Inspection on 29/11/06 for Lakenheath Village Home

This inspection was carried out on 29th November 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

Lakenheath Village Home 05/10/07

Lakenheath Village Home 11/01/06

Lakenheath Village Home 07/09/05

Lakenheath Village Home 21/03/05

Lakenheath Village Home 04/01/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lakenheath Village Home 7 Back Street Lakenheath Brandon Suffolk IP27 9HF Lead Inspector Deborah Kerr Unannounced Inspection 29th November 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 Lakenheath Village Home DS0000024429.V322501.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. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakenheath Village Home Address 7 Back Street Lakenheath Brandon Suffolk IP27 9HF 01842 860605 01842 861661 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 Mrs Jeanette Neilson Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide respite care for one named person under the age of 65. 11th January 2006 Date of last inspection 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. The home 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. Lakenheath village is compact with all local amenities and is reasonably close to the Home. The original building has been extended to accommodate a maximum of 21 residents aged 65 years and over. 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 and bathing facilities but these are conveniently located in close proximity to resident’s accommodation. Residents are able to welcome their guests in either of the two lounges or the library. There are two dining rooms where residents are able to take their meals if they wish. Residents have access to mature landscape gardens and car parking is available at the front of the home. A detailed statement of purpose, colour photographic brochure and a service user guide handbook provides detailed information about the home, the services provided and access to local services. Each resident has a contract of terms and conditions, these do not currently reflect the fees and how much they are expected to pay on a weekly basis. Fees are calculated depending on the needs of the resident; they range from £331 – £440 per week. These do not cover additional services for example, the hairdresser, chiropodist and personal items such as toiletries and receipt of daily newspapers. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over nine hours during a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained from 12 residents ‘Have your say about’ and 11 relatives/visitors comment cards. Time was spent talking with 4 residents, 6 staff, a district nurse, the administrator and the manager. A number of records were inspected including those relating to residents, staff, training, medication, quality assurance and a selection of policies and procedures. We are currently testing a method of working where ‘Experts by Experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ is used to describe people whose knowledge about social care services comes directly from using them. Mr Peter Godden-Kent an Expert by Experience joined the inspector on this site visit. Mr Godden-Kent’s comments and observations are added to this report and can be identified in bold text. What the service does well: What has improved since the last inspection? Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 6 There have been improvements made to the interior décor of the home including the staffing area and a number of resident’s bedrooms. New coffee tables and armchairs have been purchased; these were seen providing comfortable seating in the lounges and library. Training records reflected that staff have attended a range of training to meet the particular needs of the residents, which include hearing support, caring for a person in the last few days of their life and nutrition for the terminally ill. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6, Quality in this outcome area is good. Prospective residents can expect to be provided with detailed information about the home, however cannot be assured that the information will be available in an suitable format to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s statement of purpose has been updated to reflect the name and qualifications of the new registered manager. A resident’s handbook and colour photographic brochure provides prospective, respite and new residents with detailed information about the services provided. Consideration should to be given to how this information is provided to the residents with a sensory impairment. The service user guide informs residents how and when their fees are to be paid, but does not state the range of fees charged by the home. Resident’s files contained a written contract setting out the terms and conditions of living in the home, which reflected how fees are calculated, and when fees were payable but did not state the residents agreed individual fee. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 9 Each resident had a pre admission needs assessment completed; these were very detailed and provided information about the resident’s health, personal care and social needs. Training records reflected that staff have attended a range of training to meet the particular needs of the residents, for example, four residents living in the home have a hearing impairment and to ensure staff are aware of their needs they have attended a course for hearing support. A Macmillan nurse helped to provide training for caring for a person in the last few days of their life and nutrition for the terminally ill. A resident confirmed that they had had the opportunity to visit Lakenheath Village Home before making a decision to move into residential care. A residents ‘Have your say’ card confirmed that residents are provided with an opportunity to visit the home; they stated, “ I used to visit friends who lived at the home and my family helped me to arrange an initial respite stay”. The care plan of a resident admitted following an emergency placement showed that a full needs assessment and plan of care was completed on the day they moved in to the home. The expert by experience spent time talking with the resident, they were most anxious that they would be able to stay permanently as they liked the home so much. A relatives comment card stated “Our relative is very happy at the home, we are very happy with the way Lakenheath Village Home found a room for them at very short notice after their health deteriorated”. The home does not provide intermediate care, however, they do have one respite bed, which is on a contract basis with Suffolk Social Services. