Care Home: Freda Gunton Lodge

What the care home does well The home continually strives towards developing best practice in all aspects of the service. The standard of assessment and care planning is high with the focus on meeting individual needs and cultural diversities. Residents are supported by their allocated key worker who has designated time that enables them to spend time getting to know residents and taking them out into the community if that is their wish. Residents are fully involved in the development of their care and supported to make decisions. There is a strong emphasis on residents` self care with mobility encouraged. There is an active and dynamic programme of social activities and entertainment that includes craft and art groups and strives to integrate into the local community. Residents are fully consulted on all aspects of life at Freda Gunton Lodge. The quality and variety of meals provided is very good. All food is cooked fresh on site, including cakes and biscuits. There are regular cultural themed days provided that includes meals from other countries. Staff recruitment, training and development are excellent and above average staffing levels are provided. The manager is supported well by senior management and health and safety standards are maintained to a high standard. What has improved since the last inspection? A new manager has been registered with the Commission since the previous inspection. Issues with medication storage have been addressed. Residents` choice in time of getting up and other activities has been promoted. Care planning has been further developed to include a social care assessment on admission and there is a strong emphasis on meeting individual needs, for example sensory impairment and dexterity. Residents have been fully consulted on reviewing the menus and the recent introduction of `fruit smoothies` has promoted a healthy and easily digestible alternative to the standard provision of fruit. What the care home could do better: Staff must ensure that all medication with a limited shelf life has the date of opening recorded. CARE HOMES FOR OLDER PEOPLE Freda Gunton Lodge Balkerne Gardens Colchester Essex CO1 1PR Lead Inspector Diana Green Unannounced Inspection 3rd December 2007 01:00 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 Freda Gunton Lodge DS0000017824.V356008.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. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freda Gunton Lodge Address Balkerne Gardens Colchester Essex CO1 1PR 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) 01206 574786 01206 542149 admin@balkernegardens.fednet.org.uk www.balkernetrust.org.uk Balkerne Gardens Trust Limited Mrs Dawn Jennifer Conroy Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 Brief Description of the Service: Freda Gunton Lodge provides residential care for 40 older people. It does not offer nursing or dementia care. It is situated within the grounds of the Balkerne Garden Trust, who also have sheltered housing on the same site. The trust is a non-profit making charitable organisation that offers accommodation, predominantly, to service users who live in the Colchester area, or have family living in the area. Accommodation is provided on three levels with 36 single rooms and two double rooms, the majority of rooms having en-suite facilities. There are two passenger lifts. All rooms are well maintained, comfortably furnished and spacious. The home is situated within walking distance of the centre of Colchester and close to local amenities. These include shops, restaurants, a post office, a theatre, a library and parks. The complex has a security system in place for the protection of service users. The fees range from: En-suite single room - £595.00 per week Respite room - £85.00 per night. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 10/01/08. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that was undertaken on the 3/12/07 and lasted 5 hours. The inspection process included: discussions with the registered manager, administrator, the Director of Care, the laundry assistant, the cook, eight residents, two care staff and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Evidence was also taken from completed surveys and the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. The outcomes for people who use the service were looked at in relation to twentyfive National Minimum Standards. Seven were excellent and one requirement was made. The Director, manager and staff were welcoming and helpful throughout the inspection. What the service does well: The home continually strives towards developing best practice in all aspects of the service. The standard of assessment and care planning is high with the focus on meeting individual needs and cultural diversities. Residents are supported by their allocated key worker who has designated time that enables them to spend time getting to know residents and taking them out into the community if that is their wish. Residents are fully involved in the development of their care and supported to make decisions. There is a strong emphasis on residents’ self care with mobility encouraged. There is an active and dynamic programme of social activities and entertainment that includes craft and art groups and strives to integrate into the local community. Residents are fully consulted on all aspects of life at Freda Gunton Lodge. The quality and variety of meals provided is very good. All food is cooked fresh on site, including cakes and biscuits. There are regular cultural themed days provided that includes meals from other countries. Staff recruitment, training and development are excellent and above average staffing levels are provided. The manager is supported well by senior management and health and safety standards are maintained to a high standard. Freda Gunton Lodge DS0000017824.V356008.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. Freda Gunton Lodge DS0000017824.V356008.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 Freda Gunton Lodge DS0000017824.V356008.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): Quality in this outcome area is excellent based upon standards 1, 3, 6. The admission process is robust and enables prospective residents to make an informed choice about where to live and provides assurance that their needs will be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that met regulations and were both available in large print or audio format on request. The statement of purpose was comprehensive and was made available to residents and their representatives in the home. Substantial information was included in the document and the manager stated that details could be copied for residents and their representatives as required. Surveys completed by residents and relatives stated that they had received sufficient information before making a decision to live at Freda Gunton Lodge. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 9 An assessment of care needs was undertaken in the resident’s own home with full involvement of their relative or representative where possible. The assessment takes into account prospective residents’ diverse needs and efforts are made to ensure these are met through staff discussion and training. From discussion with the manager and information received in surveys it was confirmed that prior to making a decision, individuals were encouraged to visit the home for a short stay and have a meal, meet with residents and staff and view the home. Copies of care management assessments were obtained prior to admission where residents were funded through the local authority to ensure needs could be met and equipment purchased as necessary prior to admission. This was also confirmed from the records viewed. A full assessment was undertaken within 48hours by the allocated key worker and included a recently introduced social care assessment that enabled staff to obtain a full picture of the resident’s lifestyle and social preferences. This home does not provide intermediate care Freda Gunton Lodge DS0000017824.V356008.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): Quality in this outcome area is excellent based upon standards 7, 8, 9 & 10. The health and personal care needs of residents are appropriately met through robust care planning and monitoring of practice that ensures residents’ privacy and dignity is respected, fully involves them in decisions and enables them to influence life at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were reviewed during the site visit. All were person centred and comprehensively recorded. Risk assessments were undertaken and recorded for falls, nutrition, moving and handling and pressure areas/tissue viability. All risk assessments and care plans had been reviewed regularly. There was emphasis in the care plans on meeting the health, personal care and sensory needs of residents with a strong focus on self care and encouraging mobility, independence and social contact which was good to see. Daily records were comprehensive and detailed good monitoring of needs and appropriate action taken as relevant. Feedback received in surveys indicated that residents and their relatives, with their agreement, were fully involved in the development of Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 11 their care plans. Positive comments were received in completed surveys received from relatives on the standard of care provided: ‘they always look clean, well dressed and cared for’; ‘they try to tailor the care to individual needs’; ‘they are extremely happy and well looked after’; personal care is very good’; ‘Freda Gunton Lodge gives an excellent balance of care and independence’. The records confirmed evidence of good monitoring of health care needs with prompt referral to GPs and health care professionals and appropriate follow up action being taken. The home had positive relationships with local GPs and district nurses who regularly attended the home. The records confirmed that residents were enabled access to outpatient services, dental, chiropody and annual eye tests with some attending their own optician as they chose. Positive feedback was received from relatives ‘they treat the residents with respectvery helpful and pleasant-they have the time to listen’; ‘their health has improved with the good care that they receive’; It was good to see staff’ rapport with residents throughout the day i.e. explaining how they were going to assist them, what food and drinks they were serving them and in general conversation with them. The home had a policy and procedures for the safe ordering, administration recording and disposal of medication. Medication was supplied in a monitored dosage system and in individual containers from the local supplying pharmacist and appropriate procedures for receipt and disposal were followed. Senior care staff who had received training and been assessed as competent administered all medication. A current list of those staff signatures and initials was available. Medication was stored in a locked trolley and shelves within the clinical room (lockable) on the ground floor of the home. Daily monitoring and recording of room and drug refrigerator temperatures was undertaken and recorded with appropriate action taken as necessary. Controlled drugs (CD) were stored in a CD drug cupboard. The CD register was viewed and confirmed that medication was appropriately recorded. The medication supplies and medicine administration records were viewed for five residents. All medication was available as prescribed and accurately recorded. One resident was selfmedicating and a risk assessment was recorded and lockable facilities provided. Information received from the home stated that monthly audits were undertaken and reviews were prompted by staff to be undertaken by GPs at minimum annually. One relative stated in a survey that staff were very good at telling them about anything they needed to know including explaining medication that their loved one was prescribed. One prescribed cream with a limited shelf life did not have the date of opening recorded on the container. Staff were observed to knock before entering residents’ rooms. Residents and their representatives who completed surveys stated that staff were polite, friendly and always knocked before entering. The majority of residents’ rooms were single with some en-suite accommodation and treatment was therefore provided in their room ensuring their privacy was respected. Feedback Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 12 received from a health professional stated that staff always treated residents as an individual and with respect. