Care Home: Drewstead Lodge

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What the care home does well Residents receive support in the way they prefer and require and they are protected by the home`s policies and procedures for handling medicines Residents are able to indulge in their own particular interests and partake in appropriate social activities. Appropriate arrangements are made so that residents have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and offered to residents. The home has an appropriate complaints procedure that residents can understand. The registered providers have made sure that the physical environment of the home provides for the individual requirements of the residents. The living environment is appropriate for their lifestyle and needs and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the residents. What has improved since the last inspection? The homes electrical wiring system has been replaced since the last key inspection. Some resident`s bedrooms have been decorated. What the care home could do better: There were two requirements and one recommendation set at the last key inspection. These requirements have not been fully addressed and one has been amended. Five requirements and six recommendations have been set as a result of this inspection. The home appears to be well run and well managed. Prospective residents and their representatives/families are provided with all the information they would need so that they can make an informed choice about wether or not to use the service however this information needs to be updated. More could be done to make sure that the residents care plans and placement reviews are kept under regular review. The home has suitable vulnerable adult protection and abuse prevention measures in place however these could be updated. The home could do more to make sure that staff receives regular supervision and refresher training and so that residents benefit from having a consistent approach to their needs. The inspector would like to thank the residents, visitors, staff and the registered providers for their support on the day of the inspection. CARE HOMES FOR OLDER PEOPLE Drewstead Lodge Drewstead Lodge 93 Drewstead Road Streatham London SW16 1AD Lead Inspector James O`Hara Unannounced Inspection 25th March 2008 08:30 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 Drewstead Lodge DS0000022725.V361094.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. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drewstead Lodge Address Drewstead Lodge 93 Drewstead Road Streatham London SW16 1AD 020 8769 4912 0208 769 4912 fowasil@hotmail.com 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) Mr M Owasil Mrs Sairah Bibi Owasil Mrs Sairah Bibi Owasil Care Home 9 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (9) of places Drewstead Lodge DS0000022725.V361094.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 (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 9) 2. Dementia - Code DE (maximum number of places: 9) The maximum number of service users who can be accommodated is: 9 9th November 2006 Date of last inspection Brief Description of the Service: Drewstead Lodge is a large two storey detached house in a quiet residential street with on street parking. It has a small front rose garden and a large landscaped garden at the rear. It has two bedrooms and communal rooms on the ground floor, a chair lift, four bedrooms on the first floor and a selfcontained flat for the proprietors on the top floor. It provides a home for up to nine elderly residents in a family-run, homely atmosphere with particular emphasis on providing individualised care that maintains residents independence, privacy and self-esteem. There are currently four residents living at the home. The current weekly fee for a place at this home is £390.00 Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced site visit was carried out between 8:20am and 2:30pm. Methods of inspection included a tour of the premises, observation of contact between staff and residents and discussion with the residents, a visiting district nurse, a relative visiting the home and the registered providers/manager. Records examined included the homes Statement of Purpose, care plans, complaints, adult protection, staff training, staff personnel files, medication and health and safety. Requirements and recommendations from previous inspections were also discussed with the registered providers/manager. What the service does well: What has improved since the last inspection? Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 6 The homes electrical wiring system has been replaced since the last key inspection. Some resident’s bedrooms have been decorated. 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. Drewstead Lodge DS0000022725.V361094.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 Drewstead Lodge DS0000022725.V361094.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): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives/families are provided with all the information they would need so that they can make an informed choice about wether or not to use the service however this information needs to be updated. The home does not admit residents for intermediate care. EVIDENCE: A requirement was set at the last key inspection that the registered provider must ensure that there is a Statement of Purpose/Service User Guide that meets all the requirements of legislation. The registered provider stated that the Statement of Purpose had been updated since the last inspection however upon examination some of the key elements listed in schedule one of the Care Home Regulations had not been included. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 9 It is recommended that the registered provider reviews and updates the homes Statement of Purpose using Schedule 1 of the Care Home Regulations as guidance. One resident sadly passed away in hospital in February this year. There are currently four residents living at the home. The registered provider told us that they are considering changing the category of the home so that they can support people with mental health. They plan to contact the Commissions regional registration team for advice on how to proceed. No new residents have moved into the home since the last inspection however the registered provider told us that the home would obtain a full community care assessment from the placing authority for any new resident. The registered provider told us that she would visit the prospective resident and conduct her own assessment. An initial care plan would be drawn from the placing authorities and the home’s assessments, and any other professional assessments obtained. Wherever possible the potential resident and their relatives/carers would be invited to visit the home prior to admission, and there is always a trial period of six weeks. The home does not admit residents for intermediate care. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health, social and personal care needs are set out in the individual plan of care. However to ensure that a good service is maintained they should be kept under regular review. Residents can be assured that they receive support in the way they prefer and require and they are protected by the home’s policies and procedures for handling medicines. EVIDENCE: Two residents files were examined. Both had care plans. One resident had a community care assessment carried out in March 2006; her care plan was reviewed at this time. The registered provider must make sure that the placing authority carries out its statutory obligation of an annual placement review for each resident. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 11 Another resident is self-funding and the registered provider had developed a care plan, this care plan had not been reviewed since May 2006. The registered provider produced evidence of support from health care professionals in the form of letters from the Community Psychiatric Nurse 20/02/2008 and the Physiotherapy Team 24/01/2008. The registered provider must make sure that residents care plans are kept under review. There was evidence that all of the residents have their health care needs provided for by a full range of healthcare professionals, according to individual need. This includes the general practitioner, district nurse, domiciliary optician, psycho-geriatrician, chiropodist, speech and language therapist and physiotherapist. The home has established good working relationships with healthcare professionals. On the day of the inspection a district nurse was visiting the home to administer insulin to a resident with diabetes. She told us that the home was always clean and that residents were always clean, well presented and appeared happy. She said that she had no concerns about the level of care afforded the resident she visits. Storage, administration and recording of medication was checked and found to be in good order. The registered provider told us that medication is supplied by a local pharmacist and the pharmacist visits the home on an annual basis to offer advice and support on medication issues however the registered provider told us that the pharmacist did not record their visit in the homes visitors book or leave a report of their findings with the home. It is recommended that the registered provider keep a record of the pharmacists visits to the home and request a report from the visit including any advice offered by the pharmacist. The registered providers told us that they are Registered General Nurses. The registered provider produced documentary evidence that three members of staff attended training on dementia in November 2007. Drewstead Lodge DS0000022725.V361094.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to indulge in their own particular interests and partake in appropriate social activities. Appropriate arrangements are made so that residents have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and offered to residents. EVIDENCE: The registered provider told us that residents have a choice of activities. Some residents like to go out for drives or short walks, some residents prefer to stay at home. A television, radio, large print books, cards, dominoes and puzzles were observed in the lounge. Residents were observed reading, conversing with staff and watching television. One resident likes to read the Bible and listen to tapes of hymns. One resident likes to go sightseeing and playing dominoes. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 13 The home has a landscaped garden with patio facilities. One resident told us that she likes to have breakfast in her room and plans the rest of the day for herself. She said that she was happy staying at the home and that staff treated her well. The registered provider told us that she arranges for the mobile library service to visit the home. There was no formal record of activities offered by the home or a record of activities taken up by residents. The registered provider told us that in the past residents have visited the Horniman Museum and that Musicians visited the home on birthdays, the registered provider told us that she has offered other activities such as the cinema and meals out but these are taken up depending on the resident’s moods. It is recommended that the registered provider delegate a member of staff to organise/plan a weekly activities programme for the home. One member of staff attended training on Skills on Reminiscence in 2005. This member of staff could facilitate frequent residents meetings to discuss and plan activities along with the other household routines such as planning what to eat and what they would like to happen in the home. Although residents social activities are referred to in their care plans these could be developed further in line with the weekly activities programme. The home encourages and supports residents to keep in regular contact with family and friends where this is their choice. The regularity of relatives’ visits varies from daily to once in a while but all visitors are made welcome and shown hospitality by the home. Some residents who do not usually like to go out of the home will go out with their families to celebrate special occasions. Residents are encouraged to keep in contact with the local community via trips to shops. One relative was visiting on the day of the inspection. He visits his wife regularly three times a week. He told us that the home always smells fresh and is always clean. He said the residents are always well dressed, the staff is always helpful and that the home is very well managed and run. He said that this is probably one of the better care homes. Residents are able to exercise choice throughout the day, for example, choosing when to spend time in their rooms, where and what to eat, when to bathe, and what activities to undertake. Residents are encouraged to keep personal possessions in the home and their rooms. Residents are able to keep some of their possessions in the lounge so that they can continue with their individual interests whilst enjoying the company of the others. The registered provider told us that menus are devised based on consultation with residents. Residents have a choice of breakfast each morning, a hot meal at lunchtime and the choice of a light meal or sandwiches and soup in the Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 14 evening. On the day of the inspection residents told us that they enjoyed the food offered in the home. One resident said she likes to have breakfast in her bedroom before making her way to the lounge in the morning. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure that residents can understand. The home has suitable vulnerable adult protection and abuse prevention measures in place however these could be updated. EVIDENCE: The registered provider told us that no complaints had been made to the home since the last inspection. The home has a complaints procedure and a complaints book. One resident told us that they would approach the registered provider or staff if they had any concerns about their care. The home has an abuse policy. The inspection report of 23rd February 2006 recommended that the registered provider obtain a copy of the local borough’s adult protection policy to discuss this and the implications of the POVA list with staff. It was reported at the last inspection that this had been done however the registered provider told us on the day of the inspection that the home did not have a copy of the local authorities safeguarding adult procedures. The registered provider must obtain a copy of Lambeth Social Services Safeguarding Adult Procedures and review the homes safeguarding adults/elderly abuse policy for the home. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 16 The registered provider produced evidence that she and the staff team had attended training on elderly abuse in 2004/5. It is recommended that staff attend refresher training on safeguarding adults/elderly abuse. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered providers have ensured that the physical environment of the home provides for the individual requirements of the residents. The living environment is appropriate for their lifestyle and needs and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the residents. EVIDENCE: The registered providers have ensured that the physical environment of the home provides for the individual requirements of residents. The living environment is appropriate for the lifestyle and needs of the residents and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the residents. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 18 It has a front rose garden and a large landscaped back garden that is attractive and well kept with a peaceful atmosphere and seating for residents. There is a spacious lounge/diner on the ground floor, and a separate dining room off the kitchen, which can be used for meals or activities or visitors. The lounge is attractively decorated, fitted and furnished and an awning has been provided so that residents are shaded in the summer when the French doors are opened. Toilets and bathrooms are suitably located for accessibility. The ground floor toilet and shower are close to the lounge and dining areas, and the separate bathroom and toilet on the first floor is close to bedrooms. Bedrooms have good décor, furniture and fittings and had all been personalised according to residents’ individual preferences and choice. Each resident has a single bedroom. There are appropriate aids and adaptations throughout the home, including grab rails and bath seats in toilets and bathrooms and a chair lift for the stairway. The stairway was adapted to be unusually wide, making the use of the chair lift particularly easy. Residents are therefore able to maintain independence by operating the chair lift themselves, and the space taken up does not in anyway restrict other residents from using the stairs. Thermostatic valves have been fitted to all bedrooms and bathroom taps, and to radiators throughout the house. The home is well ventilated, lit and heated. On the day of inspection the home was found to be clean and hygienic throughout and free from offensive odours. The domestic washing and drying machines are located in a cupboard on the first floor, well away from the kitchen downstairs. It was observed that extra bits of furniture and carpet was stored in one residents bedroom, the registered provider explained that work had been carried out on the homes electric wiring system and the furniture had been placed there. These items were removed on the day of the inspection. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home could do more to make sure that staff receives regular supervision and refresher training and so that residents benefit from having a consistent approach to their needs. EVIDENCE: The home is registered to support nine residents but currently has four and staffing numbers have been reduced. The registered providers live at the home and one of the registered providers is also the registered manager, she is on duty each day, along with one care assistant for each of the morning and afternoon shifts. An extra care assistant is used if the registered provider/manager has to go out or take a resident to an appointment, so that there is always two care staff on duty. The registered providere/manager continue to provide the late evening and night cover, and at weekends, one of the registered providers are on duty with a care assistant. Three care assistants employed have NVQ Level 2. All staff has undertaken first aid, food hygiene, infection control and manual handling training, and in addition all staff have undertaken external certificated training in health and safety to update their knowledge. It was noted that some staff had attended some of this training some time ago and that some staff needed refresher Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 20 training in moving and handling, elderly needs and first aid. It is recommended that all staff training be brought up to date. A requirement was set at the last key inspection that the registered provider must ensure that regular formal supervision of staff is conducted and documented. Previous timescales of 31/05/05, 31/10/05 and 31/03/06 have not been met. As the registered providers are constantly on the premises they are able to train and supervise staff on a daily one to one basis but as at previous inspections it was found that