Inspection on 20/10/08 for Lady Spencer House

This inspection was carried out on 20th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lady Spencer House 18/06/08

Lady Spencer House 06/02/08

Lady Spencer House 05/06/07

Lady Spencer House 22/11/06

Lady Spencer House 13/10/05

Lady Spencer House 26/04/05

Lady Spencer House 15/11/04

Lady Spencer House 29/09/04

Lady Spencer House 30/03/04

Lady Spencer House 23/10/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE Lady Spencer House 52 High Street Houghton Regis Bedfordshire LU5 5BJ Lead Inspector Angela Dalton Unannounced Inspection 20th October 2008 10:25 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 Lady Spencer House DS0000014923.V372814.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. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lady Spencer House Address 52 High Street Houghton Regis Bedfordshire LU5 5BJ 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) 01582 868516 01582 868516 Resicare Homes Limited Manager post vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th June 2008 Brief Description of the Service: Lady Spencer House is a residential home for older people. The home is situated within walking distance of the centre of Houghton Regis, and also provided easy access to the town’s amenities and to Dunstable. It is a modern, purpose built house over three floors; it offers accommodation in 24 single rooms. The communal space includes two lounges, one on the ground floor and has a conservatory added and one on the first floor. A lift is used for access to the first and second floor. A number of toilets and washing facilities are located throughout the building. There are parking spaces behind the building that provide limited spaces for staff and visitors. The home also has a small back garden. Fees for this service range from £485.00 - £550.00 per week depending upon the room. Lady Spencer House DS0000014923.V372814.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 1 star. This means the people who use this service experience adequate quality outcomes. One inspector conducted this unannounced site visit on 20th October 2008 between 10:25am and 5.15pm. Two people were case tracked. We followed the care of people who use the service to ensure the care they receive is reflected in the care plan and meets their individual requirements. The case tracking process cross-references all the information gathered to confirm that what we are being told is actually happening and reflects the Statement of Purpose, which contains the aims and objectives for the service. It included discussion with service users, staff, the manager and provider. We were present for lunch and observed several aspects of daily activity. The manager was present for most of the inspection and fedback was given to her and the proprietor. The manager has been in post for four months and has succeeded in meeting requirements made at previous inspections. The service has a stable staff team and only a part time vacancy exists. What the service does well: This home provides a clean, comfortable and homely environment for people who use the service. All people who use the service appeared clean, comfortable and well cared for. This was reflected in comments made by people who use the service ‘I’m so glad I moved here’. ‘The girls are so kind.’ Two of the service users that were picked for case tracking; one had been admitted since the last inspection. Observations of care practices and discussions with service users indicated that they are treated with respect and dignity. Where possible choice is offered and this was evident at mealtimes. People who use the service can spend time in the lounge or quieter area in the conservatory. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? The manager has made many improvements since the last inspection. The Statement of Purpose and Service User guides have been reviewed and now contain all the relevant information that the National Minimum Standards require. Each person who uses the service has been given a statement of terms and conditions. Changes in documentation will ensure people who use the service and their relatives are better informed. The manager has also identified that a contract is needed for people who use the service for respite. Care plans detail individual needs and enable staff to know what action is required to meet health, personal and social care needs. Care plans are being regularly reviewed which ensures documentation is up to date and staff are aware of what current needs are. Assessments for health needs are now completed and this was previously lacking, especially regarding nutritional and pressure area. The medication system and recording has vastly improved ensuring that people who use the service are better protected. Accurate records are kept detailing medication administration and storage. Amounts of medication reconciled when checked. This issue had been ongoing and it is clear that hard work has had appositive result. A controlled drugs cupboard and record book have been purchased to ensure correct storage and documentation. Staff are better informed about safeguarding vulnerable adults and external training is planned for staff to attend. Safeguarding has been given a higher profile and is discussed during team meetings and supervisions. Hot water checks are regularly conducted and recorded to ensure that there is no risk of scalding. A quality assurance system has been introduced to evaluate the aims and outcomes for people who use the service. The manager plans to incorporate findings from the report into a user friendly format for people who use the service. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lady Spencer House DS0000014923.V372814.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 Lady Spencer House DS0000014923.V372814.