CARE HOMES FOR OLDER PEOPLE
Lakenheath Village Home 7 Back Street Lakenheath Brandon Suffolk IP27 9HF Lead Inspector
Helen Fontaine Unannounced Inspection 11th January 2006 10:00 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 Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 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. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Lakenheath Village Home Address 7 Back Street Lakenheath Brandon Suffolk IP27 9HF 01842 861661 01842 860605 adam.went@lvh.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Christian Enterprises Foundation Mr Adam James Went Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th September 2005 Brief Description of the Service: Lakenheath Village is a Residential Care Home that is run by the Christian Enterprise Foundation. The Foundation is registered with the Charity Commission as a Charitable Trust. A Board of Trustees administers the Trust. Lakenheath Village was formerly the Vicarage and was donated by Mr Lionel Alsop in 1986 to establish a Residential Care Home for older people living in and around Lakenheath. The original building has been extended to accommodate a maximum of 21 service users aged 65 years and over. Lakenheath village is compact with all local amenities and is reasonably close to the Home. Lakenheath Village Home is situated within its own grounds. The building is constructed on two levels but all the residential accommodation is situated at ground floor level. The Home provides 21 bedrooms for single occupancy. All bedrooms are fitted with a vanity unit, a television point and an emergency alarm call system. The bedrooms do not benefit from en suite toilet facilities but these are conveniently located in close proximity to service users accommodation. The Home provides three bathrooms. Service users are able to welcome their guests in either of the two lounges or the library. There are two dining rooms where service users are able to take their meals if they wish. Service users have access to mature landscape gardens and car parking is available at the front of the Home. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection of Lakenheath Village Home took place over four hours and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Three requirements and two recommendations were set at the previous inspection and the home has complied with all of the required action. One recommendation but no further requirements were identified at this inspection. The manager and the deputy manager were out during the first part of the inspection and the homes administrator assisted the inspector. A number of documents were looked at, a tour of the home and residents were talked to individually and during the tour. A number of staff talked to the inspector and this included the homes cook and staff that had come in for a meeting. What the service does well: What has improved since the last inspection?
Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 6 At the last inspection there was an issue over bedrails and the recording of the perceived risk. During the inspection documents looked at showed that the risk assessments were being done, although currently there were no residents using the bedrails. The home has now developed a new written policy for the handling of homely remedies. The home has also done some work around the training of staff over issues around Adult Abuse. The manager has a training pack, this includes a video and once a television has been set up for the staff to watch it, they will commence the training. The home have now decorated the upstairs staff area, this was seen during the inspection. The home also have a weekly system for cleaning the shower heads and the night staff run the shower to rinse each of the shower floors and the home has now acquired an additional spare shower head. 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. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that, service users can expect to have information about the service to make an informed choice whether they wish to move into the home and can expect to have their needs assessed and met at all times. Service users who use the homes respite facility can expect to have their needs met by a competent staff team. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the Choice of Home standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 9 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 and 9 Residents can expect to have their social and health care needs set out in a care plan and is protected by the homes policies for dealing with medicines. EVIDENCE: Individual care plans for the residents are set out with the first page having a photo of the resident. This first page also has their name, with signatures and witness that the resident gave permission for their photo to be taken. The plan has the resident’s basic information, which also covers the residents wish over their funeral arrangements and one file looked at documented that they wanted their family to arrange this. There was also information about allergies, GP and then a sheet that covered personal exercise programmes and as an example one looked at was for head and neck exercises produced by the Newmarket Hospital. The next section was the actual care plan, which incorporated the assessed needs of each of the residents. The areas covered were maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, mobility, working and playing, expressing sexuality and sleeping. The next section covered Dying, mood, oral hygiene, risk assessment, key risk assessment, moving and handling plan, pressure sore assessment, self administration of medication and bed rails –
Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 10 care plan. The files looked at all had risk assessments for bed rails, but at the time of the inspection no residents had to use them. Since the last inspection the home revised its homely remedies policy and this now meets the National Minimum Standard. The home is now recording and informing the pharmacy of the any homely medications being administered. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 11 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): 15 Residents can expect a wholesome and appealing diet that is convenient to them. EVIDENCE: The area around meals and it preparation is one of the areas that they home has exceeded the Minimum Standard. During the tour of the home the inspector visited the kitchen and the cook was quick to insist that the inspector wore a white coat and hat. Storage of food was appropriately kept and as an example meat was kept in its own fridge and separate from any other food. The kitchen outside door had a mesh door, as did the out buildings where food was stored. All the storage cupboards were very well stocked, with fresh, frozen and tinned foods. The cook said that they go round to each resident with the menu and the afternoon cook does the same. The cook said when asked how they would know about special diets, said that the manager or deputy come down with the care plan and this is documented in the diary. The cook said there is also a verbal dialogue with the staff and residents about any needs or wants. The home has two dinning rooms, one near the kitchen and the other down the far end of the home. The residents then have a choice of either the dining room, or in their own rooms. The residents spoken to all said that food was
Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 12 very good, one resident particularly wanted to tell the inspector how good the food was. The menu seen was varied with two choices of main course and sweet and the resident said that they could ask for anything else. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 13 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): These standards were not tested on this visit. However evidence from the last inspection was that, service user and their relatives and friends can expect to have complaints listened to and responded to promptly and to be involved in the outcome of the complaint. The staff team are supervised and supported by the manager so that service users can expect to be protected from abuse. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the Complaints and Protection standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 14 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): 20, 21, 24 and 26 Residents can expect to live in a home that is safe and comfortable and well maintained and have suitable equipment that has been assessed to meet their needs. EVIDENCE: Although this area was fully covered at the previous inspection, the home was so beautifully kept and homely that a further comment was needed to highlight this area. A tour of the home was undertaken at the commencement of the inspection and a number of residents were seen in their own rooms. Each room was individually personalized with pictures, furniture and favourite items. Residents moved around the home visiting each other and talking as they passed each other’s rooms. Residents were also coming and going from communal areas and during the moving around there was a great deal of laughter. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 15 The home was very clean and nicely laid out, at the front there was a quiet room/library. The home had originally been a vicarage and the home had maintained this room as the library. The room could also be used for visiting relatives and allow relatives to eat with the resident. The resident’s individual rooms did not have en-suite, but down the corridors there were plenty of toilets and bathrooms. The home is set in beautiful grounds and the design of the layout of the rooms gave each room a pleasant view. In the summer months there is a small outside area between the two wings of the home. This staff said was a real suntrap and very popular with the residents. Each of the rooms has a lockable cupboard and this can be used for self-medication or money and valuable. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 16 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): 30 Residents can expect to be cared for a team of staff who are trained and supported. EVIDENCE: In the previous inspection report, the home had a requirement around the training of staff on issue of adult abuse. The manager showed the inspector a training pack that the home had purchased; this consisted of reading material and a video. The manager said that as soon as they get a television and get it set up for the video, they would commence training. This issue has been documented as a recommendation in this report. The manager did have the Local Authority policy and procedure for adult abuse; this can be used in conjunction with the training pack. Residents talked to during the inspection when asked about feeling safe, were clear that they were ever so well looked after. They knew who to go to and felt that if they had any concerns it would be listened to and dealt with. A member of staff talked to, was fully aware of who they needed to contact if there was any concerns. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 17 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): 35 and 38 Residents can expect to have their financial interests safeguarded and be protected by the homes health and safety practices. EVIDENCE: The home has a mixture of privately funded residents and those funded by the Local Authority. In the case of the Local Authority funded residents, the Social worker deals with all their finances. Privately funded residents, their relatives or representatives pay by direct debit, having received the terms and conditions that they signed. Each of the residents has a lockable cupboard in their rooms where they can keep their money or valuables. The home have in the clinical room a cupboard and in this is a zip folder for any resident wanting the home to hold their spending money. Money being taken out is witnessed and signed by the member of staff and the resident and once a week the money is checked and this is signed.
Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 18 At the previous inspection a recommendation was made that the frequency of use of the shower and the risk of legionella. The manager said that the home now clean the shower head and the night staff rinse the floor of each shower each day to eliminate any standing water. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 4 3 X X 3 X 4 STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations The home undertakes the training for Adult Abuse. Lakenheath Village Home DS0000024429.V278207.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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