Care Home: Bullsmoor Lodge

What has improved since the last inspection? What the care home could do better: Two new requirements have been issued as a result of this inspection. The registered person must review every resident in the home to make sure that information about any allergies they may have are being recorded accurately on their medication chart. The flooring in the laundry is worn and could present a health and safety hazard. We have required the home to repair or replace this to make it safer. We have also issued a good practice recommendation that residents are more involved in any risk management strategies that may affect them. Key inspection report CARE HOMES FOR OLDER PEOPLE Bullsmoor Lodge 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE Lead Inspector Mr David Hastings Unannounced Inspection 22nd April 2009 10:00 DS0000010662.V375111.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bullsmoor Lodge Address 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE 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) 01992 719092 01992 650603 bullsmoor.manager@btinternet.com Scimitar Care Hotels Plc Angela Christine Dickson Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48) of places Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia, over 65 years of age - Code DE(E) The maximum number of service users who can be accommodated is: 48 30th April 2008 Date of last inspection Brief Description of the Service: Bullsmoor Lodge is a modern purpose built home owned by Scimitar Care Hotels. There are four homes belonging to this organisation. The home is registered to care for forty-eight people of either gender who are over the age of sixty-five, six of whom have may have a diagnosis of dementia on admission to the home. Currently only twelve of the forty-one residents have a diagnosis of dementia. The main lounge, dining room and kitchen are on the ground floor. All but three rooms are single and have en-suite toilets. There is an attractive garden to the rear of the house. There are two lifts that give access to all floors. The home aims to provide support and care in a homely environment. Fees are between £644 and £800 per week. This report is available through the internet. Copies may also be obtained from the provider of this service. Bullsmoor Lodge DS0000010662.V375111.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 stars. This means the people who use this service experience good quality outcomes. This Key Unannounced inspection took place on Wednesday 22nd April 2009 and was completed on the same day. The inspection was undertaken by one inspector and lasted seven hours. We spoke with seven staff on duty during the inspection. We spoke with ten residents of the home and we met five visitors. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. The home also prepared a self–assessment (AQAA) and this was submitted to the Commission for Social Care Inspection in September 2008. This information was used as part of the inspection. What the service does well: The home had a relaxed and friendly atmosphere. There is a good rapport between residents, staff and visitors. People who use the service are treated with respect and their dignity and privacy is valued and upheld. Staff demonstrated a good knowledge of residents needs and consequently an individualised service is promoted. Residents have good access to health care professionals. The home makes sure that people’s needs are assessed before they move in so that people know the home will be able to meet their needs. Residents of the home feel that the staff are kind and polite and support them properly. People who use the service and their relatives made many positive comments about the staff and the home. These included, “My room is excellent”, “The staff are most kind” and “This is a good care home”. What has improved since the last inspection? Nine requirements were issued at the last inspection. Four of these were restated from a previous inspection. The registered person has now complied with all of these requirements. As a result of these requirements being met: • • Care plans are more detailed and peoples’ nutritional needs are being properly recorded. Procedures for administering medication have improved. DS0000010662.V375111.R01.S.doc Version 5.2 Page 6 Bullsmoor Lodge • • • • • • Staff are supporting people who require assistance with eating and drinking in a sensitive and discreet manner. The organisation is undertaking monthly visits to the home and asking residents views about the quality of care provided. People who use the service are given clear information about how well the home is doing to meet the aims and objectives of the service. All staff at the home are undertaking fire drills on a regular basis and the fire alarm is being checked weekly. When domestic staff are cleaning around the home they now make sure that cleaning chemicals are not being left unattended. Where residents wish to have their door open, a self-closing fireguard has been fitted to their door so that their door will close in the event of a fire. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home carries out an assessment of individual’s needs so that they know that the home is able to meet their needs before they decide to move in on a trial basis. EVIDENCE: Pre admission assessments were examined for three people who are now living at the home. The information was satisfactory and clearly outlined each person’ s individual needs. There were also detailed assessments from the local authority or hospital to assist the home in their own pre admission assessments. The manager told us that herself or a head of care would visit a prospective resident and carry out an assessment of their needs before they moved in. There was evidence that these identified needs were also being recorded in each person’s individual care plan. People who use the service and Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 9 their relatives told us that they were involved in this assessment process and, where possible, had visited the home before moving in on a trial basis. One resident told us that although he was too ill at the time to visit the home his daughter had visited. We also saw evidence that people have a review of their placement after 4-6 weeks to see if they would like to stay at the home on a permanent basis. The home does not provide intermediate care however respite care is provided. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Seven care plans were examined. Each plan gave clear instructions to staff about how best to care for each person. All care plans covered the physical, emotional and cultural needs of the individual. Care plans were being reviewed on a regular basis and updated where needed. There was evidence that people were being asked what they thought about their own care plans and records were being maintained about the resident’s views about the quality of the care being delivered. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 11 Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. There were other risk assessments seen in each person’s file, including manual handling, pressure care and nutrition. All these were being reviewed on a regular basis. Where a risk of developing pressure sores had been highlighted action had been taken to reduce this risk by obtaining pressure relieving mattresses. The home has also developed a repositioning plan for people who are at moderate risk of developing pressure sores. One person was admitted to the home with a pressure sore. The district nurses visit the home twice a week to attend to the resident. The manager told us that the pressure sore was improving. Although residents are being consulted about their care plans it is important that they are also involved with their risk assessments. A good practice recommendation has been issued that individual risk management strategies are discussed with the person concerned, where appropriate. The service manager told us that the care plan format had been reviewed and all care plans were being updated to this new format. The new care plans are more detailed and appeared more user friendly. There was evidence from care plans that people have good access to health care professionals such as doctors, chiropodists, district nurses and opticians. The doctor visits the home once a week and records were being maintained of the outcomes of these visits with any follow up action needed. People who use the service confirmed that they had good access to health care professionals. On the day of the inspection people using the service looked well cared for, their clothes were clean and they were appropriately dressed. Satisfactory records were examined in relation to the receipt, storage, administration and disposal of medication. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. Medication records included a picture of the resident so staff could double check that the right person was receiving the right medication. We noted that on one resident’s care plan it was stated that they were allergic to Penicillin. This was not recorded on the person’s medication chart. The service manager told us that this was an oversight on her part and the medication chart was amended immediately. There was a list of other residents who have known allergies on the medication chart. To make sure that this is up to date and accurate we asked the manager to review this document. A requirement relating to this has been issued in the relevant section of this report. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 12 We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. A resident told us that the staff are, “Thoughtful, kind and loving”. Bullsmoor Lodge DS0000010662.V375111.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. Visitors to the home are encouraged and welcomed. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: The home has employed an activities coordinator. Both staff and residents were very positive about the quality of activities now available at the home. We spoke with the activities coordinator and we were very impressed by her enthusiasm and ideas about activities. The activities coordinator understood the need to not only engage with residents in groups but also on a one to one basis. One resident told us, “I involve myself in everything that goes on”. Another resident commented, “We sit in the garden and disscuss the news. We do things in the afternoon”. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 14 The activities coordinator told us she was looking forward to a forthcoming dementia training course so she could have a better understanding of the needs of the people at the home with dementia. Residents’ individual social and recreational interests were recorded in the seven care plans we sampled. Visitors to the home told us that they could visit at any reasonable time and that they were made welcome by the management and staff. Residents we spoke with said they enjoyed getting visitors and confirmed they were made welcome. It was good to see so many visitors on the day of the inspection. This gave the home a lively atmosphere. Interactions observed between staff and visitors were warm and friendly. One visitor was having lunch with their relative and we were told that this was not unusual. One relative we spoke with said they thought the care provided at the home was, “Fantastic”. The activities coordinator holds regular residents’ meetings and residents we spoke with gave us examples of how things had changed as a result of these meetings. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. We saw examples of staff offering choice in relation to meals and activities during the inspection. Peoples’ preferences in relation to getting up in the morning and going to bed of any evening are recorded in their individual care plans. People who use the service confirmed that they could exercise choice and control over their lives. One resident told us, “You can have meals at anytime”. We saw that some residents, who we were told liked to get up later, were still having breakfast in the dining room. On the day of the inspection the kitchen was clean and well stocked with fresh fruit and vegetables. The cook was aware of any special diets that people needed and told us that he would bake cakes for resident’s Birthdays. Fridge and freezer temperatures were being recorded. We looked at the menu and saw that a choice of lunch is always available. Lunch on the day of the inspection was roast pork or salmon. The food looked and smelt appetising and people told us they get enough to eat. One resident confirmed, “There is always a choice of food. They ask you the day before what you want”. Another resident told us, “I like the food very much”. Bullsmoor Lodge DS0000010662.V375111.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: Records of all complaints, however minor are recorded with details of the action taken to resolve them. There has been one formal complaint made since the last inspection. The provider notified the Commission about this including the outcome of the investigation. The complaint was upheld and we could see from examining records that this had been dealt with in an open and professional manner. All the residents and visitors we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. One resident commented, “I put my complaint in and it was dealt with”. Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 16 Records indicated that most staff have undertaken training in the protection of vulnerable people. The training officer for the organisation has attended a train the trainer course in safeguarding issues and carries out regular safeguarding training for staff. One resident commented, “I have never had a harsh word from anybody”. Bullsmoor Lodge DS0000010662.V375111.