Care Home: Deerswood Lodge

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What the care home does well Deerswood Lodge provides a homely, comfortable and well maintained environment for the people who live there and service users told us that they were happy living in the home. In order to ensure that the home can meet people`s individual and diverse needs, comprehensive pre-admission processes are carried out and people have their needs and wishes recorded in a detailed plan of care. Service users have access to good physical and mental healthcare support and the home works well with other professionals. People are offered a wide variety of activities and entertainment opportunities and there is a choice of fresh, home cooked meals. Both service users and families tell us that their concerns and complaints are listened and responded to and the staff team show a good awareness of the procedures for safeguarding people from risk of abuse or harm. There are robust recruitment procedures carried out and there are sufficient staff available to meet the needs of the people living in the home. Service users told us that the staff working in the home are very kind and caring and we observed a good rapport between service users and the staff on duty. The home is being managed by a capable and competent manager, records are in good order and health and safety issues are addressed. What has improved since the last inspection? There has been a successful recruitment drive, which means that the use of agency staff has been considerably decreased and this has had a positive effect on outcomes for service users. There are now two unit managers employed and this also has had a very positive effect on the running of the home. There are two activities coordinators who provide cover over seven days a week and this has meant that the social opportunities for service users has been increased. Systems have been put in place to regularly audit the medication system in the home and any concerns are addressed by the manager. The communal areas in the home have been decorated with photographs, posters, craft work and memorabilia and this has had the effect of making the environment more homely and friendly. Staff supervision is taking place on a regular basis, the staff team have all attended training in `Effective Team Work` and the Registered Manager has attended a three day course on Dementia awareness. What the care home could do better: In order to ensure that the needs of service users are met at all times, consideration should be given to changing how the menus are devised. CARE HOMES FOR OLDER PEOPLE Deerswood Lodge Ifield Ifield Green Crawley West Sussex RH11 0HG Lead Inspector Annie Taggart Unannounced Inspection 9th February 2009 10:30 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 Deerswood Lodge DS0000068513.V374164.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. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deerswood Lodge Address Ifield Ifield Green Crawley West Sussex RH11 0HG 01293 561704 01293 561635 deerswood.lodge.manager@shaw.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) Shaw Healthcare Ltd Ms Joanna Mosses Care Home 90 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 90. Date of last inspection 19th August 2008 Brief Description of the Service: Deerswood Lodge is a purpose built care home situated in Ifield in Crawley, which was opened by Shaw Healthcare Ltd in 2006. The home was built to replace three other homes in the area owned by West Sussex County Council but managed by Shaw Health Care Ltd. The home is registered to provide personal care, support and accommodation for frail older people and older people with Dementia. Resident’s accommodation is provided in nine units on the ground floor and the first floor, each unit has ten bedrooms, all bedrooms have en-suite facilities. Each unit has its own dedicated lounge/diner and all rooms on the first floor can be accessed by a passenger lift. The home has been designed with indoor streets running the length of the building linking units so that residents can get around easily. Additional communal areas are provided. The registered providers are Shaw Healthcare Ltd, the Registered Manager is Ms Jo Mosses and the responsible individual on behalf of the company is Mr Jeremy Nixey. West Sussex County Council currently contracts all of the 90 beds in the home. The fees range from £437.00-£689.00 per week. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 5 Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. In preparation for this visit surveys were sent to service users, staff and professionals involved with the home. We looked at the last inspection report and any information received about the home since the last key inspection visit. An AQAA, (Annual Quality Assurance Assessment) had been completed by the manager earlier in the year and information from this had been used to inform the last visit. Eight service user, three staff and two healthcare professionals surveys were returned, all were positive about the care being provided in the home and comments from these have been used in this report. The unannounced inspection visit was carried out by Annie Taggart and Ann Peace at 10.00am on 09/02/09 and lasted for 4.5 hours. During the visit we tracked the care plans and all supporting documentation such as daily records for four service users and looked at the system for administering and recording medication. We looked at evidence of activities and outings for people, at menus and food records and we saw the main meal of the day being prepared and served. Records for the running of the business including complaints, incidents and accidents, Regulation 26, Registered Provider’s visits and Regulation 37 reports, maintenance and fire records were also seen. The recruitment records for five members of staff were tracked and we looked at staff training and supervision records. We spent time with the service users currently living in the home, either in their private bedrooms or in communal areas and we also spoke with two family members and a care manager visiting the home. Feedback following the visit was given to the Registered Manager, Ms Mosses and the Area Manager Mrs Ferguson. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? There has been a successful recruitment drive, which means that the use of agency staff has been considerably decreased and this has had a positive effect on outcomes for service users. There are now two unit managers employed and this also has had a very positive effect on the running of the home. There are two activities coordinators who provide cover over seven days a week and this has meant that the social opportunities for service users has been increased. Systems have been put in place to regularly audit the medication system in the home and any concerns are addressed by the manager. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 8 The communal areas in the home have been decorated with photographs, posters, craft work and memorabilia and this has had the effect of making the environment more homely and friendly. Staff supervision is taking place on a regular basis, the staff team have all attended training in ‘Effective Team Work’ and the Registered Manager has attended a three day course on Dementia awareness. 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. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 9 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 Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 10 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 and 6 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. In order to ensure that the individual and diverse needs of service users is being met; the home carries out comprehensive pre-admission assessments and completes ‘personal preferences’ plans. EVIDENCE: There is very clear and detailed information available about the services on offer in the home and we saw that there is an updated copy of these documents available in the foyer of the home and a précis copy in Service Users rooms. We were told that the documents are available in large print, Braille and audiocassette. We looked at the pre-admission process for four people and saw that comprehensive pre-admission assessments had been carried out and recorded and people also had a ‘personal preferences’ plan in place. These plans had been completed with help from services users and their families and gave a background history and clear information about how each person wishes to be supported. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 11 For people who are privately funded there are contracts of terms and conditions of residency in place and the sample we saw had been signed by a representative of the service user. Deerswood Lodge does not provide intermediate care Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 12 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 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. People’s individual needs and wishes are recorded in a plan of care, they have access to good physical and mental healthcare support and their medication is being safely managed. EVIDENCE: For each person living in the home there is a detailed plan of care in place that gives clear information for the staff team on how the person needs and wishes to be supported. We tracked four care plans and saw that there was information regarding personal care preferences, nutritional assessments, risk assessments, moving and handling plans, communication and social, mental healthcare, spiritual and emotional needs. Where necessary there were plans for pressure care, the use of body mapping and behaviour management plans. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 13 Some people were identified as needing support with nutrition or were unwell and we saw that there were food and fluid intake charts in place and those that we saw were current and had been completed both in the day and at night. Daily records were completed for both day and night care and those that we saw gave clear information and had been written in a respectful language. From looking at care plans and talking to service users and families we saw that the home works with a variety of healthcare professionals and visits were recorded for doctors, chiropodists, dental care, care managers and the mental healthcare team. In a survey from a district nurse who visits the home we were told, ‘ the home respects people’s privacy and dignity and they afford time to residents and do not rush them, therefore promoting independence and stimulation. They provide timely healthcare support and report concerns to the team leaders and manager’. People’s individual and diverse needs are being addressed in the home and an example we saw of this of this is that two service users from different floors who are hard of hearing but use sign language have been introduced to each other and there are plans to take them to a weekly community club for people with hearing difficulties. The home has medication policies and procedures in place and we observed that staff members are trained to follow these. Only staff who had training in medication administration and have been assessed as competent are allowed to administer drugs to service users. We observed part of a medication administration round and were satisfied that safe procedures are followed. The home has its own regular audits in place, if any discrepancies or poor practice is noted these are picked up and the records we saw evidence that the manager deals with them appropriately. The medication stock room on one unit was visited and a random check on a number of Service User drugs was undertaken and we found them to all be in order. In a survey returned from a local medical practice we were told, ‘ in our experience the service responds promptly if there are queries or concerns over medication’. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The people living in the home are offered a variety of activities that provide interest and stimulation, they are supported to keep in contact with family and friends and are provided with fresh, home cooked meals. EVIDENCE: The home now employs two activities coordinators, one for each floor and in people’s care plans we saw that there is a record of the activities they undertake each day. The coordinators work over a seven-day period, one being on duty each weekend so that activities can be provided for people every day. We saw that service users are encouraged to develop and maintain personal and family relationships and observation during the day showed us that the staff team promote individual rights and choices. The staff also help people with communication skills to enable people to have a good quality of life. Each service user has a profile in their room called ‘How I like to spend my day’. This briefly describes the wishes and usual routine of the service user and how they want to be cared for. From speaking to the staff on duty we found Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 15 that they were aware of the preferences of each person they were supporting and we saw on a number of times throughout the day that staff respected these preferences. On one occasion in the dementia unit one service user asked a member of the care staff when her birthday was and the member of staff was able to tell her, which showed us that there is a good interaction between staff and service users and staff are knowledgeable about people in their care. We saw photographs of other social gatherings such as Halloween, the Summer Fayre, and service users birthdays. We saw service users in one unit making cards for another service users