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): 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people who move into the service have had their needs assessed which ensures that they can be met and appropriate care is delivered. EVIDENCE: Following a requirement made at the previous inspection the Statement of Purpose and Service Users Guide have been updated. All the information required by standard 4 and 5 and schedule 1 of the National Minimum Standards is now in place to ensure that prospective people who use the service have the necessary information to enable them to make an informed choice about choosing Lady Spencer House. Both documents could be provided in large print if needed and were displayed in the entrance hall of the home, along with the last inspection report. The service users guide was enhanced by colour photographs. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 10 The manager has introduced new paperwork to better meet the needs of people who use the service. Assessments have been completed for new and existing people who use the service; including nutritional and pressure care assessments. This provides a foundation for the care plan. All new admissions to the home have their nutrition monitored and recorded for their first two weeks. This enables staff to identify any potential problems. The manager is currently devising a contract to meet the needs of people who use the service for respite stays. The home does not offer intermediate care. Lady Spencer House DS0000014923.V372814.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health needs of people who use the service could be better met and recorded in care plans. Staff need to be equipped to deliver specialist care. People who use the service are respected and treated as individuals. EVIDENCE: Two people who use the service had their care case tracked – people who use the service have their records cross referenced to confirm that the care that they need is being provided. All records that relate to specific people who use the service are inspected to gain an overview of their experience and quality of care. The care plan system has been replaced since the previous inspection. Staff stated that they found the new care plans easier to follow and record information. The manager and staff team have worked hard to replace every care plan and ensure that they are current and reflect individual needs. Staff had a good awareness of needs and dietary needs were communicated to the kitchen staff. Some development is needed to ensure that care plans reflect all needs of people who use the service. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 12 The district nurse visits to support people who use the service with diabetes and assist with continence needs. The care plan does not reflect how to manage diabetes, epilepsy and catheter care. Staff are not equipped with information to alert the nurse should people’s condition change as the care plan does not contain this guidance. Staff have not received training to work with diabetes or epilepsy which the manager is planning to address. Risk assessments are completed for falls and are being expanded to incorporate any further risks that have been identified. It was apparent from the number of different GPs listed that the people who use the service were encouraged and supported to keep their family GP, if at all possible. The manager communicates with all GPs to ensure that medical histories received by the service are current and correct. Additional footstools have been made available following the previous inspection to enable people who use the service to raise their legs if required and reduce potential problems. The staff and manager have worked extremely hard on addressing the numerous issues that were identified by the Pharmacist Inspector in June 2008. Medication is being stored at a correct temperature and a blackout blind and air cooler have been installed to achieve this. The temperature of the medication fridge is recorded daily and is satisfactory. The manager has introduced the plans discussed previously to use one trolley for all medications and keep the medications waiting to be used or returned to the pharmacy in the second. There is no longer a second medication trolley for the first floor, which has minimised potential problems. The cupboard used to store controlled drugs now complies with the Misuse of Drugs (Safe Custody) Regulations. There is a now a proper register in use for controlled drugs instead of bound exercise books, as before. Medication amounts reconcile which illustrates that people who use the service are receiving the medication that they are prescribed and doses are not being missed. The amount of stock medication was correctly recorded and this had previously not occurred. The reverse of the Medication Administration Record (MAR) sheet is now being used to record when medication is not given – this was previously not being recorded. Staff can monitor if medication is being consistently refused or is not required and act accordingly. Medication has consistently required action at previous inspections and this has been the first occasion that all issues have been met. We witnessed some very good interaction between staff and people who use the service. Staff were gentle and patient. The manager is currently working with staff and social service to develop some positive strategies for a person who uses the service with complex needs. Lady Spencer House DS0000014923.V372814.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staff are sensitive to individual needs and offer choice where possible. EVIDENCE: An activities co-ordinator had recently been employed to work part time. She is in the process of devising an activity plan and had a number of ideas for the future. During the inspection we witnessed a music and exercise session. There had been a game of snakes and ladders earlier that morning which one person who uses the service told us he enjoyed as everyone could take part. It is hoped that in the future the activity co-ordinator will be able to show, through documentation, that she had spoken with the people using the service about their past interests and hobbies and that she had prepared an activity timetable that linked to their individual and collective needs. This timetable should be for all staff to work with so that people are offered stimulation all the time, not only when the activity co-ordinator is on duty. A record is kept of the people that participate