Inspection on 17/10/07 for Lakeview

This inspection was carried out on 17th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Lakeview 22/02/07

Lakeview 22/05/06

Lakeview 02/02/06

Lakeview 08/08/05

Lakeview 01/03/05

Lakeview 13/09/04

Lakeview 08/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lakeview Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA Lead Inspector Unannounced Inspection 09:15 17 October 2007 th 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 Lakeview DS0000022331.V347789.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. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakeview Address Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA 01922 409898 01922 403434 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) www.alphacarehomes.com Alpha Health Care Limited Mrs Christine Armstrong Care Home 151 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (68), Learning disability (1), Mental Disorder, of places excluding learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (25), Physical disability (123), Physical disability over 65 years of age (123) Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Physical Disability (PD) minimum age 60 years on admission Physical Disability (PD) minimum age 49 years on admission - 2 persons 1 DE - Named Resident minimum age 59 years on admission To provide a maximum of three day care places. Date of last inspection 22nd February 2007 Brief Description of the Service: Lakeview Care Home with Nursing, forms part of the Lakeside Site. The home is owned by Ralton Care Homes Ltd, Alpha Care Homes Ltd and was purpose-built during 1996/97. Lakeview is set within its own landscaped gardens and grounds amounting to over 5 acres. It is situated on the main A34 trunk road midway between Walsall and Cannock with a regular bus service stopping directly outside the home. Birmingham, Stafford, Wolverhampton, Lichfield and Brownhills are all within 20-30 minutes drive by car. The services offered by the home are: - Dementia, Mental disorder (excluding learning disability or dementia), Old age (not falling within any other category), Physical disability, Physical disability over 65 years of age. Lakeview has 151 beds and is divided on two floors served by three passenger lifts. Service users are accommodated in single rooms with en-suite facilities. There are a limited number of double/shared rooms, which would be ideal for married couples. The nursing and personal care areas are divided into separate corridors each with its own Head of care, team of nurses and care staff. The units were recently renamed to represent one of the lakes in the Lake District. These units are named as Windermere a 38-bedded residential Unit, Grassmere a 35bedded nursing unit and Buttermere a 25-bedded nursing unit. The 53-bedded mental health unit is located on the second floor and this is now divided into two units 32-bedded unit Ullswater and 21-bedded Loweswater. Fees - £ 309 to £ 550 Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 5 Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Lead Inspector Joanna Wooller carried out this Unannounced Key Inspection with the assistance of Jane Capron, Inspector. The manager, Christine Armstrong was in the home. The post of deputy is currently vacant. The inspection included the following elements; A tour of the building, Observation and inspection of records relating to provision of care, Discussions with several service users, Discussions with several of the staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues and health & safety. We were made very welcome in the home and all assistance was given to gain the evidence required for the report. Care documentation showed many improvements since the last inspection and the home itself and the Commission For Social Care Inspection will monitor sustained improvements. The Commission for Social Care Inspection had dealt with no complaints since the last inspection. Service Users spoken to at the visit were complimentary about the home as were the comments received from relatives. Comments included: “My father is very happy in the home, he has settled really well and other families I speak too feel the same. The staff are kind and the care is good”. “Its not home – but its very comfortable and I feel well looked after” What the service does well: The management have continued to prioritise the improvements to be made at the home and this was evident at this third key inspection. The management team remain open and approachable and the staff value the input and support they continue to be given by Mrs Armstrong and her senior staff. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 7 The home continues to identify its weaker areas and these are identified and action plans drawn up to address the problems. As commented previously the management are positive and forward thinking. Their aim is to promote good practice and excellence at the home. They are fully aware that in a large home such as Lakeview that change takes time but they are appropriately actioning small changes to ensure a sustained improvement. 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. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 8 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 Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 9 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): Standard No 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users are individually assessed prior to admission, which ensures that their needs can be met whilst at the home. EVIDENCE: The home manager, prior to admission, individually assesses each prospective service user either at home or there present setting. Clear notes were evidenced as being recorded in the care records. An admission is only arranged once the home can ensure that the Service Users needs can be met. This is then agreed in writing. Potential Service Users and their representatives have the opportunity to visit the home, read the Statement of Purpose and look around the home with a chance to speak to other Service Users and the management. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 10 Several relatives spoken to confirmed that they had been included in this admission process and procedure and had found the staff most helpful and reassuring to themselves and their loved one. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users individual health, personal and social care needs are set out in care plans to ensure their needs can be met. The documentation seen at the visit was greatly improved since the last visit. The home must now sustain and continue to improve the documentation. There was clear evidence that the service users are treated with respect and their privacy respected. Staff interaction with the service users was also greatly improved, however the staff must sustain and continue to improve this interaction. EVIDENCE: The inspectors spoke to several Service Users during the visit and they spoke openly about the care they received. Some service users had special relationships with some staff but generally they felt the staff were all good and caring. