Care Home: Derwent Lodge Care Centre

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What the care home does well What has improved since the last inspection? Risk assessments for the use of bedrails had been carried out, and written consents for their use obtained. A redecoration and refurbishment plan with timescales for completion is in place, with evidence of ongoing work taking place to bring the home up to a good environmental standard throughout. Clear records are available for the maintenance of wheelchairs. What the care home could do better: Although it is acknowledged that medication management is good in the home, one shortfall was identified in the signing for some medications following administration. This is the only requirement made in this report. 3 good practice recommendations have also been made. CARE HOMES FOR OLDER PEOPLE Derwent Lodge Care Centre Fern Grove, Off Hounslow Road Feltham Middlesex TW14 9BE Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 15:05 14th & 15th July 2008 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 Derwent Lodge Care Centre DS0000010946.V366599.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. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent Lodge Care Centre Address Fern Grove, Off Hounslow Road Feltham Middlesex TW14 9BE 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) 020 8844 2975 020 8893 1495 derwent@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Jeannine Gappy Care Home 62 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0) Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service can be accommodated on the YPD unit, as agreed by the Commission for Social Care Inspection, on 31st January 2005, for as long as there is no deterioration which affects the well being of other service users. The home must advise CSCI when the service user no longer resides at the home. The home is registered to provide Nursing Care to 26 service users with Dementia and 10 service users who are aged 18 and over who have a Physical Disability. 8th May 2007 2. Date of last inspection Brief Description of the Service: Derwent Lodge Care Centre is situated in a residential area of Feltham. There are shops, restaurants, public houses plus a social centre with a cinema, bowling alley and restaurants, within walking distance from the home. The home can be accessed by bus and main line train services. There are weekly General Practitioner visits to the home, and healthcare services are accessed by the home for service users. Two lifts are available in the home, one of which is generally used for the transportation of meals and deliveries to the kitchen, which is located on the second floor. The accommodation is situated over three floors. All the bedrooms are single with en-suite facilities, comprising of a toilet and wash hand basin. Assisted bathroom and shower facilities are located on each floor and there are separate toilets. There are lounges and dining rooms on each floor. There is wheelchair access to the well-maintained grounds and some of the bedrooms overlook the gardens. The car park is in front of the home. Fees range from £568.14 to £1000 per week. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 23 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 10 residents, 18 staff, 3 visitors and two healthcare professionals were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus CSCI surveys from residents, representatives/visitors and health & social care professionals have also been used to inform this report. Any issues raised on our surveys have been fed back to the management in general terms. What the service does well: The home had shown improvements at the last inspection, and it is pleasing to note at this inspection the improvement has been maintained and built upon. Prospective residents are fully assessed prior to admission to ensure the home are able to meet their needs. Service user plans are well completed and accurately reflect the needs of each individual and how these are to be met. Healthcare needs are well documented and there is a good level of healthcare input at the home. Medications are being well managed with one minor shortfall that should be easily addressed. Staff were seen caring for and communicating with residents in a gentle, caring and professional manner. There is excellent interaction between staff and residents and a happy, homely atmosphere throughout the home, which is commendable. End of life care needs and wishes are discussed and recorded to ensure the wishes of the residents and their representatives are respected. There is an ongoing activities programme and evidence of group and individual activities, with more work being done in this area. The home has an open visiting policy and visitors are made welcome. Information regarding advocacy services is available. The food provision at the home is good and offers variety and choice to meet the preferences of each resident. The home has a complaints procedure and complaints are promptly and comprehensively addressed. The home has robust procedures in place for safeguarding adults and staff have a good knowledge of these, thus safeguarding residents. The home is being well maintained and provides a clean, homely and safe environment for residents to live in. The work done to improve the environment for residents living with the experience of dementia is of particular note. Procedures are in place for infection control and these are practiced, minimising the risk of infection. The home was Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 6 appropriately staffed to meet the needs of the residents and the overall needs of the home. Staff recruitment procedures include the carrying out of all checks required under the Care Homes Regulations 2001. There is a comprehensive training programme to include induction training for new staff, plus ongoing training and updates in health & safety subjects and other topics relevant to the diagnoses and needs of the residents. The Registered Manager has the skills and experience to manage the home effectively and residents, staff and visitors commented that the Registered Manager is approachable and deals promptly with any issues raised. The Deputy Manager is also supportive and there is an effective management team in place at the home. Systems for quality assurance are in place and the auditing processes are effective, providing a system of review followed by action to address any issues identified. Monies held on behalf of residents are securely stored and there are clear records of income and expenditure maintained. Health & safety is being well managed at the home, providing a safe environment for residents to live in. Comments received included: ‘I give the highest praise to all who work in the home making the home what it really is – a loving, caring place.’ ‘Staff are very friendly and helpful.’ ‘The family are very pleased with the home. Our relative is thriving in their care and all the staff without exception are marvellous.’ What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Derwent Lodge Care Centre DS0000010946.V366599.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 Derwent Lodge Care Centre DS0000010946.V366599.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each unit and had been well completed. The home also obtains a copy of the assessment undertaken by social services. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 9 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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is well completed to provide staff with the information to meet each resident’s needs. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs discussed, recorded and met. EVIDENCE: Service user plans were sampled on each unit. Overall had been well completed to provide staff with information about each residents needs and how these are to be met. Service user plans viewed had been personalised and contained specific details of the residents’ preferences in relation to personal care. The service user plan documentation had been reviewed monthly and when a residents’ condition had changed, for example, on return from a hospital Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 10 admission. There was evidence of input from the residents and/or their representatives. There is also a notice on display encouraging residents and their representatives to become involved in the service user plans. Risk assessments for falls and other identified areas of risk had been completed and updated following any falls or other relevant events. Risk assessments for the use of bedrails had been completed and written consents for their use obtained. We recommended that where residents were using a lap strap that a risk assessment be completed. It is acknowledged that the lap strap was in use for safety and postural purposes only. Wound care documentation was viewed. Care plans were in place and body charts and photographs of wounds were available plus wound treatment, assessment and dressing record documentation had been completed. Pressure sore risk assessments were in place for all residents and the specific pressure relieving equipment in use for each resident had been identified. Pain assessments had been carried out and appropriate analgesia had been prescribed. Moving & handling assessments were in place and the specific equipment to be used for each move had been documented in the moving and handling care plan. Nutritional assessments had been carried out and there was evidence of regular weight monitoring, based on the residents identified needs. Continence assessments are carried out. There was evidence of input from healthcare professionals to include the GPs who visit weekly and at other times if the need arises, tissue viability nurse, dietician, speech & language therapist, physiotherapist, chiropodist, optician and dentist. We spoke with 2 healthcare professionals who both commented that the home is proactive in addressing healthcare concerns and there had been a marked improvement in communication and there is good management of any medical issues identified. We viewed the medication management for the home. A list of specimen signatures and initials for staff administering medications was available on each floor. All receipts, administration and disposals had been clearly recorded, and the correct method of disposal was in use. Several of the medication administration records (MAR) were viewed and with the exception of two MAR records on the first floor were complete and up to date. The home uses a monitored dosage system and stock control was good. Stocks were checked and correct and a running stock total is recorded of all tablets after each administration. Liquid and boxed medications are dated when opened. Registered Nurses were using the appropriate coding for when residents had refused medication. Controlled drugs records were up to date and the register was being completed correctly. We recommended that staff when signing the controlled drugs register they all use there full signature. Stock balances of all controlled drugs are checked twice a day and recorded. Medications are being securely stored in the home. Professional single use lancets are in use for blood glucose monitoring. For residents being fed via a percutaneous endoscopic gastrostomy tube this had been clearly recorded and a copy of the feeding regime is kept with the MAR. We recommended the batch number and Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 11 expiry date for each feed be recorded on the fluid balance chart. For residents on warfarin therapy, the results of the most recent blood tests with the current dosage are kept with the MAR. New good practice documentation had been introduced to improve the management of insulin administration. The medication fridge and room temperatures were within safe range. The clinic rooms were clean, tidy and well organised. The home has policies and procedures in place for the management of medications and copies are available on the medication trolleys. Medication reviews for all residents are undertaken regularly by the GP. The medications are being well managed at the home. Staff were seen caring for residents in a gentle, caring and professional manner and excellent interaction between residents, relatives and staff was observed on both days of the inspection. Bedrooms had been personalised and there was a very homely feel throughout. Personal clothing is labelled with either the residents name or room number and residents were dressed to reflect individuality and cultural preferences. Staff were seen knocking on residents bedroom doors, maintaining privacy and dignity. The home has recently attained accreditation in the Gold Standard Framework for palliative care. Care plans viewed for end of life care were personalised and reflected the wishes of residents and their families, so that these can be respected. The Palliative Care Team in Hounslow are providing training for the registered nurses in medication management and other topics relevant to palliative care needs. It was clear that staff understood the wishes of the residents and the recent training had developed their skills, knowledge and confidence in this sensitive area of care. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. The activities provision is good, and each residents right to choose to join in is respected, thus meeting their individual needs and wishes. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The activities co-ordinator has been in post for 4 weeks. We spoke with the activities co-ordinator and she is in the process of getting to know the residents and their individual hobbies and interests so that she can tailor an activities programme to suit them. The activities programme for the week was displayed throughout the home and in each bedroom. Residents were seen partaking in individual activities and the sensory room was in use, which a resident commented positively about. Residents were also seen enjoying gardening and the home has flowerbeds that have been raised to waist height to make it easier for residents to use. There are regular outside entertainers Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 13 arranged and also outings from the home. 2 of the staff are qualified to drive the local community minibuses, so this has enhanced outings. The activity diary for each resident was up to date. Comment was received that there are regular activities going on in the home and residents’ choice to join in or not is respected. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and representatives are kept up to date with any issues. Residents can choose to receive visitors in one of the communal rooms or in their bedrooms, as they so wish. Information regarding advocacy services was available and on display, to include financial advice and contact for the Alzheimer’s Society. Other useful contact numbers were on display in the foyer. There was evidence of the involvement of advocacy services for some of the residents. We viewed the kitchen and it was clean and tidy, with all the records being up to date. The home has attained a 5 star rating for food hygiene from the Environmental Health Inspectorate. Residents spoken with said that the food is good and that they are offered a choice, to include vegetarian provision. Records of meal choices were available in the kitchen, and where residents are unable to make a choice in advance, both options are plated up and taken to the resident so they can see both options and choose. We sampled the lunchtime meal options on the second day of inspection and the meals were well presented and tasty. We also viewed the lunch and suppertime serving and meals to include liquidised meals were well presented and looked appetising. The layout of the dining rooms was done in a way to encourage socialising during meals, and tables looked attractive, with linen napkins, flowers and condiments available on each one. Staff were available to assist residents with their meals and did so in a discreet and professional manner. Drinks and snacks are available throughout the 24 hour period. Comment was received in relation to cutlery provision and supper serving on one floor, and this has been fed back to the Deputy Manager, who said this would be addressed. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for safeguarding adults, thus protecting residents. EVIDENCE: The home has a clear complaints procedure and this is on display throughout the home. The home has had 11 complaints in the last 12 months, and all concerns, however minor, are recorded and addressed under the homes complaints procedure. Complaints records were sampled, and documentation was available to evidence that complaints had been appropriately investigated and responded to. The home has safeguarding adults policies and procedures in place that dovetail with the Hounslow Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. Any incidents or issues that may involve safeguarding adults are reported to the Hounslow Safeguarding Adults team as well as to us. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 15 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, 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The home has a redecoration and refurbishment plan and timescales for completion are recorded. A full list of all redecoration that has taken place in the last year was available, and there was evidence of some refurbishment also. A lot of work had been done on the first floor and this now provides a lovely environment, appropriate for those living with the experience of dementia to live in. The garden is well maintained and there is a sensory garden section plus the raised flowerbeds and a good supply of garden furniture for residents and their visitors to use. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 16 Since the last inspection the home has in place 2 new hoists, so there are now 6 hoists in the home to meet residents needs. There are rails in the corridors and in the toilet and bathing facilities. We viewed the laundry and this was clean and tidy. Good practice notices and laundering guidelines were on display. The washing machines have sluice programmes for infection control and there are 2 washing and 2 drying machines, all industrial standard. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean, bright and fresh throughout. Some of the bedrooms have flooring to assist with continence care needs and it was clear that the staff work hard to maintain a good standard of cleanliness throughout the home. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 17 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 is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place and protect residents. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: At the time of inspection the home was being staffed appropriately to meet the needs of the residents. From discussions with staff and residents, no issues regarding shortages of staff were raised. Comment had been received on a survey regarding some shortages at weekends, and the Registered Manager said that this situation had arisen some weeks ago and had been addressed. The home is being well maintained and the numbers of kitchen, domestic, administration and maintenance staff are appropriate to meet the needs of the home. The majority of care staff are qualified to NVQ in care level 2 or 3 or the equivalent, with several care staff who are qualified nurses in their country of origin. More of the care staff are currently undertaking NVQ training. 