Care Home: Fern Lodge

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What the care home does well All the residents we spoke with said they were happy with care and support they received. One resident told us that the staff were, "Very nice". The home had a relaxed and friendly atmosphere. There is a good rapport between residents and staff. People who use the service are treated with respect and their dignity and privacy is valued and upheld. People who use the service were positive about the food at the home and that they were offered a varied choice of menu. Staff demonstrated a good knowledge of residents needs and consequently an individualised service is promoted. Residents have good access to health care professionals. The home makes sure that people`s needs are assessed before they move in so that people know the home will be able to meet their needs. Residents of the home feel that the staff are kind and polite and support them properly. What has improved since the last inspection? Ten requirements were issued at the last inspection. The registered person has now complied with all of these, although two requirements made at the last inspection have been amended. Residents` care plans are being reviewed monthly so that any changes can be updated and addressed. Staff monitor what people are eating so that any problems can be highlighted and addressed promptly. A number of maintenance issues have now been dealt with to ensure the safety of staff and residents. Residents have more of a say in how the home is run through regular meetings and quality assurance surveys. The manager works closely with staff and provides regular supervision. However these supervision sessions must be recorded. A fire risk assessment has now been developed for the home so that potential problems are highlighted and can be addressed. Two good practice recommendations, issued at the last inspection, relating to health care appointments and residents` interests have both been complied with What the care home could do better: Seven new requirements have been issued as a result of this inspection. All residents at the home must have risk assessments carried out in relation to nutrition and pressure care. These assessments must be regularly reviewed so that any potential problems are highlighted and acted upon. The manager and staff must attend dementia training so that they are better able to understand the needs of people who have developed dementia whist at the home. The cook must update her knowledge and skills by undertaking a refresher course in food hygiene. Although most staff have undertaken appropriate training some need refresher courses so that their knowledge and skills are updated. The results of the quality monitoring surveys sent to residents and their representatives must be published so that everyone is aware of the improvements the home will make a result of any comments and suggestions. The Commission must be notified about any incidents that affect the well being of residents at the home. As mentioned previously the manager must record supervision sessions with staff. Four good practice recommendations have been made relating to staff training, the statement of purpose and service user guide and fire drills. CARE HOMES FOR OLDER PEOPLE Fern Lodge 24-26 Compton Road London N21 3NX Lead Inspector Mr David Hastings Key Unannounced Inspection 10:00 14th August 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 Fern Lodge DS0000010673.V364171.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. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fern Lodge Address 24-26 Compton Road London N21 3NX 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 8360 6219 020 8364 1240 jhunt12345@aol.com Mrs Angela Hunt Mrs Angela Hunt Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2007 Brief Description of the Service: Fern Lodge is a privately owned registered care home for 20 older people located in a residential area of Winchmore Hill, North London. It is situated within a few minutes walk of public transport services and close to a number of amenities such as shops, churches and GP surgery. The registered provider, Mrs Angela Hunt is also the registered manager of the home. Accommodation is provided on the ground floor and first floors in ten single rooms and five shared bedrooms, all of which meet the minimum spatial standards. None of the bedrooms have en suite facilities, though they are all fitted with wash hand basins. A lift provides access to the first floor. The home has a large garden and patio at the rear of the premises, which is accessible through french windows. The stated aim of the home is to ensure that the individuality of care to service users is emphasised; that staff provide this, pay attention to detail, and are highly experienced and professional in their care of the elderly. The fees for the service range from £395 to £415 per week depending on single or double occupancy. A copy of this report and the home’s Statement of Purpose can be obtained from the manager of the home. Fern Lodge DS0000010673.V364171.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 inspection took place on Thursday 14th August 2008 and was completed on the same day. The inspection lasted six hours. We spoke with four staff on duty during the inspection. We spoke with ten residents of the home and two visitors. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. The home completed an Annual Quality Assurance Assessment (AQAA) prior to the inspection at the request of the CSCI, and this was used to form part of the overall inspection process. What the service does well: What has improved since the last inspection? Ten requirements were issued at the last inspection. The registered person has now complied with all of these, although two requirements made at the last inspection have been amended. Residents’ care plans are being reviewed monthly so that any changes can be updated and addressed. Staff monitor what people are eating so that any problems can be highlighted and addressed promptly. A number of maintenance issues have now been dealt with to ensure the safety of staff and residents. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 6 Residents have more of a say in how the home is run through regular meetings and quality assurance surveys. The manager works closely with staff and provides regular supervision. However these supervision sessions must be recorded. A fire risk assessment has now been developed for the home so that potential problems are highlighted and can be addressed. Two good practice recommendations, issued at the last inspection, relating to health care appointments and residents’ interests have both been complied with 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. Fern Lodge DS0000010673.V364171.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 Fern Lodge DS0000010673.V364171.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 and 3 (6 not applicable) People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have accurate information about the home in order to make an informed choice about where to live. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. EVIDENCE: We looked at the “Service User Guide”. This gives people information about the home and services and facilities available. Although the information was satisfactory it would be helpful to include a statement about how the home encourages people from different backgrounds to use this service. A good practice recommendation has been issued that the home reviews the service user guide to include an equal opportunities statement. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 9 The manager was able to describe how the needs of people from different backgrounds and cultures can be met at the home including appropriate diets and religious observance. Pre admission assessments were examined for two people who are now living at the home. The information was satisfactory and outlined each person’ s individual needs. There were also detailed assessments from the local authority to assist the home in their own pre admission assessments. There was evidence on pre admission assessments that the person or their representative had been involved in their initial assessment. Relatives we spoke with confirmed that they had visited the home and discussed the needs of their relative with staff. Residents we spoke with said they felt the staff were able to meet their needs at the home. There was evidence that these identified needs were also being recorded in each person’s individual care plan. People also have a review of their placement 4-6 weeks after being in the home. This means that people have the opportunity to decide if the home is right for them. Fern Lodge DS0000010673.V364171.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 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Five care plans were examined. Each plan gave clear instructions to staff about how best to care for each person. Care plans were being reviewed on a regular basis and updated where needed. This was a requirement from the last inspection that has now been complied with. People who use the service told us that staff were good at meeting their physical care needs and that they were treated with respect and their privacy was being maintained. Work has been undertaken to gain a social history of people at the home so that staff can have an insight into what the person was like before they moved into the home. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 11 Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. Risk assessments in relation to nutrition and pressure care were not seen in care plans. It is important that all residents at the home are assessed for any potential problems related to nutrition and pressure care so staff are aware of any additional care needs of each person. A requirement has been issued that all residents have a nutritional and pressure care risk assessment undertaken and written instructions are provided to staff in order to minimize any potential risks highlighted. Visits by health care professionals such as doctors, district nurses, dentists and opticians were being recorded on plans we examined. These showed that people had good access to these professionals. This was also confirmed by residents and relatives we spoke with. A visitor told us that if there were any health problem with their relative the manager would contact the doctor straight away. Satisfactory records and procedures were examined in relation to the receipt, storage, administration and disposal of medication. Records seen indicated that staff have recently attended medication training. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. Fern Lodge DS0000010673.V364171.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 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service, however people with dementia are not always being kept suitably occupied and engaged. Visitors to the home are encouraged and welcomed. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: Residents’ interests, likes and dislikes are recorded when they are admitted to the home. The manager and staff were able to give examples of activities they carry out with residents. These include quizzes, sing-a-longs, board games and weekly social outings. The manager told us that outside entertainers are booked two to three times a month. Although the home does not admit anyone with a diagnosis of dementia, a number of residents have developed dementia whilst at the home. Staff told us that keeping people with dementia suitably occupied and engaged was a challenge. A number of residents told us that they would like more things to do at the home. One person told us, “There’s not much to do”. Dementia training would assist staff in understanding the issues faced by people with dementia Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 13 and would improve the quality of communication and activities at the home. A requirement has been issued that all staff, including the manager, attend dementia training with a particular emphasis on communication and the provision of activities. The manager told us that the home used to employ an activities coordinator and that she was looking into recruiting a new activities coordinator in the near future. This would ensure that more activities are available to residents at the home. Visitors to the home told us that they could visit at any reasonable time and that they were made welcome by the management and staff. Residents we spoke with confirmed this. One visitor told us that their relative, “Couldn’t be in a better place” and “Nothing is too much trouble”, for the manager and staff. There are twice yearly residents’ meetings and people told us they have a say in how the home is run. For example we saw that people are consulted about activities and the menus in the home. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. The kitchen was inspected. Fridge and freezer temperatures were being recorded and there were sufficient amounts of fruit and vegetables available. The cook was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. The meals we saw on the day of the inspection looked and smelt appetising. People who use the service confirmed that the food was good at the home and that they always get enough to eat. One person commented that the food was, “Very nice”. Records were being maintained of what people were eating and daily notes indicated if people were eating well or not. This was a requirement from the last inspection that has now been complied with. The cook has not updated her training for a while and a requirement relating to training has been made in the relevant section of this report. Fern Lodge DS0000010673.V364171.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): 16 and 18 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an experienced staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. Three complaints have been received by the home since the last inspection. Records examined indicated that these complaints had been dealt with appropriately and in line with the home’s complaints procedure. All the residents and visitors we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. Residents that we spoke to said they felt safe and well supported at the home. Training records examined indicated that some staff require refresher training in safeguarding adults from abuse. However, staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Fern Lodge DS0000010673.V364171.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 and 26 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is safe, clean and maintained and decorated to a good standard. EVIDENCE: We toured the home with the manager and visited a number of residents’ rooms. Fern Lodge is not purpose built and has been converted into a residential care home. Residents and visitors told us that they appreciated the homely atmosphere and that it did not have an institutional feel. At the time of the inspection the home was decorated and maintained to a good standard and residents rooms were cosy and individually decorated. The manager told us that the home employs a maintenance person who they call if anything needs repairing. Two maintenance issues highlighted at the last inspection have now been addressed. There are five double rooms which all contained a screen to improve the privacy of residents who share. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 16 The home employs a domestic worker three times a week. People who use the service and visitors we spoke with confirmed that the home was always clean. One visitor told us that the home always smelt fresh and clean. The home was clean and tidy on the day of the inspection. The laundry was inspected and the washing machine contained a sluice option for soiled laundry. Records indicated that some staff require refresher training in infection control. A requirement has been issued in the training section of this report. Fern Lodge DS0000010673.V364171.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 and 30 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager and staff at the home work hard to meet the needs of the residents. Staff are not always being provided with the training they need to keep updated with current care practices and health and safety legislation. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: On the day of the inspection there were eighteen people residing at the home. There were three care staff on duty as well as the manager and cook. The manager said that there are always three care staff on duty in the evening and two waking night staff on duty throughout the night. Rotas examined matched the names of staff on duty. People who use the service told us that the staff were nice and that there were currently enough staff on duty to meet their needs. The manager of the home is very, “Hands on” and works closely with residents and staff at the home. Staff interviewed were very knowledgeable about the needs of the residents and staff turnover is low. Information received by the Commission from the home indicated that just under 50 of staff have completed NVQ level 2 or equivalent in care. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 18 As previously mentioned, staff training records indicated that a number of staff need refresher courses so that they can keep up to date with current care practice and health and safety issues. To assist the manager in identifying the training needs of staff, a good practice recommendation has been issued that a staff training overview is developed which lists the mandatory training undertaken by all staff including the dates of the training. A requirement has been issued that all staff receive the training they need to perform their roles and responsibilities. Three staff files were examined from staff recently employed by the home. We checked these files to see if the home’s recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof of identity and criminal record checks. Fern Lodge DS0000010673.V364171.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 and 38 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is working hard to improve the quality of care provided at the home. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are being promoted and protected. EVIDENCE: The registered manager, Mrs Angela Hunt, has been running the service for more than thirty years and is a qualified nurse. The residents, relatives and staff were very positive about the manager. One relative told us the manager was, “Fantastic”. A staff member said the manager was, “Supportive in every way”. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 20 Although the manager attends training with her staff, she has not completed the required management training. The manager informed us that she would be starting the Registered Manager’s Award in September this year. There was evidence that residents and relatives meetings now take place twice a year. This was a requirement from the last inspection that has now been complied with. The manager was able to explain how suggestions made by residents and their relatives at these meetings have been put into practice. The home now has a quality assurance system in place, which includes questionnaires being sent to residents and their representatives. This was also a requirement from the last inspection. The home will need to collate and publish the results of these surveys so that interested parties can see what improvements the home intends to make as a result of the surveys. A new requirement has been issued relating to this in the relevant section of this report. As the manager is very “Hands on” in her approach we were able to see that she regularly asks residents how they are and listens to any comments and suggestions they may make. The home does not hold any money on behalf of residents of the home. Residents managed their own money or if they are unable to do this, their relative or their representative manages their money. A requirement was issued at the last inspection that the manager must provide supervision for staff at least six times a year. The manager told us that she supervises staff regularly however these supervision sessions were not being recorded. A new requirement has been issued that all supervision sessions with staff either as a group or individual are recorded. This should ensure that both the manager and the staff are clear about the outcomes of any meetings including identifying the individual training needs of staff. A requirement was issued at the last inspection that a fire risk assessment and emergency plan is developed so ensure that safety of both staff and residents at the home. A fire risk assessment and emergency plan have now been developed by an outside contractor. The home keeps a record of any accidents or incidents that happen at the home. The Commission has not always been notified about accidents or incidents as required by Regulation 37 of the Care Homes Regulations 2001. A requirement has been made regarding this issue. It is important that the Commission is aware of any incidents that affect the well being of residents at the home so that it can monitor the actions taken by the management. A requirement was issued at the last inspection that a business and financial plan are available for inspection. The business manager told us that this was still being developed however he reassured us that there are no financial concerns about the business. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 21 Records indicated that staff undertake regular fire drills both during the day and at night. It would be helpful if the names of the staff taking part in the fire drills were recorded so that the manager knows who may not have taken part in a fire drill for some time. A good practice recommendation has been made in the relevant section of this report. We checked a number of health and safety certificates to see if the maintenance of equipment and the home were being kept up to date and safe. We saw satisfactory records in relation to gas safety, electrical safety and fire safety. Fern Lodge DS0000010673.V364171.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Fern Lodge DS0000010673.V364171.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 OP8 Regulation 12(1) The registered person must ensure that all residents have a nutritional assessment carried out and are assessed for the risk of developing pressure sores. 2. OP12 16(2) n The registered person must ensure that the manager and staff undertake dementia training with particular reference to communication and the provision of activities for people with dementia. This should ensure that those residents with dementia are kept suitably occupied and engaged. 3. OP15 18(1) c The registered person must ensure that the cook undertakes a refresher course in food hygiene so that she is aware of any updated good practice and current legislation in this area. 01/12/08 01/01/09 Requirement Timescale for action 01/11/08 Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 24 4. OP30 18(1) c The registered person must ensure that all staff undertake up to date, mandatory training as identified by the manager. This should ensure that staff are trained and competent to carry out their roles and responsibilities. 01/01/09 5. OP33 24(2) The registered person must ensure that the results of any quality monitoring surveys are published and made available to all residents and other interested parties. 01/11/08 6. OP36 18(2) The registered person must ensure that staff supervision sessions are recorded so that both parties have a record of what was discussed and any action that may need to be taken as a result. 01/11/08 7. OP38 37 The registered person must ensure that any accidents or incidents that affect the well being of the residents at the home are reported to the Commission without delay. 01/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 25 1 OP1 The registered person should ensure that the home’s “Statement of Purpose” includes an equal opportunities statement detailing how potential residents from diverse backgrounds are welcomed and encouraged by the home. 2. OP18 The registered person should ensure that all staff undertake training in adult protection so they understand the policies and procedures in relation to protecting vulnerable people at the home. 3. OP30 The registered person should develop a training overview for all staff so that any gaps in training can be easily identified and addressed. 4. OP38 The registered person should ensure that the names of staff who participate in regular fire drills are recorded so that the manager can identify the staff that need to take part in the next fire drill. Fern Lodge DS0000010673.V364171.R01.S.doc Version 5.2 Page 26 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. 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