Inspection on 05/02/08 for Wilton Lodge

This inspection was carried out on 5th February 2008.

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

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

Wilton Lodge 27/04/09

Wilton Lodge 22/05/08

Wilton Lodge 23/08/07

Wilton Lodge 13/06/06

Wilton Lodge 31/10/05

Wilton Lodge 24/06/05

Wilton Lodge 21/12/04

Wilton Lodge 29/06/04

Wilton Lodge 29/01/03

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

CARE HOMES FOR OLDER PEOPLE Wilton Lodge 55 Wilton Road Bexhill-on-sea East Sussex TN40 1HX Lead Inspector Rebecca Shewan Unannounced Inspection 10:00 5 February 2008 th 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 Wilton Lodge DS0000021290.V352852.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. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilton Lodge Address 55 Wilton Road Bexhill-on-sea East Sussex TN40 1HX 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) 01424 216250 www.angelhealthcare.co.uk Angel Healthcare Ltd Vacant Care Home 12 Category(ies) of Dementia (12) registration, with number of places Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the maximum number of service users to be accommodated is twelve (12). That service users accommodated will be aged 65 years, or over on admission. That service users accommodated will have a dementia type illness. That a maximum of two (2) service users between the ages of 55 and 65 years, who would otherwise fall within the main category, may be accommodated at Wilton Lodge at any one time. The home is not registered to accommodate service users with primary symptoms of drug or alcohol abuse, or acquired brain injury. 23rd August 2007 5. Date of last inspection Brief Description of the Service: Wilton Lodge is a Victorian terraced property set close to the seafront and town centre in Bexhill-on-Sea. There are bus routes and a mainline railway station, within a short distance. The home, one of four care homes owned by Angel Healthcare Limited, is registered to provide residential and social care for twelve older people with dementia type illnesses. Accommodation is provided on three floors. Stair lifts are fitted, providing assisted access to rooms on the first and second floors. There is a staff sleep-in room on the fourth floor that doubles as the managers office. At the rear of the premises is a small, private courtyard for use by residents. Potential service users find out about the service via word of mouth, Angel Healthcare website, brochure, contacting the home direct, through care managers and placing authorities. The ranges of fees charged (at the time of this report) were £410 to £560 per week. Extras are charged for hairdressing (£6.50 - £20 dependent on treatment), chiropody (£8 - £12) and toiletries (varied). Wilton Lodge DS0000021290.V352852.R01.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 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection took place during the morning and afternoon of the 5th February 2008. Incident reports and previous inspection reports, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took five and three quarter hours. Records such as care plans, staff files, medication records and Health and Safety records were also viewed. Ten service users were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Deputy Assistant Manager, two staff and one service user (known as residents) were spoken with. The CSCI also conducted Service User, Relatives and staff surveys. Of which nil were returned. What the service does well: What has improved since the last inspection? Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 6 People who use the service have been safeguarded from some areas of hazard within the home, this is supported by suitable risk assessments now being in place. Residents benefit from a staff training programme that is now on going and appropriate to the level of needs of people who use the service. 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. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 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 Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new resident’s benefit from the home processes for assessing care needs, with services being offered to only those resident’s whose needs can be met. Improvements to the homes Statement of Purpose, Service User Guide and contracts (Statement of Terms and Conditions) are required in order to provide new and existing residents with the most up to date information regarding the fees paid for the services they will/do receive. EVIDENCE: The home’s Statement of Purpose and Service User Guide were viewed. It was evidenced that the Statutory Requirement that these documents are up to date and provides accurate information about the home and the service it provides, remains unmet. The documents do not provide information about the scale of charges/fees charged by the home. This Statutory Requirement remains unmet for the fourth consecutive inspection. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 9 Residents individual contracts were viewed and it was evidenced that each resident has a contract in place. The Statutory Requirement that each service user is provided with a copy of terms and conditions, which meets NMS 2 and evidence of this is kept in the home remains unmet. In that contracts were not being kept up to date and did not reflect actual fees being charged. This Statutory Requirement remains unmet for the third consecutive inspection. The home’s Deputy Assistant Manager carries out pre- admission assessments. Copies of care management assessments from a placing authority, where this exists, are also obtained. Records inspected showed that pre-admission assessments are carried out on all new and potential residents. It was evidenced that one of the five Pre Admission Assessments viewed was recorded on an A4 lined piece of paper, which also had a ‘Christmas to do’ list written on it. Therefore a Recommendation for good practice has been made. The Deputy Assistant Manager confirmed that any potential resident whose needs could not be met, would be declined the services of this home. Intermediate/rehabilitative care is not provided by the home. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and staff do not benefit from a comprehensive care plan system. Residents are offered a good provision of health care and personal support by the home. The lack of suitable risk assessments and review of electrical equipment and wiring leave residents at risk of harm. Medication administration recording errors leave residents at risk of being under medicated. All care is administered in ways that protects residents privacy and dignity. EVIDENCE: Care plans were sampled and these were found to be brief in content and devised as part of a tick box format. Monthly reviews of these documents were evident. Care plans covered all aspects of resident’s needs but due to the nature of the tick boxes, they are not written to allow the assessor to gain a good overview Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 11 of individuals medical, social and personal care needs i.e. care plans viewed showed that some service users require assistance with washing and dressing, eating and/or external socialisation. The nature of the tick box format however, did not give the assessor clear or specific details of the service users needs or their level of limitations. It was evidenced that the Assistant Deputy Manager has revised some of the care plans in order to make them more comprehensive in detail. Records viewed highlighted that this has not been completed for all residents. It was evidenced that the Statutory Requirement that care plans must include mobility, health, nutrition and dietary needs, communication, financial, social, recreational and therapeutic needs has not been met in full. This Statutory Requirement remains unmet for the third consecutive inspection. It was evidenced that the Statutory Requirement that the home also review service users needs in terms of sharing rooms and ensure that people do not share bedrooms unless they have chosen to do so and it is in keeping with their needs has not been met. The Assistant Deputy Manager reported that residents who currently share a bedroom had agreed to this prior to admission but that no further revision of this arrangement, has taken place since that time. This Statutory Requirement remains unmet for the third consecutive inspection. Daily care records were maintained. It was observed that these are recorded on an A4 lined piece of paper, which are named, dated and signed. The Assistant Deputy Manager reported that plans are in place to produce a more appropriate format for recording daily entries. The health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. Residents are registered with one GP from one of the two local surgeries. Resident’s are encouraged to attend the GP surgery where able and home visits are conducted when necessary. Referrals to the Optician, Occupational Therapist, Physiotherapist, Dietician and Audiologist are made via the GP or the hospital. Residents access private dental surgeries, where able, and access to a domiciliary dentist is also available. A visiting Chiropodist attends residents six weekly, with additional appointments being arranged if necessary. It was evidenced that the Statutory Requirement that full and comprehensive risk assessments are undertaken for each service user covering all aspects of care and safety has been met. It was observed that comprehensive resident risk assessments are now in place. It was evidenced that the Statutory Requirement that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated has not been met. In that equipment and facilities in the home are maintained to a safe standard including electrical wiring and electrical equipment has not Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 12 been conducted. This Statutory Requirement remains unmet for the fourth consecutive inspection. The home has good, clear procedures in place for the monitoring and recording of all drugs entering and leaving the home. A monitored dose box system is in place for many medications prescribed. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Administration Record (MAR) sheets were viewed for all residents and it was noted that multiple ‘F’ omission codes had been used. These were recorded as ‘unable to take’, ‘out of stock’ and ‘not given’, leaving the residents at risk of being under medicated and at risk of side effects associated with this. Therefore an Immediate Requirement was made. It was evidenced that the Statutory Requirement that the Home must ensure that it has a system in place to evidence staff competency to administer medication as part of a medication induction and on an ongoing basis has not been met. Medication training for staff was provided for staff prior to the last inspection of August 2007. There was also no documented evidence to support that a system has been implemented to review staff competency in medication administration. This Statutory Requirement remains unmet for the third consecutive inspection. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. There is a Privacy and Dignity policy in place. The protection of residents privacy and dignity is highlighted as one of the main aims of the home in its Statement of Purpose and Service User Guide. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 13 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): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Social contact with friends and relatives is positively encouraged and in accordance with residents wishes. The home does not provide a daily wide range of social, cultural and recreational facilities on a daily basis, meaning that residents are unable to enjoy a full and stimulating lifestyle. Dietary and nutritional needs are met, with resident’s choice and wishes relating to diet and food being respected. EVIDENCE: It was evidenced that the Statutory Requirement that the home evidences through service user assessments and cares plans that activities being provided are in keeping with their needs and wishes and are consistent has not been met. It was noted that activities are currently arranged by care staff. The Assistant Deputy Manager and care staff reported that activities are only arranged ‘when they have time’. As a result there is no published list of activities for residents to refer to. This Statutory Requirement remains unmet for the third consecutive inspection. At the time of the inspection it was observed that no activities were taking place throughout the duration of the inspection process. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 14 Activities conducted are a visiting music person (who plays keyboard and sings songs) attends the home monthly, whilst staff conduct bingo and quizzes. Records found in care files sampled had recorded when residents had entertained a visitor and did not detail specific activities. Therefore a recommendation for good practice has been made. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion if they wish. Discussions with the Assistant Deputy Manager highlighted that although the current residents fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Contact with family and friends is positively encouraged, with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Residents are treated with respect and there was a good rapport observed between staff of the home and residents. The home’s menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and residents guests are also welcome to have meals at the home. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 15 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 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: There is an established complaints procedure in place. The Assistant Deputy Manager reported that no complaints have been received since the previous inspection of August 2007. Both Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. The home has a copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. Staff have attended training in the Protection of Vulnerable adults, this was evident from the staff files that were viewed. There have been no safeguarding alerts since the previous inspection of August 2007. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well maintained and hygienic environment. The size and layout of the home is unsuitable for the current dependency levels of residents, leaving staff and residents at high risk of harm. EVIDENCE: The home is well maintained and all areas of the home, including the garden, are accessible to residents. Staff reported that there was a high level of risk associated with residents having free access to the kitchen area. This has been appropriately risk assessed by the Assistant Deputy Manager, though care staff reported that when they are cooking meals there could be, at times, up to five residents in the kitchen with one carer. This is unsafe and leaves the residents and staff member at high risk of injury. Therefore a Statutory Requirement has been made. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 17 There is a daily cleaning schedule in place, which is conducted by care staff. There is an infection control policy in place and staff have received recent training in infection control procedures. This was evidenced from staff training files viewed and staff spoken with. Staff were observed adhering to infection control procedures, particularly at meal times. It was evidenced that the Statutory Requirement that the Home must consult with the EHO and ensure that the standards of cleanliness in the kitchen are in keeping with regulations has not been met. The Assistant Deputy Manager reported that the EHO had not been contacted and no deep cleaning of the kitchen area had taken place since the inspection of August 2007. This Statutory Requirement remains unmet for the second consecutive inspection. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 18 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet many of the needs of current residents. Staffing numbers are to be improved to ensure that residents needs are met more effectively. Staff are recruited in an effective manner, in order that residents are safeguarded from the risk of harm. Staff receive appropriate training to conduct their jobs effectively. EVIDENCE: It was evidenced that the Statutory Requirement that the number of staff on duty on each shift must be reviewed using the Guidance document issued by the Department of Health (DOH) Care Staffing in Care Homes for Older Persons. Also the number of staff rotered for each duty must be based on the dependency of each person rather than the number of people currently accommodated has not been met. The Assistant Deputy Manager reported that staffing numbers have not changed from the previous inspection of August 2007. Plans are in place for a ‘Supper Assistant’ to be employed to assist with kitchen duties in the evening. It was observed that three care staff are on duty during the morning period. During this time one care worker is completing care duties, whilst the other two care workers are conducting laundry and/or domestic duties. As previously mentioned in the Environment outcome group, Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 19 care staff find this to present a risk of hazard to both staff and residents. This Statutory Requirement remains unmet for the fourth consecutive inspection. The home has a permanent staff team of ten carers. Five staff are trained to National Vocational Qualification (NVQ) level 2 in care. Additionally two carers have been signed up to undertake NVQ level 2 in care training, which will commence in the coming months. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. Many of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. The home has an Equal Opportunities policy in place and is an equal opportunities employer. It was evidenced that the Statutory Requirement that satisfactory CRB and POVA checks are in place for all care staff prior to their commencement of employment at the home has been met. It was evidenced that the Statutory Requirement that all staff must receive appropriate induction training and that records are maintained to evidence that all staff have undertaken appropriate training in all areas as needed has been met. A sample of individual staff training files were viewed and it was evident that staff had received training in English (for overseas staff), Food hygiene, Fire safety, Moving and Handling, POVA, medication, challenging behaviour, Health & Safety and induction. The Common Standards Induction package is now utilised for all new staff members employed. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 20 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 & 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and staff do not benefit from efficient management processes, due to the lack of an Appointed Manager being in place. Appropriate Quality Assurance monitoring systems are currently not in place, meaning that the success of the home in meeting it aims and objectives is not measured effectively. Staff are not supervised and do not receive the benefits of having regular formal supervision. The health, safety and welfare of both staff and residents are not met on a consistent basis, leaving staff and residents at risk of harm. EVIDENCE: It was evidenced that the Statutory Requirements that the Organization is required to appoint a manager that they have recruited and retained that has Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 21 the appropriate experience, qualifications and competencies to manage the service and be in day-to-day control and that the manager when they are appointed makes an application to be registered in respect of the service so that they are in compliance with the Care Standards Act 2000 and the associated legislation has not been met. The Assistant Deputy Manager conducts care duties as well as management duties, though it is reported that often the allocated management hours are utilised for care duties, due to the dependency levels of current residents. The Registered Provider has not appointed a new Manager and an application has not been made to CSCI. These Statutory Requirements remain unmet for the fourth consecutive inspection. It was evidenced that the Statutory Requirement that the registered person shall establish and maintain a system for reviewing, at appropriate intervals and improving the quality of care provided at the care home has not been met. A formal Quality Assurance process has not been introduced. The views of residents, their representatives, stakeholders and other interested parties are not obtained. Staff meetings are held six monthly and residents meetings do not take place. This Statutory Requirement remains unmet for the second consecutive inspection. The home does not take any responsibility for many of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. The Assistant Deputy Manager maintains a ‘personal allowance account’ for one resident. Records of all transactions are maintained and provide a clear audit trail of all monies entered into and debited from this account. It was evidenced that the Statutory Requirement that the registered person shall ensure that persons working in the care home are appropriately supervised has not been met. Formal staff supervision has not been implemented. This Statutory Requirement remains unmet for the third consecutive inspection. A review of the homes maintenance records confirmed that fire drills, fire alarm testing and fire equipment checks and water checks had been carried out since the inspection of August 2007. From the tour of the premises it was evidenced that windows in two bedrooms and a bathroom on the first floor had not been restricted. Therefore an immediate Statutory Requirement was made. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 22 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Timescale for action The registered person shall make 05/02/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care Home. In that multiple ‘F’ omission codes must cease and all medication omissions must be fully explained onto the back of MAR sheets. This is an immediate Statutory Requirement. 2. OP26 23 (2)(d) The registered person shall have regard to the number and needs of the service users ensure that all parts of the Home are kept clean and reasonably decorated. In that the Home must consult with the EHO and ensure that the standards of cleanliness in the kitchen are in keeping with regulations. (This was a previous Statutory Requirement. The last time scale Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 24 Requirement 05/03/08 was 14/10/07) 3. OP27 13 (4) (a) (b) (c) (4) The registered person shall ensure that— (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. In that the Home must consult with the EHO as to how the kitchen area can be safeguarded to reduce the risk of injury to both service users and staff. 05/03/08 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. Refer to Standard OP3 Good Practice Recommendations That all Pre Admission Assessments are recorded on the appropriate recording tool. DS0000021290.V352852.R01.S.doc Version 5.2 Page 25 Wilton Lodge 2. 3. OP12 OP26 & OP27 That records of activities attended by residents are expanded to include all activities taken. That a cleaner is employed, who may also carry out carpet cleaning and laundry tasks, to ensure that consistently satisfactory standards of cleanliness and hygiene are maintained, also to free up care hours in meeting the levels agreed by the National Residential Forum. Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Wilton Lodge DS0000021290.V352852.R01.S.doc Version 5.2 Page 27 - 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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