Inspection on 11/05/06 for Worsley Lodge

This inspection was carried out on 11th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Worsley Lodge 10/11/08

Worsley Lodge 01/07/08

Worsley Lodge 15/02/08

Worsley Lodge 08/11/07

Worsley Lodge 06/08/07

Worsley Lodge 16/02/06

Worsley Lodge 18/08/05

Worsley Lodge 13/10/04

Worsley Lodge 20/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Worsley Lodge 119 Worsley Road Worsley M28 2WG Lead Inspector Elizabeth Holt Key Unannounced Inspection 11th May 2006 11:00 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 Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Worsley Lodge Address 119 Worsley Road Worsley M28 2WG 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) 0161 794 0706 0161 794 7715 Southern Cross Home Properties Limited Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 48 service users aged 65 years and over may be accommodated. Minimum Nurse staffing levels will be maintained as specified in the Staffing Notice of 5th February 2003 issued in accordance with section 13 of the Care Standards Act 2000 with regards to the service users accommodated on the first floor. Dependency levels of service users requiring personal care only must be continually assessed and staffing levels adjusted in order that care staffing levels will be maintained in accordance with the minimum levels specified in the Residential Forum Guidance for staffing in Care Homes for Older People. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 16th February 2006 3. 4. Date of last inspection Brief Description of the Service: Worsley Lodge is a detached ,purpose built property set in its own grounds. The home is registered to accommodate up to 48 older people on two floors. A maximum of 20 residents requiring personal care only can be accommodated on the ground floor and up to 28 residents requiring nursing care can be accommodated on the first floor. Forty eight of the bedrooms are single, with 33 of them having an en suite facility 16 with shower en-suites and 17 toliet en suites. A passenger lift is available to both floors. A variety of aids and adaptations are around the building to allow residents to move about independently. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on the 11th May 2006. All the core National Minimum Standards (NMS) were reviewed during this inspection. Information was gathered as part of the inspection process which included a questionnaire completed by the manager which gave information about the residents, the staff and the building. Time was spent talking to the residents, visiting relatives, the manager and the staff team about the day to day life in the home and to establish what the home was like for the residents living there. A partial tour of the premises was undertaken and examination of documents and care files for individual residents. Ten resident/relatives questionnaires were left to be forwarded to the Commission. Only 4 responses were received at the time of this report being written. The former deputy manager started as the home’s manager on the 1.01.06. A requirement was made at the last inspection for the manager to apply to the Commission for Social Care Inspection (CSCI) for registration. This application has been submitted but without all the appropriate information. Since the last inspection the CSCI are investigating one complaint under the Adult Protection procedures. A number of requirements have been made in this report following the findings of this investigation. What the service does well: The relationships between the residents and the staff appeared to be generally friendly and chatty. From observations made and conversations with staff members and residents it appeared that the privacy and dignity of the residents was maintained. One resident said, “I couldn’t be better looked after anywhere, the girls and boys are very kind to me”. Relatives were met during the inspection and it was evident the home had an open visiting policy. One relative commented that “the staff are good at keeping me up to date of any changes and they do care for my mum”. The home maintained a good standard of cleanliness and the management of any odour was satisfactory. A choice of menu is available for residents and residents spoken to were happy about the food provided. The staff made a positive effort to make mealtimes a sociable occasion for the residents. The kitchen was well stocked with both fresh and frozen food. Action had been taken and planned for following a recent inspection by the Environmental health department. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 6 The home has a programme of activities and employs the services of an activities organiser. Residents spoken to said they enjoyed the activities offered and had thoroughly enjoyed socialising outdoors on the patio area. It was pleasing that the manager had made plans for staff to receive training to assist the staff to meet the social care needs of the residents with mental health problems. The manager was encouraging and supporting staff to undertake NVQ level 2 and to attend training courses/study days as appropriate. What has improved since the last inspection? What they could do better: Procedures are available to meet the needs of prospective residents are fully assessed. Procedures were not always followed which could lead to a residents’ needs not being met. Although some improvements were seen in the care plans since the last inspection, a number of shortfalls remain in the recording of the appropriate information which has the potential to put residents at risk. Further devlopment of the care plans is required to ensure they reflect the health, personal and social care needs of the residents accommodated. This is detailed in the next section. Systems and procedures for staff dealing with medication require improvements to fully protect the residents. During this inspection a training need was highlighted particularly in relation to the administration of medication for pain relief. Further training /auditing of the medication administration charts was required. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 7 Staff files were examined and although these were generally in line with the required information, there were some gaps noted in the information provided and no evidence to suggest this information was explored at the interview. Policies and procedures were available relating to Adult Protection and some staff had received training in the protection of vulnerable adults. This training must be provided for the manager and the rest of the staff so they are confident on the action to take in the event of an allegation of abuse. During the inspection some areas of the home required maintenance to ensure the safety of the residents. Some areas in the report highlighted the need for redecoration due to wear and tear. 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. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this area outcome area is adequate. This judgement has been made using evidence made available and following a visit to the home. Procedures are available to ensure that the needs of prospective residents are fully assessed before they are admitted to the home. However the procedures were not always followed which could lead to a residents needs not being met. EVIDENCE: Since the last inspection Sothern Cross had provided a new Statement of Purpose and a Service User Guide. A pre admission assessment format was available to ensure prospective residents are admitted following a full needs assessment. The assessment included involvement of the prospective resident where possible, his/her representative and any relevant professionals. Residents who were referred through a social worker had a Care Management assessment; a copy of this was made available to the home pre admission. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 10 However one person was admitted did not have a fully completed preadmission assessment which led to his health and medication needs not being fully addressed. The home does not provide intermediate care therefore this standard was not relevant. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Care plans were available for each resident however some shortfalls in the recording had the potential to put residents at risk. Some improvements were required in the procedures for dealing with medication to protect residents. EVIDENCE: Four care plans were examined. Due to the company changing hands, the home had worked at care planning to implement the new paperwork. A requirement made at the last inspection involved the need for staff to write sufficient and accurate detail in the care plans and to include reviews of risk assessments. It was evident that there was some slight improvement in the care plans, evaluations and risk assessments however some serious shortfalls were noted. Sometimes the care plans were vague and did not fully detail the actions the staff needed to ensure all aspects of the residents’ care are met. The daily Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 12 statements did not reflect clearly the planned care. The manager had held meetings with the staff to detail what is required within the documentation since the last inspection and she felt this had improved lines of communication. There was evidence of the staff making an effort to communicate with a resident who used British sign language as her means of communication. The care plan was not appropriately worded for this resident and did not contain an appropriate risk assessment and care plan for the identified nursing problems. This was discussed with the manager and highlights a training need for the staff in meeting the needs of this resident. Following the Adult Protection investigation a requirement was made in relation to a specific care plan for catheter care. The detail and daily care required was not available. This was required in December 2005 and the home provided an action plan stating this was being carried out appropriately. One resident’s medication administration record sheet (MAR) sheet stated the resident had choking episodes. It was of concern to note this information had not been transferred into the individual risk assessment and care plan. Evidence was seen of resident/relative involvement with the care plans and involvement of referrals to other professionals. Following training in “customer care”, the manager considered that the staff were more proactive in reporting any changes in the health status of the residents. Observations made during the course of the inspection showed the staff treating the residents with respect and in a dignified way. One staff member was seen to be aware of a resident’s individual needs and was kind and compassionate in her approach. It was pleasing to see that following a discussion with this staff member she demonstrated her depth of knowledge of the residents underlying condition and how to manage her care needs in an appropriate way. One relative commented that “the staff are always friendly and very helpful and caring.” Residents spoken to were positive about the staff and said they were treated with respect and their rights were respected. Some comments from relatives were made in relation to communication problems at times, particularly with staff for whom English is a second language. The manager must ensure that staff have sufficient skills to communicate effectively and meet the diverse needs of all residents in the home. In response to a requirement made at the last inspection the home had implemented a new monitored dosage system and provided medication training for the nursing and care staff responsible for its administration. Controlled drugs were stored appropriately however a requirement was made in relation to accurate recordings on the medication administration record Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 13 charts.