Care Home: Sunset Lodge

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What the care home does well Residents say they are well looked after by staff who are competent, well trained, kind and caring. They know that any requests for care or support will be responded to promptly. Residents` physical and mental health needs are well met with access to health professionals.Residents like living in a house that has plenty of communal space, lovely gardens, where they have rooms they can personalise and which they know will be kept clean. Residents value the opportunity to be themselves, to be private if they wish or to have activities that they can join in with. Residents who move into the home to follow Christian principles value being able to do so. There is an open and friendly atmosphere with good interaction between residents, staff and visitors. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. What has improved since the last inspection? Prospective residents know that at the time of admission Sunset Lodge will be able to meet their needs through a sound assessment process. Residents are made safer from harm through sound recruitment procedures which include proper written references, criminal records bureau certificate and POVA (Protection of Vulnerable Adults) check, and from regular fire drills and practices for all staff including night staff. Parts of the home have been redecorated. The risks of cross infection have been reduced since a washbasin has been fitted in the first floor toilet area and the sluice is used for all cleansing and de staining of toilet equipment. Residents have a better choice of food now the menus are revised. What the care home could do better: How residents` care needs are to be met would be better identified through improved care planning and recording. The service and management will be better able to identify how the service could improve by implementing a comprehensive quality assurance system and ensuring the manager has time to carry out research into current practices in care for older people. CARE HOMES FOR OLDER PEOPLE Sunset Lodge Pembury Road Tunbridge Wells Kent TN2 3QT Lead Inspector Gary Bartlett Unannounced Inspection 10th March 2008 09:00 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 Sunset Lodge DS0000036527.V359469.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. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunset Lodge Address Pembury Road Tunbridge Wells Kent TN2 3QT 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) 01892 530861 01892 531656 cherildene.umasanthiram@salvationarmy.org.uk The Salvation Army Mrs Cherildene Cecilia Umasanthiram Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home has 11 bedrooms over 16sq.m of which 2 can be used for double accommodation at any one time. When so used, the total number of service users will not exceed the registered number of 22 Date of last inspection Brief Description of the Service: Sunset Lodge is owned and operated by the Salvation Army. It is a large detached property on three floors, with a shaft lift and stair lifts to all floors and stands in its own grounds. It was previously a private residential house and was converted for use as a residential home for the elderly in the 1940s and was refurbished in 1979. It is registered for 22 service users. The home has a strong Christian ethos and is a no smoking, no alcohol environment. All rooms are currently used for single occupancy although 2 would be suitable for double accommodation on request. There is ample communal space. Space for car parking is available and there are large well tended gardens for service users to use. Sunset Lodge is located on the outskirts of Tunbridge Wells where there are the usual facilities of a town. There is access to public transport close by and the nearest doctors surgery is approximately 2 minutes walk away. The Homes staffing team comprises the Manager, senior care staff and care staff who work a roster that gives 24-hour cover. The Home also employs other staff for catering, domestic duties, administration and maintenance tasks. At the time the report was written fees ranged from £326.23 to £550.00 per week. Residents pay separately for hairdressing, chiropody, opticians, personal toiletries and newspapers at cost. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Sunset Lodge from 9.00 a.m. until 2.00 pm. During that time the Inspector spoke with some residents, 2 visitors and some staff. Parts of the home and some records were inspected and care practices observed. A number of survey forms were received prior to the inspection. Residents, their relatives and health care professionals responded that they like the home and think there are good standards of care. Survey forms included the comments: • “Kind and loving care in a peaceful, clean and orderly environment”. • “They really seem to care and to take an interest”. Other statements made are quoted in the text of the report. The Manager and staff gave their full co-operation and help throughout the inspection. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Sunset Lodge prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. What the service does well: Residents say they are well looked after by staff who are competent, well trained, kind and caring. They know that any requests for care or support will be responded to promptly. Residents’ physical and mental health needs are well met with access to health professionals. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 6 Residents like living in a house that has plenty of communal space, lovely gardens, where they have rooms they can personalise and which they know will be kept clean. Residents value the opportunity to be themselves, to be private if they wish or to have activities that they can join in with. Residents who move into the home to follow Christian principles value being able to do so. There is an open and friendly atmosphere with good interaction between residents, staff and visitors. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. What has improved since the last inspection? What they could do better: How residents’ care needs are to be met would be better identified through improved care planning and recording. The service and management will be better able to identify how the service could improve by implementing a comprehensive quality assurance system and ensuring the manager has time to carry out research into current practices in care for older people. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 7 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. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 8 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 Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 9 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): 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they are appropriately placed due to good preadmission assessments and benefit from being able to visit the home prior to admission. Sunset Lodge does not provide intermediate care. EVIDENCE: The Manager described how a pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. If practical, a member of the management team would visit the prospective resident in their home or hospital to ensure the necessary information was Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 10 current and accurate. Records show that prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. Residents said they or their families had been able to visit Sunset Lodge before moving in. A resident’s friend who was visiting confirmed this and said staff are very helpful in assisting new residents to settle in. Respite care can be provided if a room is available and the service can meet the resident’s needs. There is no specific accommodation for short term care, the resident is free join in with daily life in the home. Sunset Lodge does not provide intermediate care. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care and health needs are well met in a dignified and appropriate manner. An improvement to care plan records would better evidence how they are met. EVIDENCE: The judgment for this outcome group has taken into account the quality of life for all the residents. The judgement also includes assessment of the level of knowledge and understanding displayed by staff when providing both personal and health care. Comments made by residents, observation during the day of the site visit and as recorded in previous inspection indicates the standard of care provided is very good. Residents say that staff are fully aware of their needs, particularly their key-workers with whom they feel they have a ‘special’ relationship. Staff are aware of far more information than is recorded in care plans. A staff member said detailed information is shared at shift handovers. Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 12 The Manager described how she has recently obtained a copy of a detailed care planning format that she intends to implement in the near future. She said training has been arranged to help facilitate this. Current care plans are adequate. They contain some risk assessments and are accessible to staff. Some detail of individual needs is given including personal preferences and a brief pen picture. Staff record daily, weekly and monthly summaries of care, the weekly and monthly summaries being more useful than the daily notes which routinely read ‘slept well’, ‘usual day’. Overall, residents consider they have their health needs well met. References were made to visits by the chiropodist, optician and audiologist appointments and of good relationships with local general practitioners. Entitlement to NHS services are upheld and advice given when private funds might be needed. The Manager and senior carers are responsible for medication. The Manager has nursing experience and the senior carers have undertaken medication training. There is a designated medical room and a mobile drug trolley. Standards of storage and cleanliness in the medical room are very good. The Medication Record Administration Record (MAR) sheets inspected are completed appropriately. Medicines were seen to be given in accordance with good practice guidelines. Residents feel that staff are kind and gentle, this was confirmed by observation and discussion with visitors. Staff are considerate of the age and dignity of residents and treat them with courtesy. The home aims to care for people until the last stage of life. Christian support is offered where the resident wishes. Last wishes are identified and recorded in a compassionate way. Relatives and friends can be with the resident if the resident wishes. Sunset Lodge DS0000036527.V359469.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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a relaxed, comfortable lifestyle with opportunities to occupy themselves with a range of interests. EVIDENCE: A survey form completed by a Care Manager included the comment: • “Very caring home – specially in recognising the individuality of the service users”. Sunset Lodge is a place where residents can live a life as much as possible to their own choosing and where they can welcome friends and family. Whilst there are the expected routines of a well managed service and residents understand this, as far as practicable residents can make their own choices about their day. Residents said that, within reason, they could get up and go Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 14 to bed when they chose. Meals are at set times which residents said they didn’t mind. Bath days are set with residents asked whether they prefer a morning or later bath. Staff provide activities each day. A diary of activities is