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, Quality in this outcome area is good. Residents can expect to have care plans in place that reflect their health, personal and social needs, however they cannot currently expect to be protected by the home’s procedures for administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans of three residents were inspected to track their care and the level of support they required. Each section was divided into activity of living assessment, which identified the residents health and personal care needs, however these could be expanded to further describe the level of support required by the resident. Individual assessments and daily living notes reflected the resident’s general health, well being and identified specific health needs. For example, a resident who has a catheter fitted to help manage their continence had appropriate charts in place reflecting pressure area care, a waterlow score, manual handling assessment and a nutritional chart. They were also receiving regular support from the district nurse team. Another resident’s nutritional screening form linked to their activity of living plan to ensure they ate a healthy balanced Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 11 diet to help manage their diabetes. A residents ‘Have your say’ comment card reflects, “I am very well looked after at the home and I am very happy, especially as I am very deaf, old and frail”. A record of clinical visits showed that residents were being supported to access healthcare professionals, for example there were regular entries of visits to the general practitioner and visits to the home by the district nurse team. A wound assessment and body map were seen in one resident’s file and the nurse’s notes monitoring the progress of a pressure area. One of the district nurses was visiting the home during the inspection and confirmed that residents were provided with pressure relieving equipment either by the home or by the district nurses where more specialised equipment was required. They complimented the home for the care they provided to the residents and that it was a pleasant, odour free home. They often saw residents from the home out and about within the community and residents always appeared to be happy. They felt the district nurse team and the home had a good relationship, the home were always quick to consult them if they had concerns about a resident. A resident told the expert by experience it was very difficult for them to sit comfortably for long periods in their electric wheelchair. They had a recliner chair, which they used in their own home but which could not be fitted into their room. They reported they were not allowed to use a blanket to cover their legs when using their wheelchair because of the risk that it would slip and become entangled in the wheels. They commented that on one occasion, when a member of staff had taken them out in the rain, they had improvised by putting a plastic bin liner over their feet and legs to keep them dry, and had found it “as warm as toast”. They also said that they needed “more driving lessons and a test” in their wheelchair, for which they had been waiting for a long time, so that they could be allowed more freedom of unaccompanied movement. These matters were discussed, at the end of the visit, with the Inspector and the Home Manager. It was confirmed that the recliner chair could not reasonably be placed in the bedroom, because there was too little space and it severely obstructed movement. There are no larger rooms to which the resident could move into. The Manager accepted the suggestion that a “sleeping bag” style of leg cover, which would not be able to slip off sideways, would be appropriate for use in the wheelchair and agreed to pursue this. They also recognised the residents need for “driving lessons and test” for which everyone including the resident themselves, had joked about their collisions with the décor and furniture. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 12 An audit of the incident and accident log showed in the last 12 months 52 falls had been logged, these were mostly attributed to four residents. This was discussed with the manger who confirmed they had been in contact with a falls co-coordinator and that they would contact them again to visit the home for advice, support and staff training. There were also four reported incidents where residents had spilt hot tea or coffee in their laps. The manager agreed to undertake risk assessments to assess resident’s ability to hold cups of hot drinks where resident’s dexterity has decreased. The senior on duty was observed completing the morning administration of medication. The Monitored Dosage System (MDS) is used and each blister pack had a photograph of the resident for identification purposes. The Medication Administration Records (MAR) charts were seen and reflected a number of errors. One resident’s MAR chart showed they were prescribed Lorazepam ½ to 1 tablet four times a day (PRN) as required, where the medication was being administered staff had correctly recorded if ½ or 1 Lorezapam tablet had been given. However if the resident had refused in some cases staff had entered in a code ‘F’ (other reason) which was recorded as refused, which is not required for a PRN medication and made the MAR chart confusing to read. Two residents MAR charts showed that they were prescribed Aqueous cream to be applied twice daily, however there were several gaps in signatures which suggests the cream was not administered. Several gaps on the MAR chart for a resident prescribed regular paracetomol had no explanation recorded why the medication was not administered. The MAR chart showed that a signature had been crossed out for the previous morning