Care Home: First Care Lodge Limited

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What the care home does well The home is well organised and runs along the same lines as the proprietor`s other two homes. It is small and homely with a relaxed atmosphere. There are a number of languages spoken among the staff group so communication is well supported, as are other cultural needs. The proprietor and manager are both experienced mental health nurses. The manager works closely with mental health professionals and ensures that service users are fully involved and supported by these services. There is a focus on rehabilitation and service users are fully suported to become increasingly independent and take more responsibility for their lives.First Care Lodge LimitedDS0000072388.V376299.R01.S.docVersion 5.2 What has improved since the last inspection? This is a new service. What the care home could do better: The inspection resulted in seven statutory requirements and five good practice recommendations. The home must improve its medication security and recording. It must make its recruitment practice more robust and safe. Policies need to be developed for areas which have not been covered. The manager is involved with the proprietor in further expansion of his business but he must ensure that standards at this home are not compromised in any way. Key inspection report CARE HOME ADULTS 18-65 First Care Lodge Limited 804 Longbridge Road Dagenham Essex RM8 2AA Lead Inspector Anne Chamberlain Key Unannounced Inspection 30th June 2009 09:00 First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service First Care Lodge Limited Address 804 Longbridge Road Dagenham Essex RM8 2AA 020 8586 7895 020 8586 7895 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) First Care Lodge Limited Jessen James Chinnapan Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Mental Disorder, excluding learning disability or dementia - Code MD 2. The maximum number of service users who can be accommodated is: 3 Date of last inspection This is the first inspection of this service. Brief Description of the Service: The home provides care for three adults who have mental health needs. It is situated in Dagenham and is close to transport links and shops. The home has two bedrooms upstairs and one downstairs. There are two bath/shower rooms, and a kitchen, garden room, lounge and small office. The home also has a garden at the rear. First Care Lodge Limited DS0000072388.V376299.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 two stars, this means that the people who use this service experience good quality outcomes. The inspection was carried out on behalf of the CQC and the terms we and us will be used throughout this report. This was the first inspection of this new service and it was carried out over five hours on one day. We were assisted by the manager of the service and the proprietor. We spoke with service users and viewed two service user case files and two staff personnel files. We also viewed key documentation and records for the home. We undertook an inspection of the premises and the garden. We would like to thank the service users and staff at the home for their assistance and co-operation with the inspection. What the service does well: The home is well organised and runs along the same lines as the proprietors other two homes. It is small and homely with a relaxed atmosphere. There are a number of languages spoken among the staff group so communication is well supported, as are other cultural needs. The proprietor and manager are both experienced mental health nurses. The manager works closely with mental health professionals and ensures that service users are fully involved and supported by these services. There is a focus on rehabilitation and service users are fully suported to become increasingly independent and take more responsibility for their lives. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. First Care Lodge Limited DS0000072388.V376299.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 First Care Lodge Limited DS0000072388.V376299.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of prospective service users are well assessed before they are offered a place at the home. EVIDENCE: The home has a referral and admission policy. In the two files we inspected we found that good assessment information had been collected before the service users had been accepted at the home. The home has its own referral form and this is supported by reports from mental health professionals. In one case there was a lot of high quality, detailed information provided. The manager advised that in addition to written information he or the proprietor visit the prospective user in whatever setting they are and trial visits to the home are arranged before placement. We noted good records kept of trial visits with proper telephone handover to ward staff after visits. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 9 First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning at the home is good but can be improved to address physical needs more fully. Risks are carefully assessed and monitored. Service users are encouraged to make their own decisions wherever possible. EVIDENCE: We saw evidence on file of care planning, for example, one service users care plan had four parts, mental health/behaviour, risks management, physical needs and social needs. The other service user plan had two parts one regarding symptoms, and one for alcohol. Care plans specified signs of deterioration in mental health so that carers can monitor mental state effectively. The focus of the care plans was very much on the mental halth and stability of the service user. They should First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 11 be developed and extended to cover more areas of service users needs, like medical conditions (one service user has diabetes, one has an optical condition), contact with families, and friends, and community involvement. The standard of care planning which had been done was clear and focussed. The manager stated that care planning is discussed with carers. We understand that because the home is small, with just three service users, staff know their needs and routines. However we would like to see these documented. We also noted evidence of review at six