Care Home: Alsley Lodge

Similar services:

• Chirnside House
• Keer Sands Residential Home
• Ruskin Lodge
• Bushell House
• Langrigg House
• Parkside
• Dystlegh Grange
• Thornton Lodge

What the care home does well What has improved since the last inspection? Some parts of the home had been improved and decorated to provide a better environment for the residents. "I like what they are doing outside" said one resident. Much progress had been made with staff training and development, which should help ensure staff provide good care for the residents. Residents meetings were being held to give people the opportunity to make comments and suggestions. People were being written to following their assessment, to provide an assurance that home is suitable for meeting their needs. Care Plans were being reviewed monthly, to help ensure peoples changing needs were known and planned for. To reduce the risk of people harming themselves, all radiators had been fitted with covers. To help people move around the home more easily, handrails had been fitted on corridors. CARE HOMES FOR OLDER PEOPLE Alsley Lodge Station Road Rufford Ormskirk Lancashire L40 1TB Lead Inspector Mr Jeff Pearson Unannounced Inspection 18th June 2008 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 Alsley Lodge DS0000066875.V363547.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. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alsley Lodge Address Station Road Rufford Ormskirk Lancashire L40 1TB 01704 821713 01704 822753 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) Raycare Limited Mrs Jeanette Ann Vaill Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 24 service users in the category of OP (Old age, not falling within any other category). Date of last inspection 24/05/06 Brief Description of the Service: Alsley Lodge is situated in a rural area in the village of Rufford, West Lancashire. The home, once a public house has been developed over the years to provide accommodation for up to 24 older people. The property is set in its own grounds, with far reaching views from the rear of the home. There is a car parking area to the front of the home, a courtyard in the centre and patio area to the rear. The residents’ accommodation is single storey; there is a large lounge, separate dining room and additional seating in the hallway. There are both shared and single rooms, a number having en-suite facilities. Various aids and adaptations are provided including handrails and grab rails and assisted bathing facilities. Staff are available to provide assistance with personal care and support 24 hours a day. The home had a Statement of Purpose and Service User Guide providing information about the care and services available. This information, which should help people make an informed choice about moving into Alsley Lodge, was available in the home. At the time of this inspection visit, the range of fees charged were between £412.00 and £525.00 per week, there were additional charges for hairdressing, chiropody, opticians and dentistry. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people using this service experience good quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Alsley Lodge on the 18th June 2008. The visit took 8¼ hours and was carried out by one inspector. Since the last inspection we had carried out an annual service, we do this when there has been no major inspection of the service (we call this a key inspection) in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review. The residents, their relatives and staff were invited to complete surveys, to tell the Commission what they think about the care service provide at Alsley Lodge, some were received at the Commission. Prior to the site visit, the registered person had been required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of three people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with the residents, registered manager, deputy manager care staff and cook. Various documents, including policies, procedures and records were looked at. Some parts of the home were viewed. What the service does well: The home was being run by a team of staff; who were keen to provide a good service for the residents. Relatives completing surveys, made the following comments on what they felt the home does well – “the relationship developed with residents” “care given to each individual” “the manager always reports Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 6 back on any query that I have particularly in relation to medication, follow up to doctor” Positive comments from residents were -“I like it here very much” “I think its marvellous” and “I wouldn’t move from here” People were getting attention for health care needs and personal privacy needs were being dealt with sensitively and they were being treated with respect and as individuals. Residents said, “They treat me with respect, they are kind, they have a good approach”. Most people were happy with the arrangements for activities and daily routines were fairly flexible and had been agreed with individuals. Most people liked the food at Alsley Lodge, they said, “food is good we get a choice”, “I like the food” and “its okay” Positive comments were made about the staff team, residents said, “the staff are jovial and helpful, they will do anything to help you” “They are very kind” “Nothing is too much trouble” What has improved since the last inspection? Some parts of the home had been improved and decorated to provide a better environment for the residents. “I like what they are doing outside” said one resident. Much progress had been made with staff training and development, which should help ensure staff provide good care for the residents. Residents meetings were being held to give people the opportunity to make comments and suggestions. People were being written to following their assessment, to provide an assurance that home is suitable for meeting their needs. Care Plans were being reviewed monthly, to help ensure peoples changing needs were known and planned for. To reduce the risk of people harming themselves, all radiators had been fitted with covers. To help people move around the home more easily, handrails had been fitted on corridors. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alsley Lodge DS0000066875.V363547.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 Alsley Lodge DS0000066875.V363547.