for a resident prescribed Pantoprozole. It was not clear if the medication had been administered. One resident’s lactulose prescribed twice daily had not been signed for 5 days and there was nothing recorded to suggest the resident had refused. An entry had been recorded in pencil on one MAR chart where a resident’s Co-amilfrouse had been stopped; this is an official document and must be written in ink. At the back of the MAR chart folder the home had a protocol in place supported by the general practitioner for the use of homely remedies. A record was being kept of all homely remedies being administered and a stock balance. A record is made of the date, time, recipient, dose and who administered. The medication trolley is locked in the clinic room; entry to the clinic room is by a coded keypad. The homes controlled drugs are stored within a separate locker in the clinic room. The controlled drugs book was seen, which had an accurate record of the controlled drugs in the home, however Buprenorphine had been received into the home on the previous day, but the date had been omitted from the entry. The returns book reflected that two staff had counted and signed the medication to confirm the return; the pharmacist had countersigned this. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 13 Residents were observed being called by their preferred name and felt that staff respected their privacy. Staff were observed knocking and waiting before entering resident’s rooms. The interactions between residents and staff were observed to be friendly and appropriate. The expert by experience spoke with a resident, who told them about their long and varied career in the UK and abroad, which included working at the home. They had initially felt some discomfort at their situation when they had moved into the home but praised the staff for their care and attitude towards them and other residents. A resident talked to the expert by experience about their personal wishes and about the deaths and burials of their family. They described their wish that in due time their own cortege should go round the drive of the Home “so that they could take their leave of the other residents in their own way”; this, they said, had been willingly noted at the Home and by the local Funeral Director. They were a Roman Catholic and had formerly attended services at the church in Brandon but this was too far away to be practicable for them now because of transport availability and cost. In conjunction with the district nurse team the home has developed and used the Liverpool Care Pathway to support the palliative care and end of life needs of the residents. This is a detailed document identifying an initial assessment of the resident’s condition, ongoing assessment of changing needs which also links to supporting the family and the process for verification of death. A residents care plan had their wishes recorded, that they wished to be pain free and only transferred to hospital if it would help their condition and that they wanted their family around them. Lakenheath Village Home DS0000024429.V322501.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is excellent. Residents can expect to live in a home that supports a lifestyle that matches their expectations and be involved in the day-to-day decisions made about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A whiteboard was seen in the hallway, which provided information about social and daily news, including the day and date (in large bold letters) and information about the weather and the season. A list of activities showed that residents have access to a range of religious services, regular sherry and coffee mornings and a hairdresser that visits the home once a week. Residents were observed in attendance at a worship service, which was in progress provided buy the Abundant Life Church. Alternatively residents can attend a communion on a Friday provided by the Anglican Church. There is also an interdenominational service held in the lounge on a Sunday afternoon. An activities list was displayed for November and the lead up to Christmas. In November, resident’s had the option to attend a remembrance service, a beetle drive and reminisance sessions. Other activities include watching videos and joining in a sing a long and bingo. Residents can also have a manicure on request. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 15 December activities include a session with a ladies keep fit group who visit the home. A classic clothes party has been advertised in the new parish newsletter and it, is hoped that people from the village will attend and purchase clothing. A coffee and mince pies morning with a Christmas draw has been planned and a variety of entertainers followed by a buffet tea. Crocheted bags have been filled with sweets to give the children from Lakenheath Royal Air Force (RAF) when they visit. Residents have been involved in practical activities organised by the home activities co-ordinator, for example, painting and basket making. There are four people living in the home with a visual impairment, materials in bright colours have been purchased to enable the residents to take part in these activities. Residents have requested to take part in bread making as an alternative activity. Resident’s commented on what it was like for them to live in the home. These included “ I am very glad to be here, staff are very kind, it is just the place when you can’t manage”. Another resident said “ Everyone is very good to me hear and the food is lovely”. A relatives comment card states, “Staff at the home are always pleasant and cheerful and my relative always has praise for the way they are cared for, it is a joy to visit”. Another resident commented “The home provides ample activities, a religious service and always a party for resident’s birthdays and lots of things to do at Christmas”. A residents meeting held in November discussed the forthcoming entertainment and a trip to Felixstowe that took place in September, all agreed that they wanted to book again for the following year. An additional trip to Abbey Gardens in Bury St Edmunds in April/May 2007 was discussed and with residents approval agreed. Residents were asked for their