Care Home: Craigielea Lodge

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What the care home does well Service users and their relatives were complimentary about many aspects of the service provided at Craigielea Lodge. Many positive comments were made about different aspect of the home, such as the food provided, staff`s approach and the environment. Some comments received from service users` relatives include: "The welfare and happiness of the residents comes first with all staff, I cannot praise them enough." "We have confidence in the staff at the home. They are hard working and very caring. There is a friendly homely atmosphere when walking in." Service users particularly made positive comments regarding the way staff supported them and addressed them. Service users said: "The staff are really kind." "They are good at their job." "The staff are very very good, they know what they are doing." The home endeavours to address the diverse interests and social cultures of the service users living at this home. Each person`s individual interests and preferred way of life are respected and supported.Craigielea LodgeDS0000007388.V341830.R01.S.docVersion 5.2One service user stated that, although they do not continue to follow all of the interests they had prior to moving into the home, there was enough going on and enough choices to make their life interesting. Service users felt that everyone was treated equally. An activities worker is employed in the home, and provides both 1 to 1 and group activities. These include trips out to local places of interest, and the home has access to its own adapted minibus. Service users spiritual and cultural needs are recorded, and measures taken to ensure they are met. What has improved since the last inspection? The home has had a variation made to their registration so that they are now registered to provide care for one person with Dementia. So that service users are safeguarded from unsuitable staff working with them the manager makes sure that a clear CRB check is received for all new employees prior to them starting work at the home. All service users living at the home are in receipt of a contract between them and the home. This means that all service users are aware of the home`s terms and conditions that they have agreed to. A Monthly Newsletter now informs service users and their relatives about what has gone on in the home and what is planned to take place. Relatives particularly find this very helpful to keep them in touch with life in the home. What the care home could do better: So that the risk to the service user is minimised when using bedrails the assessment carried out by the occupational therapist that dictates their use must be recorded in the individual care plan. This decision must also be monitored so that it is clear that the use of the bedrails continue to be necessary and guidelines for carers to follow when checking their safe use must be put in place. So that the storage of incontinence aids do not compromise the dignity and privacy of individual service users discreet storage should be found. So that service users are protected by the local authority`s procedures regarding Safeguarding Adults the manager and staff should regularly up date training in relation to these. So that all service users live in an odourless free environment the manager should make sure that any unpleasant odour is addressed directly.Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 To ensure that service users` changing needs and activities organised are supported effectively the manager should regularly review and address the ratio of staff needed. One relative commented: "They do their best but further staffing would be beneficial." CARE HOMES FOR OLDER PEOPLE Craigielea Lodge Lyndhurst Avenue Low Fell Gateshead Tyne & Wear NE9 6AY Lead Inspector Mrs Elsie Allnutt Unannounced Inspection 10:00 1 August 2007 st 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 Craigielea Lodge DS0000007388.V341830.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. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Craigielea Lodge Address Lyndhurst Avenue Low Fell Gateshead Tyne & Wear NE9 6AY 0191 482 5823 0191 487 0639 sj@craigielea.fsbusiness.co.uk 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) Gateshead Dispensary Housing Association Limited Patricia Anne Hillary Care Home 33 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (33), Physical disability over 65 years of age (2), Sensory Impairment over 65 years of age (2) Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Categories MD(E), PD(E) and SI(E) relate to current residents only. The DE(E) category of registration refers to current service user only Date of last inspection 17th May 2006 Brief Description of the Service: Craigielea Lodge is care home, providing personal care for up to 33 older people. Nursing care is not provided, but District Nursing services can be arranged where necessary. It is a purpose built care home with accommodation provided over two floors, with level access throughout. A lift provides access between the two floors of the home. Adapted bathing facilities have been provided and there are hand rails fitted to the corridors. There are garden areas to the front and around the home. This includes a paved seating area. The home is situated in the Low Fell area of Gateshead, near to local public transport links. It is also situated near to a wide range of local facilities, including a doctors surgery, a library, shops, pubs and places of worship. The home is attached to a separately registered home with nursing owned and managed by the same Company. Since the last inspection a variation to the registration of this home has been granted to provide a service for one person with dementia (DE over 65 years of age). A detailed Service User Guide has been developed and a Home Brochure is available. These documents provide clear information about the service offered at this home. A copy of both and a copy of the previous inspection report are available in the entrance hall to the home. The fee level for the home is £359.00 per week. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day in August 2007 and was a scheduled unannounced Key Inspection. The inspection included a separate look at the Annual Quality Assurance Assessment (AQAA) completed by the manager, and comment cards received after the inspection from 5 service users’ relatives. The care experienced by a sample of service users was ‘case tracked’ (this is where the inspector focuses on the service provided for individual service users) and time was spent chatting with service users and observing life in the home. A tour of the building took place, and a sample of staffing and service users’ records was inspected. The inspector took a meal with service users. The judgements made are based on the evidence available to the inspector during the inspection, the AQAA supplied by the registered manager and the comment cards completed by service users and their relatives. What the service does well: Service users and their relatives were complimentary about many aspects of the service provided at Craigielea Lodge. Many positive comments were made about different aspect of the home, such as the food provided, staff’s approach and the environment. Some comments received from service users’ relatives include: “The welfare and happiness of the residents comes first with all staff, I cannot praise them enough.” “We have confidence in the staff at the home. They are hard working and very caring. There is a friendly homely atmosphere when walking in.” Service users particularly made positive comments regarding the way staff supported them and addressed them. Service users said: “The staff are really kind.” “They are good at their job.” “The staff are very very good, they know what they are doing.” The home endeavours to address the diverse interests and social cultures of the service users living at this home. Each person’s individual interests and preferred way of life are respected and supported. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 6 One service user stated that, although they do not continue to follow all of the interests they had prior to moving into the home, there was enough going on and enough choices to make their life interesting. Service users felt that everyone was treated equally. An activities worker is employed in the home, and provides both 1 to 1 and group activities. These include trips out to local places of interest, and the home has access to its own adapted minibus. Service users spiritual and cultural needs are recorded, and measures taken to ensure they are met. What has improved since the last inspection? What they could do better: So that the risk to the service user is minimised when using bedrails the assessment carried out by the occupational therapist that dictates their use must be recorded in the individual care plan. This decision must also be monitored so that it is clear that the use of the bedrails continue to be necessary and guidelines for carers to follow when checking their safe use must be put in place. So that the storage of incontinence aids do not compromise the dignity and privacy of individual service users discreet storage should be found. So that service users are protected by the local authority’s procedures regarding Safeguarding Adults the manager and staff should regularly up date training in relation to these. So that all service users live in an odourless free environment the manager should make sure that any unpleasant odour is addressed directly. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 7 To ensure that service users’ changing needs and activities organised are supported effectively the manager should regularly review and address the ratio of staff needed. One relative commented: “They do their best but further staffing would be beneficial.” 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. Craigielea Lodge DS0000007388.V341830.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 Craigielea Lodge DS0000007388.V341830.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): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good information about the service. This helps service users to make an informed choice about where they would like to live. A contract is in place that informs service users of the home’s terms and conditions and the fees to be paid. Good multidisciplinary preadmission assessments demonstrate service users’ needs and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: The home has developed a Statement of Purpose and a Service User Guide. Both documents have recently been reviewed and updated to ensure that they include up to date information about the service. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 10 To welcome new service users into the home a Welcome Pack including information about the home is available in individual service users’ rooms. A bunch of flowers is also placed in the room for their arrival. Of the care files sampled a contract that describes the home’s terms and conditions and the full fees charged was in place. A clear breakdown of the fees informs service users or their representatives of the contribution they need to pay and how the remaining amount will be paid. The home has a policy that states that prior to anyone moving into the home a full assessment of need is carried out by the referring agency and by the home. These are evident in the individual care files sampled and enable the manager to make an informed decision whether the home can meet the identified needs. One of the files examined was that of a service user who pays privately and did not receive a full assessment from a referring agency. The manager carried out a full assessment of need covering all aspects of health and social care and made a judgement that the service could appropriately meet the identified needs. A care plan has been put in place to reflect these. An assessment of need is currently being carried out in relation to a prospective service user still in hospital. Prior to making a decision regarding admission, the manager is waiting until the person is well enough to visit the home, so that they can make an informed decision whether they want to live at Craigielea. This home does not provide Intermediate Care. Craigielea Lodge DS0000007388.V341830.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans that: guide staff to appropriately support service users’ care needs and enable staff to support service users to make choices about their lives, are in place and are an outcome of ongoing assessment. However service users could be at risk of harm if staff do not consistently follow written guidelines regarding the use of equipment assessed by other professionals. Service users’ personal and healthcare needs are met in a flexible but consistent manner, in a way that promotes their dignity and acknowledges their right to privacy. Medication arrangements are appropriate to the needs of service users and they are managed safely and appropriately, ensuring that the welfare of the service users is safeguarded. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 12 EVIDENCE: There is a care plan in place for each service user living at this home. The information recorded in them is current and clearly guides staff to effectively address the individual service users’ personal, social and emotional care needs. The information found in the care plans sampled includes detailed information written in a way that guides staff to give a consistent approach and assist the individual in a way that they prefer. Staff work in a way that reflects the information and guidance in the care plan. They speak to service users kindly and with respect and explain to them what action they are to take to assist them with a task. All areas of care are included in the care plan depending on the individual’s identified need. For example a Malnutrition Risk Assessment assists staff to identify possible health problems related to dietary needs and the risk of pressure sores is identified through tissue viability assessments. A decision has been made that one service user needs the protection of bedrails. This was the outcome of an assessment carried out by an occupational therapist who also assessed that the bedrails accessed and the bed they are fitted to are compatible. Although a risk assessment signed by the family regarding their use is in place, a copy of the original assessment of need is not included in the service user’s care file, neither are there written guidelines for staff to follow when checking the bedrails. So that the assessment of need can be monitored and adapted as necessary and the monitoring of the use of the bedrails is consistent, the manager was advised that: • A copy of the assessment must be kept in the individual care file • The assessor must be monitor the assessed need. • Guidelines for staff to follow when monitoring their use must be recorded in the care plan. Staff work effectively with health care professionals who, when the care staffs’ knowledge is limited, give advice and guidance. Although there are no service users currently who are dependent on insulin the district nurse advices staff regarding service users who are on medication for diabetes or control it by diet. Other health professionals who work closely with staff are The Parkinson’s Disease nurse specialist and the Continence Advisor. Staff confirmed that they have attended training in the administration of medication and their knowledge and the way medication was stored and administered reflects this. Craigielea Lodge DS0000007388.V341830.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): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live appropriate and fulfilling lifestyles both in their own home and the local community. So that service users do not become socially isolated they are encouraged to maintain contact with families and to maintain friendships of their choice. As a result of staff promoting service users’ independence, service users’ are actively encouraged to exercise choice and control over their lives. Meals are healthy, nutritious and attractive, and are prepared to meet the individual dietary needs of each service user. EVIDENCE: The home employs a member of staff especially to plan and coordinate activities for service users. The post is shared with the neighbouring care home and is effective in setting up a programme of activities for service users to take part in both in the home and the local community. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 14 Comments made by service users when referring to the activities coordinator included: “She’s wonderful” “She arranges good trips out.” Activities are carried out on a regular basis and on the day of the inspection a trip out to Bede’s World was taking place. This was the result of careful planning and on their return service users spoke with enthusiasm about it. An Activity Programme evident in the home clearly advertised forthcoming events and informed service users and visitors of them. This includes trips to Tynemouth Aquarium, Bede’s World and the Theatre Royal in Newcastle. Staff and service users spoke about a barbecue that had recently taken place for service users and their families and which was well represented. The large grounds around the home effectively accommodate such events including fund raising Spring and Autumn Fayres. Service users described individual activities that take place. These include reading in the privacy of their own room, listening to music and knitting. One care plan explains how one service user who, rather than be part of a big group, prefers to read in their own room, listen to music and enjoys the view from their window. It also records how the home organises books to be delivered from the library. A small group of ladies are currently involved in a knitting project for Age Concern. Photographs of activities that have taken place decorate the walls in the home. A midday meal was taken with the service users, this was a pleasurable experience. Four small dining rooms that are attractively decorated and furnished accommodate small groups of service users together. Meals are served from a hot lock that is brought from the kitchen and staff ensure that service users are served the meal of their choice. One relative commented: “XXXX refuses to eat at times and all encouragement is given whatever X wants to eat is prepared for X during these times.” Service users said that, “The food is excellent.” “The food is always good, the cook has been here for a lot of years and knows what we like.” Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 15 One service user who did not eat their dinner was asked if they preferred something else and as a result a sandwich was served and appreciated. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure of which service users and their representatives are aware. Service users were confident that their concerns or complaints would be addressed appropriately. Service users and their representatives are encouraged to discuss their concerns on a daily basis and these are addressed directly. The daily notes in individual care plans confirmed this. One relative commented: “Any concerns about XXXXX care has always been discussed openly and the carers listened with an open mind. I have never had cause to complain about care.” Staff have receive training regarding the local authority’s Safeguarding Adults procedures and they are aware of the action they would take if an abusive incident was observed or reported to them. The manager was advised that this training should be updated regularly. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 17 All staff have attended training regarding handling verbal and physical aggression and further training regarding Challenging Behaviours is planned for later this year. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely, comfortable, clean and decorated and furnished to a good standard. This helps to promote service users in a positive image, and ensures they remain safe and comfortable. EVIDENCE: The service users’ bedrooms are spacious and nicely furnished. Currently there is an ongoing refurbishment programme. When the home was first built individual bedrooms included kitchen type sink units that now are no longer used. These are in the process of being removed to provide space for fitted wardrobes. This could provide service users with much needed storage space. Most bedrooms have en-suite facilities. Currently incontinence aids are stored openly in the bedrooms or the en-suite. The manager confirmed that so the Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 19 service users’ dignity and privacy can be promoted, different ways of storing the aids away from view are currently being explored. Individual bedrooms are furnished and decorated with personal items and many reflect the personality of the person living there. Service users confirmed that they are happy with their personal space and one said: “It is nice to have a place to come to when you want to be quiet, I’m very comfortable here, some of this is my own furniture.” So that service users can have their room doors open if they prefer, electronic devices have been fitted so that they are held open and released automatically if the fire alarm is activated. The lounge is spacious and looks out on to the gardens. The chairs are arranged in small groups to encourage the opportunity for social interaction to take place. A new well-equipped hairdressing salon has been developed that is shared with the home next door and can be accessed without going outside. One service user said: “I feel so much better after being to the hairdressers.” The appearance and cleanliness of the home reflects effective cleaning routines, however an unpleasant odour was present in one room. The manager discussed how this is currently being addressed. The laundry is well organised and fitted out with appropriate facilities. A designated member of staff attends to the laundry tasks. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs a competent and qualified staff complement that effectively meets the needs of the service users. The robust recruitment procedures ensure that the welfare and interests of the service users are protected. EVIDENCE: The manager deploys staff in a manner that promotes the effective operation of the home. This is a sufficient number of staff to address the needs of the people currently living at this home. However the number of staff needed must be regularly monitored to ensure that any changing needs or activities arranged are appropriately supported. The home employs a team of staff with diverse experiences and qualifications. The manager and records confirmed that most staff have now achieved NVQ 2 or 3 and those who have not are working towards it. All staff receive a range of training including issues surrounding dementia care. Some staff have also recently completed distant learning training regarding Equality and Diversity and Health and Safety. A training record is kept and a Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 21 computer programme identifies who and when mandatory training needs updating. One relative commented: “There are a lot of experienced staff with appropriate qualifications. Every shift has a senior carer in charge. New inexperienced staff appear to always have the support of a senior/mentor.” Care practices observed in the home reflect the skill and dedication of a well trained and motivated team. Staff were observed sensitively interacting with service users and working as a team. A sample of staff files was examined; this included the recruitment records of staff recently employed. All included appropriate documents, for example an application form identifying a clear up to date record of employment, 2 written references and a satisfactory CRB (Criminal Records Bureau) check. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. External management support and oversight arrangements ensure that the registered manager is supported to effectively address her role. Effective quality assurance systems are in place and these include seeking the views of service users, relatives and others. These systems operate well and ensure that the service is run in the best interests of service users and ensure that the risks to the health and safety of service users, visitors and staff are minimised. Good arrangements are in place to safeguard service users monies held in the home. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has worked at this home for several years and as manager for the past three. She is registered with CSCI (Commission with Social Care Inspection) and is qualified in the Registered Managers Award (RMA) and NVQ 4 in Care. The manager is supported well by her deputy manager and the nurse manager from the neighbouring home. The Chief Executive of the Company also gives good support as her line manager and meets once a week to discuss issues about the home. The manager is up to date with mandatory training and attends training to support her role. Recent training includes care planning, supervision and appraisal, Parkinson’s disease and the Mental Capacity Act. The manager and staff work well together with service users to establish a good working ethos in the home. Staff are designated specific responsibilities and are guided through these by following daily routines that are recorded where staff can refer to them. There is a good quality assurance system in place the outcomes of which are recorded in one file. This ensures that the home’s policies and procedures are put into practice and that the service is led in the best interests of the service users. Risks identified throughout the home are monitored and addressed well. A recent visit from the fire department commended the home on the risk assessment and procedures in place regarding safeguarding service users and staff against fire. Accidents to both service users and staff are recorded and addressed satisfactorily. Although good risk assessments and procedures are in place regarding fire safety, the checking of fire equipment and staff training, there are discrepancies regarding the recording of fire drills. Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13(4)(c) Requirement The registered manager must ensure that: • A copy of the assessment carried out by the occupational therapist regarding the use of bedrails must be kept in the service user’s care file • The assessor must monitor the assessment and records must be kept. • Guidelines for staff to follow when monitoring the use of the bedrails must be recorded in the care plan. The registered manager must ensure that: • Staff who work during day hours practice fire drills every six months. And • Those who work night shift practice fire drills every three months. • These must be clearly recorded. Timescale for action 30/09/07 15(1) 2 OP38 23(4)(e) 30/09/07 Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP10 OP18 Good Practice Recommendations So that the privacy and dignity of service users can be further promoted consideration should be given to how incontinence aids can be stored. So that the manager and staff, are reminded of and kept up to date with any changes regarding the local authority’s procedures for Safeguarding Adults, training should be accessed regularly. The registered manager should ensure that all parts of the home are free from offensive odours. The registered manager should regularly monitor the numbers of staff needed to effectively address the needs of the service users and the activities taking place. 3 4 OP26 OP27 Craigielea Lodge DS0000007388.V341830.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 - 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. 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