Inspection on 09/09/08 for Victoria Lodge Care Home

This inspection was carried out on 9th September 2008.

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

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

Other inspections for this house

Victoria Lodge Care Home 07/09/09

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Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOMES FOR OLDER PEOPLE Victoria Lodge Care Home 138 Thorne Road Edenthorpe Doncaster DN3 2LU Lead Inspector Valerie Hoyle Key Unannounced Inspection 9th September 2008 08:45 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 DS0000071783.V370499.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000071783.V370499.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Care Home Address 138 Thorne Road Edenthorpe Doncaster DN3 2LU 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) 01302 884806 victoria.lodge86@yahoo.co.uk Mrs Saima Munir Raja Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places DS0000071783.V370499.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 24 The maximum number of service users who can be accommodated is: 24 First inspection of the service 2. Date of last inspection Brief Description of the Service: Victoria Lodge is situated on the outskirts of Doncaster in the village of Edenthorpe. The home provides accommodation for 24 older people. A number of bedrooms have ensuite facilities while others have toilet facilities close by. The home has bedrooms on both the ground and first floor and these can be accessed by a passenger lift. There are three lounges, one is designated as a quiet lounge and there is a dining room. There are gardens and car parking at the front of the home and an enclosed garden at the rear of the building with a paved area with garden furniture and flower tubs planted in the summer. The home was registered by the Commission for Social Care Inspection in April 2008 and the registered provider is Mrs Saima Munir Raja. Information gained on the 9th September 2008 confirmed the current fees range from £390.00 to £414.00 for residential care. Additional charges include private chiropody, hairdressing, and outings. The home provides information to people who use the service and their relatives prior to admission into the home. Service Users Guides are available in all bedrooms or on request from the manager. DS0000071783.V370499.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This unannounced inspection was the first inspection of the service since being registered with CSCI in April 2008. All National Minimum Standards were looked at during this inspection. The inspection took place over one and a half days 9.5 hours (8.45am to 3.15p.m first day, 10.00am to 1.00pm second day). Four people who use the service, three relatives, a visiting district nurse and four staff were spoken to during the visit; their views were included throughout the report. The home contracts with the local social services department, and they are building up there client base following their registration with CSCI in April. On the day of this inspection there was 9 beds occupied. Recruitment, safeguarding adults and complaints policies were looked at to assess the agencies ability to protect people who use the service. The office premises were looked at to ensure people’s records were stored safely. The Statement of Purpose and Service User Guide were looked at to assess the quality of information provided to people who use the service. Four peoples care plans were looked at to assess how they were supported in their own homes. Three members of staff, was interviewed; their views are included throughout the report. Six staff recruitment and training records were examined to assess how people were protected. Surveys were left at the service to be given to relatives, one had been returned at the time of writing of this report. There views were collated and contained in this report The manager, Sharmane Papworth was appointed when the home was registered, although she has not commenced the process to be the registered manager with CSCI. She has the required experience and qualities to run the home. She was sent the AQAA. This was returned to us on time which demonstrates responsiveness and cooperation. An annual quality assurance assessment (AQAA) is a self-assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The DS0000071783.V370499.R02.S.doc Version 5.2 Page 6 AQAA also provides us with statistical information about the individual service and trends and patterns in social care. The inspector would like to thank everyone who agreed to being interviewed as part of the inspection process, and the friendliness of staff. What the service does well: What has improved since the last inspection? What they could do better: Information provided to new and prospective people should be in formats that are user friendly, including the use of pictures and larger print. People who purchase their care privately should have a copy of the terms and conditions of residence and a copy should be kept on the personal file. Care plans could be improved when risks are identified. Risk assessments had been completed although the action to minimise the risk were not sufficiently detailed. Risk assessments should be agreed with the individual or their representative with regard to the use of bed rails. Medication procedures were generally well managed although an error in the dosage for one persons looked at could pose a significant risk to there health. Eye drops should be dated when opened to ensure they are not used past the 28 days once opened. Daily records were generally of good quality, although the manager should give guidance to the standard of entries, in particular for staff whose entries were difficult to read. DS0000071783.V370499.R02.S.doc Version 5.2 Page 7 Mealtimes could be improved by ensuring the menu is displayed daily which shows the alternative choice. Cooked breakfasts and hot evening meals should be offered and a clear daily record should be made of the food served to people. The homes ‘Elder Abuse’ policy should be reviewed and updated to include the full contact details of all agencies involved in the protection of vulnerable adults. Staff requires formal training to recognise the signs of abuse and act on information about allegations of abuse. Training is also required in areas of moving and handlings and health and safety to ensure staff have the required skills and competencies to keep people safe. Recruitment of staff could be improved by ensuring gaps in employment is checked during the interview process. The manager should also insist that references are obtained from the last or previous employers. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000071783.V370499.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000071783.V370499.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs could be met. EVIDENCE: The registered provider had developed a Statement of Purpose and Service User Guide which is given to all new prospective people. Some of the information contained in the Service user Guide was incorrect. This was amended during the inspection by the manager and area manager. The home should consider developing the information in other formats to ensure it is user friendly. Contracts are established on admission to the home although a copy was not available on any of the files looked at. The manager confirmed that most DS0000071783.V370499.R02.S.doc Version 5.2 Page 10 people were placed by the local Social Services department, and arrangements for there placement was arranged at the head office. All new people receive a full needs assessment before admission; this was carried out by the manager who had the required skills and competencies. The service was efficient in obtaining a summary of assessments undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. The manager confirmed that people were encouraged to have a free trial day at the home, to enable people to see the bedrooms and meet other residents and staff. Where emergency admissions occur the manager said she would endeavour to follow the same process. Four assessments were looked at and they focused on achieving positive outcomes for people who use the service. Before agreeing admission the manager and staff carefully considers the needs assessment for each prospective person and the capacity of the home to meet their needs. Relatives said they had looked at a number of homes and were happy with the way Manor view cares for their relative. They said staff were very supportive and answered all their questions about the home and staff. Intermediate care was not provided at the home. DS0000071783.V370499.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive was based on their individual needs. The principles of respect, dignity and privacy were put into practice. Medication procedures were generally well managed by staff that have the necessary competencies. EVIDENCE: Four care plans were looked at to ensure care was delivered as described. The information was sufficient, although the risk assessments to keep people safe could include more details. Risk assessments were looked at regarding one person who was visually impaired, they did not include maintaining a safe environment (person’s bedroom) to ensure the person would not trip and fall. There was good details recorded regarding the importance of informing the person about how there food was arranged on the plate and ensuring there was a plate guard to help with maintaining the person’s independence. DS0000071783.V370499.R02.S.doc Version 5.2 Page 12 There were no risk assessments with regard to the use of bed rails. There should be an agreement with the person or there relative to confirm all risks had been explained. The manager said regular checks to ensure the bed rails were fitted correctly takes place although this was not recorded. Daily records were seen on all care plans looked at most of the entries were of a good standard, although some were illegible. The manager should give some guidance to staff with regard to the standards expected when recording information. There was good evidence to confirm people’s waterlow assessments had been completed, however the information was not transferred onto the care plan. An example of this was a person who was receiving care from the district nurse. There was no care plan to describe how staff should care for the person’s skin to keep in good condition. Moving and handling risk assessments could be developed further to describe the details of transfers. It should include the type of equipment to be used when hoisting, and moving people up and into the bed, and how people were moved when bathing and toileting. There were good examples of people being treated with respect, staff spoke quietly to people and informed them about meals and activities in an appropriate manner. People were addressed by their preferred name and this was clearly recorded on the care plans looked at. One relative said he was pleased with the way the home cared for his mother. He said staff always kept him informed about changes to his mother’s condition. A district nurse said she visited the home twice a week and found staff to be pleasant, although she did say that on a few occasions’ staff seemed to have limited knowledge of the reasons for her visit. She said staff did not respond quickly to requests for assistance and she was left waiting in the entrance for a number of minutes. The home understands the need to comply with the administration, safekeeping and disposal of medication including controlled drugs. Medication was administered from a trolley which was stored in the office. Staff had the necessary competencies to administer medication safely. The current Medication Administration Record (MAR) charts were looked at. Good records were made at the time medication was administered; this was demonstrated by the lack of any gaps on the MAR charts. A list of all staff that has the required competencies to administer medication should be kept in the front of the MAR. This means it is possible to identify who was involved in administration if a query or problem occurred. One person’s medication was recorded incorrectly for two items prescribed. The digoxin was recorded as 125mg on the MAR although the dispensing label DS0000071783.V370499.R02.S.doc Version 5.2 Page 13 said 65.5mg. Ramipril should have been prescribed one daily but the MAR records showed one twice a day. Medication must be checked to identify any discrepancies when it is booked in to ensure the correct dosage is administered. Eye drops were stored appropriately in the fridge, however they should be dated when they are opened to ensure they are not used past the 28 days which is stated by the manufacturer The controlled drugs cabinet was suitable for use; this means there was a safe system for the storage of these medicines. The senior carer sad they did not have anyone who required controlled drugs, but she understood how controlled drugs must be stored and administered. . DS0000071783.V370499.