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Inspection on 05/10/07 for Lakenheath Village Home

Also see our care home review for Lakenheath Village Home for more information

This inspection was carried out on 5th October 2007.

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.

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

What the care home does well

The home continues to provide good quality personal care and health care for its residents who all told the inspector that they were happy living in the home. There was seen to be an easy rapport between the residents and the staff who encourage them to make as many appropriate choices and decisions about their own lives as it is safely possible for them to so do and who give the residents good support to live in the home as independently as possible.

What has improved since the last inspection?

Since the last inspection a number of improvements works have been carried out including redecorations and the provisions of new furnishings and equipment to better meet individual residents changing needs. Improvements have been made to the care plan recording in line with the recommendations following the last inspection.

What the care home could do better:

The standards of care and the management of the service continues to be maintained. However, some improvements could be made in the administration of medication to ensure residents safety.

CARE HOMES FOR OLDER PEOPLE Lakenheath Village Home 7 Back Street Lakenheath Brandon Suffolk IP27 9HF Lead Inspector Mrs Jan Sheppard Unannounced Inspection 5th October 2007 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.V352584.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.V352584.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 jeanette.neilson@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.V352584.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. 29th November 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 good local amenities, which are 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 with information as to their current fees, which range from £341 to £455 per week. Extra charges are made for additional services including hairdressing, chiropody and personal items such as toiletries and receipt of daily newspapers. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours during a weekday. This inspection focused on the core standards relating to older people. During this inspection the inspector made a tour of the building, had in depth discussions with the homes manager, met all the residents and spoke individually with many of them, spoke also with the staff on duty and carried out spot checks on a number of the homes records. The comments in this report reflect the findings made by the inspector during that visit and also take account of information gathered over the past months from the homes manager and by way of pre-inspection questionnaires completed by the majority of the residents, their relatives and other professional stake holders in the home. This was a positive inspection. The home had a well-ordered and homely atmosphere where staff and residents were seen to be interacting positively together. The residents looked happy and without exception all said that they were well cared for. Comments such as “This is a happy home nothing is too much trouble for the staff ” were made repeatedly by the residents to the inspector. The requirements and recommendations made at the last inspection have all been met; one requirement and one good practice recommendation are made following this inspection. What the service does well: The home continues to provide good quality personal care and health care for its residents who all told the inspector that they were happy living in the home. There was seen to be an easy rapport between the residents and the staff who encourage them to make as many appropriate choices and decisions about their own lives as it is safely possible for them to so do and who give the residents good support to live in the home as independently as possible. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V352584.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.V352584.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): 3. Standard 6 is not applicable. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be assured that admissions to the home are not agreed until a full needs assessment has been carried out and the home is satisfied that it can meet these needs. Sufficient information is provided for prospective residents and their families to enable them to make an informed choice about using the service. EVIDENCE: All prospective residents referred to the home receive a home assessment visit from the manager accompanied by one other member of staff. Together they make a full assessment of the applicant’s care and social needs. If it is thought that these could be met in Lakenheath Village Home then the prospective resident, and if they wish it, friends or family members also, are invited to visit Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 9 the home. Prospective residents are encouraged to spend time viewing the home and the available accommodation, meet with and possibly share a meal or join in with an activity with the other residents and to meet with the care staff and catering staff. Written and verbal comments made to the inspector evidenced that this process is thoughtfully carried out at a pace, which meets the needs of the prospective residents. A range of literature is provided, which gives good information about the facilities and services offered and the costs involved. The manager discussed with the inspector the various ways in which she ensures that this literature is in an appropriate format for the prospective resident to easily understand for example in large print or in an audio format. The home does not provide intermediate care so standard 6 is not applicable. The home has one respite care bed which is on a contract basis with Suffolk Social Services. Records evidenced that this bed is regularly used and has future bookings. A short stay resident that was admitted to this place during the day of this inspection explained to the inspector that they had had several previous short stays in the home and that they had always been very happy with the care and services provided. They said, “I know all the staff and many of the residents also, everybody is very kind I like to come here as often as possible.” Lakenheath Village Home DS0000024429.V352584.