opinion about the quality of food and cleanliness of the home. It was unanimously agreed that food is plentiful and of excellent quality. A request was made for more diabetic cakes. All residents in attendance at the meeting agreed they were satisfied with the cleanliness of the home in particular their own rooms. The expert by experience met more than half of the residents, either by visiting them alone in their rooms or by chatting with them at lunch. All those to whom they spoke with were from Lakenheath or had lived nearby. The comments of all the residents without exception were similarly very favourable about the home. All were happy in this setting, and confirmed that they felt well cared for and that their wishes were respected. The expert by experience joined the residents for lunch. This was clearly enjoyed by the residents who praised the quality and choice of food. In conversation, two residents mentioned how they had arranged for the dispersal of some of their personal effects with the help of their families. The expert by experience asked whether they knew of any independent agency, such as an advocacy service, which they could have asked for help had they not had supportive families; neither knew of any such service, but leaflets from a local service were in fact openly available in the home. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 16 Time was spent talking with the catering manager and the cook. The home has a four-week rolling menu, which changes with the seasons. Residents are informed what is available for lunch at breakfast so that they can make a decision on the day. The menu confirmed residents had a choice of brisket of beef or fish fingers, accompanied by mash or roast potatoes, parsnips, carrots, swede and broccoli, followed by bread and butter pudding. A chart held in the kitchen reflected seventeen residents had chosen the beef and the remainder the fish fingers. The cook was aware that seven residents were diabetic and had made another bread and butter pudding using artificial sweetener. Three residents required their food puréed, meals were served keeping each food item separate to present a more appetising appearance, which the resident could identify, the colour, taste and texture. A residents ‘Have your say comment card’ stated, “The food is excellent, especially the fresh vegetables” and “we have a choice at all mealtimes”. Residents are supported to maintain contact with relatives and friend; one resident showed the inspector some flowers that their family had brought them for a recent birthday. They had also been provided with a telephone in their room so that they could speak with their family in private.” Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 17 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. Residents can expect to have their concerns listened to and responded to. Where allegations are made these are reported to the appropriate people and fully investigated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints log showed that residents and relatives are making complaints and evidence shows that these are dealt with in an appropriate manner. All complaints are logged and investigated by the manager and a record of the outcome made and feedback to the complainant. The complaints log seen showed that six complaints had been received and dealt with since the previous inspection in January 2006. A relatives comment card stated “Our family are pleased with the care our relative receives, they are happy in the home apart from a few small hiccups (which are usually misunderstandings) we have no complaints, we find the staff very helpful”. The whistle blowing procedure supports the policy and procedure for preventing and identifying abuse. These were both reviewed and updated in July 2006. They direct staff to report any allegations of abuse to the Suffolk inter agency policy for the Protection of Vulnerable Adults, Customer First team. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 18 Records show that there have been four adult protection referrals made to the customer first team of Social Services. Three of these related to residents making allegations about the same member of staff. Following investigations into the separate incidents and disciplinary action the member of staff has been dismissed. The fourth referral related to a resident staying for respite who alleged that money had gone missing, however investigations into the missing money were inconclusive as the resident could not be sure if they had had money in their purse. The home has now included this as an item on the inventory sheet when any resident enters the home. Staff spoken with confirmed they were aware of the Whistle blowing and Adult Protection procedure, they confirmed they would report any concerns about improper conduct of their colleagues towards a resident to the manager. Training records showed that all staff have received updated training in recognising abuse in care homes. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,24,25,26, Quality in this outcome area is good. Residents can expect to live in a home that is safe and comfortable and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The building has two storeys, but all residential accommodation is on the ground floor. Residents’ rooms have a washbasin but bathrooms and toilets are communal. Residents have the use of two lounges or the library, where they are able to welcome their guests, and two dining rooms. The Home has accessible mature gardens. The home is an old vicarage and the interior although equipped for resident’s safety, retains a lot of its old charm and period features. At the back of the property outside the dining area there is a sun terrace, which is equipped with wooden benches, a table and parasol for residents to use in the nicer weather. All residents’ bedrooms are fitted with a call bell and had a door lock. They are offered the opportunity to hold a key to their room and to the front door of the Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 20 home. Rooms were nicely decorated and evidence was seen that residents had brought their own possessions with them to personalise their rooms. Several bedrooms had been