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to socialise with family and friends and mealtimes were well managed. EVIDENCE: Activities were arranged which were suitable for the people who live at the home. The Inspector observed games of bingo taking place in the main lounge, and staff spent time talking to people about the things they liked to do. A record was seen which detailed the activities that had taken place although involvement was limited due to the amount of people currently living at the home. As more people are admitted into the home the providers will need to consider the arrangements for activities including allocating an activity coordinator. Visitors to the home said they were always made welcome and they could visit their relative in the main communal areas or in their relative’s bedroom. People said they were able to exercise their choice of where to spend their time. One person said they liked having a lay in, getting up mid-morning, and DS0000071783.V370499.R02.S.doc Version 5.2 Page 15 going to bed a little bit later. Another person said they liked spending time in their bedroom watching TV. Most people said they were admitted from the locality and had chosen to live at Victoria Lodge so that they could maintain links with family and friends. Mealtimes were well managed and the food looked appetising and sufficient. People said they had enjoyed there meal of liver and bacon with mashed potatoes and vegetables. The cook said the menus were arranged around the likes of people who use the service, and while there was only a limited number of people living in the home menus were agreed daily. The menu was not displayed and people seemed unaware of what was being prepared for lunch and if an alternative was on offer. The cook kept a record of the food delivered daily including the amount of food consumed. The records were looked at and they did not confirm where people had chosen the alternative choice. The record showed most people had porridge and toast for breakfast. There appeared no option for people to choose a cooked breakfast, although the cook said one person had a boiled egg. The cook prepares peoples evening meal before finishing work mid afternoon. The records show most evening meals was soup and sandwiches, and the cook said that was what people wanted. The providers will need to consider the catering arrangements as more people are admitted into the home, to make sure a varied menu can be provided throughout the day. DS0000071783.V370499.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were able to express their concerns, and have access to an effective complaints procedure, and were protected from abuse, and had their rights protected. EVIDENCE: The home had a complaints procedure that was available to people and visitors. The procedure was also referred to in the information given to new people, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection was included in the procedure, although the address and telephone number needed to be updated. The manager and information contained in the AQAA (Annual Quality Assurance Assessment) confirmed that no complaints had been made since the homes registration in April 2008. People said they would speak to the manager if they had any concerns, and relatives confirmed they were aware of the complaints procedure. The home had there own Safeguarding Adults and Whistleblowing policy, although it did not include all the agencies that needed to be involved if there was an allegation of abuse. It must be reviewed and updated to reflect the contact details of all the agencies involved in any investigations. The manager had not obtained a copy of the South Yorkshire Safeguarding Adults DS0000071783.V370499.R02.S.doc Version 5.2 Page 17 procedures, although they acted swiftly to obtain a copy, and had downloaded a copy by the second day of this inspection. The manager said she would investigate fully any allegations of abuse and would follow the necessary procedures if any were substantiated. The manager holds discussions with staff to talk over issues and how to recognise different forms of abuse, although staff requires training in the protection of vulnerable adults. DS0000071783.V370499.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23, 24, 25 & 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered provider continues their refurbishment of the home to ensure the environment is safe and suitable for service users to spend their time. EVIDENCE: The registered provider has made a number of improvements to the environment since their registration in April 2008 and they have a clear refurbishment plan which they intend to implement as soon as practicable. New carpets have been fitted in 8 bedrooms and new sink units have been fitted throughout. There has been a complete redecoration programme of bedrooms. The manager said that there were plans to re-carpet the entrance hall, stairs and landings. Bathrooms were to be refurbished and a new shower facility is to be installed in a first floor bathroom. A staff room is being created DS0000071783.V370499.R02.S.doc Version 5.2 Page 19 in a room on the first floor to enable staff to take a break away from main area. Equipment to move people safely and other aids and adaptations were available, and people’s bedrooms were personalised to individual taste. The home is currently cleaned by care staff as there was no domestic staff employed. The registered providers will need to review the domestic arrangements as more people move into the home. DS0000071783.V370499.