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Inspection on 05/06/07 for Lady Spencer House

Also see our care home review for Lady Spencer House for more information

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective service users are formally assessed prior to admission so that they can make an informed choice about where they live and be assured their needs can be fully met in this home. Detailed individual care plans are in place and reviewed appropriately to reflect changing needs of service users. Observations of care and discussions with service users during this visit indicated that the relationships between staff and service users are familiar but respectful. One service user said. "I like it here, it was strange at first, but they treat me well and look after me, they don`t rush me and they are very pleasant and understanding". Service users are encouraged and assisted to make personal choices about their daily life and social activities, so that their social, recreational and cultural needs are met.The owner informed the inspector that there had been no formal complaints to this home since the last inspection. Service users that were interviewed were aware of who they should speak to if they had any concerns, and appropriate information is available within the service user guide. Issues relating to the Protection of Vulnerable Adults (POVA) are generally referred appropriately, and follow up meetings are well documented. Overall this home provides a safe, clean, and homely atmosphere for its service users.

What has improved since the last inspection?

The owner of this home and the trainee manager have worked hard to improve the standard of their individual care plans. These are now detailed documents that contain clear, concise information about the individual people who use this service, and the level of care and assistance they require. They are reviewed on a monthly basis to reflect any changes in need that may occur.

What the care home could do better:

The Service User Guide fails to provide any information regarding the fees for this home. The systems for the administration of medication are failing which may compromise the safety and well being of service users. Unfortunately there appears to be major confusion with the input of omission codes on these documents. Poor management of clinical waste was identified at this inspection and may compromise the hygiene of the home so that the people who use this service are not always protected from infection. Staff are trained to a satisfactory level of competency to do their jobs safely, however there still some anomalies in the recruitment of staff so that people who use this service may not always be supported and protected. Staff are generally sufficiently trained in mandatory subjects to a satisfactory level of competency to do their jobs safely, however there are still some anomalies in the recruitment and training of staff so that people who use this service may not always be supported and protected. The lack of efficient management systems and non- compliance with previous requirements indicates that the safe running of this home continues to be compromised.