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 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Good care plans that residents have been involved in preparing are maintained identifying care needs. Residents can be assured that they will have prompt access to medical services whenever these are needed. Residents are given every opportunity and encouragement to make as many decisions about their own lives, as it is safely possible for them to so do. The homes medication storage and administration system is generally robust and gives good protection to the residents. However, some improvements could be made. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 11 EVIDENCE: The health and personal care needs of the residents are met following an assessment of their individual needs and with due reference to them retaining their dignity and respect. A number of care plans were inspected to track how the care was determined and delivered and to see how the level of support required was ascertained. Each plan was well maintained with all files kept in a uniform manner, with information filed within clearly defined sections. The recording was seen to be up to date and regular care need reviews and reviews of risk assessments could also be evidenced, these accommodating changing care needs. In some cases the residents were seen to have signed these reviews thereby evidencing their involvement with this reviewing process. The pattern of care for specific health needs such as pressure area care, catheter and continence care and nutritional care could be evidenced via the various recording charts including a waterlow score, manual handling, wound care and nutritional and weight recording charts which included the management of diabetes. Aids and equipment are provided usually following an OT assessment, these to encourage maximum independence for the residents. The care records reviewed showed that residents have regular access to doctors, the community nursing service, chiropodists, opticians, dentists, Speech Therapy, the Audio and Dietician services and to a Hairdressing service. The manager confirmed that the home benefits from having well-established professional working relationships with local GPs and other specialist medical practitioners. GPs make pre-planned weekly visits to the home and on other occasions offer a prompt visiting service. All the residents were observed to be wearing smartly laundered clothing. Many of the pre inspection surveys commented favourably on the quality and promptness of the laundry services. Overall the personal hygiene of the residents was very good and supported their dignity. Personal care was seen during this inspection to be being delivered to the residents in a kind and understanding manner by staff who clearly understood their care needs both physical and emotional. Staff were seen to reassuringly intervene when a resident became somewhat anxious, this being done in a manner which promoted their independence and feeling of well-being. The home uses the Liverpool Care pathway to support the palliative care and end of life needs of the residents, this in conjunction with the district nursing team. End of life training has recently been delivered for all staff via the MacMilan Nursing service. There have been no changes to the medication administration system since the last inspection. Staff who administer medication have been trained to do so. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 12 The home continues to use the Monitored Dosage System (MDS) and a senior staff member was observed administering medication during this inspection. It was seen that each blister pack had a photograph of the resident for identification purposes. Administration around the home is carried out using a locked medication trolley, which is otherwise stored in the clinical room. This room is kept secure via the use of a coded keypad. The Medication Administration Records (MAR) charts were well maintained with good use being made of the reverse of these to give explanation of changes. Where alterations or omissions were made these were explained either using the recording codes or by written explanation on the reverse of the chart. The manager said that she regularly checks the accuracy of the MAR sheets although no written record of this check could be evidenced. Records of the medication entering and leaving the home are checked in and out with appropriate records kept. The records relating to the administration of Controlled medication were accurately kept. Controlled medication is properly stored within a separate cabinet within the clinic room. Consideration may need to be given as to whether the capacity of this storage cupboard is adequate given the amount of controlled medication prescribed. A record was kept of all homely remedies being administered and a stock balance kept. The home has a protocol in place for the use of homely remedies, which is supported by the general practitioner. The homes medication procedures are generally robust and offer protection to the residents. Two areas where improvements could be made were identified; 1.The need for temperature control and monitoring in areas were medication is stored was discussed with the manager. 2. The need for a system to evidence the regular Management checks of the accuracy of the MAR administration recording records was discussed with the manager. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience a good quality outcome in this area. This judgement has been made using available evidence including a visit to this service. The diverse social and activity needs of the residents are well supported and enjoyed by all. The residents receive a healthy diet of freshly prepared good quality food, which is provided with good variety according to individual needs and preferences. EVIDENCE: The home provides a wide range of activities outings and social events, which are planned to meet individual residents needs and to accommodate their interests and requests. Information about these activity programmes is advertised in the homes entrance hallway and individual activity planning was recorded on the residents care plans. The home employs an activities organiser who works several afternoons each week and in addition a number of care staff lead other activities on a daily basis. The range of activities includes chair exercises, bingo, word searches, a knitting group, craft making, gardening and reminiscing groups. A number of religious services are held in the home whilst Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 14 some residents who are able are assisted to attend services in local churches of their choice. Residents who are able make regular outings from the home assisted by staff or friends and relatives. One such visit to Newmarket was to take place on the day of this inspection. The resident told the inspector that staff always assists them to make these outings, which they do regularly. Other residents spoke with the inspector about the summer visits that they had to the Abbey Gardens in Bury St Edmunds and to the sea at Felixstowe. The programme for activities to be held over the Christmas period was being discussed with the residents when the home will benefit from a number of visiting choirs and entertainers. Being a local village home with strong well established local connections the home benefits from regular visiting from local groups and several relatives and friends of the residents were seen to be visiting the home during the day of this inspection. Without exception the residents’ comments made to the inspector during this inspection and their comments recorded on the pre-inspection survey questionnaires concerning the food provided by the home were entirely positive. Residents said that they always had sufficient quantity frequent variations were made to the menus following the cooks regular discussions with them concerning preferences and that locally sourced and seasonal food is taken advantage of. The meals observed by the inspector during the time of this inspection all looked attractive and appetising and residents were seen to take their time and enjoy having a chat in a relaxed manner during their meal times. Comments such as “ the food is always excellent, so tasty” and “ the cook always makes birthday and celebration cakes for us” were made by several residents. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows the residents to express their views and concerns in a safe and understanding environment. The homes complaints policy is clear and freely available. The home has a good understanding of the policies and procedures concerning Adult Protection and Whistle Blowing and how these give protection to the residents. EVIDENCE: Information concerning the homes complaints policy and procedures was seen to be freely available in the home. Information gathered from residents and relatives evidenced that they had a good awareness of these. Several residents commented that if they had any reason to complain they would first discuss the problem with a member of staff or the manager because they had confidence that things would be sorted out simply without the need to resort to formal procedures. The records showed that the one complaint, not resident related, had been received since the last inspection and that this had been dealt with promptly and according to the homes policy and procedures. There have been no incidents concerning Safeguarding Adults (Adult Protection) since the last inspection. Staff consulted had a good awareness of the homes Whistle Blowing procedures. The training records evidenced that all Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 16 staff have undertaken Safeguarding training and that refresher training on this was ongoing. The home keeps a record of Compliments that it receives and a number were discussed with the inspector. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is very well appointed and subject to regular maintenance and so offers a good environment, which meets the space standards and the residents needs. EVIDENCE: Lakenheath Home is an old vicarage set in its own grounds in a quiet road with good access to the facilities of the nearby village. The building has been renovated for use as a residential home and provides a homely environment with a domestic feel and appearance. The resident’s accommodation is all on the ground floor with staff offices above. The home is attractively decorated and retains much of its old charm and period features. All the resident’s rooms are for single occupation and were comfortably furnished with the choice of colours and furnishings made by each resident to reflect their own interests Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 18 and tastes. All the residents spoken with said that they were very happy with the arrangement of their rooms. Staff assist new residents who have no relatives to help them, set up these rooms. None of the bedrooms have ensuite facilities but the home has adequate bathroom provision located in reasonable proximity to bedrooms. A range of aids and adaptations were seen to be provided to meet individual needs and were often provided following professional OT assessment. The manager discussed with the inspector the planned maintenance programme for the home and showed where redecorations and new furnishings had been provided since the last inspection. Choices of colours and furnishings for the proposed redecoration of the rear dining/ lounge were being discussed and would be shared with the residents. Several residents mentioned the recently complete rear patio area with raised garden beds, which they had enjoyed cultivating during the recent summer months. The garden and grounds are quite extensive and were very well maintained. On the day of this unannounced inspection the home was found to be very clean, with a well-ordered tidiness that did not detract from its homely lived in atmosphere. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Experienced and trained staff are employed in sufficient numbers to support the people who use the service and thereby ensure the smooth running of the service. EVIDENCE: The service is fortunate in being able to retain a very stable staff group many of whom have worked at the home for many years. The home has sufficient numbers of permanent and bank staff so that it only very rarely has to use agency staff and these are always properly introduced into the home before commencing their shift. The home has male carers and can thereby accommodate resident’s choices. The staff were observed to be working very well together as a team in a proactive rather than a reactive manner. They were enthusiastic about their work and clearly had very good relationships with the residents several of whom had also been living in the home for many years. The staff demonstrated a through understanding of the particular needs of the residents and thereby could deliver effective person centred care. The comments made by the residents both written and verbal evidenced that they felt that there Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 20 was always sufficient staff to meet their care needs although some times of the day were always busier than others. Staff spoken with were keen to undertake further training and personal development. The home has a good training record with over seventy percent of staff having obtained a National Vocational Qualification (NVQ) at either level 2 or 3. All senior staff holds this qualification at level 3 and one other member of staff is just completing this qualification. Since the last inspection all staff have attended core training in a range of subjects including palliative care, moving and handling and ‘sloppy slipper’ training delivered in house by the Falls Co-ordinator from the district nursing service. The managers have attended training on Diversity and Equality and plan to cascade this information to the wider staff group. The recruitment records of recently appointed members of staff evidenced that the correct procedures and checks had been carried out and that the new staff had not commenced duties until CRB checks had been made. New staff then work alongside experienced staff whilst undertaking their induction-training programme. New staff told the inspector that they felt well supported by the existing staff team and that they had had time to get to know the residents thoroughly. Care needs to be taken to ensure that references can be fully verified, usually by way of the company stamp and that any other actions that the manager might take to ensure that references are legitimate are recorded. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured a competent, experienced and qualified manager and management team leads the home. The management and administration of the home is based on openness and respect. An effective quality assurance system is in place to ensure people’s views are obtained and incorporated into the running of the home. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. She has a clear understanding of the key principles and focus of the service and her aim is to continually improve an increased quality Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 22 of life for the residents, with a good awareness of the need for equality and an understanding of the diversity needs of the residents. Staff and residents spoken with confirmed that the manager is supportive and approachable. Written comments from relatives also confirmed this and evidenced that the home is run in the best interests of its residents. The home has clear health and safety policies of which staff had a good awareness. Random checks are made by the manager to ensure that standards are maintained. Spot checks made of these records during this inspection including fire testing, water temperature logs and risk assessments evidenced that the records are well maintained and that routine checking is carried out. The manager discussed with the inspector the need to ensure that where a resident chooses to use a hot water bottle this has a suitable protective cover and their safe use is discussed with the resident. She said that a separate risk assessment is carried out and the bottles are replaced for new each year. Records are kept securely and staff are aware of the requirements of the data Protection Act. Residents are able to gain access to their records and to contribute to them if they wish. The good maintenance of these records promotes the safety for the residents. Appropriate Staff supervision records were seen these also evidencing that a programme for annual staff appraisal is in place. Detailed minutes evidenced that staff meetings are well attended and regularly held. It would be advantageous if the dates for achieving any action points recorded on these minutes could be noted on the minutes and to include the person responsible for this action so that these points could be followed through from meeting to meeting. Proper safeguards and recording arrangements are in place to ensure the safety of residents monies kept by the home. Each resident has a lockable cupboard in their rooms where they can keep their money or valuables if they wish. The home has a current Liability Insurance Certificate and the CSCI Registration Certificate was on display. The quality monitoring system includes written questionnaires and the information gathered from these is collated into an annual report. The recently introduced CSCI Annual Quality Assurance (AQAA) form, issued to the home for this inspection, was returned in good time with clear and detailed information. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 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 x 3 x 3 x 2 3 Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement All medicines in the home must be handled in accordance with the Medicine Act 1968, Guidelines from the Royal Pharmaceutical society and the requirements of the Misuse of Drugs Act 1971. 1. The temperature of the medication storage areas must be monitored to ensure it is at or below 25 degrees centigrade. This is to ensure that the clinical effectiveness of medication is not compromised 2. Management checks made of the accuracy of the Medication Administration Record charts should be formally recorded to provide a robust audit tool. Timescale for action 30/12/07 Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP37 Good Practice Recommendations To improve current practice it is recommended that where action points are noted on the minutes of staff meetings these also include dates set for these to be achieved with a named responsible person. Lakenheath Village Home DS0000024429.V352584.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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.V352584.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!