Inspection on 14/11/07 for White Lodge Residential Home

This inspection was carried out on 14th November 2007.

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

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

Other inspections for this house

White Lodge Residential Home 09/05/08

White Lodge Residential Home 14/12/06

White Lodge Residential Home 06/02/06

White Lodge Residential Home 15/08/05

White Lodge Residential Home 13/12/04

White Lodge Residential Home 06/07/04

White Lodge Residential Home 16/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE White Lodge Residential Home 67 Havant Road Emsworth Hampshire PO10 7LD Lead Inspector Ian Craig Unannounced Inspection 14th November 2007 09:30 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 White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Lodge Residential Home Address 67 Havant Road Emsworth Hampshire PO10 7LD 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) 01243 375 869 WLCareltd@aol.com Mrs Jill Cathryn Dowsett Mrs Kay Ellen Smy Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Agreement to accommodate one named service user D.O.B 7/10/1945 in the category P.D (Physical Disability) 14th December 2006 Date of last inspection Brief Description of the Service: White Lodge is a residential care home providing care and accommodation for up to twenty-five service users aged 65 years and over; situated on the Havant Road, in Emsworth. The home is privately owned. White Lodge is a detached building set back from the main road. There are parking facilities and gardens to the front and rear of the home. The home has twenty-five single bedrooms, sixteen of which have an en suite toilet facility. The home’s weekly fees range from £331.02 to £574.00. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection involved two persons: the CSCI inspector and an Expert By Experience. The Expert By Experience is a relatively new scheme, which involves an assessment of the service by someone who has an experience of the relevant care setting. At this inspection the Expert By Experience looked at the premises, talked to residents and relatives of residents, joined residents for the midday meal and spoke to and observed staff. The findings of the Expert By Experience are included in this report. The inspector also toured the premises, spoke to residents, and spoke to two staff. Records, documents, polices and procedures were also looked at. Discussions took place with the manager, the deputy manager and the owner, Mrs. Dowsett. Survey forms were sent to residents and relatives to ask their views on the service provided by the home. Four of these were returned and information in these has been used as evidence for this report. Service providers are required to complete an Annual Quality Assurance Assessment, which is returned to the Commission. Information contained in this document has been used for this inspection report. What the service does well: White Lodge is clean and well maintained with a homely atmosphere. Residents are able to personalise their bedrooms, several of which were noted to have numerous personal belongings related to hobbies and interests such as musical instruments. Comments by residents and relatives were overwhelmingly positive and include the following: • “A clean environment and clean clothes. Good quality meals with choice. Entertainment and exercise for residents. Library of large print books regularly changed. Hair care and chiropody. Good quality care by experienced staff.” • “The staff are very caring and kind to my relative, spending time with him/her when they can. They care for her physical and bodily needs well under difficult circumstances. They are always cheerful. The food is very good. The cleanliness is good. As my father/mother has got older White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 6 they have taken on more work to give him/her a good quality of life for which I am most grateful.” Comments also referred to the skills of staff in meeting the care and health needs of the residents. The Expert By Experience reported: One of the residents said that ‘it is very homely, relaxed and not regimented’, and another who had only been there for 2 weeks remarked, ‘There is a very nice ambience here.’ Three different visitors I spoke to also mentioned how homely it is and one of them whose mother had just arrived there commented ‘I was struck by the calmness about the place.’ I observed that the staff use a warm friendly manner towards the residents to which the latter responded well. Staff have access to a variety of training courses including NVQ levels 2, 3 and 4 in care. Each person has a care plan, which they have agreed to. Activities are provided but there is scope to develop this further. Residents have a choice of good quality food. The home’s management are receptive to feedback from residents and their relatives about how the home could improve. It was also apparent that the home’s management are willing to make changes based on the findings of this visit. The home’s AQAA form shows that the home’s management has plans for improvement in the near future. What has improved since the last inspection? The home continues to develop its staff training programme and has introduced additional training in adult protection procedures. The numbers of staff trained to NVQ level 2 or higher has increased since the last inspection. The laundry has been refurbished with new washing machines and driers and the floor has been replaced. Health and safety checks have increased. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 7 What they could do better: 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. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive information about the service and are able to visit the home to help them decide if it meets their needs. The home assesses each person’s needs before coming to a decision as to whether or not the person is suitable for White Lodge. EVIDENCE: Residents and residents’ relatives confirmed that they received information about the service, although 3 of the 4 respondents state that they do not know how to make a complaint. It was also confirmed that contracts are given to White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 10 residents. A sample of contracts signed by the resident or their relative were seen. The complaints procedure is contained in the contract. A letter and a small brochure are supplied to prospective residents, which gives details about the service provided by the home. The home also has a Statement of Purpose and a Service Users’ Guide. Opportunities are available for prospective residents and/or their relatives to come and have a look around the home to decide if it is the right choice. Records show that following a referral for possible admission to the home an assessment of need is carried out and recorded. These are called, ‘Pre Admission Assessment.’ This involves a representative of the home visiting the service user to carry out an assessment. For those referred by social services, the home obtains a copy of the care manager’s assessment and care plan, as well as any other relevant details such as medical information from hospitals. The pre admission assessments contain information about the needs of residents including their personal preferences such as cultural and religious needs. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ individual needs are detailed in care plans, which they have agreed to. Health needs are met with the exception that dental checks are not carried out on a regular basis. Medication procedures are generally of a good standard with the exception for one medication, which has the potential to be unsafe. Residents’ are treated with dignity and respect. EVIDENCE: White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 12 Records show that each resident has a care plan completed within 2 or 3 weeks after admission to the home. The plans give details of how needs are to be met with guidance for staff to follow in the following areas: • Mobility • Washing and dressing • Continence • Social needs and interests • Dietary needs • Mental and emotional health • Eyesight and hearing • Sleeping • Lifting and handling • Hobby care plan Personal preferences and religious needs are recorded. A record is not maintained of the preferred rising and going to bed times of the individual residents although a resident confirmed that he/she is able to exercise choice in this area. Health needs are included in each person’s records showing that weight, blood pressure and blood sugar levels are monitored. Evidence also shows that contact is made with general practitioners and district nurses when needed. A general practitioner and a district nurse were visiting residents at the time of the visit. Records show that regular eyesight checks take place. There is no evidence that regular dental checks take place; this is arranged “as and when needed” according to the home’s management. Residents and relatives confirm that their health and personal care needs are met. A hairdresser was visiting the home at the time of the inspection. One resident stated how much she likes having her hair washed and set. Medication procedures were looked at. Records of medication administered to residents are maintained by the responsible staff who enter a signature to acknowledge that medication has been administered. Procedures for holding and recording temazepam need to change to meet current guidelines. Medication is administered as prescribed and staff sign a record each time this occurs. Procedures for temazepam need to improve as the details of the medication on the administration recording sheet supplied by the pharmacist do not tally with the home’s practice and the prescription. Quantities of medication from previous supplies are used and had not been returned to the pharmacist. The home administers the medication by two staff who both sign a record of this, but do not record the quantity of medication dispensed and the amount remaining. This is a recommended procedure. The White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 13 amounts being held in the home should tally with the record of the amounts remaining. Medication records are not securely stored and were left on top of the medication trolley in the office, which was unlocked for long periods. It was also noted that confidential medical correspondence was displayed on the office notice board. Residents and there relatives describe that the staff treat the residents with dignity. There are options for residents to have a key to the lock on their bedroom door for privacy and security. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there is an activities programme there is evidence that this is an area that could be developed so that residents have a more active and interesting life. A nutritious and balanced diet is provided. EVIDENCE: There is varying evidence regarding the provision of activities. Survey forms from residents and relatives show satisfaction with the level of activities but also suggest that this is an area that can be improved. The Expert By Experience made the following comments: White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 15 All of the 6 residents and 3 visitors I spoke with reported that they had no complaints, apart from a lack of activities and outings organised. One resident said, ‘I wish there were more activities.’ The home has an activities programme, which is displayed and includes movement to music and arts and crafts. Outings for residents are mainly via resident’s relatives with the occasional trip out organised by the home according to the home’s management. The Expert By Experience suggested that a staff member with dedicated time to organise and/or facilitate activities might be beneficial to the residents. It was also suggested that the provision of a radio or music system in the lounges might be stimulating for the residents. The home has a portable radio/CD player in the office, which is used by the residents. Residents were observed receiving and going out with visitors. A relative commented that the home has a supply of books for residents to read. Several residents have a daily newspaper delivered. It was clear from discussion with residents that there is choice in how they can spend their time, with some preferring to stay in their rooms and others in the lounge. Bedrooms contain items relating to hobbies and interests including musical instruments which one resident plays. Residents confirmed that they are able to go to bed and get up at the times they wish. One resident described how he/she likes to get up early and that the staff always help him/her and bring a cup of tea. The routines and staffing arrangements, however, mean that there are limitations on the times that residents can get up before 9am. At 9am a third staff member comes on duty. The home has a menu plan, which is displayed, in the home. Residents confirmed that they are given a choice about what to eat. The Expert By Experience makes the following comments: The L-shaped dining room was light and pleasantly laid out with damask tablecloths, tablemats and huge damask napkins. The lunch was Roast Chicken, stuffing balls, roast potatoes, broccoli, cauliflower and peas with gravy followed by Arctic Roll for pudding. The meal was well-cooked and wellpresented and tasted good. Water only was served. The owner helped serve a lady her food and warned her of not touching her hot plate. The residents were not rushed at all, and were later offered coffee or tea at the table. The week’s lunch and supper menus were displayed on a notice-board, but were a little difficult to work out for an elderly person. There was no Today’s Menu separately. A choice of three meals was given to residents in advance for lunch and supper. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home listens to, and acts on, any concerns of the residents or their relatives. Residents are protected from any possible abuse. EVIDENCE: The home’s complaints procedure is given to residents and their relatives in either the contract and/or the Service Users’ Guide. The feedback from several survey forms, referred to in the Choice of Home section, indicates that the home may need to remind residents and relatives of the complaints procedure. Records are maintained of any concerns or complaints raised and of the outcome of dealing with the matter. Residents and relatives reported that the home’s management deal with and resolve any complaints or concerns. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 17 Staff receive training in the principles of protecting vulnerable people from abuse. This was confirmed from training records and discussions with staff. The home has its own policy for dealing with suspected abuse as well as a copy of the local authority social services procedure. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well maintained, comfortable and homely environment. EVIDENCE: The home is clean and well maintained although the Expert By Experience noted wear and tear in several areas and the need to dust furniture more thoroughly. There was an absence of any unpleasant odours. The lounges are comfortable, homely and well furnished. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 19 Each resident has a single bedroom. These are also decorated to a good standard and contain numerous personal possessions. Residents are able to bring their own furniture to their rooms. Residents described how they like their bedroom. The home is surrounded by well maintained gardens, which residents can see from their rooms and from the communal areas. A tree has been chosen by a residents and planted by the home outside her window, which she showed the inspector. Several residents have a key to their bedroom door for privacy. Residents are also able to have their own telephone line to their room. Bathrooms are clean and well appointed although the Expert By Experience noted that paper towels in one bathroom were on the window sill and not near the wash basin. The home has a passenger lift which residents and visitors were seen to use. Hoists are available for those with mobility and lifting needs. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not deploy sufficient staff at key times of the day having the potential to restrict residents’ preferred daily routines, placing too many demands on staff, and heightening the risks associated with infection control. The home’s recruitment procedures do not give residents adequate protection. Staff receive training in the care of older persons. EVIDENCE: The home’s staff rota was examined and discussions took place with the home’s staff and management about the staffing levels. The home’s staff and management expressed the view that the home deploys sufficient staff. There was evidence to show that the staffing levels in the period 7.30am to 9 am need to be reviewed when only 2 staff are on duty to care for the residents and prepare and serve the breakfasts. Residents are White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 21 helped with getting up from 9am when an additional third member of staff comes on duty. Three staff are on duty from 9am to 4pm. Night time staffing consists of two ‘waking’ staff. Staff confirmed that they are supported in their work and that there is a team spirit at the home. Supervision and appraisals take place. The home is still developing its induction procedures for newly appointed staff. More than half of the staff are qualified at NVQ level 2 or above, and three staff are studying the qualification at