Inspection on 07/09/05 for Lakenheath Village Home

This inspection was carried out on 7th September 2005.

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

Other inspections for this house

Lakenheath Village Home 05/10/07

Lakenheath Village Home 29/11/06

Lakenheath Village Home 11/01/06

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 Debbie Seddon Unannounced 7 September 2005 th 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 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 I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lakenheath Village Home Address 7 Back Street, Lakenheath, Brandon, Suffolk, IP27 9HF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01842 860605 01842 861661 None Mr Bruce Rutterford Christian Enterprises Foundation Mr Adam Went CRH 21 Category(ies) of OP - 21 registration, with number of places Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 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. The Trust is administered by a Board of Trustees. 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 it’s 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 I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced incorporating an investigation following an anonymous complaint received at the commission for social care inspection (CSCI). The inspection started at 10am over seven hours during a weekday. Time was spent with the manager, deputy manager and administrator to discuss how the home had addressed the previous requirements and the complaint. Three members of staff and three service users were spoken with separately and a number of records were examined relating to service users, staff and medication. A member of the board of trustees was at the home and a social worker was visiting during the inspection, both spent time talking to the inspector. A management meeting was held during the inspection, the inspector was invited to attend and a tour of the premises was made. Investigation of the complaint concluded that although there was evidence throughout records examined that there had been issues with a particular member of staff, the management team had dealt with the situation appropriately in line with their disciplinary procedure and were continuing to supervise and support the individual. Service users and staff spoken with gave no evidence to suggest there were any concerns with staff attitude and conduct. What the service does well: The home presents a nice friendly atmosphere and service users spoken with gave positive feedback about the staff and service they receive. They spoke of the home as ““best home ever, it is a good home” and “carers love you, do all they can for you, cooking, cleaning and washing, it’s beautiful, we are not neglected at all, it is a lovely place” and “the home is top hole” The care plans are very detailed and contain the necessary information to ensure that service users needs are identified and met and monitored on a regular basis. Service users wishes are documented and respected with respect to the sensitive issue of death, dying and serious illness. Social services have a contract with the home for one respite facility; feedback from a social worker was that this is considered to be an excellent service and that the feedback from service users is always good and the bed is always occupied. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 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. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 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 standard(s) 1,3,4,6, 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 home has a statement of purpose, and residents guide both gave relevant information about the home for prospective service users and were found to meet the relevant regulations and standards. No changes had been made since the previous inspection in March 2005. Three service users care plans were seen. Each care plan had a detailed pre admission assessment, comprising of 13 sections, which contained key information about the service users background and care needs. At the bottom of each element of the pre admission assessment there was a requirement for the home to state whether or not the home could meet the identified need. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 9 All the information from the pre admission assessment formed the basis of the individual service users care plan. Each care plan seen had an application for residency which was either completed by the service user or their next of kin and one service user had had an advocate involved in making the application on their behalf. The home does not provide intermediate care, however, they do have one respite bed, which is on a contract basis with Suffolk Social Services. During the inspection a social worker arrived to discuss with the manager the needs of a service user being admitted for a period of respite. The social worker informed the inspector that the home offered a very good service, they commented that” the respite facility was terrific, the bed was almost always full and that the home is very accommodating and will assist at short notice to complete an assessment of need for service users needing respite quickly” they also spoke of the care “as very good and that staff are excellent, no bad comments and that service users who have stayed at Lakenheath Village home always want to come back,” Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Service users can expect to have their health and personal needs identified and reviewed on a regular basis to ensure that their needs are met at all times. Service users can expect to be protected by safe administration of prescribed medication. Service users can expect to be