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe, clean, well maintained and furnished and decorated to a very good standard. EVIDENCE: We looked around the home with the service manager and visited a number of residents’ rooms. The home was well maintained and decorated to a good standard. Peoples’ rooms were individual and contained their personal possessions. Residents told us they were happy with their rooms. On the day of the inspection the home was clean and tidy. The home employs domestic workers and the residents and visitors were spoken with confirmed that the home was always clean. One visitor we spoke with said that the cleanliness of the home was one reason their relative chose this home. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 18 There are satisfactory policies and procedures in place to reduce the risk of cross infection. The laundry area was clean and all toilets and bathrooms had paper towels and anti-bacterial soap. The flooring in the laundry will need to be repaired or replaced as it is becoming worn. A new requirement has been issued relating to this. Records indicated that staff have attended infection control training and we saw that new staff have also been booked to attend this training. Bullsmoor Lodge DS0000010662.V375111.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff at the home work hard to meet the needs of the residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: One the day of the inspection there were eight care staff on duty in the morning and seven staff on duty during the evening. There are three waking night staff on duty throughout the night. There appeared to be sufficient staff on duty to meet the needs of the people they support. Residents and their families we spoke with were positive about the staff. One resident told us, “You have fine staff here”. A care worker we spoke with told us, “It’s a good team”. We spoke with the training officer who is responsible for providing training to staff at the home. She told us that over fifty percent of care staff have attained the NVQ level 2 qualification or equivalent. All the care staff we spoke with told us they either had this qualification or were currently undertaking it. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 20 Staff were very positive about the training offered by the home and records and certificates seen indicated that staff are attending the appropriate training they need to support people properly and safely. This training included medication, moving and handling, adult protection and first aid. The training officer and the service manager are also providing a very practical training session on dignity and respect. This involves care staff being assisted with eating and drinking. Staff told us this has improved their understanding of what it is like to be on the receiving end of care tasks. Four staff files were examined from staff recently employed by the home. We checked these files to see if the home’s recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof of identity and criminal record checks. The registered manager told us that she would phone referees to confirm the reference. Referees are also requested to include a company stamp or letter headed paper to further confirm the authenticity of the reference. Bullsmoor Lodge DS0000010662.V375111.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents do have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are promoted and protected. EVIDENCE: The registered manager has been in post for over five years and both residents and staff were very positive about her work at the home. One resident said the manager was “A nice and excellent person”. Staff confirmed that the manager is approachable and supportive. The manager has completed the required Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 22 training to manage a care home. It was clear from discussion with the manager that she knows and understands the need of the residents at the home as well. The manager also understood her responsibilities in relation to running this busy home. The home has a satisfactory quality assurance system, which is now up and running. We examined the published results from the last quality questionnaires that were sent to residents and their representatives. These were set out clearly and included action taken to resolve any issues that arose. This now means that residents have a say in how the home is run and can see how well the home is doing to meet the aims and objectives of the service. The service manager told us that a new quality assurance questionnaire would be sent out to residents soon. As stated previously residents meetings are now being held on a regular basis. Monthly unannounced visits by the organisation are now taking place and the service manager said these have been very useful not least has they provide a chance for residents to comment on the care they receive. The home does not usually hold money on behalf of residents. Those people who can look after their own money have lockable drawers in which to store it. Relatives manage the finances of most others. The manager said that she will authorise payment of items or services from the home’s money and the relative will then be sent an invoice to repay the home on the resident’s behalf. Monthly invoices sent to relatives were examined and appeared to be clear and accurate. Satisfactory health and safety records were seen in relation to electrical installation and equipment servicing such as hoists and lifts. The maintenance person is a qualified electrician and carries out regular PAT testing. We also checked records in relation to fire safety. Records indicated that both day and night staff were undertaking fire drills on a regular basis. Fire training has been given to all staff and staff confirmed they have undertaken this training. Records of checks for the fire alarm, emergency lighting and fire extinguishers were also satisfactory. Records indicated that staff are undertaking the required health and safety training. The training officer told us that enough staff have undertaken the first aid training so that there is a qualified first aider on every shift. Bullsmoor Lodge DS0000010662.V375111.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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Bullsmoor Lodge DS0000010662.V375111.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 OP9 Regulation 13.2 Requirement The registered person must ensure that all residents’ medication charts are reviewed so that up to date information about any possible allergies are accurately recorded. The registered person must ensure that the flooring in the laundry area is either repaired or replaced. Timescale for action 30/06/09 2. OP26 23.2 (b) 01/09/09 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 OP7 Good Practice Recommendations The registered person should ensure that residents are able to be involved in any risk management strategies that affect them. Bullsmoor Lodge DS0000010662.V375111.R01.S.doc Version 5.2 Page 25 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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