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home were sufficiently trained, and in sufficient numbers to support the people who use the service. Recruitment policies are generally followed ensuring the safety and protection of people who live at the home. EVIDENCE: Staff rotas were looked at to assess if sufficient numbers were available to meet the needs of the people who use the service. Rotas should include the full name and designation of staff working at the home. Two staff were on duty during the day with one waking night staff and one sleep in staff. The manager should continue to monitor the staff numbers as occupancy increases. Staff have sufficient skills to meet the needs of people who use the service, although some gaps in there knowledge could pose a risk to people. The manager said distant learning training in areas of infection control and food hygiene had been arranged for September. However training in safeguarding adults, moving and handling and health and safety still need to be arranged. The AQAA confirmed that staff were enrolled and working towards NVQ awards in care, although they do not meet the required 50 of staff who had achieved NVQ’s. The manager said that all staff attend the ‘Skills for Care’ induction and completed inductions were seen on most files looked at. Staff confirmed that DS0000071783.V370499.R02.S.doc Version 5.2 Page 21 they had been given opportunities to develop their skills by watching training videos, and completing a test at the end. Staff said they enjoyed working at the home and felt supported by the manager. Six staff recruitment files were looked at to check how people were protected by robust procedures. The files contained applications forms and references, although three files did not have the required last employer reference. There were no interview notes which should confirm the manager had checked gaps in employment history. All files contained CRB (Criminal Record Bureau) checks and POVA (Protection of Vulnerable Adults) checks. DS0000071783.V370499.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has sound management practises, and peoples views were actively sought to improve the service. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The manager was able to demonstrate her ability to manage the home. She was appointed into her current position in April 2008, although she has not submitted an application to be the registered manager. She has achieved the RMA (Registered Managers Award) and was continuing to develop her knowledge by attending training provided by the organisation. She operates an DS0000071783.V370499.R02.S.doc Version 5.2 Page 23 open door policy to ensure she was accessible to staff and people that use the service. Relatives and people who use the service spoke highly of the manager and said she was very caring, well organised and competent. The manager has responsibility for the supervision of all staff employed at the home, most staff had only worked at the home for a few months, and therefore supervisions had not taken place. People who use the service were able to manage their own finances although most were assisted with this process. A number of peoples financial records were looked at, the records were accurate and there were clear auditing procedures to ensure peoples monies are managed in their best interests. Quality assurance systems were in place, although they had not been tested as people have only recently moved into the home. The manager said they intend to survey people twice yearly to gain their views. The manager said a monthly quality audits takes place to assess areas such as the environment, nutrition, recreation, laundry and care planning, although some had not yet been completed. The registered provider undertakes monthly visits (regulation 26) and completed reports were looked at during this inspection. Accident reports were analysed by the manager to ensure risk assessments were developed where required. Maintenance and service records were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures were in place and service records were looked at and were current, ensuring the safety of people who use the service. DS0000071783.V370499.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 3 DS0000071783.V370499.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 1st Inspection of the service 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 15 Requirement Care plans must include comprehensive risk assessments to enable staff to maintain people’s safety. Risk assessments must be established which bed rails are in situ. This must include signed agreements from the person or their representative. Medication must be checked when received to ensure the record and the prescription describes the correct dosage. This means people will receive the correct medication as prescribed. Staff must receive training in the protection of vulnerable adults. Gaps in employment history should be checked on all staff employed at the home. Employment references must be obtained for all staff to ensure the safety and protection of people who use the service. Timescale for action 01/01/09 2. OP9 13(2) 01/11/08 3. 4. OP18 OP29 13(6) 18(1) 19 Schedule 2 01/11/08 01/11/08 DS0000071783.V370499.R02.S.doc Version 5.2 Page 26 5. OP30 18 Staff must receive training in areas of safeguarding adults, moving and handling and health and safety to ensure they have the required skills and competencies to keep people safe 01/01/09 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. Refer to Standard OP1 OP2 OP9 OP15 Good Practice Recommendations The Service User Guide should be developed in formats that are user friendly, including the use of pictures and larger print. People should have a statement of terms and conditions of residence (contract) at point of admission and they should be made available for inspection. Eye drops should be dated when opened to ensure they are administrated as described by the manufacturer. Menus should be displayed in the dining area daily and should include the alternative choice of main course and dessert. Catering arrangements should be kept under review to ensure a varied menu can be provided for evening meal. This should include cooked hot food and an alternative dish. The ‘Elder Abuse’ policy must be reviewed and updated to reflect the contact details of the multi-agencies involved in any safeguarding investigations. Staff rotas should include the full name and designation of all staff. A minimum of 50 of staff who are NVQ level 2 qualified should be employed at the home. The manager should make an application to be the registered manager with CSCI. 5. 6. 7. 8. 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