Inspection on 06/02/07 for Worcester Lodge

This inspection was carried out on 6th February 2007.

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

The inspector 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

Worcester Lodge 26/10/08

Worcester Lodge 29/03/06

Worcester Lodge 25/07/05

Worcester Lodge 26/01/05

Worcester Lodge 12/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Worcester Lodge 32 Castle Road Walton St Mary Clevedon North Somerset BS21 7DE Lead Inspector Catherine Hill Unannounced Inspection 6th February 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 Worcester Lodge DS0000038262.V319414.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. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Worcester Lodge Address 32 Castle Road Walton St Mary Clevedon North Somerset BS21 7DE 01275 874031 01275 872717 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) Worcester Garden (No.1) Limited Mr John Allsopp Care Home 39 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (39) of places Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Worcester Lodge is registered to provide personal care to up to 39 elderly residents, 11 of whom may have dementia and are accommodated in a separate garden wing. The main part of the building is Victorian and on two storeys; the accommodation for people with dementia has been built more recently and is all at ground floor level. Stairlifts provide access to most areas in the old wing. There is no passenger lift. Each wing is allocated its own staffing levels and has its own communal and garden areas. Meals are provided to both wings from the main kitchen. The building has many original features and pleasant gardens. The reception area is staffed during office hours. The home is in the Lady Bay area of Clevedon. Local amenities are a short distance away by car. At present, the home is only able to receive Welsh television stations but can get one English channel in the downstairs lounge. The current fee levels range between £414 and £545. Residents are expected to pay for their own newspapers, hairdressing, chiropody and activities. The home provides an escort to hospital in emergencies free of charge, but a fee is payable for escort duties provided to routine appointments. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection comprised a pre-inspection consultation of people associated with the home and a one-day visit of approximately 8 hours to the home. Prior to the visit, the inspector received CSCI comment cards from 9 health and social care professionals and had telephone feedback from 7 residents visitors. During the visit, the inspector spoke with 8 residents and 3 visitors. She also spoke with 7 of the staff on duty and spent time sitting in the lounges with residents. The morning of the visit was spent talking with residents, relatives and staff in the old wing of the building, and looking at the premises. The early afternoon was spent with residents and staff in the garden wing, which is for people with more advanced dementia. The remainder of the inspection was spent looking at records, including: • the Statement of Purpose • pre-admission assessments • residents care records • the complaint procedure • the homes abuse and whistle-blowing procedures • the staff rota • staff recruitment and training records • records of equipment safety checks What the service does well: Without exception, all the feedback from visitors to the home was positive. Many of the visitors said that they usually visit without warning, but that standards are always the same and that they are always made welcome. Health and social care professionals feedback indicated that the home makes good use of their advice and support, and works closely with them to ensure residents get the best possible care. Two of these professionals commented how impressed they were with the standard of care provided, and one added that the home has a very pleasant atmosphere and nice staff. Residents visitors were very happy with the quality of service and the environment. One person described the overall standard as superb. Many people told the inspector that they are kept informed about any significant events, and have a lot of confidence in senior staff. Everyone commented on Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 6 the commitment of care staff: one person said, My mother hasnt looked so well in years, and another said, I know that shes safe here. Many people commented on how gentle and kindly staff are with the residents. Visitors described a high standard of care, approachable and friendly staff, flexible routines, and good meals. One relative said that staff bend over backwards to accommodate individual preferences, and another commented that there always seemed to be plenty of staff on duty. Several said that the place is always kept very clean and that laundry is always done beautifully. Residents each told the inspector how nice the staff are. One person said the girls work really hard, and another commented that its always the same, no matter who’s on duty. Residents also enjoy the menus. One said, I wasnt eating very well when I came but I tuck into it now - the food’s excellent. What has improved since the last inspection? What they could do better: Pre-admission assessments should be dated. Induction training should include a record of the guidance given to staff on the homes abuse and whistle-blowing procedure. The use of kylies on lounge chairs should be discontinued, and these chairs should be covered with a suitable fabric if necessary. Residents independence on the garden wing might be increased if there was more signage to orientate them, and they should routinely be offered a key to their own bedroom door unless a risk assessment indicates this would not be safe. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 7 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. Worcester Lodge DS0000038262.V319414.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 Worcester Lodge DS0000038262.V319414.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives get clear information about the home before deciding to move in, and the home gathers sufficient information about the person to be reasonably sure it can meet their needs. The admission procedure is flexible. EVIDENCE: The Statement of Purpose gives clear information on the service provided but has been re-drafted because the home is applying to be registered solely for people with dementia. It is planned to accommodate people with mild confusion in the old wing and people with more advanced dementia in the garden wing. Initial information about the person is noted on the enquiry form, and this can sometimes serve as the pre-admission assessment, along with the placing Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 10 Social Worker’s care plan. Where possible, senior staff try to visit the person before admission to get more information on their needs and preferences. The records of these pre-admission assessments were not always dated. Residents and their representatives are welcome to visit as often as they need to before making a decision to move in for a trial period. The home does not provide intermediate care. Worcester Lodge DS0000038262.V319414.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from a high standard of care. The home works closely with all other carers to ensure residents receive the best possible service. EVIDENCE: An initial assessment and care plan is done as soon as a new resident moves in. This is reviewed at least once a month, and expanded as staff get to know the persons needs better. Care plans were clear and informative, and incorporated the residents viewpoint. They also addressed residents spirituality and sexuality. Staff were well-informed about the content of care plans, and were familiar with individual peoples preferences. Daily notes gave an all-round picture of the person: what has been done to meet their care needs, any new needs that had been noted and what action has been taken to address these, and information about their social and leisure lives. Some of the entries in these notes also indicated how flexible staff are in trying to meet residents needs and expectations. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 12 Photos are kept on residents files of the property and pictures they brought with them when they moved in. This is a useful form of inventory. All of the residents looked well cared for. Hair was well combed, spectacles and nails were clean, and clothing was well laundered. A couple of residents had asked staff to follow particular routines with their laundry, and told the inspector that staff had adjusted their practice accordingly. Medication records were clear and up-to-date. Any allergies were noted on the Medication Administration Record Sheet. Medicines were kept securely and in line with current guidance. The staff team works closely with external professionals, particularly as residents become frailer and need more structured care. Any guidance from healthcare professionals is included in the care plan, and the daily notes show how this has been carried out. Relatives are encouraged to maintain the sort of relationship they had with the resident before the person moved into the home. If both people are happy with the arrangement, relatives can continue being responsible for particular aspects of the resident’s personal care. Relatives who do this felt that staff work really well with them. Worcester Lodge DS0000038262.V319414.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although activities levels in the old wing have dropped recently, residents usually enjoy a good range of interesting leisure opportunities. The home supports residents and their friends to maintain their relationships. Residents benefit from a friendly, respectful and inclusive atmosphere, and good quality meals. EVIDENCE: Several residents and relatives told the inspector that there had been a really good range of in-house activities and outings until recently, when the activities co-ordinator moved to another role within the home. People were really missing this, and several were very disappointed that it has lapsed. However, some outings and activities are still being laid on. Recent events have included a visit to the pantomime and visits to the home by the Pat-a-Dog service. The manager said that he is interviewing someone for the post of activities coordinator and hopes to have it filled shortly. Staff working in the garden wing do frequent, short activities with residents, including singing or dancing to music, indoor skittles, and accompanying Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 14 individual residents for a chat while they are walking around. Although some of the residents living on this wing have difficulty holding a conversation, everybody looked engaged and interested, and several of the residents happily interacted with each other. Residents used gestures and facial expressions to communicate, and looked very relaxed. People smiled a lot and responded very positively when staff approached them, which they did frequently. The inspector was impressed by the fact that, although one of the residents complained loudly to her in the lounge, staff did not try to intervene or contradict this person but gave her room to have her say. The inspectors observations indicated that this perception was this resident’s alone, and was not caused by staff omissions. Staff unfailingly treated residents with respect. Even when the person was not able to express themselves clearly, staff gave them their full attention and showed interest in what they were saying. Staff asked residents if they would prefer television