Care Home: Oak Lodge

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What the care home does well Admissions to the home are managed well, senior staff conduct pre-admission assessments to ensure that the home is able to meet the needs of the individual. Individual care plans and daily records show that people are treated as individuals and that the health and personal care needs are met. Daily records indicate that people are able to exercise choice within their daily lives. The people who use the service have access to the right health and social care professionals through routine check ups and also when they require specific care and support. The service works well with members of the Community Health Care Team such as doctors and district nurses. The staff are mindful of the privacy and dignity of the people who use the service. People are supported to maintain links with family and friends and also to maintain their faith. The management has an ongoing decoration programme, several of the bedrooms have been redecorated and refurbished. All of the care staff are qualified to at least National Vocational Qualification Level 2 in Care. What has improved since the last inspection? The service has responded well to the findings of the previous inspection. As a result of that inspection thirteen requirements were made which told the management what action they had to take. All of these requirements have now been addressed which means that the Statement of Purpose is now up to date, the standard of the Individual plans of care have been improved including the pre-admission assessments, there is also more detailed instruction to staff about the way that the people who use the service need and wish to be cared for and these are being reviewed on a monthly basis. There are now the right risk assessments in place for the management of falls, falls from the bed, nutrition, pressure and the risks associated with the use of dental cleansing agents. The management have also fitted a radiator guard to protect against the exposed radiator surface and appropriate privacy locks have been fitted to the bedroom doors. An automatic closure device has been fitted to the fire door which had previously been wedged open. The management are now telling us about the things that happen in the home and are keeping the right records when accidents that happen in the home. The arrangements for social activity have been improved following consultation with the people who live at Oak Lodge. Environmental improvements include full re-glazing of the premises and increased security with the installation of wrought iron fencing and gates. What the care home could do better: The management need to make arrangements for controlled drugs to be stored appropriately and to maintain the right records. The menus also need to be reviewed to reflect the preferences of the individuals and to offer real choice and variation at meal times. The management need to make sure that they obtain all of the required information for new employees before they start working in the home. The management need to make sure that all the privacy locks are maintained in good working order. The management need to make sure that staff have access to all of the right training and that it is renewed in a timely way. They should improve their systems for monitoring and planning staff training. The manager should ensure that his working shifts are specified on the duty rota so that people know when he will be available to them. The management must also make sure that they conduct all of the right Fire Safety checks on a regular basis and also should arrange for staff to have regular staff supervision to make sure that they have the right skills and competence to care for people properly. The management must also review the arrangements for supporting the people who use the service with the safe storage of their money to ensure that it is held in individual accounts where there are able to obtain individual interest. Key inspection report Care homes for older people Name: Address: Oak Lodge 2 Peveril Road Old Duston Northampton Northants NN5 6JW     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Stephanie Vaughan     Date: 2 1 0 9 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 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 Homes for Older People 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. 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 Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Oak Lodge 2 Peveril Road Old Duston Northampton Northants NN5 6JW 01604752525 PF0160475252 oaklodge10@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Restgate Limited care home 36 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Restgate Limited is registered to provide personal care and accommodation at Oak Lodge Care Home for service users who fall into the following categories :- Old age not falling within any other category (OP) 36 Dementia over 65 years DE(E) 36 The maximum number of service users to be accommodated at Oak Lodge Care Home is 36 Date of last inspection Brief description of the care home Oak Lodge is situated in a quiet residential street in the Duston district of Northampton. The home is registered to provide personal care, without nursing, for up to thirty-six older people, including people with dementia related care needs. Oak Lodge is accessible by the local bus service from Northampton town centre, and there are local shops and other community facilities in the immediate locality of the home. Within Oak Lodge there is a passenger lift and stair lift. Oak Lodge currently has thirty single bedrooms with seventeen rooms having en-suite facilities. There are Care Homes for Older People Page 4 of 30 0 0 Over 65 36 36 Brief description of the care home three double bedrooms, one of which has en-suite facilities. There is a garden to the rear of the building, which the service users are able to enjoy in the warmer weather. Accommodation fees currently range from 411 pounds a week for a ground floor shared room; to 457 pounds a week for a second floor floor room with ensuite facilities. An additional weekly charge is made for the care of residents with dementia and additional variable charges for hairdressing, chiropody and for personal items such as clothing and toiletries. The service has copy of the most recent of the Commissions Inspection reports displayed in the main entrance. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Before this inspection we spent three hours in preparation. This included looking at the Annual Quality Assessment which is a document sent to us by the management, the previous inspection reports, associated requirements, the service history and other documentation. The last inspection for this service was completed on 21st July 2008. We sent some surveys to the people who use the service, to some of the staff and also to a General Practitioner. We received twelve completed responses which indicated a good level of satisfaction with the care provided. Some of the less favorable responses related to the provision of activities and the food provided. We have received one very recent complaint about this service which relates to staffing levels, the provision of social activities and access to the acting manager. This has Care Homes for Older People Page 6 of 30 been referred to the provider for investigation and their response is due to be returned by mid October. There has been one Safeguarding allegation referred to the Local Authority Safeguarding Team regarding the care and management of one resident who is no longer at the home. The final outcome of this is as yet unknown. The Commission have a focus on Equality and Diversity and issues relating to this are included in the main body of the report. The site visit was conducted over a period of nine hours during which the inspector made observations, spoke to the people who live there and the staff. A limited tour of the premises was conducted which unloved reviewing the communal areas and some of the bedrooms. Case tracking is the method used during the inspection where a sample of three people were selected and aspects of their care and experiences were reviewed, including the individual plans of care and associated documentation. The service specialises in the care of people with Dementia as such some of the people who live there have limited ability to recall and communicate their experiences. In these circumstances observations are used to inform the inspection activity. In addition to this we conducted a short observational framework inspection that involved the inspector making specific observations for a 45 minute period where the activities and personal interactions between a small group of people and the staff were observed and noted. The findings of this exercise was very positive indicating that staff are respectful, are attentive to the people who use the service and are aware of their individual needs. The Acting Manager was present during most of this inspection. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? The service has responded well to the findings of the previous inspection. As a result of that inspection thirteen requirements were made which told the management what action they had to take. All of these requirements have now been addressed which means that the Statement of Purpose is now up to date, the standard of the Individual plans of care have been improved including the pre-admission assessments, there is also more detailed instruction to staff about the way that the people who use the service need and wish to be cared for and these are being reviewed on a monthly basis. There are now the right risk assessments in place for the management of falls, falls from the bed, nutrition, pressure and the risks associated with the use of dental cleansing agents. The management have also fitted a radiator guard to protect against the exposed radiator surface and appropriate privacy locks have been fitted to the bedroom doors. An automatic closure device has been fitted to the fire door which had previously been wedged open. The management are now telling us about the things that happen in the home and are keeping the right records when accidents that happen in the home. The arrangements for social activity have been improved following consultation with the people who live at Oak Lodge. Environmental improvements include full re-glazing of the premises and increased Care Homes for Older People Page 8 of 30 security with the installation of wrought iron fencing and gates. 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. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive clear and up to date information to enable them to make an informed decision about whether or not they might wish to live in the home. Evidence: Following a requirement made at the last inspection the Statement of Purpose has been reviewed. This document now contains the right information so that people who may wish to use the service have access to appropriate information. This is available in the entrance hall of the home. Inspection reports are available in the home on request and can be down loaded from www.CQC.org.uk. People who use the service have contracts in place, although the contracts have not been recently updated the terms and condition are reviewed on an annual basis with the funding authority and this information is kept on file. Care Homes for Older People Page 11 of 30 Evidence: The service has improved the way that it handles admissions to the home, more detailed pre-admission assessments are conducted to ensure that the home is able to meet the needs of the individual. One person commented The home is welcoming, the staff are attentive, friendly and helpful they always polite to my visitors. I enjoy the wide variety of meals which are well cooked and presented well. I am happy with the running of the home and enjoy myself. The service does not provide Intermediate Care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 people that use the