Inspection on 26/04/05 for Valentine Lodge

This inspection was carried out on 26th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Valentine Lodge 02/10/08

Valentine Lodge 08/10/07

Valentine Lodge 14/05/07

Valentine Lodge 29/01/07

Valentine Lodge 14/06/06

Valentine Lodge 01/02/06

Valentine Lodge 22/11/04

Valentine Lodge 29/06/04

Valentine Lodge 18/02/04

Valentine Lodge 15/10/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Valentine Lodge 28 Edith Road Canvey Island Essex SS8 0LP Lead Inspector Bernadette Little Unannounced 26/04/05 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 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. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Valentine Lodge Address 28 Edith Road, Canvey Island, Essex SS8 0LP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01268 696955 01268 696955 Valentine Lodge Ltd Mrs Valerie Sheila Matthews CRHN 20 Category(ies) of OP (20) registration, with number of places Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1) Nursing and personal care to be provided for up to 20 people over the age of 65 years. 2) Maximum number to be cared for shall not exceed 20. Date of last inspection 22/11/2004 Brief Description of the Service: Valentine Lodge offered accommodation with nursing care for twenty older people. The home was situated near to local amenities and transport on Canvey Island. There were six shared bedrooms on the ground floor, all with a toilet, wash basin and shower, and eight single bedrooms on the first floor with hand washing facilities. There were two lounges and a dining room downstairs and there was a passenger lift. There was limited parking to the front and side of the home and a very small garden to the rear. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that lasted about eight hours. It was done by two inspectors, Bernadette Little and Michelle Love who were helped by a third inspector, Claire Brookes-Nandara, as part of her induction training. A lot of time was spent sitting in the lounges, talking to residents and seeing everyday life in the home. Records and documents were looked at and there was a tour of the premises at different times of the day. Visitors and staff were also spoken with. After the last inspection, the home had a list of things to do to make sure they met the standards of care and management needed. Some of these had been left over from the inspection before. The person registered, and responsible with the manager for Valentine Lodge, had been asked to send a second plan to the Commission by 31st March 2005, to say that they would do all the things needed, and explain how they would do them, but the Commission did not get this plan. Some of these things were again not to a good enough standard on the day of this inspection and six notices were given to the home, telling them that they must make some things right straight away. Soon after this inspection, a letter was received from Valentine Lodge to say that they were going to do things to make right five of the six notices. (They had twenty eight days to send a plan of training to the Commission, which was the sixth thing.) The letter was not signed by anybody. The people responsible for Valentine Lodge must now show the Commission that they have made much more effort to put things right. The Commission may decide to do extra inspections to the Valentine Lodge to check on this and how the home is looking after the residents. What the service does well: Most of the staff at Valentine Lodge had worked there for some years. This gave the residents familiar faces and people they knew to look after them. Residents spoken with said they were satisfied with the care provided at the home. They all said they liked the food. Visitors said they felt welcome to come to the home and said that residents were well looked after. The records of the shifts that staff worked showed that the right number of staff had been on duty, including registered nurses. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2, 3 5 and 6 Some information was available and visits are invited to the home, to allow people to make a decision about moving into Valentine Lodge. Not all information was able to found and inspected so this will need to be looked again at a future inspection. EVIDENCE: The Service User Guide could be written in a way that made it easier for residents to see and understand. A copy of the last two inspection reports was displayed on the table in the entrance hall, next to the visitors’ book, which is good practice. Copies of residents’ contracts were not available on request. No new residents had been admitted to Valentine Lodge since the last inspection. The Service User Guide stated that all prospective residents would have an assessment done by social services. The home does not have a tool to assess dependency levels. Staff need training on issues related to the care and conditions of older people. The homes Service User Guide stated that people who enquire about the home’s services are given all information possible and invited to visit. Valentine Lodge does not offer intermediate care. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 9 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 standard(s) 7, 8, 9, 10 Care plans and risk assessments did not have enough information. Residents’ health care needs were not always met and their safety was put at risk by some staff practices. Medication records showed practices were not safe. Residents were not always treated with respect. Staff deployment needs to be reviewed. EVIDENCE: Four care plans were sampled and some areas had been reviewed since the last inspection. The care plans identified some areas of the care that was needed for each person, but did not tell staff how/when to do this, for example, shaving or oral care. Some issues were found in the file, for example, where people were quite confused, or smeared faeces in a shared bedroom, or showed aggression to staff and others, or wandered and recently attempted to leave the premises. These were not detailed in the care plan. An Immediate Requirement and Feedback sheet was given to the home to improve the quality of the care plans. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 10 The care notes were usually only written once a day, and generally with no night records. They were repetitive and did not always give enough information to help to monitor the residents’ care, and any changes. Risk assessments were reviewed regularly, which is good. Risk assessment did not show enough thought on all the issues to ensure the residents safety, for example, bed rails, and the required monitoring was not shown in the records. The homes own risk factors had been ignored in the care actions taken. Care notes showed where a resident needed a medication review by a GP. The residents’ health care notes or care plan did not record that this had happened, or that any changes were made to help the resident. Fluid or turning records were not available, where these were needed for highly dependent residents. No resident had a pressure sore, which is good. Staff used unsafe and inappropriate ways to move and transfer some residents. An Immediate Requirement and Feedback sheet was given to the home to improve the quality and safety of moving and handling practices. The medication storage system was secure and well organised. Policy and procedure on medication, including the guidelines issued by the Royal Pharmaceutical Society on medication in Care Homes were available. Medication Administration Records were checked for all residents. Seven times were noted where the record was not signed to show that the resident had been given their medication, or show a reason if this had not happened. The controlled drugs record and the amount of drugs left, did not tally. An Immediate Requirement and Feedback sheet was given to the home to improve the quality of the medication administration and records. Some staff spoke to and interacted well with residents. Other did not. A staff member was seen to walk into a lounge, walk up to resident and shave the resident without speaking one word to the person. Care notes also recorded other occasions where a resident had been shaved in the lounge. This showed no respect for the person, or their right to privacy and dignity. Throughout the many hours sitting in the lounges and observing, it was particularly noticeable that staff were rarely available in the lounge with residents for any period of time, except when they were involved in a task. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 11 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 standard(s) 12, 13, 15 Some social activities did take place. Limited attention had been given to finding out residents’ preferences for interests and pastimes, and for giving them opportunities for meaningful pursuits. Some residents had more choices than others in what they did during the day, and this needed to be improved. Arrangements for visitors were satisfactory. The opportunity for choice at meals varied. The quality of both the environment and time given to residents at mealtimes needed to be improved. EVIDENCE: Three care plan files showed no clear plan to help the residents have a good experience of social activities. One noted a resident’s hobby as ‘smoking and watching sport on television’. One care plan said that a resident now showed little interest, but was still included in all the activities in the lounge. This resident was seated at the back of the lounge, behind, and facing, another row of high backed armchairs. This limited the person’s view and any benefit they could have had from of any happenings in the lounge. A few staff did chat to the residents as they came in and out of the lounge. Other staff brought residents in and out, or gave personal care, without speaking to the residents. A ball game was played in the lounge a few minutes before residents needed to be moved to the dining room. Many residents were confused and the majority were not mobile. No one to one ‘social’ time was Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 12 given to individual residents by the care staff. Records and residents said that some residents go out with their visitors. A resident spoken with said they would love to go out. An activity person had been employed to come into the home twice weekly to do activities and she is setting up a ‘residents’ story and family tree’. Records show that bingo and aromatherapy massage had been made available to residents. The activity person had introduced a residents meeting. The home may wish to gain further advice on appropriate activities for the elderly from the National Association for Providers of Activities for Older People on 01376 585225. Visitors said they were made very welcome, that the staff were nice, residents were always clean and nicely dressed. During the morning tea round, residents were offered a choice of two named biscuits, which the staff then handed to the resident. Gloves or tongs were not used and the home could think about letting the person choose their own biscuit from a plate with some biscuits on it. One resident said they choose what time to go bed or what to do with their day. Another resident told staff several times during the afternoon that they wanted to go to bed, only to be returned to their chair and told to stay there or that they didn’t need to go to bed. Three residents said they were happy with the food and the choices given. Menus showed better choices for breakfast and teatime that at lunchtime. It was good to see that people could have a cooked breakfast. The table cloths were taken off the dining tables before residents ate and then put back on afterwards. Care staff were not especially patient with residents who were not so easy to communicate with, and some residents were not given adequate time and assistance to finish their meal. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 13 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 standard(s) 16, 18 The complaints procedure allowed visitors and residents to make complaints and give compliments. The home did not use it as they should. It had enough information, but could have been difficult for residents to read. Staff were not given enough information or training on how to keep residents safe. EVIDENCE: The complaints procedure needed to be written in bigger print and in a way that made it suitable for the residents. The registered manager advised that, since the last inspection, one complaint had been received from a resident through a relative. The relative was said not to want the home to do anything more about it. The complaint, and the decisions taken, had not been recorded formally by the home. A written compliment was seen from a relative who said that they were their relative was very well looked after, safe and they were happy with the care provided. Staff spoken with had not had any training on the Protection of Vulnerable Adults, or how to care for residents who show aggression to them or other residents. A whistleblowing policy and a restraint and risk taking policy were available. A copy of the home’s own, or the local authorities, policy and procedure on Adult Protection could not be found when requested. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 14 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 standard(s) 19, 20, 21, 24, 25 and 26 Some parts of the premises were unsafe. Some facilities for residents were not adequate. Storage was inadequate. All parts of the home and equipment were not kept clean, well maintained or decorated. Safe hygiene rules were not practiced. EVIDENCE: The carpets in some parts could have tripped residents and staff. The specific areas were explained to the registered manager. The hot water in one bedroom was tested and was too hot. There was no hot water in several service user bedrooms. The person registered had been told about these issues at previous inspections. An Immediate Requirement and Feedback sheet was given to the home to make the carpets and hot water safe and give residents safe hot water in each room. Corrosive dishwasher liquid was left on the seat by the residents’ telephone. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 15 The fire doors in the front and back lounge were not shut properly and the alarms did not sound when the doors were opened. The registered manager said that there was no risk as no residents wandered or tried to get out. She was told about the care notes that showed that this had happened on more than one occasion recently. Furniture impeded access to some fire exits. Bathrooms and toilet areas were crowded with equipment, for example wheelchairs, the hairdressers’ trolley etc. Many areas looked poorly kept, for example the flooring in the bathroom. Cobwebs hung from the dining room ceiling, and walls needed washing and/or painting. Equipment, for example the legs of overbed tables and commodes etc., looked rusted and not clean. A number of rooms had an unpleasant odour. Something that looked and smelt like faeces was reported to the registered manager as being in a resident’s sink. This was still found to be there some hours later. The staff room opened off one resident lounge and there was a regular smell of cigarette smoke in the lounge throughout the day. The garden space able to be used by residents was very small. Ways to make it bigger and better for residents had been suggested previously to the person registered. No risk assessment had been completed relating to Legionella and the safety of the water storage system. Information on this can be obtained on the booklets “ Essential Information for providers of residential accommodation” and “A guide for employers” on 01787 881165 or at www.hsebooks.co.uk Staff were seen bring yellow bags of clinical waste through the residents back lounge and pile up the bags outside the (fire exit) door to the garden. Sometimes staff did not wear protective gloves and even when they did, several surfaces were touched. The bags were later put into the proper bins outside. The home can obtain advice and information on Infection Control by contacting Essex Health Protection Unit on 01376 302282. Yellow bins in bathrooms were not overfilled which is a noted improvement from the last inspection. All light fittings in corridors contained bulbs, which is also an improvement following previous inspections. Windows were low enough for residents to be able to see out of. Radiators were fitted with covers to protect residents. While some bedrooms had few personal items, others were nicely personalised. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28, 29, 30 Staffing levels and/or deployment did not best meet residents’ needs. The necessary records on staff, to protect residents, were not in place. Staff training is not adequate to meet residents’ needs and provide good care outcomes. EVIDENCE: Rosters showed that minimum staffing levels were being met and that a qualified nurse is on duty each shift. Staff deployment needed to be reviewed, as staff were not available in the lounges as a routine throughout the day. Staff had to be called for a resident who was confined to bed and without access to the call bell, and calling out for assistance as they were wet. Some staff work twelve or thirteen hour shifts, which is a long day and not considered best practice. They clearly need proper breaks during this time, but this could regularly reduce the staffing levels available to residents throughout the day. Staffing levels may need to be increased to compensate. Twelve staff recruitment files were inspected. None of them had the complete records needed to show that safe recruitment practices were in place at Valentine Lodge. It is accepted that some staff had worked at the home for a number of years and references etc. could not be obtained now. They should however, have other things like copies of passport, or photograph and Criminal Records Bureau check. A file for a staff member employed under the new requirements did not have all the documents. The person registered had been told about these issues in previous inspection reports. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 17 An Immediate Requirement and Feedback sheet was given to the home to obtain all the required checks and records to protect residents. Three said were said to have completed NVQ Level 2 and two further staff are currently undertaking this training. Other staff expressed interest in this, and other training. No staff are undertaking NVQ Level 3. The need for staff training and skills development was seen in practice during the day. Staff spoken with confirmed limited mandatory training, for example fire, moving and handling or infection control, or training on issues related to older people, for example catheter care or Parkinson’s disease. The twelve staff files sampled also evidenced limited training. The person registered had been told about these issues in previous inspection reports. An Immediate Requirement and Feedback sheet was given to the home to provide staff with mandatory and specialist training within given timescales, to have an individual training profile for each staff member and to provide the Commission with a plan of training for 2005 –2006 within twenty eight days. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 38 The registered manager needed to be supported by the person registered/ owner to take a more active role to manage the home effectively. The persons registered needed to look again at whether the home is run in the best interests of the residents. Staff were not adequately supervised. Systems needed to be in place to monitor all aspects of the home, including health and safety. EVIDENCE: The registered manager was a qualified nurse. She advised that she had now agreed to undertake the NVQ 4 In Care and Management, Registered Managers Award. The registered manager was again advised that she must have more supernumerary shifts to allow her to do the tasks that her position as registered manager required. Earlier sections of this report show times where it seemed that residents of Valentine Lodge were no longer really seen as people with rights and choices and their best interests were not given enough importance. In response to a Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 19 previous inspection, the home had given residents a questionnaire to complete some months ago. This had not been repeated, or outcomes assessed and actions taken. The home needed to consider a proper system of quality monitoring and assurance, to include all areas, for example care management plans and records, recruitment, training plans, regular premises cleanliness, maintenance and safety checks. Formal staff supervision had again not been introduced at Valentine Lodge. Informal supervision also needed to be reviewed. Copies of the report on the home that the person registered must do each month had not been sent to the Commission as required. Issues on health and safety are noted earlier in this report in relation to infection control, safety of the premises and staff training. Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 2 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 1 2 2 2 x x x 1 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 2 x 1 x x 1 x 2 Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The Statement of Purpose must include all the required information. A copy to be sent to the Commission.(Previous timescales from 18.02.04, i.e three inspections, not met). The Service User Guide must include all the required information. A copy to be sent to the Commission. (Previous timescales from 18.02.04 not met) A contract or statement of terms and conditions that includes all relevent information to be available to all residents. (Previous timescale from 18.02.04 not met). The person registered must show that the home can meet the assessed needs of residents and ensure that staff are provided with training to enable them to meet these needs.(Previous timescale of 22.11.04 not met). A written care plan must be prepared for each resident, based on their assessment, that identifies how the residents needs in all aspects of their health and welfare are to be Timescale for action 1 July 2005 2. 1 5 .1 July 2005 3. 2 14(1) 1 June 2005 4. 4 18(1) 26 May 2005 5. 7 15 26 April 2005 Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 22 6. 8 13 (1)b 7. 9 13 (2) 8. 10 12(4)a 9. 12 16(2)m 10. 15 12(1) & 18 (1)a 11. 16 22 12. 18 13(6) 13. 18 13(6) met.This includes detailed risk assessments. (Previous timescale of 22.11.04 not met). The person registered must make arrangements for the resident to receive any treatment necessary from their GP or other healthcare professional. The person registered must ensure safe handling, administration and recording of medication. The person registered must make suitable arrangements for the home to work in a way that shows respect for residents and their dignity. Residents must be consulted about their social interests, facilities and staff must be provided to meet them and care plans must include details of how they are to be met.