Inspection on 15/03/07 for Wyvern Lodge

This inspection was carried out on 15th March 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wyvern Lodge 07/02/06

Wyvern Lodge 17/10/05

Wyvern Lodge 03/02/05

Wyvern Lodge 22/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Wyvern Lodge 89 Drove Road Weston Super Mare North Somerset BS23 3NX Lead Inspector David Kidner Unannounced Inspection 15th March 2007 09:30 Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 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 Wyvern Lodge DS0000020374.V308363.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 Adults 18-65. 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. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyvern Lodge Address 89 Drove Road Weston Super Mare North Somerset BS23 3NX 01934 612416 01934 612416 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Elizabeth Anne Hendry Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 8 Adult Patients with Mental Disorder excluding those detained under Mental Health Act 1983 Staffing Notice dated 13/09/1999 applies Manager must be a RN on parts 3 or 13 of the NMC register Date of last inspection 7th February 2006 Brief Description of the Service: Wyvern Lodge is a community home for eight people with enduring mental health problems. The home adopts a psycho/social approach, which includes helping service users to maintain and develop independence, well being and meaningful integration into the community. The home is close to local amenities and a short walk from the main town centre and beach. Wyvern Lodge has eight single bedrooms with one bedroom located on the ground floor. There is a communal lounge that is designated as non-smoking, a large dining room and a large conservatory that is identified as the smoking area. There are two communal bathrooms, one located on each floor. There is a domestic style kitchen and laundry facilities. The home also has a rear garden. Aspects and Milestones Trust owns the property. The Registered Manager is Mrs Elizabeth Hendry. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a Key Unannounced Inspection and was conducted by one Inspector. The inspection lasted one day (7.0hrs). The Inspector met most of the service users and a number of the care team. The Registered Manager was not on duty at the time of the inspection. The Deputy Manager was available in the afternoon. As part of the inspection process the inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, staff recruitment, staff training and viewed some areas of the home. The Inspector spoke to some service users in private and in communal areas and spoke to a total of three care staff. The Inspector would like to thank the service users for making the Inspector welcome in their home and for their contribution to the inspection process. The Deputy Manager and care team were very welcoming. As a result of this inspection the home has one requirement and two recommendations. What the service does well: Wyvern Lodge provides the service users with a comfortable home that focuses on service user empowerment, involvement and promoting independence. Service users rights are respected in all aspects of daily living. Privacy, dignity and respect is promoted. Care Plans are detailed and regularly reviewed. Service users are involved in the choices of menus and a healthy diet is promoted. Throughout the inspection the Inspector noted that there was constant interaction between the care team and service users. The Inspector noted that staff were offering service users choices in all aspects of day-to-day living. The home appears very well run. Staff appeared very motivated and confident in their roles. The home is pro-active in promoting a well-trained workforce. Over 50 of the care team have obtained NVQ Level2 or above. The home is clean and well maintained. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1245 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Wyvern Lodge has a detailed Statement of Purpose and Service User Guide. The home conducts a detailed pre-admission assessment prior to someone moving to the home. The home encourages all prospective service users to visit the home and to meet service users and the support team. EVIDENCE: Wyvern Lodge has a clear and concise Statement of Purpose and Service User Guide and both documents have been recently reviewed and updated. Both documents contain the information for service users to make an informed decision. The Inspector viewed the pre-admission assessments of the most recently admitted service users. The Registered Manager had conducted the assessments. They were detailed and comprehensive. All prospective service users are offered the chance to visit the home for a week so that a full assessment can be made; this visit involves the prospective service user taking Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 9 part in the homes activities and community meetings. Current service users also have a final say about the suitability of the prospective service user. The Inspector spoke to one service user who had recently moved to the home. The service user confirmed that they had visited the home, stayed overnight and met the service users. All service users have a signed contract or statement of terms and conditions with the home the also agree to the home rules. The fees vary according to individual assessed needs. The current range of fees vary from £382-£391 per week. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care and support plans are comprehensive and up to date. Service users know their assessed and changing needs are reflected in their individual plans. Service users are assisted to make decisions about their life and are fully encouraged to participate in all aspects of life in the home. The home conducts detailed risk assessments. Service users personal information is stored securely. EVIDENCE: The Inspector viewed three care and support plans. They contained very clear and detailed information. Key workers update the care and support plan on a monthly basis. Day to day records are maintained of the care and support that is provided. There was clear evidence that the care plans sets out how Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 11 specialist requirements will be met. Any restrictions on choice and freedom are identified in the care and support plan. Service users that the Inspector spoke to freely commented on some of the personal restrictions imposed. The service users that the Inspector spoke to stated that they were aware of their care and support plan and are able to contribute to it. The service users had also signed them. All care plans had recently been reviewed. Any limitations imposed are agreed with the service users on admission and they agree to the house rules; these have been set and agreed by current service users. Community house meetings are held every evening, Monday to Thursday and the daily running of the home is discussed during this time, service users spoken to said they found the meetings helpful and the minutes, which are kept by the residents, showed that they considered all aspects of running the home from maintenance needs to leisure activities. Service users are also involved in the recruitment of staff. Service users stated that as much as possible, they are offered choices in all aspects of daily living. All service users are able to manage their finances with minimal support for the care team. The home has a comprehensive risk management process. A detailed risk summary is completed and individual risk assessments are conducted as needed. The risk assessments that were viewed had recently been reviewed. All records are stored securely and both service users and care staff are well informed of the importance of observing confidentiality. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home provides opportunities for service users to pursue personal development and to gain meaningful occupation. Wyvern Lodge encourages and supports service users to be part of the local community, and engage in appropriate leisure activities. Service users rights are respected in all aspects of daily living. Privacy, dignity and respect is promoted. Service users are involved in the choices of menus and a healthy diet is promoted. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 13 EVIDENCE: The Inspector viewed documentation for service users receiving appropriate interventions in relation to treatment and recovery programmes. One service user advised the Inspector that they access a church of their choice. Wyvern Lodge continues to encourage and support service users in maintaining personal development with courses at the college and training centres and part time jobs, or voluntary posts to enable them to return to the working world. The Inspector was advised that at present three service users are working in the ‘Helping Hands Project’. The project is a small property management business organised by the service users where they receive paid employment within the organisation. This is agreed within benefit constraints. At the time of the inspection service users were decorating a bedroom at the home. Another service user attends college and another does voluntary work two days per week. Service users confirmed that they access a variety of leisure and social facilities including the sports centre and cinema and local community based facilities such as shops and the post office. Service users confirmed that they pursue their hobbies and interests. There are photographs in the hallways of recent holidays that service users had been on. Wyvern Lodge encourages contact with family and friends. Some service users see their relatives on a very regular basis. One service user advised the Inspector that they regularly go home at weekends and that their family is invited to social events such as BBQ’s and quiz evenings at Wyvern Lodge. Photographs being displayed in the hallway evidenced this. Service users stated that the care team are very respectful and polite. One service user stated that the staff are “helpful, supportive, sympathetic and speaks to them in a nice positive manner” Service users also confirmed that the care staff always knock bedrooms door before being invited in. None of the service users require support in personal care other than odd comments of encouragement. Service users are offered a key to their bedroom, however some service users choose not to lock their bedroom door. All service users and staff are involved in housekeeping tasks. Rotas are displayed confirming this. At the time of the inspection service users were involved in many household tasks. All service users commented that the food was very good. Service users are fully involved in the development of the menus and those spoken to stated that they have access to food and drink whenever they so wish. The four-week menu is then assessed by a dietician for its nutritional value. Snack lunches are generally chosen and cooked by the service users as each service users has a ‘self catering day’. Some have more than one opportunity to cook and Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 14 prepare their own meals. Service users accompany the care staff to shop for the groceries. The home emphasises healthy eating. The care team monitors the diet of service users with nutritional needs. All service users are encouraged to obtain their food hygiene certificates. This is commendable. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer this includes both physical and emotional support Service users have access to a variety of health care professionals. Service users are assisted to retain, administer and record their own medication, supported by a clear risk assessment. Some issues relating to the management of medicines need further attention. EVIDENCE: Service users that the Inspector spoke to felt the care they received was what they required. They felt the emphasis was on support to become more independent and move on to more independent living. Records viewed showed that personal preferences were taken into consideration when care plans were written, they also showed evidence of both physical and emotional needs being taken into consideration. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 16 Service users have access to a variety of health care professionals. The home keeps records of visits to GP’s, dentist, optician and specialist health care professionals such as psychiatrists and psychologists. The Inspector viewed the arrangements for the management of medicines. The home has a medicines policy and procedure. All staff receive training in the management of medicines and receive refresher training when needed. The Registered manager has confirmed competency. The home’s MAR sheets were viewed and discussed with the deputy manager. It is recommended that the home should ensure that hand transcribed medicines and any alterations to the MAR sheets, are supported by two staff signatures. It is also recommended that the home contact the GP to review the agreed homely remedies for some service users, as this had not been done for a number of years. The home keeps record of ‘as required’ medicines and of medicines that are returned to the pharmacy. The policy for the receipt, storage and administration of medication includes a very detailed and concise procedure for self-medication, involving a structured risk assessment agreed with the service user. Service users are assessed for competence and progress through different stages as identified in their care plans; service users receive differing levels of observation and support as they progress through the stages. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has robust procedures in relation to complaints and protection. EVIDENCE: The home has a Complaints policy and procedure that includes the address of the Commission for Social care inspection (CSCI) The Inspector viewed the record of complaints and noted that there were no recorded complaints for a number of years. Service users that the Inspector spoke to were able to demonstrate how they would make a complaint if so wished. The home has very clear policies and procedures for the protection of vulnerable adults, and for whistle blowing. Care staff receive training in the protection of vulnerable adults. Certificates were seen in staff personal files to support this. Training in issues concerning vulnerable adults and adult protection is considered as statutory training within the home, all staff have received training in the local No Secrets policy. All newly appointed staff sign to say they have read the Aspects and Milestones whistle blowing policy ‘Do the Right Thing.’ The care staff Inspector spoke to new of the whistleblowing policy and demonstrated what action they would take. There are also policies and procedures in the management off service users finances. The home does not use physical intervention. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 18 Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 28 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. Communal areas are homely and well maintained. The home is clean and hygienic. EVIDENCE: The Inspector viewed the communal areas of Wyvern Lodge. The home consists of a lounge that is very domestic and homely in style, a large dining room that is very nicely presented and a large conservatory that is designated as the smoking area. There are strict rules for smoking. The kitchen is very domestic in style and very well equipped. Furnishings, fitting and equipment is of good quality Service users and staff commented that they have the kitchen equipment they need. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 20 Service users and the care team have a rota for the cleaning of all communal areas. Service users confirmed that they are actively involved in all aspects of this as it is seen as developing independence. At the time of the inspection service users were participating in cleaning many areas of the home. The home has good laundry facilities and appeared very well organised. On the day of the inspection Wyvern Lodge was clean and hygienic. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. The home places great emphasis on staff achieving a formal qualification. The homes recruitment process needs to be more robust. EVIDENCE: The Inspector spoke to a number of service users who confirmed that the care team are approachable and will listen to them. The Inspector observed staff communicating with service users in a respectful and professional manner. Each staff member has a record of the training that they have undertaken. From records viewed the Inspector noted that staff have received training in matters relating to mental health and the protection of vulnerable adults. The home places great emphasis on staff achieving formal qualifications. Currently there is 11 care staff. At the time of the inspection six care staff have Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 22 gained NVQ qualification at level 2 or above and one staff is currently undertaking NVQ Level 2 qualification. This equates to approximately 65 of the workforce. From records viewed and comments from service users and staff there appears to be adequate staff on duty at all times to meet the needs of the service users. Rotas are amended to facilitate events and activities both within and out of the home. Agency staff are used if all other resources are exhausted. The home has regular staff meetings. The minutes to these were viewed. The Inspector viewed the recruitment files of three recently appointed staff members. The Inspector discussed these files in detail with the Deputy Manager. The files did not contain the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. This must be addressed. Aspects and Milestones has a clear commitment to training and personal development, all staff have attended statutory training and training appropriate to the needs of the current service users. Staff that the Inspector spoke to confirmed that they had received such training and found the training useful. Each staff members training record is recorded individually with copies of certificates and achievements. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home with an open and approachable ethos towards management. The home has a good quality assurance and quality monitoring systems. The home promotes matters relating to health and safety with good records kept. EVIDENCE: The Registered Manager is a qualified Registered Mental Nurse and has achieved the Registered Managers Award. Mrs Hendry has also obtained A1 Assessors Award and has undertaken Care Ambassadors Training. The Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 24 Registered Manager also undertakes refresher training as and when needed. The Inspector received many positive comments in relation to the Registered Manager and as to how the home is managed. The home has effective quality assurance and quality monitoring systems. The home has conducted service user and care staff satisfaction questionnaires in August and September 2006. A relatives’ satisfaction survey was conducted in May 2006. The home has policies in relation to equal opportunities and equality and diversity. The Inspector viewed a number of documents in relation to health and safety. Fire Safety: The Fire Procedure is dated 28/11/06. The Fire Risk Assessments is dated 20/12/06. Weekly checks are conducted on fire points and emergency lighting. The annual service of the fire system, emergency lighting and fire fighting equipment was conducted on 28/06/06. Regular fire drills are undertaken. The home also conducts weekly visual checks on fire doors and detectors. All staff receive regular fire training, The Inspector noted that recently appointed staff had also received such training. Hot Water: The temperature of the hot water is tested weekly with records kept. The home also cleans the showerheads twice weekly with records kept. Electrical Hardwiring Certificate: This is dated 29/10/03 and was valid for five years. Portable Appliance Testing: Annual testing took place on 23/10/06. Gas Safety Certificate: This is dated 30/06/06. Health and Safety Audit: The home conducted an audit on 08/11/06. Food Safety: An inspection took place 0n 22/05/06. The report stated a good standard of cleaning. Accidents: Records are kept of all accidents. The Inspector viewed records relating to these and noted that the Registered Manager signs all records of accidents as part of the audit process. COSHH: The home has a policy in relation to this. All products are stored securely. First Aid: All staff are trained in first aid. Newly appointed staff have been identified for this training as soon as possible. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 25 Fridge/Freezer: The home keeps daily records of fridge and freezers and keeps food probe records. Risk Assessments: The home has a detailed risk management policy. The Inspector viewed a number of individual and environmental risk assessments. A large number of environmental risk assessments had been reviewed on 01/10/06. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 X 3 X Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 27 NO 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. 1 Standard YA34 Regulation 17 Requirement The Registered Manager must ensure that the staff recruitment files contain the required documents as listed in Schedule 2 of The Care Homes Regulations 2001. Timescale for action 02/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations The Registered Manager should ensure that hand transcribed medicines and any alterations to the MAR sheets be supported by two staff signatures. It is also recommended that the home should contact the GP to review the agreed homely remedies for some service users, as this had not been done for a number of years. Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Registration Team 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 Wyvern Lodge DS0000020374.V308363.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!