5 of the registered nurses are undertaking NVQ level 4 in healthcare and management. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 18 We viewed 3 sets of staff employment records and these contained all the information required under the Care Homes Regulations 2001. Southern Cross Healthcare has an induction programme based on the Skills for Care common induction standards. 2 completed booklets were viewed and the carer, their mentor and the Registered Manager sign the booklet once it has been completed. Staff said that they receive regular training and updates in topics relevant to the needs and care of the residents, to include specialist care needs. The home has a training co-ordinator who has 12 hours a week allocated for training purposes. We spoke with her and it was clear that she arranges the training sessions to cater for all staff and to fit in with their shift patterns wherever possible. Several notices were seen on display for various training sessions that had been planned. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 19 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. The Registered Manager has the skills and experience to manage the home effectively and promotes an atmosphere of openness and respect, thus making residents, visitors and staff feel valued. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and is in the process of completing the Registered Managers Award, NVQ level 4 in management. She has been in post for 2 years and prior to that had over 2 years experience as a Deputy Manager. The Registered Manager has attended various training Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 20 sessions and courses relevant to her role and to the diagnoses of the residents. The home also has a Deputy Manager and it was clear that there is a good management team for the home. Staff spoken with said that the Registered Manager is approachable and supportive, and takes time to visit each department daily to find out what is going on and ensure any issues are addressed promptly. The management team also work alongside the staff on each floor to ensure that care practice is effectively undertaken. Southern Cross Healthcare has an annual development programme for quality assurance. Monthly Managers audits are carried out and these are comprehensive and cover all aspects of the home. Other audits to include service user plans, medication management and nutrition had also been carried out and it was clear from the maintained and in some cases improved standards in these areas that auditing is carried out and followed up effectively at the home. There is an annual schedule of meetings for ancillary, care, nursing and administration staff so everyone knows the dates for the year in advance. Meetings are minuted and there was evidence that where an issue had been identified at one meeting, action had been taken to address this by the following meeting. Weekly team leader meetings take place. Relatives and residents meetings take place every 3 months, and this timescale was discussed and agreed with those attending the meetings. In addition to this the Registered Manager holds a weekly evening ‘surgery’ for any relatives who are unable to attend the meetings or who just wish to meet with the Registered Manager to discuss any issues. Regulation 26 visits on behalf of the Registered Provider are carried out and reports are available. Annual surveys are done and the results of the surveys were on display. Clear computerised records are maintained for all monies being held on behalf of residents. Receipts for all income and expenditure are kept. Interest is allocated to each residents account. Monies are securely stored. The Registered Manager said that she is planning to purchase a small safe unit for storing any monies or valuables handed in outside office hours, so that they are securely stored before being transferred to the main safe at the next opportunity. The home had up to date insurance cover. Maintenance and servicing records were sampled and these were comprehensive and up to date. The Fire risk assessment was last completed in April 2007 and the Registered Manager said that a new assessment is to be completed in the near future. The home has a fire evacuation assessment that is updated weekly and clearly identifies each residents mobility and the equipment and number of staff required for evacuation purposes. Fire drills are carried out on a regular basis for both day and night staff. The timings had not always been included, however they had been for the most recent drills and the Registered Manager said she would ensure this was included for every drill in the future. Risk assessments for equipment and safe working practices were in place. The Registered Manager and the Deputy Manager have completed the Health & Safety training for Managers. It was noted that one resident was Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 21 being transported without footplates on the wheelchair. The staff were clear that this was the residents own choice and the resident was able to confirm this to us, and the service user plan was updated to reflect this. The training records show that staff receive training and updates in health & safety topics to include moving & handling, fire safety, food hygiene, infection control, safeguarding adults and First Aid. Health & safety is being well managed at the home. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 22 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 4 11 3 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 X X 3 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 3 Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 23 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 All medications must be signed for at the time of administration to confirm the resident has received their medication. Timescale for action 16/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Where lap straps are in use we strongly recommend that a risk assessment be completed to evidence that it is suitable for safety and posture purposes. That full signatures be used when signing the controlled drugs book. That the batch number and expiry date of the entral feed be entered on the fluid balance chart or the MAR. Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Derwent Lodge Care Centre DS0000010946.V366599.R01.S.doc Version 5.2 Page 25 - 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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