(Previous timescales from 18.02.04 not met). The person registered must ensure that the home makes proper provision for the care of residents. This refers to being enough time and assistance to eat their meals. Complaints must be fully investigated and records available to evidence this. (Previous timescale of 22.11.04 not met). The person registered must ensure the safety of residents by providing staff with clear and relevant procedures on Protecting Vulnerable Adults and ensure that staff are aware of this. (Previous timescales from 18.02.04 not met). Arrangements to be made by the person registered to provide staff with training on Protection of 26 April 2005 26 April 2005 23 May 2005 23 May 2005 23 May 2005 23 May 2005 23 May 2005 25 May 2005 Page 23 Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 14. 19 23(2)b 15. 19 23(2) c&d 16. 20 23(2)o 17. 18. 21 22 23(2)j 23(2)l 19. 26 13(3) 20. 27 18(1)a Vulnerable Adults and management of behaviour that challenges.( Previous timescales from 18.02.04 not met). The person registered must ensure that the care home is kept safe and well maintained. This refers to the carpets, the hot water and the storage of hazardous substances.(Previous timescale regarding the carpets from 18.02.04 not met). The person registered must ensure that the home is kept kept clean, reasonably decorated and equipment is well maintained.(Previous timescales from 29.06.04 not met). The person registered must ensure that the external grounds are suitable and safe for residents and appropriately maintained.(Previous timescales from 31.08.04 not met). All residents to be provided with safe hot and cold water in their ensuites. The person registered must ensure that there is adequate storage for equipment such as wheelchairs and hoists to aviod storage in residents bathrooms and bedrooms.(Previous timescales from 31.08.04 not met). The person registered must ensure appropriate infection control measures in the home. This refers to the safe hygenic handling of the clinical waste.(Previous timescale of 22.11.04 not met) and to not taking such waste through rooms used by residents. The person registered must ensure that at all times there are enough suitably qualified and competent staff on duty to meet 26 April 2005 23 May 2005 23 May 2005 23 May2005 23 May 2005 23 May 2005 23 May 2005 Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 24 21. 29 19 , 17(2) Schedules 2&4 22. 30 18(1)a 23. 30 18(1)c 24. 31 9(2)(b)i 25. 31 10(1) & 2(a) 26. 33 24 27. 36 18(2) residents needs. This refers to staff deployment and the number of hours they work each shift. The person registered must evidence robust and safe recruitment procedures and have all the required records and documents available at all times.(Previous timescales from 18.02.04 not met). The person registered must ensure that staff are competent to undertake the tasks they are to perform. This refers to some poor moving and handling and care practices seen during this inspection.(Previous timescale for these issues of 22.11.04 not met). The person registered must ensure that receive training to the work they are to perform. (Previous timescales from 18.02.04 not met). The registered manager must demonstrate that they have the skills and training to manage the home effectively. (Previous timescale of 22.11.04 not met). The registered provider must demonstrate that they are carrying on the home with sufficient care, competence and skill and undertake any necessary training to ensure this. The registered person must ensure systems are in place for monitoring and improving the quality of the care services provided by the home. ( Previous timescales from 18.02.04 not met). Staff must be appropriately supervised. (Previous timescales from 29.06.04 not met.) 26 April 2005 26 April 2006 26 April 2005 23 May 2005 23 May 2005 23 May 2005 23 May 2005 Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 25 28. 37 26 29. 38 23(4)d 30. 38 23(4)e 31. 38 13(3) Monthly reports must be undertaken by the registered provider, as required by Regulation and copies sent to the Commission.(Previous timescale of 22.11.04 not met). The person registered must ensure that staff working at the care home receive suitable training in fire prevention. (Previous timescale of 22.11.04 not met). The person registered must ensure that staff working at the home participate in regular fire drills. (Previous timescale of 22.11.04 not met). The person registered must ensure the safety of the water storage system and undertake appropriate risk assessment and actions. 23 May 2005 23 May 2005 23 May 2005 23 May 2005 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. Refer to Standard 1 3 9 15 16 19 28 Good Practice Recommendations The Service User Guide and Statement of Purpose should be written in larger print to be in a format suitable for residents. The home should have a dependency rating assessment tool, to be used regularly to assist with monitoring staff training and staffing levels. Risk assessment should be undertaken to determine if any resident could self medicate. Dining tables should keep the table cloths and be pleasantly set while residents are eating, unless risk assessment shows otherwise. The complaints procedure could be written in bigger print and be in a suitable format for residents A written progamme of maintenance, decoration and renewal should be available. 50 of care staff should achieve NVQ Level 2 I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 26 Valentine Lodge 8. 31 The registered manager should achieve NVQ Level 4 in Management and Care Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea, SS2 6BG 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 Valentine Lodge I56 I06 15564 Valentine Lodge V222878 260405 Stage 4.doc Version 1.20 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!