Inspection on 03/05/06 for Valley Lodge Nursing Home

This inspection was carried out on 3rd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Valley Lodge Nursing Home 02/05/07

Valley Lodge Nursing Home 18/01/06

Valley Lodge Nursing Home 22/08/05

Valley Lodge Nursing Home 21/03/05

Valley Lodge Nursing Home 23/09/04

Valley Lodge Nursing Home 08/03/04

Valley Lodge Nursing Home 18/09/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Valley Lodge Nursing Home Bakewell Road Darley Dale Derbyshire DE4 3BN Lead Inspector Anthony Barker Unannounced Inspection 09:45 3 & 4th May 2006 rd 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 Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Valley Lodge Nursing Home Address Bakewell Road Darley Dale Derbyshire DE4 3BN 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) 01629 583447 Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Vacancy 1 Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: Valley Lodge is a care home registered to provide accommodation and personal care with nursing for up to 33 older people. The home is located in the village of Darley Dale around a half mile from Matlock town centre off a main bus / transport route. Accommodation is provided on 2 floors with a large lounge on the ground floor and a smaller quieter lounge also. A communal dining area is also on the ground floor. Catering, laundry, domestic and maintenance services are centrally provided. The home is set in accessible and attractive well-maintained grounds with car parking space provided. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 11.75 hours over two days in May 2006 and was a routine unannounced inspection. The last inspection took place in January 2006 and was unannounced. Four residents, the Manager, the Deputy Manager and two other members of staff were spoken to and records were inspected. There was also a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Documented risk assessments and care plans for residents must be regularly reviewed. Recording practices relating to the administration of medicines must be improved. Qualified staff must attend Adult Protection training. Residents must be able to access the wash hand basin in one bathroom. Sluice rooms Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 6 must be kept clean and hygienic and personal toiletries must not be kept in communal areas, for reasons of hygiene. All information and documents detailed in Schedule 2 of the Regulations must be in place before new staff are appointed, for the safety of residents. Mandatory training must be completed for all staff. The Registered Provider must ensure that application is made to the CSCI for manager registration. 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. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 the following standard(s): 3&6 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs were being fully assessed before admission. EVIDENCE: Three residents’ files were case-tracked. Just one of these residents was funded by Social Services and there was a needs assessment and care plan recorded by the care manager prior to admission in March 2006. All three files had pre-admission assessments undertaken and recorded by the Home. This Home does not provide intermediate care. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9 & 10 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs were being well set out in individual plans of care although these were not all being reviewed regularly. Residents were being treated with respect but they were not being fully protected by the Home’s practices for dealing with medicines. EVIDENCE: From an examination of the three case-tracked residents’ files it was clear that the Home had very comprehensively recorded and well-worded care plans and risk assessments for residents. There was a record of agreement to provide bed rails to one case-tracked resident, with a signature from a relative, but not on one other file where this equipment was in use. Not all the care plans and risk assessments examined were being reviewed each month and the Acting Manager said that only a few care plan review sheets included a signature from the resident or their representative. She produced a Care Plan Quality Check form she had started to use. There was evidence that care plan recording practices were continuing to improve. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 10 The care plans examined included risk assessments relating to nutrition, tissue viability and weight gain/loss. A good range of health professionals were visiting the Home and GP visits were being recorded. At the last inspection there had been seven items of concern relating to medication recording and storage practices. Four of these were still in evidence… • there was one omission of a signature on a Medication Administration Record (MAR) sheet, • photographs were not all in place beside MAR sheets, • handwritten instructions on MAR sheets had not all been signed by two members of staff and • a list of staff initials and signatures for those staff who administer medication was not in place. A copy of administration of medicines policies and procedures was being kept in the treatment room and there was evidence of improved practices, storage and disposal arrangements. A visit was made to the Home, two weeks after the last inspection, by the Home’s pharmacist. A copy of his report was seen and this concluded that he thought “on the whole, the Home was run very efficiently with regard to medication use”. One case-tracked resident confirmed he was treated with respect by staff and said they were “marvellous”. When he was visited by his GP his bedroom was used for the consultation in order to maintain his privacy. He felt that the laundry system was satisfactory as he usually was provided with clean clothes that belonged to him, with just occasional exceptions. One member of care staff reported that residents’ clothes were well laundered and returned uncreased. One of the two laundry assistants was briefly spoken to and she displayed a very positive attitude. A letter was seen, from relatives of a deceased resident, that referred to “the efforts you made to keep (the resident) comfortable and dignified at the end of her life”. Other aspects of standard 11 were not assessed on this occasion. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were being provided with a range of satisfying activities and were able to maintain contact with relatives and the local community. They were being provided with a satisfying diet. EVIDENCE: The Acting Manager stated that, since the last inspection, two hours each day had been allocated for staff to provide dedicated time to physical and art/craft activities for residents. She spoke of a more structured programme of activities being available, reflecting staff interests and skills. Additionally, she said, staff are expected to spend one-to-one time with every resident. An entertainer was visiting during one of the afternoons of this inspection and photographs from previous events were seen – some being displayed in the entrance hall. The Acting Manager said that residents are offered one or two trips out per month. Residents are asked about the activities programme on a regular basis, she added. One case-tracked resident said that he enjoyed the activities provided by the Home and he could exercise choice with respect to his daily routines. One member of care staff spoke about improvements to the range of activities provided to residents since the last inspection. The Home’s Weekly Events Guide was displayed in the entrance area. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 12 The entries in the Home’s visitors book showed that the Home was visited by a number of people each day and one case-tracked resident spoke about visits he receives from family and friends. The Acting Manager said that there was an ‘open door’ policy regarding visiting hours and that a number of residents’ relatives regularly have a meal at the Home. Links with other care homes in the group have been set up. The Acting Manager added that 99 of referrals to the Home were from recommendations and that the Home was well thought of locally. The Acting Manager reported that no residents were currently in need of an external advocate but she knew who to contact if the need arose. Regarding access to personal records a Care Plan Access Details form had been devised, operating as a consent form, and a signed form was seen in one of the three case tracked residents’ files. The Home’s 4-week ‘rolling menu’ was examined although only 2 weeks were in place. The Acting Manager said that new menus would be starting soon. The lunch-time meal on the first day of this inspection differed from that on the menu. A catering assistant said that currently meals were reflecting the contents of the freezer. She added that the cook asks residents each morning about their preferences for lunch that day although no record is kept of this or of what the residents actually eat. There was no menu displayed for the day’s meals although minutes from the last residents’ meeting indicated that menu cards on dining tables were being considered. Staff were observed helping residents to eat their meal. Tables were set with cloths and individual serviettes. Several residents spoke positively about the quality of food provided by the Home. One case-tracked resident reported that the food was of “excellent quality and quantity”. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents felt confident that any complaints they had would be listened to. They were being protected from abuse although not all senior staff had received appropriate training on this subject. EVIDENCE: A well-worded complaints procedure was displayed in the entrance hall. The Home’s complaints record had six entries for 2006 and indicated that matters had been addressed to a satisfactory conclusion. One case-tracked resident stated that he had no concerns about the service he receives but would feel able to talk to any staff if he did have. The Acting Manager had attended a one-day training course in Adult Protection but was unclear how many of the qualified staff had attended this training. One member of care staff said she had attended Adult Abuse training. The Acting Manager was able to show her awareness of local Protection Of Vulnerable Adults (POVA) procedures. A copy of a Regulation 37 notification to the Commission was seen, confirming that appropriate measures – including the early involvement of the local Social Services Department – had been taken following an allegation of assault on a resident. The Acting Manager made assurances that the Home now follows local POVA procedures even though this had been a matter of ongoing debate within Ashmere Care Group. The Home’s Whistle Blowing policy was appropriately worded and one member of care staff said she was aware of this policy. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 the following standard(s): 19,21,24 & 26 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents were living in a homely and generally well-maintained environment and had personalised bedrooms. There was need to improve Health and Safety matters in certain toilet, bathroom and sluicing areas. EVIDENCE: The Home was decorated to a good standard and appeared homely in most areas with a number of attractive items such as lamps, blinds and wall pictures. The Acting Manager stated that all communal areas had been decorated and corridors were currently being decorated. She described a rolling programme of decoration. A number of rooms were cluttered with inappropriate items: • first floor bathrooms 37 and 20 were filled with boxes of continence materials, • ground floor bathroom 8 was cluttered and untidy with two hoists and a linen trolley, Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 15 the first floor sluice room was cluttered with bed sides and a parasol, the ground floor sluice room was also cluttered, with decorating materials, and paint stains were all over this room. The Acting Manager agreed that there were inadequate storage facilities in the Home. Bathrooms 37 and 20 had non-assisted baths and the Acting Manager said they were not used. There were two other, assisted, baths in the Home. There was no access to the wash hand basin in bathroom 8, for anyone using the WC, because of the items stored in there. Bedrooms were nicely personalised. There was no lockable furniture in bedroom 16 and not all rooms were furnished to National Minimum Standard 24.2. The Acting Manager confirmed that there was no recorded evidence, on care plans, (i) that residents had been informed that they are entitled to the provision of comfortable seating for two people and a table to sit at, or (ii) of residents declining this provision. She said that the Home currently had 7 or 8 adjustable nursing beds and that there was an ongoing programme of providing these. Suitable locks had not been provided to residents’ bedroom doors, as required at the last inspection. The Acting Manager said that no resident had ever requested locks and new residents are not offered this facility. The matter had not been raised at a residents meeting. There was a soiled commode pan on top of the sluicing machine in the first floor sluice room. The ground floor sluice room had a urine-stained pot on the draining board. A container of shaving foam was found in ground floor toilet 13 and a toothbrush and toothpaste in bathroom 8. Use of these personal toiletries could cause cross infection. There were policies and procedures on a wide range of infection control issues and the Acting Manager described good practices regarding the handling of infected material. The Home was free from offensive odours. • • Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 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 & 30 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents’ needs were being met by satisfactory levels of staffing and a generally well-qualified staff group. Residents were not being fully protected by the Home’s staff recruitment procedures. Staff had not received a full training programme to provide them with all the skills to do their jobs. EVIDENCE: The staffing rota for week commencing 17 April was examined. This showed that minimum staffing levels - of one nurse plus three carers (two at night) were being maintained. On some days there were four care staff on duty. However, to achieve these staffing levels one member of care staff was working a week of four double shifts followed by a week of three double shifts, amounting to an average of 52 hours a week. These excessive hours could potentially place residents’ welfare at risk. The Acting Manager stated that staffing levels had improved following the immediate requirement notice left at the last inspection. There had been a recruitment problem, rather than poor staffing establishment levels, she said. Staff recruitment was now taking place over a larger geographical area and staff were being appointed who were willing to work any shift, including nights, she explained. The Acting Manager stated that, out of a group of 15 care staff, nine had achieved a National Vocational Qualification in Care at least to level 2. That is 60 . Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 17 The personal file of the most recently appointed member of staff was examined. There was only one written reference on file although the Acting Manager had received a second satisfactory (verbal) reference but had not recorded this. A full employment history had been obtained but there was no written explanation of two gaps in this record. The Home’s job application form did not require applicants to detail any police cautions given. All other aspects of the revised Schedule 2 of the Regulations had been met. The most recently appointed member of staff had started work on 28 April 2006. Her personal file included a completed Week 1 of the Home’s induction pack. A fully completed induction pack was seen on another staff member’s personal file. A large ‘white board’ was displayed in the Acting Manager’s office showing - at a glance - training undertaken by staff in 2006. All except the most recently appointed staff member had been provided with Moving and Handling training and the majority of staff had received Basic Food Hygiene and First Aid training. The Acting Manager said the remaining staff will have received this training by the end of 2006. A significant number of staff had not been provided with Fire training within the last 12 months. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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 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): 31,32,33,35,36 & 38 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents were living in a Home run and managed by a person who is fit to be in charge – although not registered for this Home – and with a good management approach. The Home was being run in the best interests of residents, with their financial interests safeguarded and their health and safety generally promoted. Staff were being appropriately supervised. EVIDENCE: The Acting Manager was well experienced and had been found ‘fit’ to be a registered manager at another care home. However, she was not proposing to apply for registration as manager of this Home. The Acting Manager said she felt supported by her General Manager and was satisfied there were clear lines of accountability within the Home. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 19 One case-tracked resident said he thought nursing staff were good role models for the staff group. One member of care staff stated that it was, “a happy Home” and said, “I’m proud to be a staff member here”. A letter was seen, from relatives of a deceased resident, which stated that the, “openness and friendliness of all the staff contributed to the relaxed atmosphere that pervaded the home”. The Acting Manager stated that Residents and Relatives Meetings were held monthly and minutes from the last meeting indicated that a good range of issues had been discussed. She added that, although the meetings tended to be poorly attended by residents they do have plenty of opportunity to informally share their thoughts with their key worker and other staff. This was reinforced by one case-tracked resident. Some completed residents, relatives and staff questionnaires were seen and the Acting Manager described improvements made following this feedback. The monthly visits to the Home by the General Manager, following Regulation 26 requirements, were very comprehensive and insightful. The Home was holding only three residents’ personal money. The Acting Manager stated that fees include all services. The amount of one resident’s money held was cross-referenced with the Home’s record and was found to match the balance. The two other residents had zero balances. Money was held in a secure place. No one at the Home was acting in a position of appointee for residents. The Acting Manager described a satisfactory system of staff supervision and confirmed that it included elements of staff training and development as well as assessment of staff competence. One member of care staff confirmed she received bi-monthly supervision. The Home employs a full-time ‘handiman’ and had a good set of maintenance records. These indicated that defects were dealt with quickly. There were a well-recorded set of accident forms that included a follow-up record. This was good practice. Good food hygiene practice was being followed. An example of this was covered drinks jugs in the refrigerator with the day of the week stamped on top. Recorded risk assessments of each bedroom were seen as well as of communal areas. In the visitors’ toilet there was an obsolete emergency call system pull cord. An alternative method of ensuring the safety of any resident who may attempt to use this facility was discussed with the Acting Manager. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 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. 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 2 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 2 3 X 2 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 3 Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 14 Requirement Documented risk assessments for service users must be regularly reviewed. From inspection reports 08.03.04, 22.08.05 & 18.01.06. Previous timescale 30.04.06. Care plans must be regularly reviewed. From inspection reports 08.03.04, 22.08.05 & 18.01.06. Previous timescale 30.04.05. The registered person must ensure that the four matters identified in standard 9 in the main body of the report are actioned. Previous timescale 31.03.06. Qualified staff must attend Adult Protection training. Items stored in bathroom 8 must be moved to ensure that anyone using the WC can gain access to the wash hand basin in there. Sluice rooms must be kept clean and hygienic and personal toiletries must not be kept in communal areas. All information and documents detailed in Schedule 2 of the DS0000002094.V292386.R01.S.doc Timescale for action 01/07/06 2. OP7 15 01/07/06 3. OP9 13(2) 01/07/06 4. 5. OP18 OP21 13(6) 13(3) 01/09/06 01/07/06 6. OP26 13(3) 01/07/06 7. OP29 19 Sch 2 01/07/06 Valley Lodge Nursing Home Version 5.1 Page 22 8. 9. OP30 OP31 18 c) 1) 9 Regulations must be in place before new staff are appointed. Mandatory training must be completed for all staff. Previous timescale 30.04.06. The Registered Provider must ensure that application is made to the CSCI for manager registration. Previous timescale 31.03.06. 31/12/06 01/09/06 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. 3. 4. 5. 6. 7. Refer to Standard OP7 OP7 OP15 OP15 OP19 OP21 OP24 Good Practice Recommendations Care plans should be reviewed in consultation with residents or their representative and evidence of this recorded on file. A record of agreement to provide bed rails to all residents using such equipment should be kept on file. Menus should be in place that accurately reflect the meals provided to residents. Records should be retained that show the food provided to residents in sufficient detail to indicate whether each resident’s diet is satisfactory. Suitable storage facilities should be found to reduce clutter in the areas identified in this report. The use of the Home’s four bathrooms should be reviewed to ensure that residents can exercise choice as to where they bathe. Suitable locks should be provided to residents’ bedroom doors, which they may actively choose to use and in consultation with them and in accordance with risk assessed needs. (Previous requirement from 08.09.03) All bedrooms should be provided with lockable storage space. All residents should be informed that they are entitled to the provision of comfortable seating for two people and a table to sit at. These should be provided if safe to do so given the size and layout of the room. Residents who decline this provision should have their reasons recorded DS0000002094.V292386.R01.S.doc Version 5.1 Page 23 8. 9. OP24 OP24 Valley Lodge Nursing Home 10. 11. OP27 OP38 on their care plan. Staff should not regularly work in excess of 40 hours a week. A high door bolt, or other method of ensuring the safety of any resident who attempts to use the visitors’ toilet, should be provided. Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Valley Lodge Nursing Home DS0000002094.V292386.R01.S.doc Version 5.1 Page 25 - 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. 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