CARE HOMES FOR OLDER PEOPLE Lady Spencer House 52 High Street Houghton Regis Bedfordshire LU5 5BJ Lead Inspector Mrs Louise Trainor Unannounced Inspection 5th June 2007 07:30 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.V334624.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.V334624.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 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.V334624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2006 Brief Description of the Service: Lady Spencer House is a residential home for older people, specialising in the care of people with mental and physical disabilities. The home was situated within walking distance of the centre of Houghton Regis, and also provided easy access to the town’s amenities. It is a modern, purpose built house and with three floors, it offered accommodation of 24 single rooms. The communal space included 2 comfortable lounges, one with a small conservatory attached, for service users to sit together, and the staff are able to spend time with them, paying attention to all individuals. A lift was used for access to the first and the second floor. A number of toilets and washing facilities were located throughout the building, allowing easy access. The parking space behind the building and a small garden was sufficient for staff and visitor’s cars. Fees for this service range from £445.00 - £485.00 per week. Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Key Inspection for this home. It was carried out on the 5th of June 2007 between the hours of 07:30 hours and 17:00 hours by Regulatory Inspector Louise Trainor. The trainee manager and the owner were both present throughout the day to assist. The care of three people who use this service was ‘tracked’, these were picked at random by the inspector. The case tracking methodology involved examining all the individual’s care documentation, observing the care provided to them, and seeking their views on the care they receive. This was done through informal interviewing and observations. Also during this inspection, five members of staff from this home were interviewed, and three staff files were examined. Other documentation relating to staff training, supervision, medication administration and quality assurance were inspected. Unfortunately the inspector did not have the opportunity to interview any visitors to the home during this inspection. The inspector would like to thank everyone involved for their support and assistance throughout the day. What the service does well: Prospective service users are formally assessed prior to admission so that they can make an informed choice about where they live and be assured their needs can be fully met in this home. Detailed individual care plans are in place and reviewed appropriately to reflect changing needs of service users. Observations of care and discussions with service users during this visit indicated that the relationships between staff and service users are familiar but respectful. One service user said. “I like it here, it was strange at first, but they treat me well and look after me, they don’t rush me and they are very pleasant and understanding”. Service users are encouraged and assisted to make personal choices about their daily life and social activities, so that their social, recreational and cultural needs are met. Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 6 The owner informed the inspector that there had been no formal complaints to this home since the last inspection. Service users that were interviewed were aware of who they should speak to if they had any concerns, and appropriate information is available within the service user guide. Issues relating to the Protection of Vulnerable Adults (POVA) are generally referred appropriately, and follow up meetings are well documented. Overall this home provides a safe, clean, and homely atmosphere for its service users. What has improved since the last inspection? What they could do better: The Service User Guide fails to provide any information regarding the fees for this home. The systems for the administration of medication are failing which may compromise the safety and well being of service users. Unfortunately there appears to be major confusion with the input of omission codes on these documents. Poor management of clinical waste was identified at this inspection and may compromise the hygiene of the home so that the people who use this service are not always protected from infection. Staff are trained to a satisfactory level of competency to do their jobs safely, however there still some anomalies in the recruitment of staff so that people who use this service may not always be supported and protected. Staff are generally sufficiently trained in mandatory subjects to a satisfactory level of competency to do their jobs safely, however there are still some anomalies in the recruitment and training of staff so that people who use this service may not always be supported and protected. The lack of efficient management systems and non- compliance with previous requirements indicates that the safe running of this home continues to be compromised. Lady Spencer House DS0000014923.V334624.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. Lady Spencer House DS0000014923.V334624.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.V334624.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, 3, 4, 5, 6 Quality in this outcome area is adquate. This judgement has been made using available evidence including a visit to this service. Prospective service users are formally assessed prior to admission so that they can make an informed choice about where they live and be assured their needs can be fully met in this home. However the Service User Guide and Statement of purpose require further adjustment to ensure their content is sufficient and accurate. EVIDENCE: The Statement of Purpose and the Service User Guide have been reviewed and amended since the last inspection in November 2007, and now appropriately reflect the present management in the home. These documents are very detailed and include information about the accommodation, meals, social/ recreational provisions, staffing, special needs and the complaints procedure. However the Service User Guide fails to provide any information regarding the fees for this home, and the name of the allocated Commission for Social Care Inspection (CSCI) inspector is now incorrect. This has already resulted in the Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 10 response to a complaint being delayed although this is through no fault of the home. The address and telephone number of CSCI are sufficient for this document. The three service user files that were examined during the inspection all contained assessment documents that had been completed prior to admission. Two had been completed by the home following a visit to the service user, and the third was a very detailed document that had been brought to the home by a social worker from Camden. The home owner felt that Camden was too far to go and do an assessment, so the prospective service users family and social worker attended the home to assess its’ appropriateness and the decision for admission was made. Contracts were not viewed during this inspection as they are stored at a ‘sister home’ and so were not available on the premises for inspection. This home is not presently providing any intermediate care. Lady Spencer House DS0000014923.V334624.