treated with respect and dignity and have their wishes respected at the time of their death. EVIDENCE: Service users care plans seen were well organised and maintained. Each plan detailed the abilities and needs of service users with respect to a range of issues including communication, eating and drinking, elimination, controlling body temperature, washing and dressing, mobilising, sleeping and night care, mood, oral hygiene, working and playing and expressing sexuality. One service users plan looked at identified that they suffered with asthma and made staff aware that they were susceptible to chest infections and breathlessness on exertion, another service user was sensitive to penicillin. One service user ‘s care plan identified that they had a colostomy bag in place. A body map was used to inform staff where the colostomy was positioned and Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 11 regular entries were seen where the care plan was updated. The service users weight was being monitored and a record of clinical visits was kept. The contact details of the stoma nurse were noted in the front of the care plan. Service users had current moving and handling assessments on file as well as risk assessments around specific risks such as falling. The care records evidenced that care plans were reviewed on a monthly basis with the service user signing the plan to confirm their involvement. At the previous inspection it was noted that Bedsides or ‘cotsides’ were being used. Whilst the risk assessment held on the service users care records covered issues such as whether there was a risk of the service user climbing over these bedsides and consent for use of them had been given and recorded, the risk assessment did not identify why bedsides were required in the first instance. Evidence was seen at this inspection that risk assessments had been amended to identify the need for ‘cotsides’ to be used, however, in one care plan looked at this had not been updated. Formal risk assessments identifying pressure care were seen on each service users care plan, the Waterlow pressure sore risk assessment format was being used and there was evidence seen that these were being updated on a regular monthly basis and that the district nurses involvement had been sought. Records of clinical visits were kept with a continuation sheet to follow up advise from the general practitioner (GP) or district nurse. The monitoring of pressure sores and potential pressure areas, together with any remedial action taken is adequately documented within the service user’s care records. The manager confirmed that a policy and procedure had been implemented and showed a copy to the inspector; this was a requirement from the previous inspection. The homes policies and procedures for the administration of medication were seen. The home has procedures on administration of medication, including controlled drugs and safe storage of medicines and equipment, prescription and verification of drugs and medicines and procedure for disposing of unwanted drugs and medicines. Medication is kept in a room called the clinic, the door is locked at all times and the lock is operated by a pin number keypad. Lakenheath Village home has close links with a local doctors surgery, the General practitioner (GP) holds a surgery once a week at the home and will see service users individually in the privacy of their own rooms. Service users can request to see the GP and their name is recorded in the diary in advance. Six service users had seen the GP on the 6th September One of the service users as a result of the visit had had their medication changed. A member of staff had been to the pharmacy to collect a prescription, which they had taken to the chemist to be dispensed and had collected the medication. A senior member of staff was observed booking in the new medication. The service user Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 12 had been prescribed Haloperidol liquid instead of tablets and their cobendolopa had been changed to dispersible tablets instead of capsules. The senior checked the name of the medication, the dose and the date on the label and recorded an entry on the medicine administration record (MAR) chart. The previous tablets were recorded as stopped and dated and signed. An entry was also made into a communication book to inform other senior staff of the changes made. The home has a controlled drugs cabinet, which is a metal lockable cupboard, situated inside another cupboard. The controlled drugs book was locked separately. One service users controlled drugs was tracked, the MAR sheet showed the name and dosage, and that the medication Temazepam was prn (as required) the number of tablets held in the controlled drugs cabinet matched the record in the controlled drugs book. The home uses the Boots monitored dosage system (MDS). The blister packs are housed in a locked cupboard in the clinic room and the medication trolley, which is kept locked and secured to the wall. When medication is being administered, the blister packs for the time of day are taken form the locked cupboard and placed into the trolley and taken to the service users. The MAR charts use a colour code as well as the date and time to highlight the time of day that medication is administered and to highlight the PRN medicines. Any medication that is refused by the service user is disposed of in a separate container and returned to Boots. An entry is recorded on the MAR chart as refused and an explanation recorded on the reverse of the MAR chart. MAR charts seen were all signed with no gaps. The home has a cupboard of homely remedies, which has a stock of paracetomol, soluble paracetomol, cough linctus, imodium and senna. They