provided and includes table games, shopping, prayers, quizzes, exercises and music amongst other things. In the summer months outings are arranged using the homes small minibus. The home is based on Christian principles with prayers each day and a Sunday service. Some residents go to the local Salvation Army centre for the ladies group. Family and friends feel welcome and know they can visit at any reasonable time. A notice on the front door states that visitors are not allowed after 8pm in the evening, visitors are welcome to visit at all other times. During the inspection a number of visitors were seen in the home and the visitors book records regular visits by families, friends and others. The design of the Sunset Lodge provides seating areas within the communal areas where residents can entertain their visitors, in addition to the privacy of their own room. Visitors can stay for meals at a small charge. Relatives are encouraged to take as much part in the daily life of the resident if the resident chooses and are invited to quarterly reviews. Residents are encouraged to personalise their rooms with their own possessions if they wish. Most residents have brought items of furniture and plenty of personal effects with them. As rooms are differently shaped and sized this leads to very individual environments. A newly admitted resident said she really liked her room. Residents said they liked the food and thought it was well cooked and well presented. There is a planned menu which routinely offers two choices for lunch, both main course and dessert. Since the last inspection, the menus have been reviewed to ensure a good variety of types of food. Fresh fruit is always available. Cake, bread and butter and soup is provided each suppertime with a cooked option. Sunday evening tea is a buffet in the lounge. The dining room is well set out and it was a pleasure to observe the manner in which food and accessories such as condiments, sauces, butter etc were presented and the high standard of setting up the tables. The meals are generous in portions and look appetising. Mealtimes are relaxed; staff are patient and helpful and allow residents the time they need to finish their meal comfortably. Hot and cold drinks are available through out the day. Sunset Lodge DS0000036527.V359469.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know their complaints are listened to and acted on. There are systems to protect residents from abuse. EVIDENCE: The complaints procedure is readily available to residents and their relatives. They said they feel confident that they would be listened to and any necessary action would be taken. A visitor said: • “If there are any problems, they are always quick to sort things out”. The Home keeps a record is of all complaints received by them. There have not been any formal complaints received by the home in the last 12 months. The Commission has not received any complaints about the home in that time. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The staff induction and NVQ training have elements of adult protection training and there has Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 16 been POVA training for staff. Those spoken with have a sound understanding of adult abuse and protection procedures. The Manager stated any allegation of abuse would be referred to the concerned agencies without delay. There have not been any alerts in the last twelve months. Sunset Lodge DS0000036527.V359469.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): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a homely, clean and comfortable environment in which to live. EVIDENCE: Sunset Lodge is a large detached house, located near the centre of Tunbridge Wells adjoining a separate unit of independent flatlets. The home has large private grounds which can be used by residents. The home is commendably clean and free from offensive odours. Residents’ bedrooms are bright and airy, warm and comfortable. The design of the house allows for a variety of shapes and sizes of rooms giving the possibility of two being used for shared occupancy on request, such as for Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 18 married couples. Bedrooms are very well personalised and have plenty of space to display personal possessions, store clothing, sit and relax and have a comfortable bed. Comfortable communal areas are provided for residents. There is a quiet room/library, a large lounge with plenty of seating and a dining room. The lounge has a loop system for the hard of hearing. Chairs placed in the large entrance hall give the opportunity to sit and watch the comings and goings. There is a designated hairdressing room. Staff have their own good sized staff room with adjacent toilet. Residents can gain access to the upper floors by passenger lift, and there are stairways with a stair lift which can be used in emergency. Aids and adaptations are provided such as lifting hoists, grab rails and toilet riser seats. A Parker bath is well liked by residents. A staff call system is available with calls being answered promptly at the time of the inspection. Residents are protected from the risks of burns or scalds by safe surface radiators and thermostatically controlled hot water outlets. There is a designated laundry that is suitably equipped with systems in place to reduce the risks of cross infection. The sluicing facilities are also clean and well ordered. Disinfectant gel dispensers are fitted in high-risk areas. Sunset Lodge DS0000036527.V359469.