redecorated. The home was found to be clean, bright and well maintained and had no unpleasant odours. A residents comment card noted “The home is always cleaned to a high standard, the cleaners are very friendly”. New armchairs and coffee tables have been purchased for the lounge providing a range of seating for residents. The home has eight toilets and three assisted bathrooms, one of which has a walk in shower. Two dining rooms provide residents with a choice of where to eat or they can choose to eat in their own rooms. For wheelchair users, corridors, communal lounges and dining rooms have enough space for them to manoeuvre freely around the home. Corridors have grab rails fitted to provide assistance to residents to help maintain their mobility and independence. In the entrance hall a copy of the statement of purpose, visitors book and current registration certificate were on display. There was also a board displaying the names of the staff on duty for residents and relative’s information. A small side room houses moving and handling equipment, so that equipment is stored out of the way leaving corridors bedrooms and bathrooms clutter free. Water temperatures are being recorded daily; these were tested and found to be within the safe recommended temperature of near to 43 degrees centigrade. A good supply of plastic aprons, disposable gloves, liquid hand soap and paper towels were available in all bathrooms and toilets. The laundry room was clean and tidy and contained two washing machines which both had a sluice cycle for dealing with soiled linen used in conjunction with red bags specifically for soiled items. A sluice disinfector is available in a separate sluice room for disinfecting urine bottles and commode pots. The homes infection control policy and procedure was seen covering the principles of infection, hand washing, waste disposal and the importance of using personal protective equipment such as disposable gloves and aprons. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, Quality in this outcome area is good. Staff are well trained, however consideration should be given to providing additional staff at peak times to ensure staff are available in sufficient numbers to meet residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff roster reflected that there is five staff on the early shift between 7.45 and 3pm and three staff on the late shift between 2.45 and 10pm. There is two waking night staff on duty between 9.45pm to 8am. Additionally there is a part time activities co-ordinator, cook, kitchen assistant and two domestics. A relatives comment card stated, “Small numbers of staff in the evenings make it difficult for staff to be able to see to all the residents needs and to respond promptly to call bells”. A residents ‘Have your say’ card stated “Evenings are short staffed, staff are not always available when I need them”. Staff confirmed that they felt pressured working the late shifts, as the seniors role was mostly taken up with administering medication leaving the two care staff to attend to the needs of 21 residents. Due to the increasing needs of the residents and manual handling constraints this often meant that the two carers where needed to assist one resident. This was discussed with the manager who felt there is sufficient number of staff on duty in the evenings. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 22 Training records and files reflected a commitment to staff training and development. Seventy four percent of staff have obtained a National Vocational Qualification (NVQ) at either level 2 or 3. All staff have attended core training throughout the year which included moving and handling, fire safety and prevention, control of substances hazardous to health (COSHH), first aid, food hygiene, infection control and recognising abuse in the care home. Senior staff had attended training for the administration of medication. Other training consisted of palliative care, stroke awareness, nutrition for the terminally ill, caring for a person in their last few days, effective communication and hearing support. Three new staff had attended induction training; evidence was seen that they had completed work specific training relating to their role, which linked into the Skills for Care induction standards. Staff files seen confirmed the home operates a thorough recruitment process, which includes obtaining all the appropriate paper work including police and protection of vulnerable adults (POVA) checks. Staff are also issued with a handbook which contains information about their terms and conditions of employment and professional code of conduct. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36,37,38, Quality in this outcome area is good. Residents can expect to live in a home, which is effectively managed, however cannot expect to have their safety protected until the home’s working practices comply with the Control of Substances Hazardous to Health (COSSH) regulations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Jeanette Neilson was approved as the Registered Manager of the home with the Commission for Social Care Inspection (CSCI) in October 2006. They have completed their National Vocational Qualification (NVQ) level 4 and the Registered Managers Award. Staff and residents spoken with confirmed the manager is supportive and approachable. A relatives comment cards states “My family cannot praise enough the level of care, which our relative is receiving. I consider the home provides a very good standard of care for my relative and the day to day Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 24 running of the home always seem to reflect a good team with good management. It is a very good well run home.” Regular staff, residents and relatives meetings take place. Copies of the minutes were seen displayed on notice boards around the home. The minutes showed that people living in the home and relatives and staff are able to contribute to discussions and the decisions made about the running of the home. The home employs an independent company to undertake the human resources role, monthly quality assurance and health and safety inspections. The last monthly quality assurance was completed on the 22nd