also held asprin, which the inspector was informed was administered on the advice of the GP. These were being administered to service users and staff, however there was no agreement with the home and the pharmacy of these medicines being kept and administered. The home did not have a policy or procedure for guidance to staff on the implications of administering medication alongside prescribed medicines. The senior staff spoken with confirmed that they had had initial Boots MDS training and yearly in house refresher training focusing on the homes procedures with a test at the end of the course. A rota on the notice board in the clinic room showed three staff are booked to undertake the Boots MDS training on the 12th September 2005. Service users privacy and dignity was seen to be respected throughout the day. One service user spoken to confirmed “that staff were courteous and polite when talking to them and that they felt their privacy and dignity was respected and that they had never had any concerns with staff helping them to wash and dress”. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 13 Each service users care plan has a section, which discusses their preferences in the event of death and dying. One service users wishes had been discussed and respected with the assistance of an advocate. It was documented and signed by the service user and witnessed that it was their choice not to be resuscitated or kept alive by artificial means and it was also their wishes to leave their kidneys to be donated for medical purposes. They had also expressed that “no one was to view them when they were dead and that they wished to be cremated”. Another service user chose not to discuss dying. Their decision was reviewed on a regular basis. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 Service users can expect to live in a home that supports a lifestyle that matches their expectations and to be able to maintain relationships with family and friends. Service users can expect to be supported to take decisions about choice and control over their daily lives. EVIDENCE: During the inspection the management team were having a meeting to discuss and risk assess an outing to the coast. The trip was to the Red Cross centre in Felixstowe, which is situated on the sea front. One of the management team had been to the centre to check out the facilities prior to the trip. The facilities seen were adequate for the service users; the building was on one level with ramps for easy access in place for wheelchair users and had wheelchair accessible toilets available. There were tea and coffee making facilities, and a fish and chip lunch was being organised. The outing was for 14 service users to be accompanied by 16 staff. Service users spoken with were looking forward to the trip. During the afternoon a bingo session had taken place, this had proven to be a popular choice amongst the service users. Two service users informed the inspector that they attend a church service held at the home every Sunday and another service user spoken to said, “they enjoyed the bingo and trips out, but did not always join in as their two daughters visited most afternoons”. Other Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 15 relatives were seen visiting during the day and entries in the visitor’s book suggested that visitors were regular to the home. Service users are encouraged to have choice and control over daily aspects of their lives, care plans seen show that service users are encouraged to hold keys to the front door so they can come and go as they please, also to have a key to their own room and a key to the lockable storage safe in their own rooms. Service users sign a document to accept or refuse to hold their own keys. Service users spoken with described their experiences of living in the home. One service user quoted “I can’t expect to get anything better than I get, the home is top hole” and that “they would not change anything”. The service user had brought their own furniture and possessions and was very happy with their room, where they chose to spend most of their time. Another service user spoken with described the home “best home ever, it is a good home” and “carers love you, do all they can for you, cooking, cleaning and washing, it’s beautiful, we are not neglected at all, it is a lovely place”. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. Service users 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 Commission for Social Care Inspection (CSCI) received an anonymous complaint about the attitude of a member of staff. The complaint was investigated during the course of the inspection. The inspector looked at various records including staff files and the complaints log. They also talked to staff and service users; there was no negative feedback about the conduct of any members of staff. There was several entries in records to suggest that there had been several incidents involving the member of staff, however, there was good evidence to suggest that management team had addressed the issue in an appropriate manner in line with the home’s disciplinary procedures and was continuing to support the member of staff through regular supervision. The inspector was shown a copy of the homes disciplinary policy and the manager had acted in accordance with the written procedures. The complaints log showed that service users were able to make complaints and know that they would be dealt with in an appropriate manner. All complaints were logged and investigated by the manager and a record of the outcome made and feedback to the complainant whether it was the service user or relative on their behalf. The complaints log seen showed that 3 Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 17 complaints had been received and dealt with since the previous inspection in March 2005. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 Service users 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: The inspector made a brief tour of the home. The building was found to be clean, pleasant and hygienic. All service users accommodation is on the ground floor and accessible. The upper floor is used solely by staff. All the service users bedrooms seen were nicely decorated and had their own possessions to personalise their room. The home was found to be clean, bright and well maintained, however, it was noted that the ladies staff toilet and dressing area required some decoration. The home is an old vicarage and the interior although equipped for service users safety, retains a lot of its old charm and period features, there is a library, which is used mostly by service users and their relatives when they visit. There is a table and chairs which offer a private space for the relatives to have a meal with the service user. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 19 The home had an assessment carried out on 29th March 2005, by an independent Occupational Therapist (OT) to assess the fixtures and fittings required in order to improve the health and safety of the service users. Several recommendations were made by the OT, including the installation of handrails and grab rails at entrances and doorways. The home has eight toilets and 3 bathrooms, one of which had a walk in shower. The OT recommended that the home replaced all the raised toilet seats with new pieces of equipment or highlevel toilets and appropriately positioned grab rails. Evidence was seen that a programme of replacement and installation of rails was in progress. The chairs in the lounge were seen to be in good condition, but were all the same height and style. The manager informed the inspector that the OT had suggested that these chairs be replaced with a variety of seat heights to cater for the differences in height of service users and that the home has obtained some money from a charity to replace the chairs and change the fire place. 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 service users to use in the nicer weather, however, the manager was in the process of trying to update the call system to integrate a system for service users to call for assistance when outside. In the entrance hall there was a small side room that housed the standing aid and other moving and handling equipment. 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 service users to see. The fire alarm panel was high on the wall and one member was unable to reach it, however, the inspector was assured that all other staff could reach and that the member of staff that could not always had someone with them who could reach. Steward Safety Supplies had checked the fire fighting equipment around the home in June 2005. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Service users can expect to be cared for by a team of staff who have the skills and knowledge to care for them. Service users can expect to be cared for by a staff team who are supervised, supported and available in sufficient numbers to meet their needs. EVIDENCE: The staff rota seen indicated that there was sufficient staff on duty to meet the needs of the service users. There was 4 care staff plus 1 senior on duty between the hours of 7.45am to 3pm and 2 care staff plus 1 senior between 2.45pm to 10pm, and 1 carer and 1 senior on waking night duty between 9.45pm to 8am. In addition to the care staff, there was an activities coordinator, cook, kitchen assistant and 2 domestics on duty throughout the day. The three care staff on the afternoon shift were spoken with and had a range of skills and knowledge. The senior member of the care team had completed National Vocational Qualification (NVQ) levels 2 and 3, and was hoping to undertake her NVQ assessor award soon. They were booked to go on a foundation course in health care training on the 22nd September 2005 and had recently been on a course on Strokes and after care. They felt the training had been excellent and gave them a better understanding of the needs of 2 service users at the home who had had a stroke. They commented that staff received a lot of training and that they had a good staff team. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 21 Another member of staff spoken with was a new employee and had been working at the home for 3 weeks. They felt that they had been well supported by the other staff and had also found the management team very supportive and approachable. The member of staff was undertaking her induction training and was being supervised by the senior member of staff. They informed the inspector that they were booked on a moving and handling course at Kerrison on the 15th and 16th September. The third member of staff spoken to commented that they loved working at the home, and that they found the management team to be supportive and helpful. They had completed their NVQ 2 and 3, and received a lot of training. They had also been on the stroke course and were able to tell the inspector how strokes can affect people in different ways. They had also been on food hygiene courses and moving and handling. Staff files looked at confirmed that staff received core training which included moving and handling, fire and evacuation, control of substances hazardous to health (COSHH), First Aid, food hygiene and that staff completed the induction and foundation training in line with the sector skills council for social care (TOPPS), however, there was no evidence seen the files that staff had received adult protection training. Other training consisted of optical care, listening, loss and bereavement and communicable diseases and infection control. There was evidence on each staff file seen that regular supervision with staff was taking place, and in one file a compliment’s record from a relative of one of the service users had been included and feedback to them during supervision. The compliment read “I feel I must say your 2 new members of staff are both wonderful carers and very kind and caring, nothing is too much trouble for them, a big thank you to them both” Staff files seen contained all the appropriate paper work involved in their recruitment, all staff had had an enhanced criminal records bureau (CRB) check and evidence of these were seen on a separate file locked in the managers office. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36,38 Service users can expect to live in a home, which is effectively managed. EVIDENCE: The senior management team comprises of the manager and a deputy and the administrator. During the inspection the management team had a meeting and the catering manager also attended. Several issues around the running of the home were raised and the previous actions discussed. Issues ranged from replacement carpets being fitted, quotation being obtained for alterations to the call system, bed linen, night staff cleaning wheel chairs, care needs of individual with failing health and the need for an assessment to be made of their care needs, food hygiene training booked for the new employee, a CRB returned for new cleaner to be contacted for a start date and the complaint. Issues around the food budget were discussed and problems with the diseased trees at the front of the premises. (The district council were coming to look at the trees as they are protected by preservation and conservation orders.) Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 23 All items on the agenda were actioned or another date set for completion. Another management meeting was made for the following Monday, 12th September 2005. A member of the board of trustees was present at the home on the day of the inspection. They oversee the running of the home and look after the financial viability of the home. They also held the registration for the criminal record bureau (CRB) checks made from the home and discussed with the inspector that the volume of criminal record bureau (CRB) checks produced was not enough to warrant their own registration and may look to use an umbrella body in the future. At the previous inspection the home did not have a valid certificate of employer’s liability on display. The manager showed the inspector the current issue of the document, which was dated from the 10th March 2005 – 9th March 2006. The home has a comprehensive file of policies and procedures. The manager had purchased the complete file on a computer disc (CD Rom) from the British Federation of Care Homes and had adapted these to meet the requirements for Lakenheath Village Home. These were being reviewed on an annual basis as part of the quality assurance process. Evidence seen on staff files and discussion with staff confirmed that staff were receiving regular supervision, training and support appropriate to their role. Water temperatures were being monitored on a regular basis, however the inspector was informed that the shower was only being used on average twice a week. A discussion took place of how the home manages the risk of legionnaires; due to water sitting in the pipes and showerhead for periods of time. There was no procedure or risk assessment in place to assess the risk of legionella bacteria growing in stagnant water or removal of dirt and limesacle from the showerhead. All water outlets had been fitted with mixing valves and thermostats fitted to prevent the risk of scalding. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x 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 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x 3 x 2 Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 7 Regulation 14, 15 Requirement The registered person must ensure where bedsides are in use, that their reason for use and percieved risk to the service user is recorded. The registered manager must ensure that the home has safe systems for administering, disposal, handling and storage of homely remedies and records kept of when homely remedies have been administered to a service user. The registered manager must also ensure that the home has a written policy or procedure for guidance to staff on the implications of administering medication alongside prescribed medicines. The registered manager must make arrangements for all staff to attend training in the protection of vulnerable adults to prevent service users being at risk of abuse. Timescale for action 7th October 2005 2. OP 9 13(2) Sch3(3) (i) 7th October 2005 3. OP 30 13(6) 7th November 2005 4. Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 26 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 OP 19 (2) Good Practice Recommendations A programme of routine maintenance and renewal and decoration of the premises is implemented and records kept, this relates particularly to the staff arrangemnts ladies toilet and changing room on the 1st Floor. The registered manager should make arrangements to ensure the health and safety of service users regarding the frequency of use of the shower and the risk of legionella. 2. OP 38 (3) Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 5th Floor, St Vincent House 1 Cutler Street Ipswich Suffolk, IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lakenheath Village Home I54-I04 S24429 Lakenheath V248031 050907 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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