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 poor. This judgement has been made using available evidence including a visit to this service. Detailed individual care plans are in place and reviewed appropriately to reflect changing needs of service users. However the systems for the administration of medication are failing which may compromise the safety and well being of service users. EVIDENCE: The instructions for care are however somewhat limited, for example, one care plan identified that the service user had a catheter, but there was no instruction for catheter care or how staff would recognise if the catheter required changing. The owner stated that all staff acquired this knowledge through training. None Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 12 of the staff that were interviewed had had any specific catheter care training, but they were able to discuss the type of observations that would raise concerns for them regarding the catheter, and would prompt them to contact the district nurse. Two other care plans identified that service users were diabetic, however there was no reference or instructions relating to testing blood sugar levels. The owner stated that this was the responsibility of the district nurses, but this was not clear from the care plans. Observations of care and discussions with service users during this visit indicated that the relationships between staff and service users are familiar but respectful. One service user said. “I like it here, it was strange at first, but they treat me well and look after me, they don’t rush me and they are very pleasant and understanding”. Medication administration was not observed during this inspection, but the Medication Administration Record (MAR) sheets were checked and reconciliation was examined. Unfortunately there appears to be major confusion with the input of omission codes on these documents. At the foot of the MAR sheet is a list of codes to identify reasons for medication not being given. Also in the medication file is a typed list of codes to identify reasons for medication not being given. Unfortunately the two lists did not correspond therefore staff were using all sorts of different codes to identify the same reasons for omissions. Of the MAR sheets inspected, seven had errors on them and did not reconcile correctly with the stocks remaining. Lady Spencer House DS0000014923.V334624.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. Service users are encouraged and assisted to make personal choices about their daily life and social activities, so that their social, recreational and cultural needs are met. EVIDENCE: On arrival at the home at 07:30 hours many of the service users were up and dressed in the lounge. At 08:00 hours a care worker told the inspector that, “Pretty much everyone was up”. This seemed rather early, but when the inspector spoke to numerous residents they confirmed that this was their preference. This information was also detailed on the ‘suggested care sheet’ in the service user files. One service user that was interviewed by the inspector expressed her satisfaction at being allowed to read, watch television and generally do her own thing. She did not like the group activities. She also told the inspector how she always goes to her room before 19:00 hours, she said. “I enjoy pottering at my own pace until I’ m ready to go to bed”. This clearly indicated that this home promotes personal choice and that although activities are available, ultimately it is the service users choice as to whether or not they participate. Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 14 During the afternoon of the inspection there was a sing a long in progress. This was being thoroughly enjoyed by some of the service users. One service user talked about her visitors and about a recent trip home she had had to celebrate an anniversary. She also commented on the menus stating. “I give it a thumbs up, no complaints, there’s always a choice, but I usually just request sandwiches at tea time”. Unfortunately the inspector did not have the opportunity of speaking with any visitors during this visit. The home does promote an open visiting policy, although this is not clearly identified in the service user information documents. Lady Spencer House DS0000014923.V334624.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. The complaints procedure is sufficient to ensure that the people who use this service and their representatives are confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: The owner informed the inspector that there had been no formal complaints to this home since the last inspection. Service users that were interviewed were aware of who they should speak to if they had any concerns, and appropriate information is available within the service user guide. Issues relating to the Protection of Vulnerable Adults (POVA) are generally referred appropriately, and follow up meetings are well documented. Copies of POVA referrals were filed in the office with the exception of one that did raise some concern for the inspector. A service user had been out with a family member and on return was found to have bruising on her arm and a leg injury, documentation could not be found to confirm this had been referred appropriately to the POVA team, although CSCI had been informed through the regulation 37 notification system. One of the supporting managers had apparently dealt with this referral not the trainee manager. Although some staff have still not attended POVA training, all of the five staff that were interviewed were able to discuss the different types of behaviour Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 16 that they understood to be ‘abuse’, and all were very clear on what action they would take if they either witnessed or suspected such behaviour in the home. Lady Spencer House DS0000014923.V334624.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, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall this home provides a safe, clean, and homely atmosphere for its service users. However the poor management of clinical waste identified at this inspection may compromise the hygiene of the home so that the people who use this service are not always protected from infection. EVIDENCE: Generally this home was clean and free from any offensive odours. However on the day of the inspection there was a very offensive smell on the ground floor towards the rear of the building. On investigation it appeared to be caused by an overflowing clinical waste bin in one of the bathrooms. This indicated that not all of the staff appreciate the importance of infection control within this environment. Clinical waste bins in the rear car park were also noted to be over full so that they would not close properly. Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 18 Communal areas of the home, although not very spacious appear comfortable and were decorated in a homely way. They are well maintained, and there is an ongoing programme for decorating in place. Bedrooms were decorated and furnished individually. Some rooms had furniture that belonged to the service users, and the presence of photographs and personal assets in the rooms made them more personal and homely, reflecting the service users’ families and life history. Hoists and other moving and handling equipment were strategically placed in the hallway, near to the lounge where it was easily accessible but not obstructing doors or walkways. Lady Spencer House DS0000014923.V334624.