Inspection on 23/11/05 for Vale Lodge Residential Home

This inspection was carried out on 23rd November 2005.

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

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

Other inspections for this house

Vale Lodge Residential Home 22/05/06

Vale Lodge Residential Home 04/05/05

Vale Lodge Residential Home 06/12/04

Vale Lodge Residential Home 27/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Vale Lodge Residential Home 38/40 Sutherland Road Mutley Plymouth Devon PL4 6BN Lead Inspector Megan Walker Unannounced Inspection 23rd November 2005 10h30a 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 Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 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. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vale Lodge Residential Home Address 38/40 Sutherland Road Mutley Plymouth Devon PL4 6BN 01752 220456 01752 220456 valelodgepl4btopenworld.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) Miss Sheree Anne Haswell Mr Martin Frederick Atwill Miss Sheree Anne Haswell Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named Sevice User 60 years of age No more than 4 residents in cateory DE(E) may be accommodated at any one time 4th May 2005 Date of last inspection Brief Description of the Service: Vale Lodge is located within walking distance of the Mutley Plain shopping centre in Plymouth. The facilities of the home are spread over two floors with one large lounge and a dining room on the ground floor. The home has 17 single rooms, 11 of which have en suite facilities and 1 en suite double room. A stair lift enables access to the upper floor. There is an enclosed walled garden at the rear. The home has a smoking policy that allows service users to smoke in the dining room when it is not in use for serving food. Staff smoke outside the back door. The home is registered to provide care and accommodation for older people, four of whom may have dementia in old age i.e. over 65yrs. In addition to the designated categories the service describes its aim as the provision of low to medium dependency care for older people. The home does not provide intermediate care and it is not registered to provide nursing care. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Wednesday 23rd November 2005 between 10h30 and 16h45. The inspector toured the premises. All the service users at home were introduced to the inspector and seven offered comments and views about living at Vale Lodge and the care services they receive. Time was spent talking with the Registered Providers Ms Sheree Haswell and Mr Martin Atwill, and Mrs Deborah McClellan whom they have employed as an administrator at the home. Care records, staff files, and other records and documents were inspected. There were nine requirements and one “Good Practice” recommendation from the previous inspection. Three of these have been partially met, and five are still outstanding. One of the outstanding requirements had not been met by the inspection on 6th December 2004. From this inspection there were 13 requirements and 2 “Good practice” recommendations. An Immediate Requirement that adequate heating should be provided in Room 4 was issued following the inspection. The Registered Providers were informed at the time of this inspection that due to the non-compliance with requirements from previous inspections, there would be at least one more inspection within the next 4 months. This is necessary to ensure that all outstanding requirements and any new requirements have been met within the agreed timescales. What the service does well: The service users living at Vale Lodge receive a good standard of care and are encouraged to be as independent and active as possible. Ms. Sheree Haswell manages the home competently and has a good understanding of the individual needs of each service user. The comments and observation of service users showed that they are delighted with the impromptu visits of Ms Haswell’s baby son, and that such visits enhance the homely atmosphere Ms Haswell and Mr Atwill strive to maintain for the service users. One service user has chosen to keep a rabbit and a guinea pig and is actively encouraged with this by the Registered Providers. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 6 All the bedrooms were comfortable and reflected individual service users’ choice and style. Service users can choose to have breakfast in their bedrooms although midday and evening meals are served in the dining room unless someone is poorly. This is to enable service users to socialise with one another. As well as outings either locally to Mutley Plain or further a field in the minibus, the Registered Providers support service users to join local clubs, such as the Mutley Bridge Club, and to participate in other intellectually stimulating games such as ‘Scrabble’. The Registered Providers have a good working relationship with the local Social Services and Community Mental Health Teams. What has improved since the last inspection? What they could do better: The Registered Providers had bought fifteen radiator covers prior to the last inspection in May 2005. These still have not been fitted. This is putting service users, staff and visitors to the home at risk of scalding or burning themselves. Mr Atwill has bought a PAT Tester but still the portable electrical appliances in the home have not been tested. This is putting service users, staff and Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 7 visitors to the home at risk of an electrical fault that could be life threatening or fatal. Bedroom 4 was redecorated during the summer months. The radiator in this room has not been reinstalled so the bedroom is cold. No provisional arrangements have been made to ensure the warmth and comfort of the service user. This is putting the health of the service user in this room at risk. A system to provide staff with one to one supervision has yet to be implemented. Both baths in the communal bathrooms need to be replaced. The ground floor bathroom needs to be refurbished and redecorated to make its use more congenial for service users. The Registered Providers should consider contracting independent suppliers and services to ensure the outstanding requirements are met by the agreed dates. 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. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 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 Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 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): 0 None of the above standards were inspected on this occasion as they were all assessed as met in the report of the inspection done on 4th May 2005. EVIDENCE: Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 The residents can feel sure that their health, personal and social care needs will be met. EVIDENCE: All the individual service users’ files have been put into a computer record as well as a paper record. Inspection of this system showed that each service user file has an Incident/Accident Log, a Building Risk Assessment, a Health Care Record, a Medication Record, a Moving and Handling Risk Assessment, a Personal Risk Assessment, a Pre-Admission Assessment, and a Post-Admission Assessment completed with the individual service user approximately four weeks after they have moved into Vale Lodge. There was no system of regular reviews for the care plans however whenever anything changes or there is an incident or accident then that individual’s care plan is reviewed and amended accordingly. New risk assessments are completed and added to the file if necessary. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 11 Mrs McClellan signs the Accident Book each time she removes the pages to update the individual Incident/Accident Logs and before filing those pages. This is to ensure that no pages go missing. The Registered Manager is able to use the individual Incident/Accident logs to inform the care plan reviews because the computer record shows immediately the number of accidents or incidents of each individual service user. This system also works as a back up for the Accident Book and gives an “at a glance” overview of an individual’s potentially changing needs. On the day of the inspection a service user was seen leaving for a hospital appointment accompanied by two members of staff. Prior to going, staff were observed giving the service user lots of encouragement and reassurance about keeping this appointment. One care plan inspected showed details of involvement by the Community Mental Health Team and subsequent information provided by the Registered Providers for staff to care for this service user and meet her needs. Observation showed that the Registered Providers and staff respect the wishes of service users, however, during a tour of the premises with Mr Atwill, he rarely knocked on bedroom doors before entering the room. On at least two occasions the service user was in the room. The front ground floor bedrooms are visible from the street so service users are obliged to pull their curtains to ensure privacy from passers-by. During the tour of the home, it was observed that most of the bedrooms without en-suite toilet facilities had commodes in them. Discussion with Mr. Atwill showed that there was no reason for these commodes in the majority of cases. It was agreed with Mr. Atwill that commodes would either be removed from bedrooms or if individual service users preferred to keep it in their room, then this would be recorded in the individual’s care plan. It was recommended that any commodes in bedrooms should be placed more discreetly to ensure the dignity of the individual. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 All the service users are able to make informed choices about their lifestyles within the home. Service users maintain contact with their family/friends/representatives and the local community. A staple diet is available to all service users. EVIDENCE: Observation of service users during the inspection confirmed that service users are able to choose their daily routines in the morning, that is, getting up and breakfast in their rooms if they prefer. Midday and evening meals, however, the Registered Providers stated that they prefer service users to eat together in the dining room to encourage social interaction. On the day of the inspection the midday meal was served at about 12h00, and service users were seen almost finished eating their evening meal at 16h45. There are currently no records of actual meals eaten, that is, if someone does not wish to eat the meal on the menu or if the meal is changed for any reason. There is no choice about meals although service users spoken to stated that they could ask for something else and an alternative would be offered. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 13 Service users are encouraged to go out and to participate in the local community. The staff are aware of individual interests and ensure that service users have opportunities for stimulation through various activities inside and outside the home. One Service user spoken to stated that there is a group who enjoy playing “Scrabble” in the afternoons. The Registered Manager also confirmed that this is a popular pastime for some service users. On the day of the inspection a few of the service users went out to the local shops during the afternoon. Observation of a later conversation between a service user and a member of staff confirmed that service users could be responsible for their own money if they so wish. Membership at local clubs is encouraged and one service user spoke about the Bridge Club, and attendance at the club. Religious activities such as day clubs and church attendance were also observed as being encouraged by the Registered Providers, and enjoyed by service users. Where possible the Registered Providers try to ensure that when they move into the home, service users maintain established contacts such as local churches. Throughout the inspection service users were seen to be treating the home as “their home”, encouraged by the ethos of care provided by the Registered Manager and staff. The atmosphere in the home encourages service users to be involved in a relaxed environment where they can make choices about their lifestyles, and where restrictions are those put in place by the Registered Providers to ensure individual service users’ safety. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users are protected from abuse, neglect and self-harm. EVIDENCE: The Commission has not received any complaints about Vale Lodge, and the Registered Manager confirmed that the home has not received any complaints either. Service users spoken to stated they would talk to Ms Haswell if they had any concerns about living in the home, and that she is able to resolve issues for them. The Staff Training Programme showed that three current staff members and three others no longer working at Vale Lodge have undertaken “Vulnerable Adults” training. The Registered Manger confirmed that she has been informed of future training to be held in January 2006 and is awaiting definite confirmation from the Local Authority “Adult Protection” Team. Inspection of individual service users files showed that the Registered Providers are competent in recognising potential abuse by third parties, and taking necessary action to prevent it. Where appropriate files showed Social Services’ involvement. Service User files all have an Incident/Accident log. This enables staff to see immediately if, for example, an individual is prone to falls, or has an increasing number of accidents, or is causing risk to others by a change in behaviour. This information is used by staff to inform the Service Users Care Plans, and reviews are immediately after anything happens to an individual. Where Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 15 necessary a new risk assessment is completed. Relatives, Social Services and Community Mental Health Teams are involved when appropriate. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,25,26 Maintenance to ensure the safety of service users is haphazard and erratic in priority. EVIDENCE: At the last inspection the Registered Providers informed the inspector that they had purchased fifteen radiator covers to be fitted in the near future. At this inspection the Registered Providers again confirmed that they have the radiator covers and that an independent company has provided a quote to fit the covers. Mr. Atwill stated that he prefers to fit the radiator covers himself, however the covers he has bought do not fit properly so he will need to modify them, or buy new covers. Bedroom Four did not have any form of heating and the room was cold. Mr. Atwill explained that the radiator had been removed when the room was recently decorated. He also explained that supplementary heating was unnecessary because there are heating pipes running through the room. Mr. Atwill confirmed that the sun does not reach this room at this time of year. Later conversation with the service user in this room showed that the room is too cold to sit comfortably for any period of time. Also later conversation with Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 17 staff showed that this room was decorated during the summer. An Immediate Requirement to provide interim supplementary heating was issued, and a telephone call and a further visit to the home, showed that an oil-filled radiator had been provided in this bedroom. Ms. Haswell agreed that the Commission would be informed as soon as the radiator has been re-fitted and is in working order. Observation during a tour of the home showed that single summer weight duvets were provided on the beds for service users. On the day of the inspection freezing weather conditions were forecast so another Immediate Requirement was given to support discussion with the Registered Manager that extra bedding be provided for service users to ensure that they were warm and comfortable, and their health was not put at risk. Both the baths in the communal bathrooms were seen to have chipped enamel in several places. There was also signs of corrosion around the taps and plugholes. Mr Atwill explained that the ground floor bath chips were caused by the removal of the mechanical hoist from the bath. It was not clear when this hoist was removed, however it was not recently. In the first floor bathroom Mr Atwill stated that this bath was in this condition when he took on the home. Mr Atwill did not have any immediate plans to change either of these baths although he did recognise that the ground floor bathroom is in need of complete refurbishment and redecoration. Some of the windowsills in bedrooms showed signs of aging and wear causing them to look unsightly. Two bedrooms on the first floor and ground floor rooms did not have window restrictors. Mr. Atwill agreed to install these where required to prevent risk of anyone climbing out of windows and falling, or anyone gaining unauthorised entry to the building. The home has a smoking policy for service users, however, the Registered Providers may wish to consider revising this if the number of smokers continues to be a minority. In the interests of the of service users and staff who do not smoke, suitable air-freshening devices should be fixed in the dining room, and in surrounding areas where the smell of cigarette tobacco is prevalent. Ideally an alternative room should be sought where smoking will not affect those who choose not to smoke. The Registered Providers should consider a survey of service users wishes regarding smoking in the dining room as this room provides access to the service users’ sitting room, the stair lift, and the kitchen so is in use throughout the day as well as mealtimes. The Registered Manager and the Administrator confirmed that the previous inspection report was factually incorrect because home has a sluice programme on its washing machine for any soiled linen or clothing. They also provided a policy for emptying and cleaning commodes that had clear instructions for staff to appropriately undertake this task. Observation during a tour of the home showed no liquid soap or paper towels in communal toilets and bathrooms, and in the staff toilets whilst there was liquid soap, there was also a communal towel. This shows that staff might not be fully aware of the risks of infection and how it can be prevented. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 18 Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 19 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, 29 Competent staff meet service users’ needs. EVIDENCE: The home is currently recruiting more care staff, however service users spoken to praised the current staff team and stated how well they are looked after. Observation of staff with service users showed appropriate and respectful interaction. The home has one waking and one sleeping staff on night duty. The numbers of staff during the day reflects the levels of activities. The Registered Providers supplement the staff, and Ms Haswell is included on the staff rota six days per week, Mr. Atwill works Wednesday and Sundays in the kitchen. All other days the home employs a cook. Additionally Mr Atwill assists in social activities. He is also responsible for all the maintenance of the home. Other staff have responsibility for cleaning and on the day of the inspection the home was in a clean and hygienic state, free from dirt and smelling pleasant. A sample of staff files showed all necessary checks had been made although applications for CRB checks is delayed until the staff member has completed her/his first week. Mrs. McClellan explained that this is because the home’s policy is that staff pay for the CRB check themselves and the money is taken from their first week’s wages. Prospective staff are told at interview and sign an agreement about this. Staff records showed that the application form Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 20 requires disclosure of any criminal offences. The Registered Manager confirmed that no-one works unsupervised until the CRB check is finalised. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 21 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): 33,35,36 Service users can be confident that their financial interests are protected by the home’s procedures. EVIDENCE: Mrs McClellan, the home’s administrator, explained in detail the home’s procedure for service users’ monies. She also demonstrated the efficiency of the system. All individual service users accounts are in both paper and computerised format. A sample of these accounts were checked and crossreferenced with the monthly computer update. All balances were correct. The monies however were not kept securely so following a request during the inspection all monies were moved to an alternative lockable facility. Discussion with Mrs. McClellan and the Registered Manager showed that they are both very conscientious about service users’ welfare including financial interests, and when required they would take any necessary measures to protect this. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 22 Mrs. McClellan has undertaken an extended survey to include health and social care professionals. She aims to produce an annual report about the home by the early part of next year using all the results once they have been collated. A new Staff Induction Handbook has been devised for use by staff in the home. This includes short multiple-choice tests to ensure that staff have read and understand the policies and procedures. Although staff are supervised on an informal daily basis, there is not yet any sort of formal supervision. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 23 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 2 X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 24 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 OP9 Regulation 13 Requirement An approved cupboard for the safe and secure storage of controlled drugs must be installed. This requirement was met on the day of the inspection. Commodes must be placed more discreetly in bedrooms or removed if not required, and net curtains or a screen must be provided where wash hand basins and commodes are near windows in order to ensure and maintain the privacy and dignity of the service user at all times. The Providers met this requirement within the timescale. Records of food provided for service users must show more detail particularly when an alternative has been offered or there has been a change in the set menu. Service users must be offered a choice of food as well as an alternative. The Registered Provider must supply the Commission with a DS0000003499.V268591.R01.S.doc Timescale for action 2 OP10OP21 12(4(a)), 16(2(c)) 31/12/05 30/11/05 3 OP15 Reg17 (2) Sch4 (13) 31/12/05 4 OP19 23(2b,d) 16(2c) 31/01/06 Vale Lodge Residential Home Version 5.0 Page 25 5 OP19 12(1(a)), 13(4(c)) 6 OP19OP21 4(1b) 13(4) 23(2b) 16, 23 7 OP24 8 OP25 23 9 OP25 121a 134c 162c 231a2p 10 OP26 13(3) detailed programme of planned redecoration and refurbishment Window restrictors must be fitted to the identified bedroom windows. The Providers met this requirement within the timescale. Both the ground floor and first floor baths must be replaced with new baths free of any enamel chips or other corrosion. Lockable storage space must be provided in each residents room. This requirement has been met since the previous inspection. Appropriate door locks must be installed when rooms become vacant or if individual service users request this facility or if circumstances in the home change. All radiators and pipe work assessed as a potential risk must be guarded or have guaranteed low temperature surfaces. This requirement was outstanding from the previous two inspections and the timescale extended. The Providers met the requirement within the timescale. All service users’ bedrooms must have central heating in working order. All service users’ bedding must be assessed to ensure that they are provided with adequate duvets and/or extra blankets so they are warm and comfortable, and their health is not at risk from cold conditions. The Providers met this requirement within the timescale. Paper towels and secured liquid DS0000003499.V268591.R01.S.doc 28/02/06 30/05/06 30/05/06 28/02/06 23/11/05 23/11/05 Page 26 Vale Lodge Residential Home Version 5.0 11 OP33 24 12 OP36 18 13 OP38 13,23 soap dispensers must be provided in all communal toilets & bathrooms, including staff facilities to prevent the risk of cross-infection. The quality assurance system must be extended to include health and social care professionals to establish their level of satisfaction with the care services being provided in the home. This requirement has now been met. The results of all the surveys undertaken must be published and available to prospective service users. This requirement is outstanding from the previous inspection and the timescale extended. A formal recorded staff supervision system must be set up whereby staff receive supervision at least six times a year. This requirement is outstanding from the previous inspection and the timescale extended. Portable electrical appliances must be tested as appropriate and according to the level of risk as required by the Electricity at Work Regulations 1989 and recommended by the Health and safety Executive. This requirement is outstanding from the previous inspection and the timescale extended. 31/01/06 31/01/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 27 No. 1 Refer to Standard OP19 Good Practice Recommendations The Registered Providers should consider contracting out some of the maintenance work to ensure that all outstanding and new requirements are met by the agreed dates. The Providers have met this recommendation. The Registered Provider should consider revising the home’s smoking policy to suit the health needs of the majority of the service users who do not smoke. The Registered Provider should consider installation of a sluice facility for washing commodes to help control the spread of infection. The Providers have met this recommendation. 2 3 OP19OP26 OP26 Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Vale Lodge Residential Home DS0000003499.V268591.R01.S.doc Version 5.0 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. 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