the time of the visit. Staff are also able to complete NVQ levels 3 and 4. Training records show that staff have attended the following courses: first aid, dementia, health and safety, medication, infection control, fire safety, epilepsy, coping with aggression and risk assessment. Residents and relatives describe the staff as friendly, helpful and kind. Procedures for recruiting staff were examined for three staff. Each person had completed an application form and two written references had been obtained one of which is from the most recent previous employer. The home’s management are not clear about the procedures for carrying out criminal record bureau (CRB) and protection of vulnerable adults (POVA) checks, and are following the outdated guidance that checks are portable from employer to employer. This was further confused by the fact that the CRB applications are then carried out some weeks after the person starts work. One person had been working in the home since early June 2007 without a CRB or POVA first check being obtained. The manager stated that an application for these checks had been made 3 –4 weeks prior to the inspection. A letter was sent by the Commission immediately following the inspection, outlining the urgent action the home must take. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are many positive aspects about the home’s management but improvements are needed to ensure that the home is managed to a standard that protects residents and their valuables from possible risks. EVIDENCE: The manager is qualified at NVQ level 4 and has the Registered Manager’s Award. Staff describe the manager as supportive and approachable. Residents’ White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 23 relatives also gave favourable comments about the home’s management being helpful and supportive. The inspector found the home’s management to be receptive to suggested improvements, and committed to addressing those areas found to be in need of attention. There are systems for auditing the home’s performance when a representative of the owner makes a monthly check and report about the home. Surveys have been sent to residents and their relatives to ask their views about the home’s service but this was 2 years ago. There are plans to repeat the process. An annual development plan is not used. The home does not hold any resident’s finances or valuables for safekeeping. The Expert By Experience and the inspector observed residents’ details on display in the hall at a work station, and records were left out in the office with the door wide open, which is very close to the front door. Keys were not securely stored. The home’s appliances and equipment are tested and serviced by suitably qualified persons. Records show that staff receive training in fire safety and that fire drills take place. The weekly testing of the fire alarms has not taken place since 28/08/07. Staff receive training from qualified trainers in the following: first aid, moving and handling, infection control and food hygiene. Measures have been taken to protect residents from possible scalds from hot water by the use of temperature controls on taps. The home has not carried out a risk assessment of the possibility of residents falling from first floor windows, which do not have restrictors on them. Risk assessments have been carried out regarding the possibility of residents receiving a burn from individual radiators. These need to be reviewed as a matter of priority as the risk assessment in one case did not reflect the identified high risks. This is an outstanding requirement from the previous report. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 3 1 1 White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 13(1)(a) Requirement Arrangements must be made so that residents are able to have regular dental checks and treatment. A record must be maintained of this. Medication administration recording sheets must accurately reflect the resident’s current prescription. This is a partial repeat of the requirement made for the inspection of 14/12/06. Stocks of medication from previous supplies must be returned to the pharmacist. 3 OP27 18(1)(a) The home must review its staffing levels for the period 7.30am to 9am to ensure that there are sufficient numbers of staff on duty to meet the needs and wishes of the residents and for reasons of infection control. Staff must not start work in the home until a Criminal Record DS0000043778.V350066.R01.S.doc Timescale for action 14/01/08 2 OP9 13 (2) 20/12/07 14/01/08 4 OP29 19 14/11/07 White Lodge Residential Home Version 5.2 Page 26 Bureau check has been applied for and a Protection of Vulnerable Adults ‘first’ check has been obtained. This is a partial repeat from the inspection of 14/12/06. 5 OP35 13(6) Measures must be taken to ensure the security for residents by the safe storage of keys. Residents’ personal medical and other records must be securely stored in accordance with the Data Protection Act. Risk assessments must be reviewed, recorded, and action taken to protect residents from possible burns from unguarded radiators. This is a repeat of the requirement of 14/12/06. Risk assessments must be carried out, recorded, and action taken to prevent possible falls from first floor windows that do not have opening restrictors. 8 OP38 23(4)©(i) The fire alarm must be tested on a weekly basis and a record maintained. 14/12/07 14/12/07 6 OP37 17(1)(b) 14/12/07 7 OP38 13(4)(a) 14/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 27 1 OP9 Staff should follow Royal Pharmaceutical Guidelines for the administration and recording of controlled medication when administering temazepam. White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 White Lodge Residential Home DS0000043778.V350066.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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