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 poor. This judgement has been made using available evidence including a visit to this service. Staff are generally sufficiently trained in mandatory subjects to a satisfactory level of competency to do their jobs safely, however there are still some anomalies in the recruitment and training of staff so that people who use this service may not always be supported and protected. EVIDENCE: The files of three staff were examined during this inspection. Two were for employees that had commenced work in the home since the previous inspection. All these files contained fully completed application forms, health questionnaires, copies of core policies that had been signed and dated to indicate that staff were familiar with them, Criminal Record Bureau and POVA first checks, various forms of identification, a personal manual handling assessment, a contract of employment that had been clearly signed and dated, and evidence that training and supervision was being done appropriately. The inspector was however concerned that only one of the files contained clear photographic ID. The owner stated that there was a roll of film with the most recent pictures on it waiting to be developed. There was also concern regarding references. Not all references were from the referees that had been nominated on the application form, and there was no evidence to indicate a reason for this. The inspector was also told during the inspection, that Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 20 prospective employees are given reference request forms and told to obtain the references themselves rather than being formally requested by the home manager/owner. Evidence indicated that the majority of staff are attending mandatory training appropriately, however one member of staff was complaining about a sore shoulder and this individual was not up to date with moving and handling training. Not all staff had attended POVA training, although all those that were interviewed were able to clearly discuss this subject very competently. There is ongoing Dementia training which many staff are attending however there is no specialist or awareness training in place relating to catheter care or diabetes. The inspector appreciates that the visiting district nurses are responsible for these specialist care issues, however it would be beneficial for all staff to attend an awareness session on these subjects. There are service users in this home who have care needs relating to both of the above, and it would enhance the staffs’ care competencies and confidence in the care delivery. Lady Spencer House DS0000014923.V334624.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, 36, 37, 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of efficient management systems and non- compliance with previous requirements indicates that the safe running of this home continues to be compromised. EVIDENCE: The trainee manager that came to this home following the previous inspection in November 2007 has worked hard to prove her ability as a manager, but the owner has failed to commence her registration process as was agreed during the last CSCI visit. There has been a marked improvement in some of the documentation, and staff in the home have confidence in, and respect for the trainee manager. The staff that the inspector interviewed, all made positive comments about how Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 22 nice it was coming to work now and how approachable and supportive she was. The supervision notes reflected this. Unfortunately there were issues revealed during this inspection that indicated that the trainee manager has not been given the opportunity to manage the home. During this inspection the trainee manager was called away from the office, she returned to the office minutes later and proceeded to call 999. The owner stopped her and went to check on the situation herself before returning to the office four minutes later and telling the trainee manager to continue and make the call. This had wasted valuable time in getting the emergency response team out, and also indicated that the owner did not value the initial judgement made by the trainee manager. Over the past six months the owner had arranged support for the trainee manager from managers from the sister home, however it appears this support has caused confusion and in some cases left the trainee manager unaware of serious situations that she should have been managing herself. There were no records to evidence the support that was being given, and only one formal supervision had taken place for this trainee manager since she had come to Lady Spencer House in November 2007. The trainee manager confirmed that it had not been discussed with her what level of support she felt she needed, nor had there been any further discussion about her registering as the manager. No Improvement plan has been submitted to CSCI since the previous inspection. One of the supporting managers has been dealing with POVA referrals and regulation 37 notifications. The trainee manager was consequently very vague on these matters and unable to discuss outcomes or locate some documentation. One incident that the inspector attempted to ‘track’ was clearly documented by the trainee manager in the service users notes, and a body mark chart had been completed. But no one could locate the POVA referral, and the trainee manager had no idea whether or not a strategy meeting had been held, or what the outcome had been. Incorrect and very out of date certificates of registration were still displayed in the entrance of the home. This was an issue that was raised at the previous inspection with the owner and the supporting manager and had still not rectified the matter. The trainee manager wrote a letter and faxed it to the CSCI registration team to rectify this problem before the inspector left the home on the 05/06/07. Problems with the medication administration records had been addressed since the last inspection. But the supporting manager had produced a typed list of omission codes and put it in the file with the MAR sheets. This was not done in consultation with the trainee manager. The codes on this list did not correspond with those on the MAR sheets and therefore it had just caused Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 23 further confusion and has been contributory to further requirements being made during this inspection. This home does not take responsibility for any of the service user’s money, this is done by the individuals themselves, their families or a nominated representative. Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 24 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 2 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 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 3 3 3 3 3 3 1 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 X 3 3 2 2 Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 5(1)(b) Requirement The people who use this service must be issued with accurate information in the form of a Service User Guide. This must include information to fees. When medication is administered to people who use this service it must be clearly recorded to ensure that people have received the correct levels of medication. Unmet from previous timescale 31/12/06 Any injury to people who use this service, including those of unknown origin must be reported to the Adult Protection team. All staff that work in this home must adhere to clinical waste disposal procedures to ensure that people who use this service are protected from infection and toxic conditions. Staff that work in this home must have two appropriate references obtained through the recruitment process. References not obtained directly by the company must be authenticated. DS0000014923.V334624.R01.S.doc Timescale for action 31/08/07 2. OP9 13(2) 30/06/07 3. OP18 13(6) 30/06/07 4. OP26 13(3) 30/06/07 5. OP29 19 30/06/07 Lady Spencer House Version 5.2 Page 26 Unmet from previous timescale 31/12/06 6. OP31 8 The trainee manager, currently 31/08/07 on induction, must apply for registration by the 31/08/07 as if she is to remain in this role. Unmet from previous timescale 31/01/07 – new timescale applied 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 Lady Spencer House DS0000014923.V334624.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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.V334624.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!