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process helped ensure peoples’ needs and wishes, were considered and planned for before they moved into the home. EVIDENCE: The deputy manager explained the usual assessment process, which involved gathering information and visiting people in their own environment to consider their needs and abilities. Information had been obtained from Social Services and other people such as GPs and relatives as appropriate. Records showed the home had completed assessments; taking into consideration peoples individual needs abilities and wishes in matters such as mobility, communication, personal hygiene, dressing, bathing and medication. People were being written to following assessment, with a letter of acceptance being sent, including the agreed date for admission. The cook said she was made aware of peoples’ food preferences and special diets before they moved into Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 10 the home. Bedrooms were being checked over before people moved in to make sure everything was in order. People were being encouraged to visit prior to moving in, some spoken with said relatives had helped them choose the home, one explained “My daughter came to look around for me” Most residents completing surveys indicated they had received enough information about the home before moving in. People were being offered trial periods before making a final decision to stay. At the time of this inspection Alsley Lodge did not provide intermediate care. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most health and personal care practices and procedures were effective in ensuring people’s individual needs are properly met. EVIDENCE: Residents spoken with were satisfied with care and attention they received at Alsley Lodge, one said “the way they care for you is excellent, nothing is too much trouble” This response was also reflected within most surveys completed by residents and their relatives. With residents indicating they always get the care and support they need and that staff always listen and act on what they say. Most staff completing surveys indicated they always had up to date information about peoples needs. Care plans were looked at as part of ‘case tracking’ The format in use provided scope for peoples’ individual needs to be assessed on a wide range of relevant matters, such as, sleep routines, mobility, medication, hobbies and social Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 12 needs needs. However, there was some repetition and plans seen were lacking in detail and clear instructions for staff to follow in order to properly respond to peoples’ individual needs. For example, one plan stated “assistance of one for personal needs and assistance”, which was not specific and detailed enough to effectively instruct staff in providing person centred care. This lack of precise directions to staff meant that continuity of care is largely dependant upon staff memory, with a potential for care needs not being properly met and care being reactively, rather than proactively planned. The care plans seen were also lacking in instructions for responding to social care needs. Records showed that peoples care needs were being monitored and regularly reviewed. Policies and procedures were available in relation to health matters, such as moving and handling, pressure relief, continence, also privacy, dignity and confidentiality. Health care needs were included with care plans. Records and discussion showed people were getting attention from healthcare professionals such as GP as District Nurses. Most residents completing surveys indicated they always receive the medical support needed. Additional assessments had been completed in relation to nutrition, falls, pressure areas and mental health. A visiting District Nurse indicated the home responded appropriately to health matters. All senior staff had undertaken a 12 week medication training course. Medication storage was satisfactory, clean and secure. Medication policies and procedures were available, also information sheets on prescribed items, it was advised current guidelines from the Royal Pharmaceutical Society be obtained for reference when updating policies. Most records seen were accurate, clear and up to date, but there were some discrepancies needing attention. Such as, one hand written entry on the medication record sheet did not include dosage instructions and one label showed an incorrect date. Some people were prescribed ‘variable dose’ and ‘when required’ items, but there were no clear individual instructions on how to manage these. To promote independence, some people were being supported to self-administering some items, but there were no assessments to show their ability to do this had been properly considered. The manager and deputy manager agreed to pursue these matters. The home had a charter of rights which covered dignity and privacy matters. The residents spoken with considered they were treated with respect one said “They treat me with respect, they are kind, they have a good approach. Observations of care practices during the inspection indicated peoples’ privacy needs were being respected; staff spoke with residents in a courteous manner. One comment written by a relative was “dignity and privacy always respected” People were being supported to maintain their appearance, a hairdresser was in the home and the residents appeared to appreciate this service. Alsley Lodge DS0000066875.V363547.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): 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. People living at Alsley Lodge had opportunities to make choices, join in activities and had lifestyles that generally matched their expectations. EVIDENCE: The residents spoken with indicated they were generally happy living at the home, “I like it here very much” said one person “Its alright” commented others. Routines seemed flexible, it was apparent the residents could spend time in their rooms whenever they wished and records showed preferred getting up and going to bed times had been agreed with each person. “We can eat in our rooms”, explained one person. Residents’ surveys indicated they were “usually” happy with the activities available. A list of possible activities was seen, including musical bingo, armchair exercise, ten-pin bowling, hoopla, jigsaws and dominoes. Records were being kept of people’s participation with activities; however, as previously indicated, social care needed to be better reflected in the care planning process Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 14 to make sure all needs are effectively addressed. Some people preferred not to join in and their wishes were respected. One person said “There are activities but