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 12 The service users care plans and associated documentation was evidenced as well written and through case tracking reflected the current condition of service users chosen. Identified assessments were up to date and reflected the current condition of the service user. The documentation seen enabled the inspector to evidence that health and personal care needs were being identified and in most cases addressed by the nursing staff. The documentation had undergone a period of change and staff were now familiar with the procedure and expectations required to individualise the documentation. This however must be sustained and ongoing auditing and review will ensure that the standard is maintained and improved further. The local GP’s practice supports the home and reviews their individual patients. Medication administration was inspected on some units and found to be in good order. A comprehensive medicines policy is in the home along with the NMC guidelines. One visitor spoke to the inspector about the preference of one unit over another and how the staff had supported her to move her relative. One lady said they were pleased with the overall care delivered and had been consulted regarding any changes. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were again seen recorded. Privacy and dignity were being afforded to service users, and the inspector evidenced some good interaction between staff and service users in most of the units. There was clear evidence that the care staff were able to demonstrate privacy issues being addressed in several different ways foremost staff were seen knocking on doors before entering bedrooms and addressing service users by there preferred choice of name.. Lakeview DS0000022331.V347789.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was providing most of the residents with a lifestyle that met their needs. Most people were supported to take part in activities. A good range of meals was provided and people were provided with choice however the service needed to make sure that meals were always served warm . EVIDENCE: The service had made progress in developing the social life of the service. Care plans included social care elements that were completed and reviewed by the activity staff. There was provision for activity staff members in each unit although one activity staff member had recently left one unit recently meaning that unit had less access to activities although they at times had the option to attend other units for activities. Activity schedules were present on the walls in the units. Activities included arts and crafts, music, darts, gentle physical activity and games. Additional activities were provided through external entertainers such as musicians visiting. The service also had a hairdresser that visited the service. There was a church service provided regularly for those that wanted to attend. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 14 Several people within the residential care unit were spoken to and they stated that they very much enjoyed the activities on offer. The stated that they were running a book stall the following day and had been on a number of trips. They were due to go to Walsall lights and had booked to go to a pantomime. Several said they had the opportunity to go to the local pub for a drink. A discussion with one activity staff member confirmed that she knew the people she supported well although the service needs to make sure that activities are also provided for people that may not want to join in with group activities. During the inspection an activity was taking place on the EMI unit. This included singing to wartime music and throwing a ball. One visitor who was there confirmed that regular activities took place on this unit. There was evidence of activities taking place from photos on the walls. The activity staff within the EMI unit had received some training in working with people with dementia care needs. These staff tried to make sure that everyone had the opportunity to take part in activities and provided some 1:1 time with people unable to join in the group activities. The service provided a varied menu that provided people with choices over all meals. A menu was available throughout the service. Several people we spoke to said they liked the food and confirmed that there was always a choice. One person told us ‘there is a choice of food- they know what I like’. The service provided flexible times for breakfast. People could have a choice of cereals or porridge and toast although hot breakfasts were available for people and one person we spoke to confirmed that they sometimes had a hot breakfast. The main meal was at lunchtime and there was always a choice. Apart from the main hot meal, usually some kind of meat and vegetables, there was always salad available as well as jacket potato and omelette. There was always a hot pudding available. The chef informed us that there was always fish available at lunchtime but this was not reflected on the menu of the day we saw. Tea was a lighter meal consisting of three types of sandwiches, a hot meal such as sausage rolls followed by homemade cakes. Both at lunchtime and tea there was always the option of ice cream, fruit or yoghurts available as puddings. Drinks and biscuits were available between meals and at supper people were offered jam sandwiches, fruit and biscuits. In addition to the above the chef informed us that if anyone wanted any thing different he would always try and provide it. The service was able to provide for special diets including some cultural dietary needs, diabetic diets, low fat diets, soft and pureed diets and currently was providing one person with a gluten free diet. We noted that the pureed meals were well presented by the catering staff with each food being pureed separately. We did see however one staff member mixing all the food together making it look very unappetising. Due to concerns that some food particularly the pureed food was not being served hot the service had purchased a ‘bain-marie’ for each unit in order to keep food hot as some people had to wait to be fed by staff. We saw however that some staff were not taking advantage of this system and serving out meals before they were needed and placing them on the side. This meant that Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 15 some people were not receiving meals when they were still warm. We also noted that in one unit 16 puddings had been served and were left on the side for some time before being provided to people, allowing them to go cold. The service encouraged relatives and friends to visit the service and throughout the inspection we saw lots of visitors coming into the service. We spoke to several relatives and they said that they were made welcome by the staff. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has procedures in place to respond to complaints but needs to make sure that outcomes are always recorded. Training and staff awareness of safeguarding issues was helping to protect the people that lived at the service. EVIDENCE: The service had a complaints procedure that was provided to people that lived at the service and to their relatives. The service maintained a record of complaints. There was one complaint recorded but there was no written information about the actions taken by the service and how the issue was resolved. The manager was able to explain the actions taken. The home had an adult safeguarding procedure in place and had a training plan in place to make sure that staff were aware of safeguarding issues and how to respond to any issues. The training programme offers all staff training in safeguarding issues. We spoke to staff members and they were aware of safeguarding issues including symptoms. They were able to describe how they would react if they had concerns of a safeguarding nature. There was evidence that the service had responded appropriately to safeguarding issues Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 17 and was referring any potential incidents to the local authority. Staff working on the EMI unit were aware that incidents of verbal and physical aggression could relate to people’s illness and were aware of methods of how to respond. The service had facilities to look after people’s money. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 Quality in this area is poor The service generally provided people with adequate accommodation but there were areas that needed to be better maintained. The people living in the EMI unit would benefit from having an environment that supported them to become better orientated through for example the use of colour and use of pictures. The service provided equipment to maximise people’s independence. The accommodation needs to be kept at an acceptable temperature throughout in order that people can live in a comfortable environment. There were areas of the service that were very dirty and the service needs to make sure that all areas are kept clean to control the risk of infection and to ensure that people are cared for in a clean and pleasant environment. EVIDENCE: Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 19 The service is divided into a number of units each having its own lounges, dining room and kitchenette. The vast majority of bedrooms are for single occupancy but the service does have a number of shared rooms. All rooms have ensuite facilities. The service has an ongoing improvement plan to improve the accommodation. New carpets had been provided on Buttermere unit and a number of bedrooms had been decorated. The lounge on Windermere, the residential unit was of a good standard – very homely with new carpets. Carpets on the EMI unit were cleaner. Bedrooms throughout were of a suitable size and a number of those seen had been well personalised with photos, ornaments and with small bits of furniture people had brought to the service. Two of the shared rooms we saw did not have privacy screens. The EMI unit whilst providing adequate accommodation is not decorated to take account of people with dementia care needs. The service was in most areas generally satisfactorily maintained however we did find a number of issues that needed attention. In the EMI unit we found that in one toilet the basin was unsafe being loose and the tap was unstable. In one bathroom the bath had a hole in it. We also saw that a window restrictor was broken. We also saw that some of the wardrobes were not secured to the wall and could cause a risk to people. We found that it was cold throughout the EMI unit due to many of the bedroom windows and corridor windows being open. Bedrooms were so cold it would have been uncomfortable for people to spent time in them. We also found the temperature of water varied. In one toilet the water temperature was too cold and in another it was very hot. Throughout the service there were issues of hygiene. We found that the kitchenette in the EMI unit was very dirty. The wall, the areas round the servery, behind the fridge, under the microwave, round the skirting boards and in the cupboards all required deep cleaning. We also found in several bedrooms issues of concern. In one bedroom there were crumbs on the floor, a hoist showed no signs of being cleaned recently, the area behind the door in one bathroom was filthy and there was dirt below radiators. Disposal bins in bathrooms did not have lids and one bath had mould around the sealant. In two bedrooms we saw bedrail protectors that had excrement on them. There were no paper towels for the hand-washing basin in the laundry or in one of the bathrooms. We also saw that in one shared room that there was only one bowl for washing, no soap and the razors were not named meaning that people may be sharing razors. The service had a laundry that had adequate washing and drying facilities. We did find that there were areas of the laundry that were dirty. These included the basin for hand washing and around the washing machines. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 20 The service provided a range of equipment to support people. The service had assisted baths, hoists and wheelchairs. Corridors had rails to aid people’s mobility. The service had a range of seating including high backed and reclining chairs. All bedrooms had call alarm facilities. Lakeview DS0000022331.V347789.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service, from evidencing records and from discussions with the management. Staff numbers and skill mix appeared to be satisfactory for the service users in the home. Service users confirmed that they felt they were in safe hands as the staff were competent and well trained. This group of standards was found as adequate due to staff records being incomplete and it is required that they are in line with that listed in Schedule 2 of the National Minimum Standards. EVIDENCE: There was evidence that the home was providing adequate staffing levels to meet the individuals’ needs. This again included providing additional staffing at busy times such as in the morning and at lunchtime to assist some service users to eat their meals. There was evidence that the staffing levels were based on the numbers of service users in each unit and their level of dependency. All the nursing units had a trained nurse on duty. The staffing on the EMI units was at a greater level than on the general nursing units having a qualified nurse on each unit throughout the day and nine care staff on the morning shift and seven on the afternoon shift. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 22 Although staff worked on a specific unit there was some movement of both Service Users and staff between the units depending on specific needs. In addition to the care staff at the home there were activity staff attached to each unit. With regard to providing sufficient domestic staff for a home of this size there was serious questioning. The cleanliness and hygienic state of the home was less than adequate and requirements were made to ensure that improvements will be made. The inspectors were provided with a selection of staff records including the trained nursing staff. Criminal Record Checks, references, staff training records were evidenced. In general they were evidenced to be adequate, a minimum of sections were incomplete. There is a requirement for the records to be reviewed to ensure that all the records had a current photograph, and copy of a birth certificate. The training matrix and records evidenced that statutory training was up to date and current. The manager, with the support of the administrator ensure staff training is up to date and sessions are planned. Lakeview DS0000022331.V347789.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users confirmed that they felt they lived in a well-run care home. The service users benefit from strong leadership and the home is run in the best interest of the home. Financial interests are safeguarded and staff were appropriately supervised. The health, safety and welfare of the service users and staff are promoted. EVIDENCE: From observations made, the discussions with service users and relatives, and discussions with the manager and staff, it was evident that the home was continuing to be run in the best interests of service users. Relatives generally spoke positively of the Management at the home and felt that the Manager was approachable. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 24 The Inspector checked all relevant records required meeting the National Minimum Standards, these included fire records, electrical testing, hoist servicing and testing, accident records and staff training relating to food hygiene, moving and handling and fire training. This was all in order and had been monitored well to ensure compliance. Again it was evidenced that all service users had the opportunity to handle their own finances and that most service users and their families had chosen to do so. The home had robust detailed systems in place that cross-referenced the transfer, receipt and expenditure of Service Users personal finances. Service users surveys were taken in January 2007 these documents have been forwarded to head office and comments had now been actioned in the home. Records evidenced service users meetings in each of the units with staff. Staff were being appropriately supervised but this must now be maintained and updated as necessary to maintain staff competencies and enthusiasm. Records in the home were in good order and available as required by the inspector. Records were kept secure and in accordance with the data Protection Act. The health, safety and welfare of service users and staff are promoted and protected by the safe working practices in the home. The health and safety of service users and staff is ensured by close monitoring of hazardous substances, water and electrical systems. The records for fire prevention in the home and testing of the fire system was current; the fire drills had now been appropriately recorded. Risk assessments, accident records and regulation 37 notices were in order and audited to assess the safety of service users in the home. Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 25 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 3 X 2 2 1 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 X 3 Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes 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 OP19 Regulation 23 (2p) Requirement Timescale for action 01/12/07 2. OP29 Schedule 2 The service must be well maintained including water at suitable temperatures to ensure that people live in safe and comfortable accommodation. The registered person shall ensure 01/12/07 that all the required elements required in Schedule 2 were current on the staff files. The registered person shall ensure 01/12/07 that the home have procedures in place to ensure that meals are kept warm for residents. Previous timescale of 22/03/07 not met The registered person shall ensure 10/11/07 that satisfactory standards of hygiene are maintained in the care home. This will make sure that people have a clean and hygienic accommodation and that the risk of the spread of infection is controlled. Previous timescale of 22/03/07 not met 3. OP15 16 (2i) 4. OP26 16 (2j) Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 27 5 OP21 23(2d) 6 OP25 23(2)(p) The registered person shall ensure 01/12/07 that suitable toilet, washing and bathroom facilities are provided to meet the needs of the service users. The service must be kept at a 01/11/07 suitable temperature to make sure that it is comfortable for the people that live there. 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 OP12 Good Practice Recommendations To look at ways of developing the person centred approach for residents with dementia care for example introducing of life storybooks and memory boxes. To look at ways of providing activities to those that cannot or do not wish to take part in-group activities. To make sure that people are made aware of all meal choices of meals and that pureed meals are well presented Where complaints have been received and dealt with adequate records should kept. To develop the environment to aid residents with dementia care needs to maximise independence and minimise confusion for example pictorial signs and use of colour to help with orientation. Screening to be provided in all shared rooms to maintain people’s privacy. To further record the time of day/night and time taken to execute the drill. For the staff to sign personally when they are involved in a drill. 2 3 4 5 OP12 OP15 OP16 OP24 6 7 OP24 OP38 Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House, 45-56 Stephenson Street, Birmingham B2 4UZ 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 Lakeview DS0000022331.V347789.R01.S.doc Version 5.2 Page 29 - 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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