in an activity and the outcome for them in their care plan. The upstairs lounge has fewer people who use the service with a higher level of need. There is always a member of staff present. The activities co-ordinator is Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 14 researching reminiscence equipment to meet the needs of people who use the service with dementia. Staff are midway through receiving dementia training and there are plans to reflect their training through providing activities tailored for those with dementia. A vicar visits the home regularly to enable people to observe their religion and maintain links with the community. A hairdresser visits weekly and staff maintain hairstyles to a high standard in the meantime. People living at the home had the opportunity to choose and wear their own clothes. When we last visited some of the clothes were in need of repair but people who use the service looked well kempt on this occasion. We spoke to the cook who works 9am-3pm six days a week. She told us that now plans her own menu and organises the food shopping which did not occur before the new manager was employed. The cook prepares and serves lunch, prepares tea, which includes a cooked option and makes a cooked breakfast on a Saturday. Care staff served the breakfast and tea. At lunchtime people had the choice of shepherds pie or soft fish with parsley sauce and creamed potatoes, or salad with a choice of accompaniment, followed by sponge and custard or ice cream, yoghurt or fresh fruit. Tea was a choice of soup, pilchards on toast or crumpets with toasted cheese. People living at the home were offered a choice of meals in the morning for that day. The cook was aware of the need to look into photo menus to help those with dementia and poor communication skills. The manager is looking into telephone access and exploring alternatives as the ‘phone is currently sited in the kitchen and this is not suitable for people who use the service. She plans to explore whether people who use the service would like ‘phone points in their rooms and how the office ‘phone could be more accessible. Lady Spencer House DS0000014923.V372814.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): 16.18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All staff are equipped to protect people who use the service from abuse. EVIDENCE: The manager told us that there had been one complaint made to the home since her appointment. There was evidence to reflect that this had been investigated and a satisfactory outcome reached. A complaints policy is included in the Service Users Guide. People who use the service confirmed to us that they knew how to make a complaint and had no reservations about raising any concerns. People who use the service attend regular meetings which are minuted to reflect that issues that affect them are discussed and resolved. Some staff had completed safeguarding training and those whom we spoke with had a clear understanding of what to do if they had concerns about the safety of people who use the service. The manager has secured a copy of the local safeguarding policy, and was aware of her responsibility to refer any suspected abuse, or injuries that could not be accounted for. We checked the finances of three people who use the service which were correct and records reflected that regular checks were carried out. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 16 A recent incident occurred where a person who uses the service fell. Because of circumstances surrounding the incident the manager followed the safeguarding policy. Social services made the decision not to hold a safeguarding strategy meeting and the social worker for the person who uses the service was notified. Lady Spencer House DS0000014923.V372814.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): 19,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained but safe infection control practices are not implemented in the laundry. EVIDENCE: Since the previous inspection the first floor lounge has been redecorated and hallways have also been repainted. There are plans to redecorate the dining room and downstairs lounge and replace the flooring in the dining room. There was no odour when we visited which was a noticeable improvement from last time. There are plans to connect a computer in the lounge and the manager plans to research training so that people who use the service can use it. The manager plans to devise a maintenance schedule in conjunction with the owner as she is aware of some major items requiring replacement such as a bath with a rusted area and repairing the garden wall. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 18 We found the laundry to pose potential risk. The washing machines have no sluice facility and are domestic machines which are not designed to cope with the level of washing that they currently deal with: up to six loads daily. One of the machines was not working which placed extra pressure on the other machine. There are no separate hand washing facilities in the laundry and staff use the sink in a bathroom opposite. Laundry staff are currently using a sink to rinse foul laundry which poses a major infection control risk. The proprietor is looking into an alternative site for the laundry but these issues need addressing as a matter of urgency. The staff must be able to implement the Department of Health Infection Control Guidelines for Care Homes. A previous requirement to ensure people who use the service are not at risk of scalding and Legionella has been met. Regular temperature checks are conducted and recorded to ensure that hot water is at the correct temperature. Lady Spencer House DS0000014923.V372814.