service have a detailed plan of care which indicates that they are treated as individuals and that their health care needs are met. Evidence: Following a requirement made at the last inspection the format and content of the individual plans of care have been reviewed. These now contain more detailed instruction to staff about how people need and wish to be cared for. These are based on the information that is obtained during the pre-admission assessment which includes information about peoples previous lifestyles and preferences. There is evidence that the care plans are being reviewed on a regular basis and as the needs of the individuals change. Following a requirement made at the last inspection all residents now have detailed assessments in place for the risk of falls and these contain the right information to reduce and manage the risks including referral to the falls coordinator for people who are at significant risk. Care Homes for Older People Page 13 of 30 Evidence: Following a requirement made at the last inspection the Individual Plans of care now show that the management assess people for the use of bed rails, none of the people currently using the service require the use of these. However the management are aware of the need to develop detailed risk assessments for the use and management of bed rails should they be required. Following a requirement made at the last inspection risk assessments have now been conducted to reduce and manage the risks associated with the use of dental cleansing agents. Following requirements made at the last inspection there are now risk assessments in place for the risks associated with pressure and nutrition. These are reviewed on a regular basis and the management ensure that the District Nurse and general practitioner are notified about people who are assessed as being at significant risk. Specialist equipment and support is arranged through the District Nursing Service. All of the people who use the service have access to the right health care professionals in a timely way. One person commented The home looks after people well and a member of staff also commented We provide all the care that the residents need Medication systems were reviewed and in the main found to be in good order. However the arrangements for the receipt, storage, record keeping and disposal of controlled drugs was inadequate. Two Immediate requirements were made as a result and we have since been provided with evidence that the provider has complied with these requirements. Staff were seen to be relate well to the people who use the service, to address then in the way that they preferred and to be supportive of their care needs whist being mindful of the privacy. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 management are responsive to the views of the people who use the service so that people have control over their lives and their independence is promoted. Evidence: Routines within the service are flexible with people being able to choose their preferred routines, and these are documented within the individual plans of care. Daily activities are advertised on a white board in the home, these can include events such as the Summer Fete, seasonal celebrations, clothes parties and sales of toiletries. There is also a monthly visiting musical entertainer who plays the organ and sings. Other weekly activities include Hair and nails, sing along, bingo, fitness to music, games, outings to the shops with Sunday being dedicated to family visiting. People using the service and staff completed surveys for us in July 2009 they told us that they wanted more activities one stated The home looks after the residents well and we are well treated but we would like more activities, it is quite boring just sitting around all day. Another person stated The home could improve by being better organised and providing physio and exercises. Comments from staff also indicated that there were limited opportunities for people to engage in meaningful activities. Care Homes for Older People Page 15 of 30 Evidence: One staff member commented we are good at communication and in our relationships with residents but we could do better with our activities. During the inspection there were no organised activities for people to participate in other than attendance at their individual hair dressing appointment. During the inspection we observed people using the sitting room, staff were attentive and responsive to peoples needs but there were no organised activities going on to occupy people. We discussed these concerns with the manager who confirmed that more activities have been provided since they conducted satisfaction surveys in May and June 2009. Improvements include a room designated for activities, the provision of knitting materials and board games. A new flat screen television has been purchased and separate quiet room has also been made available. Arrangements are in place for people to maintain their faith through attendance at local Churches or by the provision of Holy Communion provided by visiting clergy. People are able to maintain links with family and friends through flexible visiting arrangements. The arrangements for meals and mealtimes appear to be satisfactory, meals are served in either of the two dining rooms or in peoples private accommodation. The food choices are displayed within the home, soup is available as an alternative should people not wish to have the main choice. None of the people in the dining rooms were seen to have selected an option other than the main course. Lunch time service was observed, meals were well presented and of adequate proportion. People were assisted by staff with sensitivity and those observed were noted to enjoy the food that was served. However the comments about the provision of meals was varied, three of the six completed surveys indicated that the people who use the service only sometimes liked the meals that are provided. One person commented I enjoy the wide variety of meals which are well cooked and presented well. All of the people who currently use the service are white European and of Christian faith and values as such the arrangements for people to maintain their faith and culture are appropriate. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A comprehensive procedure for handling complaints and abuse is in place ensuring that people who use the service are able to voice their concerns and are protected. Evidence: The service has a complaints procedure which is accessible to the people who use the service. We have received one very recent complaint about this service which relates to staffing levels, the provision of social activities and access to the acting manager. This has been referred to the provider for investigation and their response is due to be returned mid October. People who use the service told us that they knew how to complain but had not needed to. They also told us that they felt safe living at Oak Lodge and that the staff were nice to them. We observed that staff related well to the people who use the service and were sensitive to their needs and wishes. There has been one safeguarding allegation about the services ability to meet one persons personal and health care needs which has been investigated by the Local Authority Safeguarding Team. The final outcome of this investigation is as yet unknown. Care Homes for Older People Page 17 of 30 Evidence: Staff files showed that staff have received recent training in the Safeguarding of Adults and were aware of their responsibilities. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 standard of the environment is good providing the people who use the service with a safe and comfortable place to live Evidence: The environment is suitable for its stated purpose and is accessible to wheel chair users. In general the standard of the environment is good with an ongoing plan to improve furnishings, fixtures and fittings. In general all areas were seen to be clean and hygienic with the exception of an area in the main lounge where there was a malodour. This was brought to the attention of the acting manager who made arrangements for this to be addressed during the inspection. The size and layout of the main lounge does present staff with some challenges regarding the occupation of the people who choose to sit there and the management need to review these arrangements to overcome the practice of having the television on at one end of the lounge and the radio on at the other end, as this means that the people seated in the middle of the room can hear both but not well enough to enjoy either one without distraction. We looked at a selection of bedrooms, these were well furnished and comfortable. The Care Homes for Older People Page 19 of 30 Evidence: people who use the service are able to bring their own possessions into the home to personalise their rooms. Following a requirement made at the last inspection the people who use the service have been consulted about the use of privacy locks, these have now been fitted. However two of the three that were checked were not working. Following requirements made at the last inspection the exposed radiator surface has now been covered, and an automatic closure device has now been fitted to the fire door that was wedged open. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The failure to implement reliable management systems which support staff recruitment and staff training means that the management of these activities is not consistent and this has the potential to put the people who use the service at risk. Evidence: There is a stable staff team at Oak Lodge and staffing levels are adequate. The management are mindful of the need to keep staffing levels under review as the needs of the people who use the service change. One person commented the staff are attentive, friendly and helpful and they are always polite to my visitors. Staff recruitment in general is satisfactory however two of the staff files showed that staff had been recruited without the right checks having been conducted. The management have complied with an immediate requirement that we made whilst we were at the home. They have now checked to make sure that all the other staff have had the right checks and have given us an undertaking that no staff will work in the home without the right checks being in place. One of the staff files showed that although two references had been obtained before a member of staff had been appointed the references had not been obtained from the appropriate sources. Care Homes for Older People Page 21 of 30 Evidence: All the staff have had training in National Vocational Qualification Level 2 in Care. Staff files showed that some recent training had been provided in Dementia Awareness, Infection Control, Safe Administration of Medication and Safeguarding of Adults and Deprivation of Liberty Standards. However there was no evidence to show that staff had received Fire Safety Training since September 2008, staff files also showed that other staff training was out of date such as First Aid, Basic Food Hygiene and Movement and Handling training. The Acting Manager could not supply the Commission with a Training Matrix to show what training had been provided and was still outstanding. The manager could also not supply a training programme to show what training was scheduled to be provided this year. We made an Immediate requirement for the management to make arrangements for the staff to receive training in Fire Safety and we have been notified that this has been arranged and is scheduled for the 19th October 2009. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is not consistently proactive, failure to maintain routine checks and systems has the potential to put the people who use the service at risk. Evidence: Following the last inspection the Registered Manager has resigned and another manager has been appointed and is due to commence employment in the near future. The existing Acting Manager has confirmed that arrangements are in place for a hand over period which should ensure a smooth transition. The current acting manager does not have his working hours listed on the staff rota this was discussed with the acting manager who has agreed to make sure that his shifts are recorded on the duty rota. Two of the staff files that we looked at did not contain all of the right information this included a missing Criminal Records Bureau Clearance and the right references necessary to ensure that the people who live there are in safe hands. Care Homes for Older People Page 23 of 30 Evidence: Two requirements were made for this outcome area following the last inspection relating to the submission of notifications, the provider is now sending us the right information about the things that happen in the home and the right information is being recorded when accidents happen. The service is developing quality assurance practices in the home including satisfaction surveys and audits of processes and procedures. There is evidence that the management use the findings to inform service development. However at present there are no arrangements in place to ensure that staff supervision is conducted on a consistent and regular basis. The service supports a small number of people with the management of their finances. Money handed to the provider for safe keeping is banked in a communal account. Individual records are maintained in the home, including receipts for the purchase of items and services. However the current arrangements do not enable people to receive proportionate individual interest and therefore these arrangements must be reviewed. Fire records showed that most of the checks were being conducted on a regular basis. However the records showed that the emergency lighting had not been checked for a significant period of time. We made an immediate requirement for this to be conducted and we have since been notified that all of the required checks have now been done. The management have complied with the thirteen requirements made as a result of the last inspection. They have also demonstrated compliance with the five immediate requirements that were made during this inspection. Care Homes for Older People Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 9 13 The provider must make 28/09/2009 arrangements to ensure that a Controlled Drug Register, which is a bound book with numbered pages is kept to ensure that all controlled drug transactions are fully documented to ensure that they are accounted for at all times and accurately maintained in accordance with the guidelines issued by the Royal pharmaceutical Society document the handling of medicines in Social Care settings published 2007. To ensure the safe keeping and administration of Controlled Drugs 2 9 13 The provider must make 28/09/2009 arrangements to ensure that all Controlled Drugs are stored securely in accordance with the requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs and the Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 and in accordance with the Guidelines from the Royal pharmaceutical Society document the handling of medicines in Social Care settings published 2007. To ensure the safe keeping and administration of Controlled Drugs Care Homes for Older People Page 26 of 30 Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 3 30 23 The provider must notify the 23/09/2009 commission of the outcome of the review of staff files to ensure that the CRB clearance checks have been conducted, including a written undertaking that no staff are currently working either now or in the future at Oak Lodge without the appropriate clearances. To ensure the protection of the people who use the service. 4 30 23 The management must make 26/09/2009 arrangements for the staff to receive the appropriate Fire Safety Training and notify us of the dates for which this has been scheduled. To ensure the health and safety of the people who use the service. 5 38 23 The management must ensure that all of the required fire safety checks are conducted and recorded within the appropriate records and timescales To ensure the health and safety of the people who use the service 22/09/2009 Care Homes for Older People Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 29 19 The provider must ensure that references are obtained and held on file from appropriate sources, including the providers of other care settings where this is applicable to the candidates previous experience as listed on their application form. To ensure that the people who use the service are in safe hands at all times. 01/11/2009 2 30 13 The staff training matrix and 01/11/2009 training programme must be submitted to the Commission to demonstrate that mandatory staff training has been scheduled at the appropriate times and that it is kept up to date. To ensure that the people who use the service are in safe hands at all times. 3 35 13 The management must 01/12/2009 review the arrangements for managing the safe custody of residents money to ensure that they money is held individually and that when it is deposited in a bank or building society that people are able to obtain their individual interest. Care Homes for Older People Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that the people who use the service are protected from abuse. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 15 The menus need to be reviewed to reflect the preferences of the individuals and to offer real choice and variation at meal times. The management should review the arrangements in the main lounge for the use of the radio and television. Privacy locks should be maintained in good working order. Care staff should be vigilant in maintaining a pleasant environment for the peole who use the service and take appropriate action to remedy malodours. Arrangements should be put in place to ensure that staff receive supervision at least six times per annum. 2 3 4 19 19 26 5 36 Care Homes for Older People Page 29 of 30 Helpline: 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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