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is excellent based upon standards 12, 13, 14 & 15. People living at Freda Gunton Lodge can expect to be consulted on all aspects of life and to enjoy a full and stimulating lifestyle with family and community involvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ social history and lifestyle preferences are assessed on admission to the home. Care records viewed provided evidence that the key worker had discussed how residents preferred to spend their days and actively encouraged them to enrich their lives through involvement in activities both in and outside the home. A range of group and individual activities were provided in the home for example craft sessions, board games, topical discussions, music and entertainment. With themed days or meals to promote other cultures. Information received from the home stated that since the previous key inspection, key workers had been allocated a minimum of one hour per week to spend with their allocated resident: this might include a trip into town, to church, a pub or a restaurant or time spent sitting talking with them. The manager and staff are commended for the efforts made in involving residents Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 14 more in the daily life of the home and the community. This has included assisting with recruitment of staff, in baking and decorating cakes to sell at coffee mornings and raise money for ‘Children in Need’ and in taking part in Tai Chi, line dancing and keep fit classes with residents in the adjacent warden assisted accommodation. Particular consideration had been made to improving access for people with a sensory impairment and dexterity problems, which was good to hear, and also confirmed from the care plans viewed. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. Several visitors were seen to come and go throughout the inspection. One resident said they had friends that come and take them out. Particular emphasis was placed on involvement with resident’s friends and family, subject to their wishes. Information received from the home stated that relatives were offered refreshment when they visited and were able to stay for a meal with their loved one and this was confirmed from the records viewed. Representatives of different faiths attended the home as relevant. Evidence that some local community groups had visited the home at Christmas i.e. local choirs and a scout band was confirmed from the record of activities viewed. Freda Gunton Lodge also had the support of volunteers who attended the home. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, ate their meals etc. Some residents had a choice of their own hairdresser, chiropodist and optician, with some attending their own outside the home. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them. Information on advocacy services was included in the statement of purpose and available in the home. The meals at Freda Gunton Lodge had been recently reviewed following discussion with residents at their regular residents’ meeting. Issues quoted by residents in completed surveys had already been addressed at the time of inspection, which was very positive to see. Menus viewed were varied and nutritious, with specialist diets and choices accommodated and were rotated over a six-week period. From discussion with the cook, it was evident that residents’ views on the food provided were obtained through individual discussion with them, from residents’ meetings, visits undertaken by the Trustees of Balkerne Gardens Trust and from the comment book supplied for their use. Efforts had been made to ensure residents were offered a healthy intake of fruit by the recent introduction of fruit ‘smoothies’ at tea twice a week; fruit and yoghurt were also offered at this time as well as various cakes and sandwiches. Residents spoken with were positive on the meals provided and the recent changes introduced. One resident who needed assistance with eating said that ‘the staff are very considerate in presenting my food in a way that helps me’; ‘staff have been very cooperative in providing me with vegetarian meals’. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon standards 16 & 18. People living at Freda Gunton Lodge can expect to have their complaints listened to and acted upon and to be protected from abuse by robust policies, procedures, staff training and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included the timescales within which complainants can expect a response and advised them of their right to refer to the CSCI at any stage. The procedure was included in the statement of purpose and displayed in the entrance of the home. Five complaints had been received since the previous inspection. All had been investigated thoroughly. All concerns, complaints and allegations were well monitored and used to improve standards. Residents and their relatives who completed surveys stated they knew how to make a complaint and who to speak to with any concern and were positive in their reply that the manager and staff kept them very well informed and were very responsive to any requests or concerns raised. The home had comprehensive policy and procedures for safeguarding vulnerable adults that had recently been reviewed. The records confirmed that all staff had received relevant training. Information received from the home stated that booklets had been obtained for residents, their carers and staff about the new Mental Capacity Act and that training for staff was planned. From previous knowledge of the home it was evident that senior management Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 16 and staff were skilled and experienced on the procedures to be followed in the event of any allegations. Records inspected showed that appropriate prerecruitment checks on new staff were undertaken prior to appointment (see standard 29). Information received from the manager stated that staff are encouraged to use the whistle blowing procedure but to also be open and sensitive to other people’s attitudes and views. There had been no allegation of abuse made since the previous inspection. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 19, 22 & 26. Freda Gunton Lodge was safe, well maintained and had a homely environment; residents’ rooms were individually furnished and equipped for their safety, comfort and privacy. The home was clean and hygienic with safe infection control practices that were well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen, clinical room, the sluices and the laundry. The home was in a good state of maintenance and decoration and was furnished in accordance with the client group. Positive comments about the environment were received in completed surveys: ‘the living environment is of a very high standard’; ‘the home is always clean with fresh flowers around’; ’ very homely’. The entrance hall had notice boards with full information displayed for residents and visitors’ information. The gardens Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 18 were kept tidy and well maintained, provided a pleasant outlook and residents spoken with said they enjoyed a walk in the gardens with their visitors during the warmer weather. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had passenger lifts to enable access throughout the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Call systems were provided throughout all individual and communal rooms. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents and the home also had their own supply. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. There were robust policies and procedures for infection control in place that included a contingency plan in the event of a pandemic. All staff received training during induction and at regular updated sessions as seen from the record of training. The home was cleaned to a high standard throughout and evidence of environmental risk assessments undertaken and minimised were seen from the records inspected. The laundry room was clean and well organised, with separate areas for clean and dirty laundry. There were three washing machines (two in use) and two driers with a separate drying room. The laundry room was clean and well organised and linen and residents’ personal clothing seen was well laundered. Sluice facilities were located on each floor of the home. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines and washing machines had the capacity to carry out sluice wash cycles. Comments received in completed surveys from residents and their relatives were positive: ‘the home always looks clean, hygienic, tidy and well cared for’; ‘the general cleanliness, hygiene and freshness is very good’. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon standards 27, 28, 29 & 30. People living at Freda Gunton Lodge can expect to be cared for by a wellmotivated and skilled staff team with staffing levels that are appropriate to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were thirty-eight residents at the home. Staffing numbers and skill mix met the levels agreed with the CSCI; from inspection of the staff duty rota and discussion with staff and residents, there was evidence that staffing levels were well maintained, and met the needs of residents. The use of agency staff was minimal so that residents were in the main cared for by staff that knew them. Positive comments were received in completed surveys from residents and relatives: ‘they are friendly and communicative’; ’ caring, professional staff’; ‘staff get to know residents well and make a priority of forming relationships with them’; ‘they always show interest and concern’. The home had 12 care staff with NVQ level 2 qualifications or above and a further 7 staff were working towards NVQ level 2 qualification or above. The percentage of staff with NVQ level 2 training was marginally less than the 50 needed to meet the standard. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 20 The recruitment files of four recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and evidence of identification and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards (records were not inspected). The home had an established training programme. The training records seen confirmed that staff had completed training on Protection of Vulnerable Adults, fire safety, and moving and handling and health and safety. Training had also been provided on first aid, food hygiene, infection control and loss and bereavement. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon standards 31, 33, 35, 37 & 38. The manager is supported well by senior management in providing clear leadership throughout the home with all staff demonstrating a good understanding of their roles and responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been appointed since the previous key inspection, following retirement of the former manager. The manager confirmed that she had Registered Managers Award and there was evidence from the records of recent updated training having been undertaken. From information received and discussion with her it was evident that she is appropriately trained and experienced to carry out her role competently. Surveys completed by residents Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 22 and their relatives stated: ‘Freda Gunton is a well run and very friendly establishment’; ‘the home is constantly working and striving to improve facilities for its residents;’;’it is an excellent organisation’; ‘we have been very impressed on all aspects’; ‘the organisational structure seems to work well’; ‘the home is fully up to our expectations and we have confidence in them’. There is a corporate quality assurance programme that includes an annual audit of the home that is used to develop an annual plan. A number of internal audits were regularly undertaken, for example medication, health and safety etc. The home monitored all complaints and compliments and also had a suggestion scheme for residents and visitors. Relatives meetings are held regularly where issues, for example the meals are discussed. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped ‘pouches’. Four residents’ records were inspected, and records, receipts and cash all balanced. Records held on behalf of residents were kept up to date and were stored safely in secure facilities. Records viewed at this inspection included: the statement of purpose, service user guide, care plans, medication records, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. The home had a health and safety policy manual and a designated health and safety manager. The records confirmed that staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). All accidents, injuries and incidents were well-recorded and appropriate action taken. Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 4 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X 3 3 Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement To ensure residents receive medication that has not deteriorated, medication with a limited shelf life must have the date recorded on the container. Timescale for action 31/01/08 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 Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Freda Gunton Lodge DS0000017824.V356008.R01.S.doc Version 5.2 Page 26 - 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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