or music, and did not make a decision until everyone in the group had been consulted. When residents made comments that indicated their confusion - such as Im going to see my mother - staff acknowledged these without actually encouraging the misperception. One resident started to become distressed because she needed to see her mother, and staff managed this situation with tact and skill. Residents and visitors said that there is no restriction on visiting times, although visitors are asked to avoid mealtimes so as not to intrude on other residents. The hairdresser visited during this inspection, and saw residents in the quiet lounge. This is evidently something of a social occasion, and the ladies who were waiting to be seen joined in the laughter and lively chatter. One of the residents came up with the idea of having a small shop on the premises, selling cards and chocolate bars. The manager said that he would look into ways of providing this service. Breakfast is served to residents in their own rooms. One person had chosen to spend the day in her room, and meals were brought to her on a tray. Staff also popped in regularly to check that she was still content. People made really positive comments about the meals. Several people gave examples of how flexible catering staff had been in trying to meet their needs. Menus were interesting and balanced, and residents said there is room for choice. Two visitors said they had spent time with the cook discussing particular dietary needs, and had been really impressed by how flexible and helpful she had been. The inspector looked at the vegetarian contents of the freezer, which included cheese and onion pastry rolls and vegetarian individual pies. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 15 One of the kitchen staff said that a few other vegetarian products were due for delivery within the next day or so. Worcester Lodge DS0000038262.V319414.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns are taken seriously and addressed promptly. Residents are protected from abuse. EVIDENCE: The home has had one complaint since the last inspection, which was dealt with promptly and positively. No complaints have been received by CSCI. The complaints procedure is clear and welcoming. The procedure in the Statement of Purpose has been updated, but the copy in the procedure file still shows the old CSCI address and does not include CSCIs phone number. The manager said he would ensure all copies are updated. Residents and relatives said they felt a great deal of confidence in the staff team, particularly management staff, and that any grumbles have been responded to positively. There is a really clear abuse and whistle-blowing procedure, which is regularly reviewed. Many of the staff have had abuse awareness training. One of the newer staff could not remember this being discussed when she did her induction training, and the induction training record does not specifically refer to this subject. However, this person knew who to talk to in the event of having any concerns. The inspector recommended that the induction training Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 17 record is amended to more clearly indicate the advice that is given to staff about abuse. This could perhaps be achieved by including a copy of the abuse and whistle-blowing procedure, and asking staff to sign for receipt of this. Worcester Lodge DS0000038262.V319414.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): 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 and pleasant environment that is well suited to their needs. EVIDENCE: Thirty five bedrooms are single and two are double. The doubles are only used by people who actively choose to share. Nine of the single bedrooms and both double bedrooms have ensuite toilets or bathrooms. The home plans to create two more ensuites soon. There are nine communal toilets and four communal bathrooms around the home. Two bathrooms have shower facilities. The ground floor bathroom has been refurbished to provide a walk-in shower and a hairdressers’ basin with seat. The hot water tap in toilet one in the old wing was not working at all. The manager bought new taps during this inspection but it is planned to fully Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 19 refurbish this toilet in the near future. Other minor repairs were remedied with similar promptness. There are two large lounges in the old wing, and two adjacent dining rooms. There is also a conservatory with seating and the French window onto the inner garden. Two of the downstairs bedrooms in the old wing have French windows onto this garden. The garden wing has a lounge and dining room separated by an archway. A French window leads from the lounge in this wing to a secure garden area. Lots of plants, fresh flowers, pictures and ornaments and to the welcoming and homely atmosphere. Stairlifts on one of the staircases provide access to the first-floor. The home is planning to install a passenger lift in place of this staircase, and the stairlift will then be moved to the front staircase. The overall standard of décor is high, but the use of kylies on lounge furniture detracts from this. Kylies were always fresh but the use of them discourages people from sitting on the chairs and gives the impression that continence problems are not being well managed. Some new armchairs have been ordered for the lounges. The inspector recommended that any furniture that is not to be replaced is covered in suitable fabric so that the use of kylies can stop. The inspector commented at the last inspection that residents might benefit from some more signage to help them orient themselves around the home, especially in the wing for people with dementia. Picture signs can be useful for people who now have difficulty reading words, as can colour-coded doors. Residents’ room numbers are