not in my line”. One comment from a relative was “could improve activities” Various outings had previously been arranged and more were being planned for, including a ‘Strawberry Tea’ at a local Church. The manager had recognised activities at the home could be improved; the home had employed an activity coordinator to work each afternoon and other incentives were being considered. The homes’ visiting arrangements were included in the homes written information, the charter of residents rights indicated they had the right to refuse visitors if they wish. Residents spoken with indicated they could see people at any time. There were several visitors in the home, those spoken with said they were always made welcome. Representatives from various religious faiths visited the home, a hymn service each month; one person confirmed the minister and other people from Church had visited them. A residents meeting was held on the afternoon of the visit, this provided opportunity for the giving and receiving of information, making suggestions and enabling the residents to make group decisions. The manager said the residents had recently chosen the new wallpaper in the lounge. The care planning process provided much scope for promoting individual choices. The residents spoken with were generally satisfied with the food provided at Alsley Lodge, some said it was “good” others that the meals were “alright”. Those completing surveys indicated they “usually” liked the meals. One relative survey comment was there were “too many sausages”, but one resident specifically said they liked the sausages! The cook, who had an NVQ (National Vocational Qualification) level 2 in cookery, explained that menus had been devised in consultation with the residents, and that they could choose from the selections available each day. Fresh produce was being used and cakes were being ‘home baked’. Special diets, such as diabetic were being catered for and a dietician had been consulted, for specific advice. Good practice in relation to meals and mealtimes was discussed with the cook. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most policies, procedures and practices provided safeguards for people using the service and supported the complaints process. EVIDENCE: The charter of residents’ rights provided a good indication of the care and service people living at Alsley Lodge can expect to receive. Most residents completing surveys and those spoken with, indicated they knew how to make a complaint, one comment made was “If I had a complaint I would speak to someone” others said they had “no complaints”. All staff completing surveys indicated they were aware of how to respond to concerns or complaints made by residents and others. The complaints procedure, which was on display in the home and included within the home’s guide, provided instructions on making a complaint, expected timescales and details of other agencies, including the Commission. There had not been any recent complaints; the last complaint was discussed with the manager. In particular, remaining impartial, devising investigation strategies and ensuring systems make proper provision for recording interviews/discussions and all action taken. Most residents completing surveys indicated they knew who to speak to if they were not happy. Some spoken with said that they felt safe at the home. All Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 16 staff had received training on June 11th 2008, on the protection of vulnerable adults. The manager expressed a very good practical awareness of appropriately dealing with any incidents, suspicions, or allegations of abuse/neglect. However, this approach was not appropriately reflected in the homes polices and procedures. Although there was some good guidance on providing safeguards, there was misleading information on ‘investigating’ matters and deciding if a referral was necessary. The staff ‘whistle blowing’ procedure included some good information, but needed the full contact details of the local Social Services and The Commission for Social Care Inspection, to ensure any unresolved bad practice is appropriately reported. The manager expressed concern about the content of the procedures and agreed to ensure they were appropriately amended. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided the residents with a comfortable and clean place to live. EVIDENCE: The residents spoken with were satisfied with the accommodation provided at Alsley Lodge, they had been enabled to personalise their bedrooms with their own belongings, which helped create a sense of home and ownership. One resident said, “I like my bedroom”. Since the last inspection parts of the home had been redecorated, the kitchen had been refitted, hand rails provided on corridors and radiators covered. New carpets had been fitted in most bedrooms. Plans were in place to continue upgrading the home. The rear patio was being improved to provide a better area for the residents, one person said Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 18 “I like what they are doing outside” and a relative wrote in a survey “The general communal areas are very good, bright clean and the garden improvements will be splendid when finished”. Not all bedrooms had been fitted with an appropriate lock; some had locks which were not easy to use from the outside. The value of providing all doors with suitable locks, to promote independence, choice and privacy of space was discussed with the manager. The standard of decoration and accommodation was good and furnishings were domestic in appearance. The home was found to be clean and free from unpleasant odours. Satisfactory laundry equipment and facilities were available; arrangements were being made to keep the home clean and a maintenance person was employed at the home to undertake repairs. Liquid hand sanitizer was provided in areas such as the entrance hallway and kitchen. Plastic aprons and gloves were available to staff. Infection control policies and procedures were available. There was a clear indication within the AQAA (Annual Quality Assurance Assessment) completed by the manager that the home was to be refurbished and upgraded in several areas. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made with staff training and development, but staff recruitment practices and staffing levels, did not always ensure the resident’s needs are effectively and safely met. EVIDENCE: Residents spoken with made positive comments about the staff team, describing them as “alright” and “Very friendly, helpful” another comment made was “Staff are Jovial and helpful, they will do anything to help you” The staff rota indicated day- time staffing levels were satisfactory, however, it was noted there were only two staff on duty in the evenings from 8 pm, which raised some questions on providing safe and effective support for the numbers and needs of the people accommodated. Some staff had indicated in surveys staffing levels were ‘usually’ sufficient and some residents considered there were ‘usually’ enough staff available. Staffing levels were discussed with the manager and deputy manager, who considered that staffing was satisfactory. The manager said staffing levels could be increased in response to peoples Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 20 changing needs, however, it was agreed staffing levels should be reviewed and adjusted accordingly to ensure people’s needs are effectively and safely met. Since the last inspection, improvements had been made with staff training; this was being given high priority at Alsley Lodge. Most of the care team had NVQ (National Vocational Qualifications) level 2, four staff had attained NVQ level 3, one person was due commence this. He deputy manager had NVQ level 4. Training courses in safe working practices, such as Safe Food Handling, First Aid and Moving and Handling, had been completed and were going. Staff surveys indicated they considered appropriate recruitment practices had been carried out. The recruitment records of the last members of staff to be employed were examined, and were found to be mostly satisfactory, however, both employees had only provided details of their last 10 years employment, as apposed to full employment history. The manager said she was not aware of the requirement, but agreed to ensure this information is requested and considered. It was noted, the declaration about criminal convictions did not request details of cautions, or a signature in confirmation, which would provide further initial screening safeguards. Records were seen of staff induction training, most staff surveys indicated this had covered everything needed; the ‘Scills for Care’ induction pack was available. New staff were being supported to undertake NVQ and mandatory training courses. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Most management and administration practices were effective in ensuring the home is run for the benefit of the residents, staff and visitors. EVIDENCE: Jeannette Vaill has been registered with the Commission to be manager at Alsley Loge since January 2007. She has a number of years experience in care management and has attained NVQ level 4 in social care management and the Registered Managers Award. She had a teacher training certificate and has updated her training in areas such as, medication practices and the protection of vulnerable adults. Relative and staff surveys included positive comments about he manager, one relative wrote “The manager always reports back on Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 22 any query that I have…” and member of staff commented “My manager runs the home very well and I find it easy to discuss any issues I have” Various surveys and questionnaires had been given to relevant people, including, residents, families and staff. The manager said minor matters arising were dealt with straight away; more significant improvements were being included in the homes development plan. The AQAA (Annual Quality Assurance Survey) had been previously completed by the manager. Ensuring enough details are noted, using the process for ongoing quality assurance and developing the service was discussed. It was advised the results/findings of quality surveys be included within the AQAA. A part time administrator works at the home. Good systems and practices were in place for managing the resident’s payments of fees. Accountable systems and records were in place for managing resident’s monies. Arrangements were in place for all staff to receive training in safe working practice subjects. The homes AQAA indicated the servicing and checking of equipment and installations, some records were seen in support of this. Health and safety policies and procedures were available. Some bedroom doors wedged open at the occupants request, this practice considered within fire safety risk assessments. The last recorded fire drill was 30/11/07, but the manager said an unofficial drill had been carried out the previous week when the equipment was serviced, this drill needed to be noted in the Fire Records and arrangements needed to be made to ensure practice drills are carried out more frequently, in accordance with Fire Authority guidance. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Schedule 2 Requirement For the protection of the residents, recruitment practices and procedures must always ensure all required checks are carried out prior to staff commencing employment. Timescale for action 31/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP9 OP9 OP9 Good Practice Recommendations Care plans should be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents personal and social care needs. A suitable auditing system should be introduced to ensure safe medication practices. To make sure people are properly supported to receive their medication, individual instructions should be written in relation to variable dose and when required medication. To make sure people are safely supported to manage their own medication, their individual abilities need to be assessed and planned for. DS0000066875.V363547.R01.S.doc Version 5.2 Page 25 Alsley Lodge 5. 6. OP9 OP18 7. 8. 9. OP19 OP27 OP38 To make sure hand written entries on medication records are confirmed as correct, they should be checked and signed as correct by two people. To make sure people are properly protected, the safeguarding policies and procedures must be amended to include more appropriate and clear instructions for managers and staff to follow. The staff ‘whistle blowing’ policy should include appropriate referral details. To promote privacy of space, it is recommended suitable locks, which enable access in the event of emergency and choice of usage, be fitted to all bedroom doors. To ensure people are effectively and safely supported, staffing levels should be continually reviewed and adjusted accordingly. To promote safe working practices, action should be taken to ensure fire drills are carried out on a regular basis, in accordance with Fire Authority guidance. Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Alsley Lodge DS0000066875.V363547.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!