formal documented supervision is not being carried out. During this inspection the registered provider told us that staff receive regular one to one on the job informal supervision on a daily basis but this is not recorded. The requirement is amended to the registered provider must keep a record of all one to one supervision informal or formal recorded sessions and what issues were discussed. Formal supervision need only be undertaken 3/4 monthly (unless circumstances arise that dictate otherwise). Continued failure to meet this requirement may lead to the Commission taking enforcement action against the registered providers. Staff employment records were checked. The registered provider told us that a Commission inspector had seen Criminal Record Checks for all staff before they were destroyed, however Criminal Record Checks from previous employers had not been removed from the files. The registered provider told us that she would now destroy these documents. Staff files included passports, two written references, qualifications, job descriptions and employment contracts. Some files did not have a recent photograph or proof of identification. It is required that all staff files include a recent photograph and proof of identification Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home appears to be well run and well managed. Residents can be sure that the home is managed in a way that promotes their independence dignity and safety. EVIDENCE: The registered providers/manager have managed the home since 1986. The registered providers are Registered General Nurses. They have extensive knowledge and many years experience of working with older people. They give clear leadership and direction to staff in an open, approachable and supportive manner. Residents said that they found both the manager and proprietor very approachable, friendly and supportive and this was observed on the day of inspection. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 22 The registered provider/manager told us that she had started the Registered Managers Award NVQ level 4 but had to drop out due to poor health. She told us that she plans to take this up again and would hopefully complete the qualification within the next eighteen months. The registered providers told us that they were considering reregistering the home so that they could support people with mental health. If this were agreed with the Commission then a registered manager and staff with experience in this field would be employed to run the service. Other staff in the home would receive training on mental health. The registered providers were advised to contact the Commissions Regional Registration Team for further advice on the matter. Quality monitoring is achieved by monitoring the health of residents, verbal feedback from them in satisfaction questionnaires and feedback from family and relatives. The registered provider told us that this is repeated each year. The home could develop satisfaction questionnaires for relatives, visitors and other professionals concerned with the home. The home does not currently manage monies for any of the residents. One resident manages their own money and all of the others have their money managed by relatives. The registered provider/manager produced an electrical wiring test and portable appliance test certificate dated 24/10/07 and a landlord’s gas safety certificate for 25/05/07. The registered provider told us that legionellas testing had not been carried out at the home however Thames Water had taken a sample of water from the home for testing saying that if there was anything to report back to the home they would do so. The registered providers are required to legionellas testing is carried out at the home. They may consider contacting Thames Water to find out if the sample of water taken from the home was a test for legionellas. Staff has received training in fire safety, first aid, food hygiene, infection control and manual handling although it was noted that some staff needed refresher training in moving and handling, elderly needs and first aid. Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 4 3 3 4 4 3 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 Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes. 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 14 (2) Requirement The registered provider must make sure that the placing authority carries out its statutory obligation of an annual placement review for each resident. The registered provider must make sure that residents care plans are kept under review. The registered provider must obtain a copy of Lambeth Social Services Safeguarding Adult Procedures and review the homes safeguarding adults/elderly abuse policy for the home. The registered provider must keep a record of all one to one supervision informal or formal recorded sessions and what issues were discussed. Formal supervision need only be undertaken 3/4 monthly (unless circumstances arise that dictate otherwise). The registered providers are required to make sure that legionellas testing is carried out at the home. They may consider DS0000022725.V361094.R01.S.doc Timescale for action 30/06/08 2. 3. OP7 OP18 15 (1) 13 (6) 30/06/08 30/06/08 4. OP28 18(1)(c) (i)18(2) 30/06/08 5. OP38 13 (3) 30/06/08 Drewstead Lodge Version 5.2 Page 25 contacting Thames Water to find out if the sample of water taken from the home was a test for legionellas. 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 OP1 OP9 Good Practice Recommendations It is recommended that the registered provider reviews and updates the homes Statement of Purpose using schedule one of the Care Home Regulations as guidance. It is recommended that the registered provider keep a record of the pharmacists visits to the home and request a report from the visit including any advice offered by the pharmacist. It is recommended that the registered provider delegate a member of staff to organise/plan a weekly activities programme for the home. Although residents social activities are referred to in their care plans these could be developed further in line with the weekly activities programme. It is recommended that staff attend refresher training on safeguarding adults/elderly abuse. It is recommended that all staff training be brought up to date. 3. 4 5. 6. OP12 OP7 OP18 OP30 Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Drewstead Lodge DS0000022725.V361094.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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