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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by well motivated staff whom they like. EVIDENCE: Survey forms completed by relatives included the comments: • “Staff members are extremely helpful”. • “Lovely, approachable staff who are both professional and caring”. • “The staff are great and have a genuine concern for all the residents”. A survey form completed by a Care Manager included the comment: • “Dedicated staff”. The home is staffed by a Manager, two Principal Carers, Care Assistants and ancillary staff. Ancillary staff carry out catering, laundry and cleaning so care staff can focus on direct care and support. The Manager’s husband is employed as an Administration Manager. There are two waking night staff on duty each night with a senior on call. Staff generally feel there are enough staff on duty to meet the needs of residents. Although there are times when Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 20 they are busy, they also have opportunities to chat with residents and to offer one to one care and support. Residents like the staff and find them approachable, polite and kind. Throughout the site visit there was evidence of good relationships between staff and residents. Staff mentioned how much they liked working with the residents in the home and this was reflected in the way care and support was given. Staff obviously know the residents well and how best to put them at ease. There is an active key-worker system in place that residents appreciate. People applying to work at the home have to complete an application form, provide two references and have a POVA and Criminal Records Bureau (CRB) check and attend an interview. The files of the most recently recruited staff show that appropriate checks are made prior to them commencing duties. All staff follow a recorded induction process which includes the Pathways to Care, Common Induction Standards workbook. Sunset Lodge is proactive in ensuring staff obtain NVQ qualifications. A number of staff already hold NVQ qualifications with others undertaking NVQ’s in care. Staff feel that training was good. One staff member said “we are always training”. The Administration Manager oversees training provision. Training offered includes core training, mandatory training, client specific and personal development with some training carried out in house and others accessed from external sources. A training matrix is used to give a management overview of staff training needs. Sunset Lodge DS0000036527.V359469.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): 31, 33, 35, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a service that is run in their best interests by a manager and staff who are committed to providing a good quality of life for older people. EVIDENCE: The registered Manager has been in post for a number of years and previously was a Deputy at the home. She holds NVQ 4 in management, has completed the Registered Managers Award and has nursing experience. Due to Salvation Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 22 Army restructuring of management in care homes there is no Deputy level, supporting senior responsibility being held by Principal carers. Suitable management systems are put in place to cover any holiday commitments of the Manager. Staff receive regular supervision from the Manager or Principal carer. Staff consider supervision is useful with supervisors feeling confident in providing good supervision. The home has elements of a quality assurance system in place but has not gathered the process into any formal system that would include obtaining the views of stakeholders or professionals and incorporating the quality assurance findings into future planning for the home. Resident and staff meetings are held. Relatives are offered the opportunity to attend resident reviews where they can make comment about the service. The Salvation Army has a quality assurance policy. The Salvation Army conduct regular in depth and comprehensive audits. Visits to the home by a representative of the organisation under regulation 26 are carried out and recorded monthly. All records seen are kept in a manner that preserve confidentiality. General record keeping is good and well ordered. The home assists some residents with day to day management of their monies. Records are held of transactions with receipts held detailing any expenditure on the residents’ behalf. These are checked by the organisation as part of their audit process. The residents spoken with say they have no worries regarding their finances and feel they are supported in managing their affairs efficiently. An up to date insurance certificate is displayed in the home. There are records of fire systems checks and fire drills/training and staff spoken with have a sound understanding of emergency procedures. The Manager said all records of maintenance and safety checks are up to date. These were not inspected on this occasion. Sunset Lodge DS0000036527.V359469.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 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 3 3 Sunset Lodge DS0000036527.V359469.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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations It is strongly recommended the Manager proceeds with the intended implementation of a revised care planning system. The system used should give clear evidence of: How care and support needs are to be provided. How they have been met. Give a true evaluation of activities of daily living including how these link to care plan issues. Responsive risk assessment which clearly state the manner in which the risk is to be reduced or removed. It is again recommend that a comprehensive quality assurance system be developed which includes obtaining the views of relatives, stakeholders and professionals and is incorporated into future planning for the service linked to an understanding of modern practices in care. 2. OP33 Sunset Lodge DS0000036527.V359469.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Sunset Lodge DS0000036527.V359469.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. 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