monthly intervals of care plans. We felt that service users have many opportunities within the safety parameters of their placements, to make decisions for themselves. They are very independent in many ways and go out and about on public transport, to the gym, to visit family etc. The service users dietary preferences are known and they either go out shopping with staff for the necessary foods, or staff will shop for the what is needed to make the dishes they prefer. The manager told me that two service users cook together for themselves, and there was evidence of this in the files. Service users decide what they want to do inside the house or garden, resting in their rooms, watching TV, sitting in the garden etc. We noted evidence on files of careful risk management. The manager explained to us how he structures his risk assessments and we felt that he was well trained and capable in these judgements. The home works in partnership with the community mental health team on the management of risk. There was clinical risk assessment information on file and relapse indicators. There are regular Care Plan Approach (CPA) meetings where risk assessments are reviewed. The level of signing and dating by service users of key documents was generally good but one service user had not signed his contract with the home. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 12 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): This is what people staying in this care home experience: 12,13,15,16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users have opportunities for personal development through education and recreational community activities. Relationships with families and friends are encouraged and supported as is taking responsibility appropriately. A healthy diet is offered. EVIDENCE: As previously mentioned the service users are able to go out and about independently. On the day of the inspection service users were coming and going. We noted that they told the manager where they were going before First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 13 they left. One service user visits his family locally on a regular basis and another spends weekends with his family. Service users walk, go to college, visit the gym, shop etc. Relationships with families and friends are encouraged and supported. All the service users enjoy the garden. The manager stated that two service users work on the garden on Wednesdays and Saturdays. The proprietor stated that there are good relationships between the service users at his three homes. Service users also get a chance to work with a number of different staff as the staff rotate around the homes and fill in for each other sometimes. The manager and the proprietor have a stable consistent presence in the home. The day of the inspection was shopping day and we noted several bags of groceries arriving into the home. There was a cupboard of spices which the service users use to make their curries. Almost all opened perishable foods stored in the two refrigerators had been labelled with ‘opened on’ dates. We remarked upon the absence of a fruit bowl. The manager stated that the service users prefer to shop for their own fruit and store it in their rooms. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal support of physical and emotional needs is good but the recording could be improved. Medication practice supports independence but the recording and security must be improved. EVIDENCE: Service users at this home do not need support with personal care. However they do need consistent emotional support, and encouragement to co-operate with their care plans, and attend appointments with mental health professionals. The home provides a structured home base, professionals who understand mental health issues and a family atmosphere. We noted that one to one interaction with staff to ventilate anxieties, is part of the care plans. The manager stated that this needs to be informal and he uses a conversational approach, to open up opportunities for service users to talk First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 15 about any difficulties they are having. We asked the manager where these conversations are recorded and he said in the daily recordings. The practice is that they are identified by a mark. We saw one example of this and asked the manager to reinforce the practice with the staff. We formed the view that the physical as well as the mental health needs of service users are well met. However as the home is very new we had limited evidence on which to make these judgements. One service user has diabetes and one service user has optical problems for which we noted, he attends Moorfields Eye Hospital. As the home has been open for less than a year there was not a great deal of health recording. We asked the manager to develop individual Health Action Plans where all physical health needs, appointments attended etc. can be recorded together. The record of the diabetes monitoring can be kept in the health action plan, rather than in the home diary where we were told they are currently recorded. We viewed the arrangements for the administration of medication. The home had recently moved the medications and they were kept in a cupboard in a locked room. However the cupboard itself must be locked to ensure the security of the medications. The manager stated that this was their intention but the lock had not been put on the cupboard door by the maintenance person yet. The manager stated that all the service users self medicate. The care staff prompt and supervise but the service users sign the Medication Administration Record (MAR) charts themselves. We observed an example of this and felt that the process was safe. One resident has all his medications dispensed in a dosette box made up by the pharmacist. When he is away overnight he takes the whole dosette box with him and returns it when he comes back. MAR charts are kept in a medication folder. We noted some shortfalls with the charts. A prn medication had been noted with a cross when not taken, but then this system had stopped for two administrations. The manager stated this was because he had advised the staff member that it is not necessary to note when a prn medication is not taken. Another medication had a gap of three administrations on the MAR chart. The