for. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users continue to have good opportunities for social and recreational activities. There was a hairdresser in the home at the time of this inspection. Some service users had a newspaper or book and a number were listening to music in the main lounge. The Registered Manager said that there have been a number of outings during the summer months including trips to Worthing, Farnham and Little Hampton. One service user said that there had recently been a BBQ held at the home, which they had enjoyed. Another service user said that they had enjoyed a cream tea in the home’s garden. Care notes examined for two service users detailed that they had been involved in a variety of structured activities in the home including light exercise and board games. There were records detailing that service users had been consulted with about their social interests. Records also detailed that service users are Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 15 able to see visitors in the home, and are supported by staff members to remain in contact with their family members by telephone. There was a weekly menu available that detailed that meals provided are varied, and that a choice is always available. Fresh, wholesome and nutritious food was available in the kitchen. The kitchen was clean and well organised and the new cook said that she had undertaken training in food hygiene. There have been improvements in the kitchen since the last inspection of the home. A kitchen worktop has been replaced and there is new flooring. A Requirement made regarding these issues is now deemed met. All service users spoken with said that meals in the home are enjoyable and of good quality. One service user said, “The food is very good” Another service user said, “The new cook came around and asked us all what we like and don’t like to eat” The cook said that specialist diets can be catered and that this would be discussed during the admissions process. There is a pleasant and homely dining room in the home. Service users may eat in their room if they choose. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. Arrangements are in place for handling allegations and instances of abuse. This ensures that service users will be protected from harm. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a concern may be raised with the Commission for Social Care Inspection. Feedback from four relatives indicated that they had been made aware of the home’s complaints policies and procedures. The Registered Manager said that no complaints have been made about the home since the last inspection The home has a copy of the Royal Borough of Kingston Council’s vulnerable adult protection procedures. Records were available detailing that some staff members have undergone training in the Protection of vulnerable adults since the last inspection of the home. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 17 Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26. There have been improvements to the environment and the home is maintained, decorated and furnished to a good standard. Facilities are clean and, in general, safe. This ensures that service users generally live in a pleasant and comfortable environment. However, the arrangements for fire safety do not fully protect the well being of service users. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is well maintained and provides a pleasant and homely environment to those who live there. There is a small, well maintained garden to the side of the property which contains seating areas. There has been an ongoing programme of redecoration since the last inspection of the home. Most of the bedrooms and the main lounge have been redecorated, re-carpeted and provided with new, good quality furniture. There have been improvements to the exterior of the building. The Registered Manager said that further environmental improvements are planned. The area towards the back of the Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 19 home was untidy in appearance, with a number of items of old furniture. This did not provide a pleasant view for service users in ground floor bedroom. The Registered Manager said that this area was in the process of being tidies. This will be examined at the next inspection of the home. The Registered Manager said that the London Fire and Emergency Planning authority have not visited the home recently. There is an environmental risk assessment in place in relation to fire and there is fire-fighting equipment throughout the home. Fire escapes were free from obstructions. It was concerning to note that there were two fire doors that were propped open at the time of this inspection. One of these doors had a broken door guard. The props were removed during the inspection and the Registered Manager was able to demonstrate that arrangements had been made for the door guard to be repaired. Doors in the home must not be propped open with anything other than a functioning, London Fire and Emergency Planning Authority approved, automatic closing devise. A Requirement is made regarding these issues. Further concerns about poor fire safety arrangements were noted during this inspection. These are discussed in more detail under Standard 38 of this report. The Environmental Health Officer visited the home in January 2006. Recommendations made are currently being implemented. Lavatories and washing facilities seen were, in general, appropriate and accessible to service users. However, there is a sign that says “Staff Only” on the shower room on the first floor. The Registered Manager said that this is because service users are not permitted to use the toilet in this room. It is inappropriate, and not conducive to a homely environment to place a “Staff Only” sign on a communal shower room. It is strongly recommended that this sign be removed. A number of service user’s bedrooms were viewed. The majority of these were well furnished and decorated and homely in appearance. Service users had personalised their rooms and some had items of their own furniture. Three service users spoken with said that they were very happy with their bedroom. One service user said that they had a key to their room and a lockable cupboard in the room. One service user said that they would like a towel rail in their bedroom and the Registered Manager agreed that this would be arranged. One room was viewed that had very few personal possessions. The Registered Manager said that this was the way the service user liked the room. All areas of the home viewed were noted to be clean and free from offensive odours. There was a cleaner on duty at the time of this inspection. Most service users spoken with said that they were happy with the home’s laundry service. One service user said that an item of their clothing had recently gone missing in the laundry. The Registered Manager said that this item had been replaced. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staff members are provided in sufficient numbers and the procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. There is a staff training and development programme that provides staff members with skills necessary for meeting the needs of service users. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staffing levels appeared to be appropriate, and in line with the needs of current service users at the time of this inspection. As well as three care staff, there was the Registered Manager, a cook and a cleaner on shift. There was feedback from service users, and visitors that staffing levels are sufficient. There is currently a vacancy for one full time staff member. An agency worker covers shifts in the home one day per week. The Registered Manager said that no new staff members have been employed to work in the home since the last inspection. Pre-recruitment checks have therefore not been examined during this inspection. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 21 Records were available detailing that there has been refresher training for some staff members in Infection Control, Abuse in Care Homes and Dementia Awareness. There is an immediate need to ensure that at least 50 of the care staff team have a qualification at NVQ Level 2 in Care. At the last three inspections of the home, the Registered Manager has stated that NVQ training has been scheduled. However, this has not occurred. The Registered Manager said that this was due to problems with the training providers. Standard 28 will not be deemed met until at least 50 of the care staff team have a qualification at NVQ Level 2 in Care. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. There continues to be good management and, in general, a good quality assurance system, however, some improvements must be made in order to ensure that the home is run in the best interests of service users. Health and safety is, in general, taken seriously. However, improvements must be made in order to ensure that the well being of service users is fully promoted and protected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are no changes in relation to management in the home. The Registered Manager has been in post for four years. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 23 Service users and their family members are surveyed on a regular basis about their views on the home and the results of a recent survey were available for inspection. The Registered Manager said that she is currently in the process of reviewing the results and has plans to publish them. Published results will be examined at the next inspection of the home. All policies and procedures in the home have been reviewed and updated. There was no annual development plan for the home. This must be developed and made available for inspection. Family members, in general, retain control over service user’s finances. Small amounts of money are kept in the homes safe for some service users for purchases such as toiletries and hairdressing. There were records detailing the money held by the home on behalf of service users. Receipts were in place for all transactions. There were records detailing that staff members are trained in safe working practices such as moving and handling, food hygiene, infection control and first aid. Records also indicated that there are regular safety checks on water temperatures, fridge and freezer temperatures, emergency lighting, fire fighting equipment, and door guards. There were records detailing that all portable electrical appliances in the home have been safety checked since the last inspection. The Registered Manager said that testing for legionella has occurred recently, but results had not yet been received by the home. There were records detailing that the home’s hoist and chair lift have recently been serviced. There are risk assessments in place for chemicals and all accidents and incidents are recorded. There were records detailing that the fire alarm has been tested on a regular basis throughout this year, however, it is of concern that these records indicated that no tests have occurred within the last month. It is also of concern that there was no record detailing that fire drills have occurred in the home. Requirements are made regarding these issues. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13 (4)(c) 15 (1) Requirement The Registered Provider must ensure that a written risk assessment in relation to moving and handling is in place for each service user at the point of moving into the home. The Registered Provider must ensure that service users and/or their representatives are given an opportunity to agree and sign the care plan. Should the service user and/or their representative decline this offer, there must be a written record reflecting this. The Registered Provider must ensure that doors in the home are not propped open with anything other than a functioning, London Fire and Emergency Planning Authority approved, automatic closing devise. The Registered Provider must ensure that at last 50 of the care staff team have, or have enrolled to undertake, a qualification at NVQ Level 2 in Care. DS0000065234.V307706.R01.S.doc Timescale for action 01/10/06 2 OP7 15 (1) 01/10/06 3 OP19 12 (1)(a) 23 (4)(a) 21/08/06 4 OP28 18 (1)(c) (i)(ii) 01/10/06 Thetford Lodge Version 5.2 Page 26 5 OP33 24 (1)(a)(b) 12 (1)(a) 23 (4)(a) 6 OP38 The Registered Provider must produce an annual development plan and make this available for inspection The Registered Provider must ensure that records are available detailing that there has been a weekly safety check of the home’s fire alarm and regular fire drills. 01/11/06 01/10/06 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 Refer to Standard OP9 OP21 Good Practice Recommendations The Registered Provider should ensure that all recommendations, made during the recent pharmacy inspection of the home, are addressed. It is strongly recommended that the Registered Provider remove the “Staff Only” sign from the communal shower room on the first floor of the home. Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thetford Lodge DS0000065234.V307706.R01.S.doc Version 5.2 Page 28 - 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!