Inspection on 14/09/06 for Lake House

This inspection was carried out on 14th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Lake House 25/02/09

Lake House 19/12/05

Lake House 28/06/05

Lake House 02/11/04

Lake House 21/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lake House Lake Walk Adderbury Banbury Oxfordshire OX17 3NG Lead Inspector Lilian Mackay Unannounced Inspection 14th September 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lake House DS0000013156.V311949.R02.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. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lake House Address Lake Walk Adderbury Banbury Oxfordshire OX17 3NG 01295 811183 01295 811260 manager.lakehouse@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust 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) Anna Hicks Care Home 43 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (18), Learning disability over 65 years of age (3), Old age, not falling within any other category (43), Physical disability over 65 years of age (12) Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of persons that may be accommodated at any one time must not exceed 43. Admittance of one named resident under the age of 65 years. Date of last inspection 19th December 2005 Brief Description of the Service: Lake House is a care home, which was purpose built in 1988. It is situated in the village of Adderbury, close to Banbury in Oxfordshire. Local shops and amenities are all within easy reach and the home is on a regular bus route between Banbury and Oxford. It is home to 43 older people and is managed by the Orders of St John Care Trust, a charitable organisation with a wealth of experience in providing residential care services. The local authority block purchases 70 of the places in the home. The single storey accommodation provides individual rooms and residents are encouraged to decorate their own rooms with their personal possessions. The communal areas are pleasantly decorated and the lounge area accommodates a day centre for older people from the community, which residents may participate in if they wish. The home provides respite care but does not provide intermediate care. The building is divided into five wings and each wing has its own sitting and dining area and small kitchen area. The home is set in attractive grounds and there is a courtyard in the centre of the building. The fees for this service range from £484 to £650 per week. Items not covered by the fees include hairdressing, podiatry, newspapers, magazines, toiletries and Bingo. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced “Key Inspection”. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that the CSCI has received about the service since the last inspection. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The home had 45 staff at this time. The purpose of this inspection was to see how the agency is meeting the National Minimum Standards for Care Homes for Older People. This unannounced “Key Inspection” took place from 09.00 to 17.25 on a weekday and consisted of talking to residents of the home to discuss their experience of the service provided, time spent inspecting policies and procedures, clients’ and staff records and other documentation and time spent talking to staff. Management contributed to this inspection by sending the CSCI full and timely pre – inspection information. Feedback was also obtained from questionnaires undertaken with residents and questionnaires sent to GPs and health and social care professionals with knowledge of the home. The organisation is reconsidering the registration of this home for learning disability [LD] and alcohol [A] as no specific training to meet the needs of residents in these categories is currently provided. When changes to the Certificate of Registration are made an amended Statement of Purpose will need to be submitted to the CSCI. Feedback was obtained from eight health and social care professionals with knowledge of the home and this was generally very positive. Five felt the home communicates clearly and works in partnership with them, six felt there was always a senior member of staff to confer with, all eight confirmed that they were able to see residents in private, seven felt that staff demonstrate a clear understanding of residents’ care needs, six felt that any specialist advice they give is incorporated into residents’ care plans, six felt medication was appropriately managed in the home, seven felt that management/staff take appropriate decisions when they can no longer manage residents’ care needs, none of them had received any complaints about the home, five felt the CSCI inspection report was available to them and seven were satisfied with the overall service provided to residents in the home. Comments made by health and social care professionals included – “Difficult to find senior staff to discuss any issues. Difficult to find carer giving care on a Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 6 wing to access the patient I have gone to see. Insufficient staff to offer regular toileting resulting in more incontinence than there needs to be. Sorry to sound negative. I have always felt positive about this home but have felt frustrated at times this last year.” “The management of Lake House seems to me to be rather chaotic – a review was set up by our day hospital and myself – despite a letter being written to them we were not expected and the member of staff who dealt with us clearly didn’t know the patient. The liaison with me compares poorly with my liaison with their sister home, Lincoln