November 2006 and a copy was forwarded to the Commission for Social Care Inspection (CSCI). This focused on the role of the administrator and the systems in place to safeguard residents with regards to recruitment, accounting and financial procedures and record keeping. The proprietor of the company is currently supporting the manager to write an up to date business and financial plan. The home’s employer’s liability insurance certificate was seen on display in the entrance foyer, which expires in March 2007. An annual quality assurance survey is conducted; questionnaires are circulated to residents, relatives and other professionals involved in the home. The most recent surveys in November 2006 had very satisfactory responses from general practitioners, district nurse team and podiatrist. Questions related to the appearance, maintenance and atmosphere of the home, conduct of the staff and the approachability of the management team. Residents and relative’s questionnaires also received mostly positive responses. Examples quoted “Very good staff, they are considerate and appropriate” and “Our relative appreciates the kindness of the carers, they are lovely carers, thank you to all the staff at the home”. However there were some negative comments where improvements could be made regarding the loss of residents clothing, more variety of food at teatime and availability of more snacks such as fresh fruit throughout the day. Staff are also provided with questionnaires, samples seen reflected that staff generally feel valued and respected by residents, relatives other staff and the management team. They felt they received the necessary support and training to do their jobs and were kept informed of policies, procedures and safe working practices. Staff files and discussion with staff confirmed that they are receiving regular supervision.. Supervision sessions consisted of discussions about work and team issues, observation of tasks and interaction with residents, personal issues and knowledge of policies and procedures. 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 their finances. Privately funded residents, their relatives or representatives pay by direct debit. The home will hold small amounts of monies for residents up to a maximum of £50 in an individual account. Two signatures are required for all transactions. Senior staff conduct a weekly audit Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 25 to ensure the cash balances are correct. The cash balances, records and receipts were checked for three residents and all were found to be accurate. Each of the residents has a lockable cupboard in their rooms where they can keep their money or valuables. The home has a comprehensive file of policies and procedures. The home previously purchased the complete file on a computer disc (CD Rom) from the British Federation of Care Homes and has adapted these to meet the requirements for Lakenheath Village Home. These are being reviewed on an annual basis as part of the quality assurance process. It was noted that some of the cleaning materials, odour kill freshener and chemex hand wash had been decanted into bottles, which did not have the relevant Control of substances Hazardous to Health (COSHH) data available in case of emergencies. The fire logbook confirmed that regular fire drills, testing of alarms, emergency lighting and visual checks of equipment were taking place. The fire safety risk assessment had been reviewed and updated in September 2006. Some recommendations were made following the completion of the assessment to provide additional emergency lighting in some of the corridors and the cellar. Additional external lighting was also required around the outside of the home. As an interim measure torches have been provided. Time was spent discussing the better food safer business pack with the catering manager. The pack was being used daily including the diary section detailed the opening and closing checks at start and end of each shift. Evidence was seen that staff adhered to good hygiene standards and food was being correctly stored in the fridges and freezers. All food was covered and dated and temperatures were being recorded. Certificates were seen confirming that manual handling equipment had been serviced under the Lifting Operations and lifting Equipment Regulations (LOLER) in August 2006 and the Portable Appliances Testing (Pat) certificate expired in February 2007. Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 X 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement The registered manager must make arrangements for each resident to have an up to date contract, which reflects their current fee. The registered manager must make arrangements for risks that adversely affect the health and safety of residents are identified and managed within the risk management framework and recorded in their care plan, for example, managing hot drinks and falls. The registered manager must make arrangements for the recording and safe administration of medicines in the care home. The registered manager must ensure that all cleaning materials, which are potentially hazardous, must not be decanted into unlabelled bottles in line with the Control of Substances Hazardous to Health (COSHH) regulations. Timescale for action 17/01/07 2 OP7 13 (4)(b) (c) 17/01/07 3 OP9 13 (2) 17/01/07 4 OP38 13 (4) (a) 17/01/07 Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 28 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 OP1 Good Practice Recommendations The service users guide and other information about the home should be available in a format suitable for the people with a visual and other sensory impairments. Although care plans detail the health personal and social needs of the residents these could be expanded to further describe the level of support required by the resident. Consideration should be given to providing additional staff at peak times of the day to ensure staff are available in sufficient numbers to meet residents needs. 2. OP7 3. OP27 Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Lakenheath Village Home DS0000024429.V322501.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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