Care Home: Ivor Lodge Care Home

What the care home does well What has improved since the last inspection? What the care home could do better: The home`s `Client Profile` form should be improved so staff have the information they need about residents presented in a positive and accessible way. Residents should be encouraged to sign their care plans as this will show they are in agreement with them. Since the last inspection the home has become completely `non smoking`. Residents` who want to smoke do so in the garden. Two residents told the inspector that they`d like some sort of shelter outside to smoke in. One said, `I need somewhere to go outside to smoke. I`ve been getting soaked in the rain.` While it is recognised that the home does not have to provide this facility, it is recommended that they give the idea consideration and discuss the pros and cons with the residents whose home it is. One member of staff, who had recently been appointed, did not have a POVA First check prior to starting work in the home, but was working under supervision. In addition, there was no photo of this member of staff on file. These documents help to ensure that staff are fit to work with vulnerable adults and must be in place. CARE HOME ADULTS 18-65 Ivor Lodge Care Home 452-454 Hinckley Road Leicester LE3 0WA Lead Inspector Kim Cowley Unannounced Inspection 10th July 2008 11:00 Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivor Lodge Care Home Address 452-454 Hinckley Road Leicester LE3 0WA 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) 0116 2547141 0116 2547141 ivorlodgeltd@yahoo.com Ivor Lodge Limited Mrs Sobha Chooramun Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration Categories: The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Both whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD Maximum Numbers: The maximum number of service users that can be accommodated at Ivor Lodge is: 14 30th August 2006 2. Date of last inspection Brief Description of the Service: Ivor Lodge is a residential care home for people with mental health needs. It is situated in a large detached house on the Hinckley Road, close to a range of local amenities. The home has ten single and two double bedrooms. There are two lounges, a conservatory, and a dining room. To the rear of the house is a small garden with a patio area. Fees are set at local authority rates. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit, we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection) spent half a day reviewing information relating to the home. During the course of the inspection, which lasted six hours, we checked the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means we looked at the care provided to three of the people living at the home by meeting them; talking with the staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were examined. We also talked to six residents, the Owner/Manager, and two carers. Eight residents surveys were returned to CSCI for this inspection. All the respondents filled the surveys in themselves. They gave a positive picture of the home, telling us they could determine their own lifestyles. They said they knew who to speak to if they weren’t happy, and that the staff treated them well. Two members of staff also completed surveys. These, too, were positive about all aspects of the home. What the service does well: Ivor Lodge is an established care home for people with mental health needs. It offers a stable environment to its residents, some of whom have lived at the home for many years. The atmosphere in the home is calm, and the residents get on well together and are tolerant of each other’s lifestyles and idiosyncrasies. One resident told us, ‘I wouldn’t like to live anywhere else. This is home to me now.’ Another said, ‘Ivor Lodge has saved my life. I was a mess when I came here, but now I’m OK.’ The premises are comfortable and homely. Residents tend to congregate in the dining room where regular ‘tea breaks’ bring them together for company and a chat. To one side of the dining room is a lounge area where residents can sit on settees chairs and still be part of the activity in the dining room. If residents want an alternative they can use a second lounge where there are books, television, and music. There is a ground floor toilet suitable for people with Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 6 disabilities, which both residents and visitors can use. This has helped to make the home more accessible to those with limited mobility. This was an unannounced inspection and the home was clean and tidy throughout. One resident said, ‘The home is always clean – you couldn’t wish for a cleaner place.’ Another commented, ‘My bedroom gets cleaned every Tuesday. The rest of the time I try to keep it tidy and the staff help me if I need them to.’ Some of the residents at Ivor House are quite energetic and enjoy swimming and going to gym, others prefer more low-key activities like board games and watching television. On the day of the inspection two residents were out shopping with a member of staff, and others were playing cards in the dining room with another staff member. One resident told us, ‘I like all the other residents here and we have a laugh. I also get on well with the staff. It’s nice and sociable here.’ All the residents we spoke to said they liked the food. Their comments included, ‘My favourite meal here is Sunday dinner – we have different meat every week’, ‘I’m on a healthy diet so I’m eating fruit as opposed to puddings. I have bananas, apples and oranges’, and, ‘The food’s brilliant here. It’s always good with lots of variety. I’m always happy with it.’ There is a regular meeting every Monday when residents discuss and decide the menu. Staffing in the home is flexible and depends on what residents are doing. On the day of inspection there were four staff on duty, morning and afternoon, as some residents were going out shopping and others had health care appointments. This flexibility gives residents more opportunities to get out and about into the community. The residents we spoke to were positive about the staff and said they got on well with them. One resident told us, ‘The staff are good, they look after you and take care of you.’ What has improved since the last inspection? Substantial work has been done to the premises including a new roof, and a new visitors/staff toilet on the ground floor. The kitchen and some bedrooms have been refurbished, and the conservatory and some communal areas have been redecorated. New settees and chairs have been purchased for lounges, and most bedrooms have had ‘touch’ taps fitted. One resident told us, ‘The Owners have spent lots of money on this place. They’ve done lots to it – it looks great.’ Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 7 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. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 8 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 Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Potential residents have their needs assessed to ensure the home is suitable for them. This judgement has been made using available evidence including a visit to this service. Standards 2 and 4 were inspected. EVIDENCE: Most residents who come to Ivor Lodge are admitted under the ‘Care Programme Approach’ (CPA). This means a multi-disciplinary team assesses them prior to admission, as do staff at the home. The Owner/Manager told us that assessments are also signed by the residents themselves to show they agree with what is written about them. This helps to involve them in the assessment process. The assessments were saw contained all the detail necessary for those involved to decide if a resident’s needs can be met at Ivor Lodge, We looked at the records belonging someone who was recently admitted to the home. We saw they visited several times before moving in. At first they came with their social worker, then they came on their own. They shared meals with the other residents and met the staff team. This gave them the opportunity to get to know the home and decide whether or not it was right for them. Ivor Lodge Care Home DS0000043227.V368417.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Detailed care plans help staff to identify and meet residents’ needs. This judgement has been made using available evidence including a visit to this service. Standards 6, 7, and 9 were inspected. EVIDENCE: Residents’ records begin with a ‘Client Profile’ form, which provides essential factual information about them. Some improvements are needed to this: • • • • the term ‘marital status’ should be replaced with ‘marital status or civil partnership status’ so as to be more inclusive ethnic origin and preferred language should be added residents’ ‘weaknesses’ to be listed – this is a negative way of identifying areas where they need extra support and should be re-worded the form should be dated on completion Making these improvements will help to ensure staff have the information they need about residents presented in a positive and accessible way. We looked at care plans for the three residents we case tracked. The information in them was clear and relevant, and covered their health, personal Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 11 and social needs. The Owner/Manager told us that residents are involved in the drawing up of their care plans, and also when they are reviewed. It is recommended that residents are encouraged to sign their care plans as this will show they are in agreement with them. Residents are risk assessed by health and social services staff prior to admission. Risk assessments are then reviewed and updated by staff at the home in conjunction with Community Psychiatric Nurses. Residents who go out unaccompanied are informed of risks and given support and advice. Staff teach them road safety and show them where nearby pedestrian crossings are. Residents take the telephone number of the home with them when they go out. Ivor Lodge Care Home DS0000043227.V368417.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): Quality in this outcome area is good. Daily living and social activities enable residents to lead full lives and grow in independence. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16, and 17 were inspected. EVIDENCE: Activities, education and training are provided on an individual and group basis, depending on residents’ needs. Care plans showed that some residents have a few structured activities, including college and day centre attendance, while others have more free time and come and go as they wish. Although all residents are encouraged to take part in activities, the Owner/Manager said it is their choice whether they do or not. Some of the residents at Ivor House are quite energetic and enjoy swimming and going to gym, others prefer more low-key activities like board games or watching television. On the day of the inspection two residents were out shopping with one member of staff, and others were playing cards in the dining room with another staff member. One resident told us, ‘I like all the Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 13 other residents here and we have a laugh. I also get on well with the staff. It’s nice and sociable here.’ All residents are expected to help in the home, depending on their abilities. This increases their independence skills. They are encouraged to keep their rooms tidy, sort their laundry, and help with the washing up. Residents are helped to keep in touch with their families and friends through visits, letters and phone calls. Staff provide transport for visits where necessary. Visitors are made welcome and invited to share meals with the residents. Staff offer extra support to residents who do not have contact with their families. All the residents we spoke to said they liked the food. Their comments included: ‘My favourite meal here is Sunday dinner – we have different meat every week.’ ‘I’m on a healthy diet so I’m eating fruit as opposed to puddings. I have bananas, apples and oranges.’ ‘The food is nice. The pork chips we had last night were lovely and tender.’ ‘I can’t make my own tea as it’s not safe for me in the kitchen. If I want a cold drink I just ask the staff and they get me one. And we have set times for hot drinks.’ ‘We all meet every Monday to choose meals for the week.’ ‘I like the curries we have.’ ‘We’re planning a barbecue for when it stops raining.’ ‘The food’s good here - really good.’ ‘The food’s brilliant here. It’s always good with lots of variety. I’m always happy with it.’ The care staff do the cooking and residents are encouraged to help them. Residents shop with staff so they can choose food for the home. There is a regular meeting every Monday when residents discuss and decide the menu. Menu records showed that residents have a varied and wholesome diet and that alternatives are provided for those who want them. Ivor Lodge Care Home DS0000043227.V368417.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents have their personal and health care needs met in the way they want by staff in the home. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 and 20 were inspected. EVIDENCE: The Owner/Manager said the residents are mostly self-caring, although some need prompting or minimal assistance. Staff talk to residents about what help they need and this is recorded in their care plans. Residents can bath/shower as often as they like, for example one resident likes to have two showers a day while another prefers one bath a week. The residents are encouraged to look clean and tidy as this can help increase their self-esteem. All residents are registered with one of three local GP surgeries, and have consultant psychiatrists, some also have CPNs and/or care managers. Local dentists and opticians either visit the home or see residents in the community. Staff encourage residents to look after both their mental and physical health and prompt them to attend medical appointments, accompanying them where necessary. One resident told us, ‘If I have any pain the Manager says I must go to the doctor and she takes me.’ Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 15 Medication is kept securely and properly administered with records kept. Staff are trained in medication administration in-house, and the home’s contract pharmacist has approved their training. At present no residents self-medicate, although they are encouraged to do so where possible. Records showed that staff monitor the effects of medication to help to ensure it is suitable for each of the residents. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Staff know how to safeguard residents and help them express any concerns they might have. This judgement has been made using available evidence including a visit to this service. Standards 22 and 23 were inspected. EVIDENCE: Ivor Lodge has a written complaints procedure, which is given to residents when they first move into the home. Their representatives are also given a copy. The Owner/Manager told us that staff go through the complaints procedure with new residents and explain it to them, so they are clear what to do if they are unhappy about anything. Residents are also reminded about how to complain at their weekly meetings. This approach helps to create a climate in the home where it is OK for residents to speak out if they have a complaint. All residents interviewed said they would tell the Owner/Manager or a member of staff if there were anything wrong. One resident said, ‘If we have any problems the Manager is there for us.’ There has been one complaint about the home since the last inspection. This is currently in the process of being investigated. Both Management and staff are aware of their responsibility to safeguard residents. New staff are made aware of the home’s safeguarding policy during their induction. A member of staff, who recently started work at the home, discussed safeguarding with the inspector. She was clear about what she would do if she had concerns about a resident’s well being, and demonstrated a good understanding of how best to safeguard vulnerable people. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. The home is community-based, comfortable, and well maintained. This judgement has been made using available evidence including a visit to this service. Standards 24 and 30 were inspected. EVIDENCE: The premises are comfortable and homely, and are continually being updated and improved. One resident told us, ‘The Owners have spent lots of money on this place. They’ve done lots to it – it looks great.’ Since the last inspection the following improvements have been carried out: • • • • • • • • a new roof a new visitors/staff toilet on the ground floor the kitchen has been refurbished the conservatory and some communal areas have been redecorated some bedrooms redecorated/refurbished a new boiler fitted new settees and chairs purchased for the lounges most bedrooms have had ‘touch’ taps fitted Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 18 The dining room is busy and lively. Regular ‘tea breaks’ bring the resident together here for some company and a chat. To one side of the dining room is a lounge area where residents can sit on settees and still be part of the activity in the dining room. If residents want an alternative they can use a second lounge where there are books, television, and music. There is a ground floor toilet suitable for people with disabilities, which both residents and visitors can use. This has helped to make the home more accessible to those with limited mobility. This was an unannounced inspection and the home was clean and tidy throughout. One resident said, ‘The home is always clean – you couldn’t wish for a cleaner place.’ Another commented, ‘My bedroom gets cleaned every Tuesday. The rest of the time I try to keep it tidy and the staff help me if I need them to.’ Since the last inspection the home has become completely ‘non smoking’. Residents’ who want to smoke do so in the garden. Two residents told the inspector that they’d like some sort of shelter outside to smoke in. One said, ‘I need somewhere to go outside to smoke. I’ve been getting soaked in the rain.’ While it is recognised that the home does not have to provide this facility, it is recommended that they give the idea consideration and discuss the pros and cons with the residents whose home it is. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Friendly and professional staff meets residents’ needs. This judgement has been made using available evidence including a visit to the service. Standards 32, 34 and 35 were inspected. EVIDENCE: Staffing in the home is flexible and depends on what residents are doing. There is always a minimum of two members of staff on duty during the day, plus further members of staff if residents are going out accompanied. On the day of inspection there were four staff on duty, morning and afternoon, as some residents were going out shopping and others had health care appointments. This flexibility gives residents more opportunities to get out and about into the community. The residents we spoke to were positive about the staff and said they got on well with them. One resident told us, ‘The staff are good, they look after you and take care of you.’ We saw that if residents had a particular need, staff were given extra training so they could provide the right support. For example, one resident was at risk of choking, so the Owner went on a course to learn how to deal with this. He then provided in-house training so all the staff would know what to do if a resident choked. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 20 Records showed that all staff have two written references and up to date CRBs. This helps to ensure that residents are safeguarded. One member of staff, who had recently been appointed, did not have a POVA First check prior to starting work in the home, but was working under supervision. This was discussed with the Owner/Manager who said she had assumed the agency that carried out the checks would have done them correctly, but this was not the case. The day after the inspection the Owner/Manager informed CSCI in writing that this member of staff now had A POVA First check, and that in future no member of staff would start work at Ivor Lodge without one. In addition, there was not photo of this member of staff on file. It is a requirement that one must be kept in the home for purposes of identification, and the Owner/Manager agreed to carry out an audit of staff files to ensure they all contained staff photos. POVA First checks and staff photos help to ensure that the staff who work in the home are fit to work with vulnerable adults, and are who they say they are. As such they are an important part of the recruitment process. The Owner/Manager and Owner are responsible for staff induction and training. Both are qualified nurses. The majority of staff have NVQ Level 2 or 3 in Care. The Owner/Manager told us that the regular staff meeting are used as training/ seminar platforms, where information about good practice in care is shared and discussed. This helps staff to keep up to date on developments in the field of mental health. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is safe and well managed and residents are involved in the way it is run. This judgement has been made using available evidence including a visit to this service. Standards 37, 38, 39, and 42 were inspected. EVIDENCE: The Owner/Manager has run care homes for 15 years and is a qualified mental health nurse. She also has a BSC (Hons) degree in Specialist Nursing Practice and is currently studying for the NVQ Assessors Award. This will make her eligible to assess staff studying for NVQ levels 2 & 3 in Care. She works full time in the home and is there during the week and at weekends. She has a calming influence on the residents, knows them well, and is warm and friendly towards them. All the residents we spoke to told us how much they liked and trusted the Owner/Manager. One resident told us, ‘The Manager’s good. She makes sure that all of us get the chance to speak (at the Monday meetings) and say what we want.’ Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 22 To help to ensure they are providing good care the Owners carry out an annual quality review of the home. This is based on surveys of residents’, relative’s, and visiting professionals’ views. When the data is collected the Owners analyse it and make recommendations based on what they have found. Polices and procedures are in place for safe working practices and the premises are risk assessed. Records showed that the maintenance of the property and its safety systems are up to date. Ivor Lodge Care Home DS0000043227.V368417.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 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 3 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ivor Lodge Care Home DS0000043227.V368417.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 YA34 Regulation 19 Requirement All staff files must contain the documentation listed under Schedule 2 of the Care Homes Regulations 2001, including a recent photo and, while awaiting a CRB, a POVA First check. This will help to ensure residents are safeguarded Timescale for action 10/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The following improvements should be made to the home’s ‘Client Profile’ form: • • • the term ‘marital status’ should be replaced with ‘marital status or civil partnership status’ so as to be more inclusive ethnic origin and preferred language should be added residents’ ‘weaknesses’ are listed – this is a negative way of identifying areas where they need extra support and should be re-worded DS0000043227.V368417.R01.S.doc Version 5.2 Page 25 Ivor Lodge Care Home • the form should be dated on completion This will help to ensure staff have the information they need about residents presented in a positive and accessible way. 2 3 YA6 YA24 Residents should be encouraged to sign their care plans as this will show they are in agreement with them. The Owners should give consideration to the idea of having some sort of shelter in the garden for residents who smoke. Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ivor Lodge Care Home DS0000043227.V368417.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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