manager said this was where a service user had been on leave out of the home. This should have been noted with an A for Absent. An anti-histamine preparation had stopped being recorded on the MAR chart. The manager stated this was because it had been replaced by a different First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 16 preparation. The MAR chart should have been noted that the administration had ceased. There were no service user photographs with the MAR charts and no specimens of their signatures. Also no information as to whether or not they had any allergies. Unfortunately apart from one medication it was not possible to check the balances of medications because there were no brought forward dates on the MAR charts. This means that the manager cannot fully audit the medication. The manager stated that he could change the system so that the dosette boxes and the MAR charts started on the same day and were auditable. We need him to do this. He agreed to audit the medications every two weeks and we need him to keep a record of these audits and the results. There was a record of medications received into the home and a record of medications returned to the pharmacy. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users feel that they are listened and their views considered. They are protected from abuse, neglect and self-harm. EVIDENCE: The home has a complaints policy and we noted that the service user guide contains complaints information. The home needs to ensure that the complaints information is updated with the current contact details for the Care Quality Commission (CQC). On surveys which service users had completed we were pleased to see that they felt they were listened to and their opinions considered. The home has a policy on safeguarding which is dated and has a review date. The policy was satisfactory and the home understands that they must work in conjunction with the local authority social services on issues of safeguarding. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 18 First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users live in a clean and hygienic, comfortable and safe environment. EVIDENCE: We toured the premises with the exception of the service user’s rooms. The house has two service user bedrooms upstairs along with a small office and a bathroom. There is a service user bedroom downstairs along with a lounge, kitchen room and garden room. There is a covered area in the garden for smoking. There were very few environmental issues. The paper in the garden room is coming off and needs to be replaced. It has polystyrene underneath it on the wall. We were advised by the manager that the fire officer who visited in First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 20 October 2008 had no issues with the polystyrene, but the home are taking it off anyway. It was very hot on the day of the inspection but the home had no fans. A service user kindly loaned us his own fan. The house should purchase some fans for hot weather. The house is generally in a good state of repair. None of the individuals in the house suffers from any infectious disease and there are no continence issues. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment practice in the home is not sufficiently safe and robust, and staff must under necessary training. Supervision was satisfactory. EVIDENCE: The home has a recruitment policy. It states that they aim to employ more people who themselves have a history of mental health issues. It also states that they advertise in the Job Centre and the local newspaper. The policy needs to be amended to state that they check immigration status of workers and that two professional references are taken up unless there is a good reason why this cannot be done. The home also has an equal opportunities statement. We viewed the files of two carers. Both had completed application forms and their personal details were recorded and immigration status checked. We were First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 22 very concerned to see that one carer had no references on file. Two professional references must be taken up for this worker as soon as possible. Neither of the two files viewed contained Criminal Records Bureau (CRB) disclosures in the name of the home. Both staff had clear 2008 CRB disclosures in the names of previous employers. Neither had a Protection of Vulnerable Adults (POVA) first check although we were able to see an e-mail from the home’s umbrella agency where these had been attached but could not be opened. The proprietor and manager stated that there had been many delays with the umbrella body which they use to apply for CRB’s and they had constantly chased them. They expect the POVA checks and CRB’s soon. We advised that no carer should start work without a clear CRB disclosure in the name of the home. If there are exceptional circumstances which have been discussed with us, a carer may be allowed to start work with a POVA first check, provided they are not left alone with service users. We noted that the carers were stated to have ‘medical clearance’. This would be better evidenced by a completed medical questionairre. The second carer did have two professional references on file, but the dates of employment given in one reference did not seem to be the same as she had recorded on her application form. The other reference did not give dates of employment. It is important for referees to give the dates of employment and for these to be checked against the application form. We formed the view that there had possibly been some urgency to get the home up and running and recruitment practice had been compromised as a result. We trust these shortfalls will be rectified and not repeated. We viewed the records of staff training. One carer had certificates for health and safety 31/5/09 and food hygiene 28/5/09 which are considered by us to be core basics. These also include first aid and adult protection. The carer had undertaken fire training in June 2009. We noted that neither carer had undertaken medication training. Carers who administer medication even if this is only prompting and supervision must undertake medication training. The manager stated that he would organise this training very quickly. The second carer had undertaken food hygiene, fire, and health and safety training, all during May and June 2009. She needs to undertake the other core basics as well as medication training. Both carers had staff orientation forms where their induction is recorded. However one carer’s form had not been completed. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 23 We checked the records for staff supervision. According to their logs both carers had had adequate supervision although we were not able to see the actual supervision records which are kept elsewhere. We were able to see an example from another carer and the content of the supervision was appropriate. There was spaces for supervisor and supervisee to sign and date. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home had three completed surveys from service users. They all said they had been made to feel welcome in the home. Service users felt that their opinions were listened to and risks supported and that their physical and emotional needs were being well met. We advised the manager that he needs to develop a quality assurance sytem with a range of tools like a business plan, audits etc. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 25 We viewed the policies kept in the home. These included safeguarding, food safety, grievance, induction, medication, and managing violence. We noted that there was no policy or procedure for missing persons, confidentiality, and contact with families. Control of substances hazardous to health (COSHH) policy was held in the Health and safety file along with the COSHH risk assessments. We suggested to the manager that he refer to Appendix 3 of the National Minimum Standards, of the Care Standards Act 2000, which is a list of policies which should be kept in residential homes. He must ensure that policies which are needed in the home are drafted. Some policies were dated and had review dates but some did not. All policies should be dated so that they can be reviewed when necessary. The daily recording was detailed and relevant but the paper used for it was too flimsy for the job and had no holes pre-punched, so the holes had been punched through the writing. The manager should ensure that these important records are produced to a reasonable standard using appropriate materials. We viewed the records for safe working practice in the home. The water temperatures are taken daily and recorded. The refrigerator temperatures are also taken daily and recorded. The fire alarms and extinguishers are checked frequently and fire drills are undertaken monthly. We viewed the records of these. The kitchen had a fire blanket and there were fire exit signs As previously mentioned we noted polystyrene under the wallpaper in the garden room. If the home wants to keep this in place they need to check with fire officer if it poses any fire risks. We saw a Portable Applance Test (PAT) for November 2008 but the manager said that many appliances have been brought into the home since then, so another PAT test must be undertaken in the home as soon as possible. The gas safety certificate was seen dated 17/9/08 and the electrical safety certificate was seen dated 17/9/08. There was a letter on file from London Fire and Emergency Planning Authority dated October 2008 stating that they had no concerns about fire safety in the home. The manager stated that COSHH items are locked away in the kitchen and we saw the data sheets for the COSHH items they use. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 26 First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 27 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 3 32 x 33 2 34 2 35 3 36 3 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 2 x 3 x 2 2 3 3 x Version 5.2 Page 28 First Care Lodge Limited DS0000072388.V376299.R01.S.doc 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 YA20 Regulation 13 Requirement Medication must be securely stored in a locked cupboard or cabinet. Medication records must include photographs of the service users and whether or not they have any allergies. The recording of administration must fully be auditable. Fortnightly audits of the medication must take place. For the safety and wellbeing of the service users. 2 YA24 23 The loose wallpaper in the garden room must be dealt with. The polystyrene on the walls beneath it must be removed or the fire officer consulted as to whether or not it poses any fire risks. 01/09/09 Timescale for action 01/08/09 3 YA34 19 For the comfort and protection of the service users. Recruitment must include, two 15/09/09 DS0000072388.V376299.R01.S.doc Version 5.2 Page 29 First Care Lodge Limited professional references with dates of employment checked, and a clear CRB disclosure. In exceptional circumstances a POVA first check may be acceptable provided the individual is not left alone with service users.. This requirement applies to all members of staff already working at the home. Recruitment must include proper evidence of medical status. The recruitment policy must be amended to include the above two points and also the need to check on immigration status. For the safety and protection of the service users. 4 YA35 18 All staff must undertake core training. Staff who administer or supervise the self administration of medication must have had medication training. For the protection and wellbeing of the service users. All necessary policies for the running of the home must be in place. Policies must be dated and reviewed. For the wellbeing of the service users. Portable appliance testing must DS0000072388.V376299.R01.S.doc 01/08/09 6 YA40 12 01/09/09 7 YA42 23 01/08/09 Page 30 First Care Lodge Limited Version 5.2 be carried out in the home. For the protection of the service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA17 YA18 YA20 YA24 YA41 Good Practice Recommendations One to one sessions should be indicated on the daily recording sheets. Health information should be recorded in a health action plan for each individual. The home should purchase a tablet counting tray to assist with medication audits. The home should purchase some fans for hot weather. The manager should ensure that the daily records are produced using appropriate materials. First Care Lodge Limited DS0000072388.V376299.R01.S.doc Version 5.2 Page 31 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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