Care Home: White Lodge

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What the care home does well The accommodation provided is of an excellent standard and provides a comfortable and homely environment. The atmosphere in the home was relaxed and members of staff were cheerful and very helpful. People are supported and encouraged to maintain their independence and to be as active as possible. Members of staff have time to spend with each person and undertake activities. People living in the home and members of staff said that they are well supported by the Manager. The food is of a good standard and the dining room is attractively laid out so that people have a pleasant place to eat. The Provider has ensured that members of staff are have a good training in place and has supported 70% of the staff team to achieve National Vocational Qualifications. What has improved since the last inspection? Care staff and keyworkers attend pre-admission assessments, with senior members of staff, for experience and continuity of care. Care plans were fully completed and reviewed with the person on a regular basis. The daily activity programme has been expanded. All staff have received training on adult protection,to improve awareness of protection issues and how to deal with incidences or allegations of abuse The front entrance has been refurbished and the outside of premises painted. The car park has also been re-designed. Upgrading of en-suite facilities and the refurbishment of several rooms. What the care home could do better: Review the safeguarding adult policy and procedure for reporting and dealing with allegations so that it reflects the guidance of the West Sussex Multi disciplinary safeguarding adult procedures. CARE HOMES FOR OLDER PEOPLE White Lodge South Strand Angmering-On-Sea Littlehampton West Sussex BN16 1PN Lead Inspector Jan Aston Unannounced Inspection 10th June 2008 09:35 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 White Lodge DS0000014835.V365215.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. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Lodge Address South Strand Angmering-On-Sea Littlehampton West Sussex BN16 1PN 01903 784415 01903 859536 lesley.trudgett@scnh.co.uk 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) South Coast Nursing Homes Limited Mrs Lesley Margaret Trudgett Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 30 persons in the registration category OP over 65 years Date of last inspection 19th June 2006 Brief Description of the Service: White Lodge is a care home able to offer personal care and support for up to 30 residents who are over 65 years of age. The property is a two storey extended detached house, set in its own grounds approximately 200 yards from the sea and village centre. Accommodation is provided in twenty-seven single rooms and two double rooms. All rooms are currently being used for single occupancy. Bedrooms have en-suite facilities and the rooms on the upper floor can be accessed by a passenger lift. Communal areas consist of a lounge, conservatory and dining room on the ground floor with an additional lounge on the upper floor. White Lodge is owned by South Coast Nursing Homes Ltd. The Manager in charge of the day to day running of the home is Mrs Lesley Trudgett Fees £475-£620 White Lodge DS0000014835.V365215.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 Star. This means that people who use this service experience good quality outcomes. Prior to the inspection surveys were sent to people living in the home, and to members of staff. Eight were received from people living in the home, one from a relative and one from a member of staff. An Annual Quality Assurance Assessment form (AQAA) was completed and sent to the Commission prior to the inspection. A visit to the home was made on Tuesday 10th June 2008 just over six hours were spent in the home. The Inspector looked around the home, examined a sample of records in relation to care plans, training, staff, complaints, accidents and Health and safety checks. Two members of staff and five people living in the home were spoken to privately during the visit. Seven people living in the home were spoken with as a group in the lounge. A relative who was visiting was also spoken with. What the service does well: The accommodation provided is of an excellent standard and provides a comfortable and homely environment. The atmosphere in the home was relaxed and members of staff were cheerful and very helpful. People are supported and encouraged to maintain their independence and to be as active as possible. Members of staff have time to spend with each person and undertake activities. People living in the home and members of staff said that they are well supported by the Manager. The food is of a good standard and the dining room is attractively laid out so that people have a pleasant place to eat. The Provider has ensured that members of staff are have a good training in place and has supported 70 of the staff team to achieve National Vocational Qualifications. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information that they need to make an informed choice about where to live. People have their needs assessed before a decision is made about them moving to the home. People have the opportunity to visit the home before they make a decision to move in. Intermediate care is not provided in the home. EVIDENCE: Information about the home is provided in the statement of purpose and service user guide and in a brochure. People who had recently moved into the home confirmed they had received written information about the home and the service provided. A relative spoken with confirmed that she had written information provided. A copy of the Statement of Purpose, Service user guide, last inspection report and complaints procedure are available in the entrance to the home. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 9 From the records examined it was seen that people had signed and received a copy of the terms and conditions of the home. This recorded the current level of fees payable and the person’s room number. Where a person received assistance with funding from the Local Authority a separate contract with Local Authority was in place. For people who had recently moved into the home there was evidence that the manager and assistant manager had undertaken a pre-admission assessment that covers all aspects of a person’s needs. This recorded the time and place of the assessment. Other information had been obtained from the Care Manager and from the hospital. Care plans had been developed with the person and had been reviewed regularly. This process demonstrates that admissions are planned and that sufficient information has been obtained to support a person well from the time they are admitted to the home. A member of staff spoken with felt that the home would be very open to people from other ethnic groups living in the home and that they would cater for their individual needs. People spoken with who had recently moved into the home said that they visited the home before moving in. Trial visits are also arranged. This gives people the opportunity to experience living in the home before deciding to move in permanently. Intermediate care is not provided in this setting. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A person’s health, personal and social care needs are set out in an individual plan of care that demonstrates the health and personal care that people receive is based on their individual needs. Medication is administered according to recommended guidelines. The principles of respect, dignity and privacy are put into practice EVIDENCE: All people in the sample had care plans in place. All had been fully completed and had been signed by the person at the time of compilation and at every review. All care plans had been reviewed at appropriate intervals. Information contained in the care plans about the support required for each person was brief and concise and gave sufficient information for staff to know how to support each person. Care plans recorded a person’s religious/cultural needs and social interests. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 11 Potential risks for a person from undertaking personal care tasks, from falling, from the environment, going out alone, infection poor eating and burns and scalds had been assessed. Where a risk had been identified measures to minimise the risk had been put in place and recorded. Records examined demonstrated that each person’s health had been assessed on admission and then monitored for any signs of illness. Health checks on admission and then undertaken on a monthly basis included blood pressure, pulse, temperature, weight and a urine test. A record is kept of any visit made by a health professional. People living in the home confirmed that they have been able to keep their own GP or register with a local GP who visits the home once a fortnight. At the time of the visit to the home it was observed that people living in the home were asked if they would like to speak with the GP who was calling later that day. People are encouraged to visit their own chiropodist and hairdresser but a chiropodist visits the home every six weeks and a hairdresser once a week. A member of staff spoken with confirmed that they maintain links with the Community Mental Health Team. The storage and administration of medicines in the home was examined and was organised and in good order. The Inspector observed the administration of medication at lunch time that was undertaken according to recommended guidelines. Members of staff have been trained to administer medication safely and to recognise any adverse effects of medication. Medication training is updated regularly. All people living in the home who were spoken with said that the staff were very helpful, respectful, polite and very friendly. They felt that their privacy was respected and staff couldn’t do enough for them. A person who responded to the inspection through surveys said, “All the staff are very cheerful and kind to me.” A member of staff confirmed that the induction programme provided information and guidance about how to respect a person’s privacy and dignity when supporting them with personal care. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their life style. A varied programme of activities ensures that people have opportunities to satisfy their social, cultural, religious and recreational interests and needs. People have nutritious and attractive meals and snacks, at a time and place to suit them. EVIDENCE: Activities are organised on a daily basis and there is an activity programme for the week. On the morning of the inspection people living in the home joined in with a quiz in the lounge. People spoken with said that activities took place regularly and included exercises, bingo, quizzes and crafts on a Thursday afternoon and they really enjoyed them. There is a library near the lounge that contains large print books and the mobile library calls regularly. A garden party is being held at the end of June. People in the home also told the Inspector that on occasions, as often as staffing levels allow the Manager asks members of staff to take people out for a while, either to the sea, or local shops or just for a walk around the garden. People also go out alone. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 13 The home employs a person to assist with general duties in the home for example informing people what is for lunch each day and what they would like to eat. This person has the time to spend to sit and talk with each person; this means that each person in the home has some individual attention during the day. Members of staff spoken with confirmed that they have time to talk with people and to provide the activity in the mornings. There are no restrictions on visitors or visiting times. People spoken with said that usually people respect meal times. It was seen that people living in the home had individual telephones in their rooms so they can speak with relatives or friends in private. There is a lounge/dining room on the first floor of the home that can be used as a private space for relatives visiting. The Manager confirmed that the organisation has provided information about the Mental Capacity Act. Members of staff have received information about this. Care plans record some information about people’s choices, likes and dislikes. People living in the home confirmed that they have opportunities to suggest changes or ask for improvements through regular residents meetings. They said that they are listened to and any suggestions acted upon. Surveys received from a person living in the home said, “We have an excellent chef who provides us with a varied menu.” “Meals are very tasty. Excellent chef.” There were two negative comments from surveys, “Sometimes parts of the meal are coldish, and sometimes the meals do not have a taste to it.” A relative said that the food was of