(MAR). Following the investigation under Adult Protection Procedures there were gaps on the records of the Controlled drugs administered on the MAR chart examined and serious concerns in relation to the times the medications were administered to the resident. A discussion highlighted the need to ensure that Registered Nursing staff receive some further specific training in the administration of medication for pain relief. Examination of the medication administration records (MARs) showed these had not been signed for upon the drugs being received into the home on the nursing floor. There were some gaps noted and codes were not always used when the drugs were not administered. A change in a resident’s prescription had been made for one resident, however the recording and signing for this was not clear. Any changes from the General Practitioner must be recorded appropriately and signed for by a registered nurse and a witness. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were encouraged to maintain contact with family and friends. Residents could exercise choice over their lives and they received a balanced and nutritious diet. EVIDENCE: An open visiting policy was held by the home and residents spoken to commented that their relatives were made welcome. Relatives spoken to felt the staff made them feel comfortable. Staff were seen to have a good rapport with some of the visitors seen during the visit. The care plans included a social profile assessment for each resident which included their individual preferences. A review of the care plans showed that the recording of social activities carried out was not always transferred into the care plan. A recommendation was made regarding this recording. It was pleasing to see that following a requirement made at the last inspection, for the staff to receive training to assist them in dealing with residents with Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 15 mental health problems associated with old age that arrangements were in place for staff to attend a training course on “Dementia in the elderly”. On the day of the inspection the activities co-ordinator was seen assisting a resident with a crossword and initiating conversation with other residents on a one to one basis. Staff and relatives spoken to commented that residents were encouraged by the staff to participate in activities however it was frustrating at times as the residents would decline to join in. Two residents commented how much they had enjoyed a trip to the local public house on a Friday night whilst another resident from the first floor commented how much she had enjoyed sitting outside “just chatting”. It was evident that the staff did make an effort to encourage some social interaction whenever possible. The manager confirmed that visits from the minister at the local church were made and residents were supported to attend church if they chose to. The menus were developed on a 4 weekly rota in line with the residents likes and dislikes. These menus offered a range of food and the lunch and tea was pleasantly presented. Residents commented that “the food is good and I am never left hungry”. The cook stated that she would prepare an alternative if a resident did not want their preferred choice at the time. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The residents and relatives had a clear complaints procedure to follow. Residents were protected from abuse. EVIDENCE: The complaints procedure was available on display and is included in the Service User Guide to the home. The home held a record of any complaints made which included one since the last inspection. This had been appropriately dealt with. An investigation has been conducted by Salford Social Services with the involvement of the Commission for Social Care Inspection into a complaint under Adult Protection procedures concerning aspects of care practices for an individual at the home. It was concluded that there was evidence of poor practice regarding the management of medication and in the recording of the care planning documentation. (See standards 7-11 ). Following a requirement at the previous inspection where the Commission were monitoring wounds and pressure sores in the home, it was evident the one hospital acquired pressure sore was being appropriately managed. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 17 A number of the staff had received training in Adult Protection procedures and when questioned staff were aware of the course of action to take in the event of an allegation of abuse. However, the manager and some of the Registered Nurses had not received training in Adult Protection and a requirement was made for this to be addressed. This training also needs to be extended to all staff working at the home. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally clean, comfortable and homely. Some areas required attention as they put residents’ safety at risk. EVIDENCE: The home provides a homely environment with well maintained grounds. A patio area which provides seating with umbrellas is accessible to all residents. There was evidence of a programme of redecoration. The resident’s bedrooms were seen to be comfortable and personalised. A tour of the home showed that some of the décor and furnishings were showing signs of general wear and tear. The following required attention; the door frame on the first floor was coming away from its casing and was a potential hazard. Action was taken to address this during the inspection. There was excessive wheelchair damage to the Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 19 corners of doors and skirting boards which leave the home looking uncared for. The cracked window pane in the ensuite bathroom of bedroom 36 must be replaced. The first floor kitchenette was generally unclean, including the floor. A mop and bucket was stored inappropriately in here. One of the baths on the first floor was left unclean after its use. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 number and deployment of staff appeared in general sufficient to meet the residents’ assessed needs, however the deployment of trained nurse staff needs revising. Shortfalls in the home’s recruitment and selection procedures may lead to residents not being fully protected. EVIDENCE: At the time of the inspection the home accommodated 19 residents in receipt of nursing care including 3 residents in hospital and 27 residents in receipt of personal care only. A sample of registered nurses and care staff files were examined. Some shortfalls were noted even though the files contained a checklist to ensure that the file contained all appropriate information. (These checklists were not always completed). For one care staff member there was no record of an induction form, one file did not have a copy of a contract of employment and there was a poor record of interview notes. The interview record was not always fully completed and did not demonstrate that gaps in the application form were explored during the interview. Staff files contained evidence of POVA and CRB disclosure checks, however this was not available for a recently recruited registered nurse. This is being followed up currently. There was evidence that the staff files contained some certificates however it is recommended that an individual training and development plan is available for Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 21 each staff member. Staff spoken to said they were receiving training and one staff member stated he had followed a structured induction programme. The home has a commitment to encouraging care staff to undertake the NVQ level 2 qualification and employed some staff who were registered nurses overseas but had not done a course in adaptation and were employed as care staff. During the inspection the Registered Nurse left the nursing floor without a Registered Nurse whilst she took a lunch break. This was raised with the manager and advice was given that this practice was unsafe. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made in some of the management practices since the last inspection including staff supervision. The health, safety and welfare of residents’ was promoted. EVIDENCE: The manager took up post on the 1/01/06. During this inspection she demonstrated her knowledge of the residents well. At the previous inspection , it was required that the manager must submit her application to be registered with the Commission for Social Care Inspection. This has recently been returned to the manager to complete the application more fully before it can be processed by the CSCI. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 23 A questionnaire was available to seek the views of residents/relatives of the service provided however this had not been sent out within the last 6 months. It is recommended that a quality audit is also sent out to visiting professionals. It was pleasing to see that the programme of formal supervision of care staff had commenced. A discussion with the manager highlighted that supervision should cover all aspects of practice, career development and philosophy of care in the home. Fire safety checks were being carried out on a regular basis. Staff had attended a recent fire drill. The home confirmed that regular health and safety maintenance checks were being carried out. The computerised records of residents’ finances were checked at the inspection in August 2005 and not at this one, however the manager explained the procedure and that the running sheets of the balances were maintained. These will be inspected at the next inspection. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 x 3 Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes, however the timescale had not been reached for some of these. 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. 2. Standard OP3 OP7 Regulation 14 13 Requirement The needs of the residents must be fully assessed before admission to the home. A full audit of all the care plans must be carried out to ensure that each resident has an individual plan of care that accurately details the action required by staff to ensure the health, social and personal care needs of the residents accomodated are met. Daily entries must be clear and linked to the care planned. Entries must be consistent and legible. The Registered Person must make arrangements for the recording, handling and safe administration of medicines. Medications must be signed for on the MAR chart immediately following administration. The registered person must ensure that records must be kept regarding medication dose Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 26 Timescale for action 19/06/06 14/07/06 2. OP9 13 30/06/06 changes. Registered nurses must receive training in the management of pain control and how to administer this medication appropriately in line with the Nursing and Midwifery guidelines. 3. 4. OP18 OP30 12 18 All staff must receive training in adult protection procedures. Training must also be provided to ensure staff have the knowledge to deal with the residents accomodated. This must include dementia care and communication. (The previous timescale of the 30/06/06 has not yet been reached). The home must ensure potential hazards to the residents safety are highlighted and repaired, for example the door casing and the cracked window pane on the first floor. A programme of redecoration and renewal must be maintained. An application must be made to the Commission for the registration of the manager. (The previous timescale of the 15/05/06 had not been met). A full audit of all staff files must be carried out to ensure they contain all the information and documents listed in Schedule 2 of the Care Homes Regulations 2001. 07/07/06 30/06/06 5. OP19 13 28/07/06 6. OP31 9 26/06/06 7. OP29 19 28/07/06 Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP12 OP29 OP29 OP33 Good Practice Recommendations It is recommended that an accurate record is kept of all activities undertaken and the residents that took part in the activities. It is recommended that any gaps in an application form are explored and appropriately recorded as part of the interview process. It is recommended that each staff member has a training and development plan. It is recommended that a quality assurance system is used to provide an audit to report on the quality of the service provided. Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Worsley Lodge DS0000006733.V293054.R01.S.doc Version 5.1 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. 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!