on small nameplates on their bedroom doors, along with the name of their key worker, but not their own name: this information might not help a person find their own room. It is recommended that larger nameplates and/or symbols or pictures that have some significance to the individual are introduced. The inspector advised that ways of supporting some people to use their own door keys should also be explored. No-one in the garden wing had their own room key but one of the residents was evidently very unhappy at not being able to access her own bedroom during the day. This person had her own door key until recently, while she lived on the old wing of the home. When this problem was discussed with the manager, he found a key for her. There are other people living on the garden wing who might also be able to manage their own door key, and this not only allows greater independence but can give a real boost to self-esteem, so it is recommended that people moving into this wing are routinely offered their own key unless a risk assessment indicates otherwise. Window restrictors are fitted where necessary. Radiator covers are fitted to ensure that radiators have low surface temperatures. Hot water temperature Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 20 regulators are fitted to baths and hand basins, and staff record the water temperature whenever they assist residents to have a bath. All areas in the home were very clean and fresh smelling. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well protected by effective staffing practices. EVIDENCE: Two staff are on duty at all times of day in the garden wing. On the old wing, two staff and a senior are on duty in the mornings; one staff and a senior are on in the afternoons. An additional member of staff covers any necessary extra work between the two wings during the daytime. Three waking staff are on duty at night, one of whom is a senior covering both wings. A part-time Administrator works in the reception area. In addition to these staff, there are cooks, domestic staff, and a handyperson. Four of the staff files were sampled. These showed that good recruitment practices being followed, with all necessary checks being satisfactorily completed before the person starts work in the home. At present, the home is using its own induction training checklist but plans to transfer to an accredited induction training course in the near future. Several staff have had a manual handling, food hygiene, and medications administration training. All staff have been given a training pack on dementia care and watched a training video. Further training in all these subjects has Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 22 been arranged for the first few months of 2007. Staff will also be having abuse awareness training. The deputy manager and assistant deputy manager will be doing courses in dementia mapping and time management. Five of the staff completed NVQ 2 but had problems getting their final work assessed by the college. These staff have again submitted their NVQ 2 coursework for marking. Four other staff already hold NVQ 2. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 23 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): 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-run home with an inclusive atmosphere and regular checks on health and safety. EVIDENCE: The manager has many years experience in care settings and of running care homes. He has recently reduced his hours, in agreement with CSCI. He now works three days a week, and the deputy manager provides management cover to the home on the remaining two weekdays. She is also on duty at the weekends, and both people work together on Mondays to allow time for information sharing and development planning. The deputy manager is starting NVQ 4. An assistant deputy manager has recently been appointed. The Responsible Individual has NVQ4 and visits the home on a weekly basis. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 24 Staff described a really happy working environment, and felt encouraged to be creative. Newer staff had been made welcome, given plenty of information, and felt encouraged to contribute their ideas. The home does not handle residents finances. Any money deposited for safekeeping is recorded and signed for, and two people sign the record when money is returned. There is a formal system of staff supervision, and each person meets regularly with their supervisor. Staff were clear about their roles and felt well supported to provide a high standard of care. All policies and procedures were reviewed in June 2006. Since the last inspection, all staff have had in-house fire training and have been taking part in a distance learning fire safety course. Eleven staff have had Appointed Person first aid training. The handyman checks hot water temperatures periodically. External contractors carry out the necessary six-monthly checks of the stairlift and bath hoists. Heating and legionella checks have all been done recently. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 25 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP3 OP18 OP22 OP22 OP22 Good Practice Recommendations Written pre-admission assessments should be dated. The induction training record should be amended to more clearly indicate the advice that is given to staff about abuse. The inspector recommended that any furniture that is not to be replaced is covered in suitable fabric so that the use of kylies can stop. Larger nameplates and/or symbols or pictures that have some significance to the individual should be used on residents doors. People moving into the garden wing should be routinely offered their own key unless a risk assessment indicates otherwise. Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Worcester Lodge DS0000038262.V319414.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!