House”. “Lake House benefits from a good, practical design – therefore a good care environment and homely atmosphere. The gardens are a bonus and it would be improved if some fencing at the front was installed so that residents could wander in the grounds safely and reduce the risk of clients walking to the main road”. The feedback from the five residents spoken to was very positive. None of them could recall receiving contracts, one felt s/he had received enough information about the home before moving in and three were unsure about this, four felt they always receive the care and support they need, four felt that staff listen and act on what they say, one felt that staff are always available when they need them and four felt they usually are, all felt they always receive the medical support they need, four felt that the home arranges activities they can take part in, all five always liked the meals provided by the home, two knew who to speak to if they were not happy, three knew how to make a complaint and all five felt the home was kept fresh and clean by the staff. Clients’ comments included – “There are odd occasions when there is not a member of staff on the wing.” “There are always staff about. They work well together.” [Following a fall] ”It was competently dealt with. First aid staff assisted and then the district nurse came”. “I’d heard of the organisation. I’d been here a couple of times as a trial.” “I’ve not been refused anything. When I’ve needed help I’ve had it.” “Sometimes I feel I get too much care and support”. ”The staff are very kind and helpful”. “They are good staff and they are kind and you cannot fault them.” “They do whatever they can to help you. They are all of the same mind.” “The staff get to know you and it gets better if you know what I mean. They do things for you before you have to ask. We get good attention.” “I enjoy sitting in the lounge meeting and talking to people. They are all very helpful here.” Feedback was obtained from two GPs. One felt the home communicates clearly and works in partnership with them, one felt there was always a senior member of staff to confer with, both confirmed that they were able to see residents in private, one felt that staff demonstrate a clear understanding of residents’ care needs, one felt that any specialist advice they give is incorporated into the resident’s care plan, both felt medication was appropriately managed in the home, both felt that management/staff take appropriate decisions when they can no longer manage residents’ care needs, neither of them had received any complaints about the home, neither knew that the CSCI inspection report was available to them and one was satisfied Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 7 with the overall service provided to residents in the home. One GP commented, “Communication is much worse in the last year – no one knows what is going on. The communication book I insisted upon isn’t used. There is rarely anybody around when I come to visit and if I find someone, they don’t know the patient. Staff are overstretched and seem not to have time.” The inspector would like to thank the Lake House staff and residents for their courtesy, assistance and hospitality throughout this inspection. What the service does well: What has improved since the last inspection? What they could do better: Ensure all care needs assessment are completed fully. Monitor all care plans to ensure these contain all the goals required to meet residents’ health care needs. Improve communication with the district nurse and GP from one practice. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 8 Ensure that at least 50 of care staff are trained to NVQ level 2 or above, as soon as possible. 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. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 9 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 Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3.6. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. All prospective residents have a care needs assessment to ensure that the home can meet, the prospective resident’s overall needs. The home provides respite care but does not provide intermediate care. EVIDENCE: Prospective residents are invited into Lake House for a full day’s assessment to ensure that Lake House is able to meet the prospective resident’s needs. This also provides an opportunity for the resident and their family to meet staff and other residents to make the prospective resident’s transfer into the home more pleasant and personal. The dependency assessment used for all prospective residents is comprehensive and gives detailed information about the individual’s overall care needs. This information then forms the basis of their care plans. One incomplete care needs assessment was seen in those records sampled. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 11 Respite care is provided to two residents at a time. Intermediate care is not provided. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ overall needs are set out in their plans of care and take into account their wishes and preferences. The home’s policies and procedures on the administration of medications ensure these are administered safely. Residents are treated with respect and dignity. EVIDENCE: Residents or their next of kin sign to agree care plans. There were clear records of frequent reviews being held and these were clearly documented. All but one resident’s care plans examined had residents’ health care needs clearly identified along with the actions necessary for these to be met. This resident’s care plan contained no goal regarding mobility although her assessment had indicated that she was prone to falls. All care plans must be Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 13 monitored to ensure these contain all the required goals to meet residents’ health care needs. A local pharmacy checks the medication administration procedures twice yearly and provides staff training. The care plans emphasise the importance of respecting residents’ privacy and dignity. This is good practice. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. 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. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Residents are supported and encouraged to maintain contact with their families and the local community and to exercise choice and control over their own lives. Residents have a range of activities available to them and are encouraged to participate in these should they wish to do so. Residents enjoy the food provided. EVIDENCE: The staff team is multicultural. The home employs a part-time activity coordinator for 20 hours weekly. Residents have access to a computer and e learning is shortly to be introduced. Residents meet visiting schoolchildren and Brownies and there are monthly trips out. Group activities such as bingo, sing a longs and quizzes take place in the main lounge and smaller group activates such as craftwork and reminiscence take place on the wings. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 15 Residents commenting on the activities suggested, “I’d like more singsongs and get togethers – something on a bigger scale”. “I’d like them to bring in speakers on other religions”. Other comments about the activities included – “You can join in if you want to – you don’t have to”. “I don’t want to join in. If I want to do anything I can do it if it’s possible and if it’s not then they explain why”. “There’s everything you can mention. We have community church services”. “I’m not a social person. There is an activity routine which seems to be very much appreciated.” “I play skittles. I go along with them”. Meal monitoring is carried out with 16 residents monthly to ensure the standard is maintained and promoted. Clients’ comments about the food included –“It suits me OK.” “It’s not like home-made but it’s good”. “They’re quite good. No complaints”. “It’s not bad”. “It’s very good that way”. “It’s quite good – it’s not over the top”. “The food is good, it’s well served, and there’s great variety.” Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 16 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 inspected at least once during a 12 month period. 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. Complaints are suitably documented and these are appropriately followed up in time. Frequent staff training on safeguarding adults helps staff protect residents from abuse. EVIDENCE: No complainant has contacted the CSCI with information concerning a complaint since the last inspection. An inspection of the home’s complaints log indicated that the one complaint received by the home since the last inspection had been dealt with appropriately and timely. Clients’ comments about complaints included –“I’d go to complain to the person in charge of our area”. “I haven’t any grumbles – I don’t think there’s anybody special so I must be happy with the way things are. They’re not stuck up people. They are kind family people. You can’t ask for more than that. They’re not grumblers.” “Someone [the manager] comes round once a month to ask if there is anything we’re not happy with”. “I’d talk to the person in charge of the area.” “I’d go and speak to them”. “I’ve got no complaints”. “I don’t think I’ve got any complaints” “I think they are very good”. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 17 Training on safeguarding adults forms part of the home’s induction training and the frequency of refresher training exceeds the National Minimum Standards. From consultation with staff, an inspection of staff training records and a review of policies and procedures the inspector concluded that residents are safeguarded well. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is clean, pleasant, safe, hygienic and well maintained. EVIDENCE: The fire service has recommended that the doors of residents wishing to have their bedroom doors open during the day be fitted with electromagnetic release devices, which close the door in the event of the fire alarm being activated. The fire service confirmed that all bedroom doors should be closed at night. The fire service has also recommended the installation of a water mist and sprinkler system. A new fire alarm system has recently been installed. Observation of the home’s fire precautions was very good. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 19 Locks have been fitted to all patio doors and a keypad installed at the front door for additional security and for the protection of mentally frail residents at risk from wandering. Other recent improvements include the redecoration of outside windows and doors, new kitchens in two wings and the replacement of a lounge carpet in one wing. There is a family room where residents can entertain their visitors without having to use their own bedrooms. Clients’ comments about the environment included – “They keep it spotlessly clean. There’s always someone around to talk to. They don’t mind you asking questions. I can’t fault it” “It isn’t absolutely fantastic but it’s very nice. Nice people, as good as being with your family”. “There’s no way it can be improved on. I’m personally quite satisfied”. With the exception of a faint odour of urine on one wing the home was fresh smelling and clean. The housekeeping teamwork hard to maintain the cleanliness of the building and individual staff take responsibility for their own wings. The housekeeping team are commended for the high standards of housekeeping observed at the time of this visit. From comments residents made and a tour of the home the inspector concluded that a good standard of housekeeping is maintained. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. 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. Adequate staff are employed. The home did not achieve the standard of 50 of care staff to be trained in NVQ level 2 or above by 2005. The home’s robust recruitment policy and practices safeguard residents. Staff receive adequate and appropriate training. EVIDENCE: The number of staff agreed in a Staffing Statement dated 10.09.06 were on duty at this time. For care staff this works out at one person in charge in addition to five care staff. The manager is supernumerary most of the time. Reasonable use is made of agency staff to make up the staffing levels whilst there are two full time vacancies for care staff. Adequate evidence of recruitment and employment checks are made by the agencies employing the staff. From an examination of staff records the inspector concluded that the home have a clear recruitment procedure, which includes scrutinising the employment histories of prospective employees and identifying the reasons for any gaps in their employment. Only 33 of staff have NVQ level 2 or above. Another five staff were reported to be undertaking NVQ level 2 training and all the home’s care leaders are expected to either already have or work towards obtaining NVQ level 3. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 21 This should mean that the home will soon address this issue. Staff have received recent training from the Oxfordshire Falls Service and on care planning to improve the consistency and quality of these. Staff are supervised and have their performance appraised at the required frequencies. This has been an area of considerable improvement since the last inspection. Over the next two years all staff, including ancillary staff, will be expected to undertake dementia training from the Alzheimer’s Society. From listening to comments residents made, an inspection of staff records and by talking to staff the inspector concluded that a good standard in respect of staffing is achieved. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The home is managed by a qualified, experienced and competent manager and is run in residents’ best interests. The quality of the service provided is monitored closely. Residents’ financial interests are safeguarded and their health, safety and welfare promoted and protected. EVIDENCE: The manager has obtained the Registered Manager Award and has an NVQ level 4. The chief executive of the organisation visits twice yearly unannounced. Residents are encouraged to give feedback and make suggestions for improving the service. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 23 Residents’ meetings are held monthly to discuss issues with the management team. Minutes of these are taken and prominently displayed at the front entrance. As the local authority contracts with The Order of St John Care Trust for services the home is subject to annual monitoring from the Contract Development section of Community and Social Services. The home achieved the ISO standard this year and received a glowing audit report. This standard will be monitored annually. An annual quality review was carried out by the organisation in July but the results of this had not been collated at this time. Generally it is the case that residents do not manage their own finances. The business administrator manages residents’ petty cash and handles the receipts and the records of transactions. A property file is kept for those residents having their valuables kept safe. All the recommended policies and procedures are available and these have all been reviewed within the last three years. Whilst all the required health and safety checks are undertaken on time it is recommended that the frequency of the gas installations maintenance be checked to ensure it is frequent enough. A specialist nurse assesses all residents for falls and a register of these is kept for monitoring purposes. The manager has consulted with the fire officer as to the safety of the residents when their doors are left open and has shared the advice given with the CSCI. One resident commenting on the management said, ““I think it’s extraordinarily well run. I’m very comfortable and have no complaints”. Lake House DS0000013156.V311949.R02.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 2 Standard OP3 OP8 Regulation 14 12[a] Requirement Ensure all care needs assessment are completed fully. Monitor all care plans to ensure these contain all the goals required to meet residents’ health care needs. Timescale for action 31/10/06 31/10/06 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 OP28 OP38 Good Practice Recommendations Ensure that at least 50 of care staff are trained to NVQ level 2 or above, as soon as possible. Check the frequency of the gas installation maintenance. Lake House DS0000013156.V311949.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 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 Lake House DS0000013156.V311949.R02.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. 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!