Care Home: Falcon Lodge

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What the care home does well The service provides individualised care that is based on detailed assessments to ensure that care needs are met. The staff and the people using the service have developed good relationships and people say that they receive the support they require. The residents are provided with a well- maintained and homely accommodation that meets their needs. Staff involve the family/ carers of the residents in their care and maintain open communication with them. People are supported to maintain links with family and friends and attend college for part of the week. What has improved since the last inspection? This is the first visit since registration. What the care home could do better: Further development of care plans to include dietary needs and meeting people`s diverse needs, including communication tools would benefit the people living at the service. As part of quality assurance the provider should develop and put in place an audit system to seek the views of people using the service. A structured staff supervision programme must be developed so that staff have regular supervision as part of their work. Although the service had policies and procedures in place, these should be reviewed regularly to ensure they reflect any changes in legislation and current good practice. CARE HOME ADULTS 18-65 Falcon Lodge 1 Falcon Way Boorley Green Botley Hampshire SO32 2TE Lead Inspector Anita Tengnah Key Unannounced Inspection 7th February 2008 10:00 Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 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 Falcon Lodge DS0000070443.V356529.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 Adults 18-65. 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. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Falcon Lodge Address 1 Falcon Way Boorley Green Botley Hampshire SO32 2TE 01489 785209 01489 785209 falconlodge@ilg.co.uk springmeadow@ilg.co.uk ILG Ltd 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) Position Vacant Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Falcon Lodge DS0000070443.V356529.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: 2. Learning disability (LD). The maximum number of service users to be accommodated is 5. Date of last inspection New Service Brief Description of the Service: Falcon Lodge is a registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to 5 people in the younger adult category with a learning disability. ILG ltd owns the service with a number of other services registered with the commission. Accommodation is provided in a large house in a quiet residential area with access to the local village and surrounding countryside. The house has a small secure garden to the back that is accessible to people using the service. The fees charged are according to the financial assessments. The current fees charged is £1262- £2716 per week. Falcon Lodge DS0000070443.V356529.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 was the first inspection of the service since it was registered in August 2007. An unannounced visit was undertaken to the service on the 7th February 08 as part of the inspection. There were five people accommodated at the service. The process included a tour of the home, where a number of the bedrooms, communal area, kitchen and bathrooms were viewed. As part of case tracking 3 staff, 3 residents and some visiting relatives views’ were sought and care records were looked at. Service users survey forms were also sent to the people living at the service and their relatives in order to gain their views. Information gained from the Annual Quality Assurance Assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. The home has a newly appointed manager who stated that he was in the process of registering with the commission. Positive comments were received from the three people who responded to the surveys regarding the care that they were receiving at the home. Care practices observed at the time of the visit showed that the staff and people using the care service and their relatives had developed good relationships and care was provided in a respectful manner. What the service does well: The service provides individualised care that is based on detailed assessments to ensure that care needs are met. The staff and the people using the service have developed good relationships and people say that they receive the support they require. The residents are provided with a well- maintained and homely accommodation that meets their needs. Staff involve the family/ carers of the residents in their care and maintain open communication with them. People are supported to maintain links with family and friends and attend college for part of the week. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 6 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. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. 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. 2 The pre admission process ensures that all appropriate information is available prior to admission to the service. EVIDENCE: The care records of two recently admitted service users were looked at as part of case tracking. Detailed pre admission assessments of needs were carried out and staff reported that this information is used to formulate their care plans on admission. The assessments of needs included medication, personal risk taking, maintaining independence, personal hygiene and social skills Care manager’s assessment was also sought at the time of referral. Part of the pre admission process includes the opportunity for prospective clients to come in and spend some times at the service and overnight stay is offered. The home has recently updated the statement of purpose and the manager stated that this was available to prospective clients as required. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. 