good quality but felt more time could be spent talking to his relative about what would make the food more interesting. All people living in the home who were spoken with said the food was excellent, plenty of variety and cooked well. They confirmed that they were always told what was for lunch and offered alternatives and choices. The main meal of the day was sampled; this was fish pie, carrots and peas, apple crumble and cream. The meal was cooked and presented well. It was observed that there are two dining areas in the home and people were free to eat either in the dining room or in their rooms. A four week menu plan is in place that provides a variety of food from roasts to sweet and sour chicken and curry. People are offered an alternative meal everyday. There is a choice of breakfast and tea. There is a full time chef employed and a weekend chef. The chef was spoken with, he confirmed that there is a good cleaning regime and they comply with the food safety regulations. The Chef said he could cater for diets for cultural or religious preferences. The Environment Health Officer’s inspection was satisfactory. The kitchen looked clean and storage of food appropriate and labelled. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives can be confident that their concerns and complaints will be listened to and acted upon. There are measures in place to ensure that people are protected from abuse. EVIDENCE: The complaints policy and procedure is provided in the Statement of Purpose and service user guide and is displayed in the entrance of the home. People spoken with confirmed that they would have no hesitation in raising a concern or complaint with the Manager. All of the people living in the home who completed surveys indicated that they knew how to make a complaint. One relative who returned a survey said they did not know how to make a complaint. There is a system for recording complaints to show the detail of the complaint, the timescales of the response and the outcome. The Annual Quality Assurance Assessment form that was completed by the Manager prior to the inspection recorded that no complaints had been received. The Commission has not received any complaints about this service. Members of staff spoken with were aware of how to recognise signs of abuse and to report any allegations in line with the West Sussex Social and Caring Services Safeguarding Adults Procedures and of the local contact details. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 15 All newly appointed members of staff receive information about safeguarding procedures as part of their induction and there is an ongoing programme of training in recognising and reporting signs of abuse. Members of staff spoken with confirmed they have received this training. From the sample of five staff records examined it could be seen that three new staff and received the training as part of the induction programme and two other staff had received training in January & February 2008. The policy and procedure in respect of safeguarding adults was examined. This does not currently reflect the requirements of the local multi-disciplinary safeguarding adults protocol and procedure, as it makes no mention of reporting allegations to West Sussex Social & Caring Services who take the lead role. The policy and procedure should therefore be reviewed. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 22, 23, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. White Lodge provides a high standard of accommodation that is safe for people to live in, well-maintained clean and hygienic. EVIDENCE: A tour of the premises was undertaken. The Providers have had a clear plan for refurbishing the home and continually keeping the premises to a high standard. Work has been undertaken to improve the car park and entrance to the home. This is attractive and has disabled access. All areas of the home looked well maintained and furnished to a high standard. The garden areas looked well kept and attractive and well equipped with garden chairs and a gazebo. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 17 People living in the home have personalised their rooms and all rooms look different. All rooms have en-suite facilities that are gradually being upgraded. The doors to peoples’ rooms are gradually being fitted with magnetic door guards that are linked to the fire alarm so they can leave their doors open but still be safe in the event of a fire. It was observed that lockable drawers have been provided in all rooms to secure valuable items. However the doors to people’s rooms are not fitted with locks and therefore the rooms cannot be secured in the event of the person going out, being in hospital or after death. It is recommended therefore that this be reviewed. Any necessary equipment is provided such as hoists, pressure relieving mattresses and cushions. Radiators and pipe work throughout the home are covered to minimise the risk of burns. However where three en-suite facilities have been upgraded the radiators have not been covered. It was seen that a risk assessment was in place in respect of risk of burns. The Manager confirmed that work is in progress to make radiator guards for the three radiators and steps would be taken to ensure radiators remain off until guards are fitted and that pipe work is covered. The Annual Quality Assurance Assessment Form recorded safety inspections on portable appliances, hoists, fire equipment, lift, heating and gas supply. There was a current Public liability Insurance certificate. The Manager confirmed that the temperature of all hot water outlets are regulated by thermostatic valves that are serviced and temperature checked regularly. All areas of the home were clean and hygienic. People living in the home who returned surveys made the following comments about the cleanliness of the home, “The home is spotlessly clean.” “Cannot fault it.” People spoken with said that rooms are cleaned everyday. A number of people particularly mentioned the efficiency of the laundry and at most times clothes are washed and ironed the same day. Particular attention is paid to preventing infection within the home. Infection control is part of the mandatory training programme provided a number of times a year and is open to all staff. Members of staff confirmed that they had received training in the prevention of infection. In the entrance hall and throughout the home antiseptic hand gel has been placed for members of staff and visitors to use. Information about hand hygiene is placed in staff areas. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 18 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): Standards 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. The numbers and skill mix of staff meets the needs of people living in the home. People are safeguarded by the home’s recruitment policy and practices. Members of staff are trained and competent to do their jobs. EVIDENCE: The staffing levels on the day of the inspection were appropriate and members of staff spoken with confirmed that the staffing levels allowed them to provide support at a resident’s own pace and to have time to talk with them. The Provider and Manager told the Inspector that they have a very low staff turnover and do not use agency staff in the home as they have a good supportive staff team who will cover for each other in times of sickness or holiday. This means that people receive support from people who know them well and understand their needs. The home uses the Skills for Care Common Induction Standards programme for any new members of staff. There was evidence that members of staff had completed the induction workbooks. Members of staff spoken with confirmed the induction programme was undertaken over a three month period and really helped with settling into the home and understanding how to support people. There is an ongoing training programme for mandatory training and one or two training topics are planned for every month. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 19 Members of staff confirmed that this training is available. The Manager confirmed that she ensures that each member of staff attends the training sessions so they keep up to date with mandatory training. There was also evidence of other training undertaken in understanding dementia, multiple sclerosis and strokes. Members of staff spoken with confirmed that they have received a good level of training from induction through to achieving National Vocational Qualifications (NVQ). So far 70 of the staff team have achieved NVQ 2; this exceeds the requirement for 50 of the staff team trained to NVQ 2 as required by the National Minimum Standards. A member of staff confirmed that she has been supported to undertake NVQ level 4 and another NVQ level 3. The sample of recruitment records showed that all the required checks are carried out prior to new staff beginning to work in the home. However it was noted that for one member of staff employed last year the criminal record check from the previous employer had been accepted as this was less than three months old. The Provider is reminded that criminal record checks are not transferable. The Manager confirmed that a criminal record check would be applied for. As the records for members of staff that were employed after this time demonstrated that the necessary checks and criminal record checks were in place the overall rating for this outcome area has been judged as good. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a person with the knowledge and experience to do so. The quality monitoring systems ensure that all areas of the home are run in the best interests of people living there. People’s financial interests are safeguarded. The health, safety and welfare of people living in the home and staff are promoted and protected. EVIDENCE: The Manager has the required qualifications and experience and is competent to run the home. She completed the RMA in July 2007 and is trained in moving and handling. The management structure within the home of Manager, Deputy, Assistant and Senior care Assistant provides a good level of management and support. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 21 Members of staff spoken with confirmed that the manager is very approachable, will listen and they are confident that they will be supported. People living in the home spoke very highly of the manager and all staff. There is a quality assurance system in place. This includes asking people living in the home, relatives, staff and other people who know the home to complete surveys annually. There was evidence that this had been undertaken in 2007. People living in the home said that meetings with them are held regularly and feel confident that they can say anything and will be listened to and action taken. There was evidence that regulation 26 visits are undertaken and reports of these visits held in the home. People living in the home are encouraged to manage their own finances and where they lack capacity to do this relatives or legal advisors assist with financial matters. The Provider and Manager do not act as Appointee’s or hold Power of Attorney for anyone living in the home. The Manager and administrator assist two people with small amounts of money for additional services and personal expenses; all transactions are recorded and moneys accounted for. Members of staff spoken with confirmed that they meet with the manager regularly through staff meetings and supervision meetings. From the records examined it could be seen that all staff in the sample had received individual supervision. The Manager is in the process of ensuring that all members of staff receive an annual appraisal. Members of staff confirmed that a person was always available on call in the evening and weekends and felt well supported. The documentation relating to the Health and Safety of the premises was in good order and up to date. Risk assessments had been undertaken in respect of burns, risk of scalding and fire. There was evidence that the fire alarm and equipment had been inspected in April 2008. All staff received fire training in March 2008. Annual safety inspections had been undertaken on electric portable appliances, lift, hoists, gas, electricity and heating. There is an ongoing training programme in the health and safety topics such as first aid, moving and handling, infection control, fire and health and safety to ensure that members of staff receive an annual update in this training. White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 3 4 4 4 4 4 3 4 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 3 X 3 3 X 3 White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection CSCI South East The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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 White Lodge DS0000014835.V365215.R01.S.doc Version 5.2 Page 25 - 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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