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have the skills, training and experience to care for people who use the service. EVIDENCE: The manager has been in post for four months and has maintained a full staff team despite an initial turnover. There is one vacancy for a part time member of care staff. There is a permanent staff group of 19 staff and on duty on the morning of the inspection there were 4 care staff, a cook, 2 domestics and an activity co-ordinator. There are 4 staff on in the evening and two overnight. There was nothing to suggest that this ratio of staff to service users, at the time of the inspection, did not meet the needs of the people living at the home. Due to sickness there had been some short staffing issues at the weekend and the manager plans to forge links with so that Agency staff can be employed should the situation arise in the future. The service has its own bank staff that are utilised when needed. We identified that some staff were working extra shifts. Some were doing 14hour days, but the manager told us that she insisted that they had regular days off, and no one complained about the extra duties when it was necessary. We spoke to some staff who confirmed that they chose to work longer shifts if Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 20 they were available and that they were able to take breaks. Staff that worked long days are offered a meal at the home and we observed this. The manager has a training matrix which identifies what training is needed and when a refreshers is required. Staff have recently completed ‘blind therapy’ training to assist staff to support people who use the service with a visual impairment. Dementia Care training is scheduled in the near future. Staff have embraced NVQ training: 7 have commenced NVQ Level 2 with 2 having completed their work, 3 staff have commenced NVQ Level 3. The cook is to commence NVQ Level 2 and 2 Domestic staff are to commence NVQ Level 2. All the National Vocational Qualifications are pertinent to their area of work and the service will achieve 50 of their staff being qualified. The manager is investigating an appropriate qualification for the Activities Coordinator. We inspected 2 staff files and both had the necessary documentation and clearance checks to ensure that the staff were suitable to work with vulnerable people. The manager is planning to review the application form to ensure that a more comprehensive work history can be obtained. Staff files also included copies of the equal opportunities policy, health and safety policy and the medication and fire procedures. Staff were asked to sign these to confirm that they had read them. Staff also signed to agree that if they left within a year of completing a training course £25.00 would be taken from their final salary. There is also an agreement that staff will purchase 2 uniforms and pay for their CRB (Criminal Record Bureau) check. Lady Spencer House DS0000014923.V372814.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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager must ensure registration to ensure improvements within the service continue. EVIDENCE: The manager has NVQ level4 and the Registered Manager Award (RMA). The proprietor has not ensured that the registration process has been completed and the manager is not yet registered. The staff team would benefit from knowing that they are being lead by a manager who is experienced and committed to them and the people who use the service. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 22 A quality audit had been sent to family and friends of the people living in the home earlier in the year. The manager is planning to conduct a further audit to ensure that people who use the service and their friends and relatives are satisfied with care delivery and service provision. The proprietor is currently dealing with the de-merger of the Resicare Homes Ltd and has notified the Commission for Social Care Inspection (CSCI) of their status of Responsible Individual (RI). Following the previous inspection we received an AQAA (Annual Quality Assurance Assessment) from the manager and this also showed us her plans for improving the home. Staff supervision has improved and the manager now plans to share the responsibility with the deputy manager to ensure that staff are supervised the required six times a year. She also planned to change the documentation so that staff had the opportunity to discuss a number of issues during supervision and make this a meaningful time. All the regular safety checks in the home are conducted by the maintenance staff. The manager is updating the fire drill records to ensure that the time of fire drills and staff who have attended are recorded. The cook was completing fridge and freezer temperatures daily and recently completed the ‘safer food for safer businesses’ guidance from Environmental Health. As discussed earlier in the report there are not safe practices in the laundry to prevent the spread of infection and communicable diseases. The manager has a responsibility to protect people who use the service and staff and ensure their health and safety. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 X X X X X 3 1 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 2 X 3 X 3 X X 2 Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) 12 (1) (a) Requirement Care plans must reflect how staff are to monitor and manage diabetes, epilepsy and catheter care. This will ensure that health needs are met and staff are competent to manage health requirements. Safe laundry practices must be implemented and Infection Control Guidelines for Care Homes followed. Suitable laundry equipment must be available. This will ensure that people who use the service and staff are not placed at unnecessary risk. The manager must be registered with the Commission for Social Care Inspection to ensure they comply with the Care Homes Regulations and are accountable. Timescale for action 30/11/08 2. OP26 OP38 13(3) 13(4)(c) 31/12/08 3. OP31 8 30/11/08 Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 25 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. 2. Refer to Standard OP10 OP12 Good Practice Recommendations Consideration should be given to providing a private area for visitors to meet with people who use the service to ensure privacy and dignity is observed. There should be evidence that the activities provided meet the varied needs of the people who use the service. Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lady Spencer House DS0000014923.V372814.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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