6,7,9 Detailed care plans were formulated and were in place on admission. Further development of care plans in appropriate formats and including dietary needs would be beneficial to people living at the service. The residents are supported to make decisions about their daily lives Service users are supported to live independently within a risk assessment framework. EVIDENCE: The care records of two people were looked at as part of this visit. The service has a key worker system in place with a nominated carer are responsible for the individual carer’s needs. The care plans seen contained detailed information about personal care, likes and dislikes, family links, communication style diet and included risk assessments. There was evidence that the carer/ Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 10 relative inputs were sought as appropriate and were involved in the formulation of the care plans. Some of the risk assessments included personal safety, hygiene, fall assessments, challenging behaviour, accessing kitchen, and going out. The care plans were person centred and provided staff with information of the person’s needs in order that care could be provided safely. As discussed the care plans would benefit from further development with details of how the assessed dietary needs for two of the residents would be met. It had been identified that one of the resident would require thickened fluid to minimize their risks of choking. There was no care plan in place to demonstrate how this need would be met and inform practice. Another consideration would be to ensure that the care plans are in the appropriate format such as pictorial in order to enable the residents to participate in their care planning and person centred. The manager discussed that one of the resident was using “Makaton” as a means of communicating his needs. We noted that another resident repeatedly communicated his needs in a different language that staff did not understand. This was discussed with the manager and should be further explored with his mother and sisters who visited regularly in order that his diverse needs could be met. The manager confirmed that a six weekly review had been completed for one of the resident who was recently admitted. The report from the review was not available and the manager would be following this up. The residents are supported in attending college as part of independent living. Two of them attended college once a week, one of them attended horticultural college and two of them went to the local activity centre. The service has its own transport and staff said that this was of great benefits to the residents. They are supported to take risks as part of independent living within a risk assessment framework. This included assessment road safety and 1:1 care when out in the community. One of the comments was “I am very happy at Falcon Lodge”. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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. 12,13,15,16,17 There is a range of activities available to meet their needs and people are encouraged to be part of the local community. The care practices ensured that people’s privacy and rights are respected. Meals were satisfactory. Further development in the way that choices are offered and attention to diverse dietary needs should be put in place. EVIDENCE: It was evident from discussion with people spoken with and comments received that they are supported to take part in activities of their choice. Some of the activities included attending clubs in the community; going to the local pubs, eating out, drive to the seaside. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 12 Comments received indicated that they were treated with respect and their rights to privacy respected. A staff member was observed to knock prior to entering the people’s bedrooms. Comments received and interaction observed on the day the day indicated that the staff and the resident and their family had developed good relationships. Comments included “the staff are wonderful”. The staff are proactive in ensuring that the residents are part of the community. Information received and discussion with the manager indicated that the staff roster is planned in order that support staff are used at different times of the day to meet the activity needs of the residents. The service had a menu that was varied and offered choices. The staff reported that the menu was flexible and the residents were involved in the choice of the menus. The care plans included food shopping and food preparation as part of their learning/ developing life skills within a risk assessment framework. Hot and cold drinks and snacks were available at all times. Any areas of concerns regarding dietary needs are addressed through referral to dieticians as appropriate. One of the residents had been recently advised to reduce his weight and the manager was in the process of making a referral to the dietician in order that a menu plan could be developed. Comments included “the food is good”. ” I like all the food”. The development of a pictorial menu would be beneficial in engaging the residents in their choice of meals and used as part of the information available to them. Another resident was identified as not eating pork on religious ground. The manager was not aware whether the dietary needs for this person included special type of food. This was discussed and must be further explored to ensure that his needs are met. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. 