imminent birthday and the unit had been nicely decorated with birthday banners and balloons. There is also a Valentines Day dinner dance planned for the week of this visit. Other future plans include a visit from a farm, which will bring farm animals into the gardens of the home for service users and a visit where falcons will be bought to the home to give a display. Since the previous visit walls of the units and ‘Streets’ have been decorated with old photos and memorabilia, which has improved the atmosphere in the home and made it more homely. Service users told us that they are able to go out to the shops either unaccompanied if they are able or staff take them if they need help. For those who do not or cannot go out there is a weekly indoor shop available. We also saw notices that a clothing company were due to visit the home to provide a clothes party. Service users are able to engage in meaningful daytime activities such as indoor gardening, (outdoor gardening is planned in the better weather). There are also exercise sessions, games, music, craft etc. The home holds weekly tea and cakes occasions in the wide corridors, which are called ‘Streets’. Service users told us that they enjoy these occasions. Not all service users wish to join in with the activities, two people said they would rather read their newspapers and complete word puzzle books and another person was enjoying a can of beer that was kept in the unit’s fridge for them. The notice board in the home has flyers informing people of advocacy services, No Secrets safeguarding policy, Age Concern contact details, complaints, the telephone number of CSCI, West Sussex Social Services and Shaw Health Care’s Head Office, a community contact list including local churches. The tables in all of the units were nicely set for lunch with tablecloths serviettes and glasses for services users who are able to use them. Menus are compiled regionally and we were told that chefs have to follow the corporate menus; there are plenty of choices and the majority of service users spoken to said they were happy with the food they were served. Service users choose what they would like to eat one day for the following day. We were told that sometimes especially on the dementia unit, service users Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 16 often forget what they have chosen and then change their minds but what they then decide they want is not always available. We discussed this with the home’s manager Ms Mosses and the Area Manager Mrs J Ferguson who said they would take it to a regional meeting this to see if there was away they could overcome the problem. We noted that the majority of service users enjoyed their meals and sufficient staff were available to help those who needed support and they did so in a sensitive manner. We were told that the floor in the kitchen is in need of repair and so the kitchen will be closed for a while. Alternative arrangements have been put in place while the work is in progress and we are confident from looking at the plans that service users will still be served good quality food during the time the works are taking place. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 17 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 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The people living in the home can be confident that their complaints and concerns will be recorded and acted upon and the home’s policies, procedures and staff practice are designed to protect people from risk of abuse or harm. EVIDENCE: There is a complaints procedure in the home that is clearly written and easy to understand and a copy is kept in each of the bedrooms. There is an open culture that allows service users and other people to express their view about the home. An example of this was given to us by a service user who said, ‘ I was not happy about a few things and told a member of staff, the manager then came to me and asked me to come to the office and have a chat about it. Everything was put right and I now have things exactly as I would like them to be’. Other service users and two visitors to the home told us that they would feel able to make a complaint and they felt they would be listened to. Three complaints had been recorded and we saw that they had been acted upon and the outcomes fed back to complainants. The West Sussex policies for safeguarding adults are available in the home and the staff team are trained to follow procedures. We spoke to four staff members about their knowledge of safeguarding issues and asked if they knew what to do if they suspected that service users were Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 18 not being cared for properly. All of them said that said they would not hesitate to report any concerns. Safeguarding alerts are always reported to West Sussex Social Services and the Commission and from looking at the records in the home we saw that outcomes of referrals are managed well and issues have been resolved by the manager of the home to the satisfaction of all involved. Records showed us that new staff members have safeguarding training during their four-day induction period and further training is followed up on a regular basis. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 19 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 20 22 24 and 26 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The home provides a homely, clean, safe and comfortable environment for the people who live there. EVIDENCE: Deerswood Lodge is a purpose built home that is broken down into smaller units for up to ten people and there are staff designated to each unit on each shift. Each of the units has a lounge/ dining/kitchen area that is bright, comfortable and homely, there are music systems, televisions, books, newspapers and magazines about in each unit and there are two cages with pet budgies in ‘The Streets’. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The atmosphere is warm and friendly and by staff decorating the walls and ‘The Street’ with posters, craft work, photographs and memorabilia it has made it more homely. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 20 The layout and design allows for small clusters of people to live together in units although service users are encouraged to visit other units via the street. We saw people moving about to go to visit other people and to a party that was being held in one of the units and some people were sitting in the smoking room together or having visitors. People have the aids and adaptations they need to promote their independence and there are specialist bathrooms, a craft room and a hairdressing room. Service users are encouraged to personalise their bedrooms and the environment now promotes privacy, dignity and autonomy for people. Some people told us that they sometimes preferred to go to their bedrooms for part of the day and have their meal there in private and we saw that this was respected. The home is well lit, clean, tidy and smells fresh, there are gloves, aprons and antiseptic hand washes available and we saw that the staff on duty followed safe infection control procedures. Maintenance records show that regular checks, for example, hot water checks and fire equipment checks are undertaken and regular audits are carried out to ensure that the home is kept safe and equipment is in good working order. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 21 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 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The people living in the home are being supported by a competent, caring and well supported staff team and they are being protected by the home’s robust recruitment practices. EVIDENCE: Service users spoken to during the day said they have confidence in the staff team who look after them. Since a successful recruitment drive has recently taken place the home uses very little agency staff compared to previous visits and we saw that this has made a significant difference to the standard of care being provided in the home. There is consistently enough staff available to meet the needs of the people using the service and the staffing structure is based around delivering outcomes for service users and is not led by staff requirements. Staffing rotas showed us that there are sufficient staff to meet the needs of the sixty three people currently living in the home, on the first floor there were six support workers, one team leader and a unit manager, and on the ground floor dementia unit there were seven carers, a team leader and unit manager. There were also a number of ancillary staff, such as cleaners and kitchen staff on duty and also and two activities coordinators. The home also has a small day care centre that provides for people living in the community and the mini bus and driver are also used by the home to provide outings. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 22 The staff members we saw on duty were happy going about their work and told us that they like working at the home. They said they are well supported and have the training to be able to meet service user’s individual needs. One person told us, ‘I love working here, there is so much you can do for people to make them more comfortable, at the end of the day this is only a big building but our job is to make it into a happy home for people’. The staff team have all attended ‘ Effective Team Working’ training and by observation during the day we saw that they are working as a team, which is benefiting service users. Records showed us that there were personal touches where communication between staff and shifts ensured that service users received individualised care. Examples of this were notes saying, (a) has told us that she would now would like to go to bed at 10.30pm and would like a hot drink when she goes to her room’ and ‘ (b) has a bit of a sore throat and we have been giving her lemon and honey drinks all day as she really likes it’. Comments about staff from service users included: “The staff look after us very well”, “staff are very good and nothing is too much trouble for them” and “ staff are really friendly I can ask them for anything”. An article in a local newspaper from satisfied relatives stated: “We can’t thank Deerswood enough they think the world of her (their mother) and she really gets on well with the staff”. We saw the recruitment files for five members of staff and this showed us that the home carries out robust recruitment practices. There was evidence of an interview process having taken place and all files contained the required documentation including a current CRB (Criminal Bureau Check) and two references. All new staff members undertake an induction in line with the Common Induction Standards and attend mandatory training and other training specific to their roles such as dementia awareness and we saw from looking at records that staff supervisions are carried out on a regular basis. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 23 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 37 and 38 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The home is being managed by a competent and caring manager and is being run in the best interests of the people who live there. EVIDENCE: The Registered Manager has the experience and qualifications to manage the home and has completed the Registered Manager’s Award. Ms Mosses attends further training to update her skills and experience and is currently booked to begin a person Centred Leadership Skills in Dementia Care at a local college. Service Users, the staff on duty and a visiting family said that Ms Mosses was friendly and accessible and ran the home in the best interests of the people who live there. Since the last inspection visit, two unit managers, who have direct responsibility for the running and monitoring of the units on their floor, have Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 24 been employed and we could see that this has improved staff morale and support, the quality of care for service users and also provides support for the home’s manager. We saw that Regulation 26 visit to monitor the conduct of the home are carried out on a monthly basis and the records of the visits were available for us to see. Regular audits are undertaken at the home on all care services and health and safety systems and copies of these were available to us during the visit. There is a quality assurance process in place, whereby satisfaction surveys are sent to service users, families and other stakeholders in the home. There was a good return of these surveys and outcomes were positive. Comments included, ‘ I am very pleased at the way my mother is being cared for, it is exceptional at times’ and ‘ I think that Jo Mosses (the manager) and her staff are doing a good job and should be highly commended’. Records were up to date and in good order and there were regular health and safety audits carried out in order to address safety issues in the home. Incidents and accidents are recorded and action taken as a result of any identified risks to people and Regulation 37 reports regarding any adverse incidents in the home are being sent by the manager to the Commission as required. A Requirement made at the last visit to review safe practices in handling hot food trolleys has been met. Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 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 3 3 3 X 3 X 3 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 X X 3 3 Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Deerswood Lodge DS0000068513.V374164.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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