18,19,20 Support was provided that met with the satisfaction of the residents. Medication records were good. Procedures to support medication management were good and included staff training in medication. EVIDENCE: Care records seen indicated that some of the people are independent in their personal care, however where prompts are needed these were recorded in the plans. All personal care are provided in private and where resident’s wishes indicated for care to be provided by person of the same gender this is respected and recorded in plan of care. All the residents are accommodated in single rooms and staff stated that keys to their rooms are available to them as requested. The residents have the support of the local GPs and staff reported that although they felt supported by the local primary care trust and advice was Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 14 available to them as needed. Records of any changes in the medical management were recorded in the personal file to inform staff practice. The service has procedures in place for receipts of medication brought into the service. Records seen indicated that these were recorded appropriately. The manager stated that only staff who had completed training in the management of medication were responsible for the residents medication. Sample of MAR sheets looked at indicated that all medication administered were recorded as required. The home was developing a record of specimen signature for staff responsible for medication. Records indicated that five carers and the manager had completed medication training in medication management and this included one night staff. The manager reported that none of the current residents were on night medication and further training for night staff would be developed to meet the needs of people at all times. All the medication was stored securely and one staff was observed administering the lunchtime medication. Staff was aware of the home’s procedure and ensured that medication was managed safely. The manager reported that there was none of the resident was receiving controlled drug at the present time. The home did not have any facility for storing controlled drug at present. The MAR sheet record indicated that one of the resident was prescribed a medication that must be stored as controlled drug. He was not receiving this medication at the time of the visit. In view of the new regulation pertaining to controlled drug, facility for storage of controlled drug needs to be put in place. This was discussed with the manager who was not aware of the new regulation and would be accessing this information. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Information on how to make a complaint was available. Developments of information in different formats should be in place to meet the needs of people at the service. There is clear guidance for reporting any allegation of abuse. The accounting for the residents’ personal allowance as managed by the service was good. EVIDENCE: Information received showed that the relatives would approach the person in charge if they had any concerns. Two comments from our survey stated that they were unsure whether they had information about how to raise a complaint if needed. Staff were unable to find the complaint procedure at the time of the visit. We found a complaint procedure in the statement of purpose and the manager addressed this issue at the time of the visit to ensure that people had access to this information. As discussed development of the procedure in other formats such as pictorial, would benefit the people using the service. The home has a complaint log and record in the log showed that the service had not received any complaints. Comments from our survey included: “Inconsistent care due to the manager initially appointed. High staff turn over and reliance on agency staff. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 16 “In general staff do not have the skills to provide the support required. Poor informal communication, leading to issues not being addressed in time”. The service has a new manager in post and feedback from relatives was positive. The service had the Hampshire adult protection procedure and had also developed an internal procedure for reporting all allegation of abuse. Staff were aware of their responsibility to report to the appropriate authority any such allegation. Training in safeguarding was available to staff. A sample of the residents’ personal allowance as managed by the service was looked at. All moneys were stored individually and securely. The manager stated that he had sole responsibility for the residents’ personal allowance. Records of transactions were maintained and the manager reported that the service had a float where small amounts of money were kept that staff could access in his absence. It is recommended that transactions undertaken on behalf of the residents who are unable to sign for themselves contain two staff signatures, as this was not available. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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 people were provided with a well- maintained and homely environment that met their needs. The infection control procedures ensured that people are protected. EVIDENCE: The accommodation is provided in a well- maintained, warm, bright, clean and homely environment. Furnishing was of very good standard and appropriate to the needs of the residents. The service users are provided with comfortable communal areas where activities are undertaken. The bedrooms were nicely furnished and residents are encouraged to bring in items of personal belongings. This was evident in the bedrooms seen and personalised according to their wishes/ hobbies. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 18 Comments included “Home is always clean and I am happy with it.” The home has a small laundry room that was on the ground floor. The laundry area was clean and good state of repair. The manager reported that the residents were supported to undertake their washings, as part of their independent living skills. Infection control procedures were in place and staff training in infection control was available. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 32,34,35,36 The staff ratio were adequate to meet the present needs of people living at the service. The induction programme for all new staff requires further development. There is an ongoing staff-training programme to safeguard people. There is a recruitment procedure in place. Records of all necessary checks were not available for all new staff. A supervision programme for staff was not available and need to be put in place for staff. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home has a planned staff roster in place that the manager reported varied according to the numbers and dependency of residents. The home has three staff on the early and late shifts with two staff on the mid shifts between twelve and sixteen thirty. Night duty has one waking staff at present. The manager stated that he was on call and available for night support as needed. Comments from people included ” you can talk to the staff”. Other comments were: “Good teamwork with staff that gel with their service users.” “They know what upsets him and have strategies in place to avoid these things flaring up.” “The carers are nice.” The home has a training programme in place that included basic food hygiene, first aid, moving and handling, challenging behaviour, safeguarding adults and medication management. The manager reported that a training matrix was being developed and was not available. As discussed this would help to monitor training and identify any shortfall in staff training/ updates. Information from the AQAA indicated that of seven permanent staff, two of them had completed NVQ level 2 or above. None of the staff are currently undertaking this training. This was brought to the attention of the manager who would be discussing with the provider. The manager confirmed that service had used agency carers in covering a number of shifts. Two of the agency carers had recently been recruited as permanent staff. There was an induction programme in place that newly recruited staff had completed. The manager reported that none of the new staff had as yet been put forward for the Learning Disability Award Framework (LDAF) training programme. There was no supervision programme for staff and the manager said he was developing this for all staff as required. The service has a recruitment procedure in place. Three staff records were looked at as part of this visit. Staff completed application forms and references were sought as part of the recruitment process. CRB and POVA first checks were available for two staff members’ records seen. However another staff did not have CRB clearance prior to employment. This was brought to the attention of the manager. The manager is aware that this must be in place and confirmed that staff had been providing care unsupervised. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 21 Following the visit we received a call from the manager to say that the CRB clearance for the staff had been found in one of the other services and a copy would be sent to us. This has not been received at the time of the draft report being sent out. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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. 37,39,41,42 The service has appointed a manager who is in the process of applying to register with the commission. As part of quality assurance the process of seeking the views of people who use the service needs to be developed. The home has policies and procedures in place for staff guidance. However these need reviewing to reflect current changes regulations and good practice guidance. The health and safety of people using the service are promoted. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 23 EVIDENCE: The service has a registered manager with a number of years experience in the caring of people in the registered client group. Comments from people using the service indicated they would address any concerns with the manager. The interaction observed showed that the staff and the residents had developed good relationships with each other. The manager is new to the service and has started his Registered Manager’s Award (RMA) that he was planning to complete by the summer this year. He has also confirmed that he will be sending to us an application for him to register with the commission. Records seen showed that that monthly unannounced visits as Regulations 26 were carried out and records of these were maintained. The service did not have an audit system in place to assess how the home was meeting their service’s aims and objectives as stated in the statement of purpose. This was brought to the attention of the manager and need to be developed. Staff meeting had commenced in January 08. The manager has recently introduced monthly key worker meeting with the residents, as part of reviewing their needs. Information received and some of the records seen showed that there was an ongoing programme for the servicing of equipment at the home. Records of fire testing and fire drills were available. Some of the weekly fire alarm testing had not been completed as required. The manager was made aware of this and action must be taken. All materials that may be detrimental to health were locked away safely. A review of the home’s policy and procedures should be undertaken to ensure that they reflect current legislations and good practice guidance. Information received indicated that some of these were last reviewed in 2001 and others in 2005. Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19 Requirement Timescale for action 30/03/08 2 YA36 18(2) 3 YA39 24(1) The provider must ensure that all necessary checks such as CRB are in place prior to new staff’s employment to safeguard people using the service. A structured supervision 30/04/08 programme must be developed for staff so that they can receive supervision and support as part of their work as required. The provider must develop and 30/04/08 undertake an audit of the service users views to assess how the service is meeting people’s needs. 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 Falcon Lodge DS0000070443.V356529.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent 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. Extracts may not be used or reproduced without the express permission of CSCI Falcon Lodge DS0000070443.V356529.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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