Inspection on 22/05/06 for Lakeview

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17/10/07

Lakeview 22/02/07

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 Mrs Joanna Wooller Key Unannounced Inspection 22 May 2006 9:15 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.V291352.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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) Alpha Health Care Limited Mrs Tracey Belinda Arms Care Home 151 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (53), Mental Disorder, excluding learning of places 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.V291352.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. Date of last inspection 2nd February 2006 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, Thirlmere is located on the second floor. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was planned as unannounced. The lead inspector and two co-workers carried out the inspection. The Manager Mrs Christine Armstrong was in the home and assisted the inspectors throughout the day. The key standards were identified for this inspection and the methods in which the information was gained included service user and relative informal interviews, case tracking, general observations and document reading. Prospective service users are able to read this report prior to moving in to the home. What the service does well: What has improved since the last inspection? Through robust recruitment and staff movement Ms Armstrong is building the team of staff who demonstrate the standards of care and professionalism that she expects. The service is open and accessible, Ms Armstrong is available at least one evening a week to ensure that she is able to meet relatives/visitors who visit at this time of day. Robust systems have been introduced to record staff training and quality audits have commenced. Overall the general tidiness and more importantly the cleanliness of the environment have improved for the service users but improvements are still Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 6 planned. Service users appeared comfortable within the lounges and commented that they were generally happy to sit with other ladies and gentlemen. 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. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. Each resident had a contract signed; following a full pre admission assessment to ensure their needs could be met in the home. The service user or relative receive a letter to confirm this.. Prospective residents and their relatives are invited to look around the home prior to making a decision. EVIDENCE: The documentation seen at this visit, the inspector evidenced that individuals had been assessed prior to admission and they had been enabled to make a choice about the home. All family members/ friends etc had the opportunity to visit the home prior to the service user choosing to stay. Several residents and relatives spoken to had visited the home prior to making a decision. Disabilities and sensory disabilities are catered for at the home. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within some service user Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 9 plans. Relatives when asked said they felt that the admission process was informative and reassuring. Their relative had been welcomed by the staff and made to feel at home straight away. Some service users confirmed that they had been fully involved with the admission process and were in agreement with the assessment results. This continues to be one area that the manager wishes to develop in the near future. The records seen and a discussion with the staff evidenced that some care staff had the necessary experience and skills to meet the assessed needs of the current service users whilst other required further supervision, which had been already identified by the management. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. Most care documentation was incomplete and did not reflect the service user as an individual- (with the exception of those on Windermere unit.) New care records had not been completed satisfactorily on most units. Medication audits had been completed and reordering system had been introduced to avoid waste and unnecessary medication. The drugs room on Thirlmere unit was in a very poor state and an immediate requirement was left. EVIDENCE: The manager prior to the previous inspection had identified this area of development. Staff at that visit was spoken to by the inspector and they were aware of the new aims and the general ethos of the home and felt that the new manager will assist them to achieve the levels expected of them. However the service user plans and associated documentation were in place in some care plans and not in others some was completed very basically and some had old documentation within it. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 11 The documentation seen at the visit made it difficult to evidence that health and personal care needs were being met. Service users did not appear to be documented as individuals and some incidents followed through with case tracking were not documented in the correct manner. Essential needs such as communication and daily life were not being documented along with personal likes and dislikes or sleep patterns. It was identified that major work was required within the records and an immediate requirement was left. On Windermere Unit the care records were individual, personalised, complete and up to date and a credit to the residential unit manager. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, but not all these events were seen recorded. During the inspection the inspector spoke to many service users who felt generally content with their life in the home and the care they received. It was observed by the inspector that there was interaction by some of the staff. One senior carer in particular was very aware of the individuals in her care that morning. Care staff was seen knocking on doors before entering. Medication Issues Oxygen in the treatment room on Thurlmere was not stored appropriately loose bottles were upright with no chains; Ms Armstrong told the inspector she was awaiting an external oxygen store. The medication room on Thurlmere unit was in a dreadful state. It was untidy, dirty and had all manner of articles around the windowsills and worktops. An immediate requirement was left to rectify this. No other issues were raised re medication. Relatives spoken to felt that the staff worked hard to meet the individuals needs but were pushed for time and nearly always seemed to busy to chat. Two senior carers on Thurlmere were very interested in mental health and the service users on the unit. They were able to discuss with the inspector about the individuals life history, which was very interesting. This attitude needs to be developed throughout the home. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. For many of the residents the lifestyle provided at the home is meeting their needs. They are provided with a range of social activities and are provided with choices over their meals and how they spend their time. Whilst the dedicated activity staff are making a difference the absence of social care plans and life histories for residents in the EMI unit is not providing the staff with the necessary information to be able to provide residents with a lifestyle based on their preferences and previous experiences. EVIDENCE: The home has dedicated activity staff for each unit, which was making a difference to the lives of residents. Staff and residents on Thirlmere unit, the EMI unit, stated that the activity staff were providing residents with activities five days a week. These included some individual activities as well as group activities such as listening to music, arts and craft, and bingo. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 13 It was noted during the inspection some care staff spending time and talking with residents there was scope for all staff on Thirlmere Unit to be more geared to the social needs of the residents and to more regularly interact with residents. During the inspection there was little activity-taking place on the unit and most residents were asleep. Case tracking on that unit showed that files did not contain information about residents social care needs nor had records of residents likes and dislikes. The residents in other units were also benefiting from activities. The home had arranged some trips out including to West Midland Safari park, Lichfield and during the summer the home had hired narrow boats for some day trips. The home had entertainers coming into the home, which all residents could attend. Residents on Windermere unit stated that they enjoyed the activities and would have liked more. The activity staff member did provide a range of activities including wood searches and quizzes for residents to do in her absence. Two of the residents on this unit regularly went out, one going for walks and another getting the bus and going shopping. Care plans on this unit did outline residents social care needs. The home had a Church of England and Catholic priest visiting and one resident and one resident played the organ and arranged a short service for residents on Windermere unit. Residents had the opportunity to have their hair done and residents in all units were using this service. The routines within the home were quite flexible although meals needed to be taken within a time framework. Residents were able to get up when they wanted. Residents were able to spend time in their rooms or in the communal areas. The homes welcomed visitors at any time and during the inspection a number of visitors were seen. Visitors were able to see a relative in private. Visitors to relatives in the EMI unit were taking an active role in the care of their relative. Residents were able to bring in small items on furniture and bedrooms were personalised with residents’ possessions. Residents spoken to liked the meals. They confirmed that there was a choice at mealtimes. The menu was not seen displayed within the home. The home previously had provided a cooked breakfast every day but due to wastage this had been reduced to twice a week. However any resident who wanted a cooked breakfast could request one. Some residents had done this but others did not seem to be aware of this option. The home provided the main meal at lunchtime, which consisted of a meat dish, and always two vegetables. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 14 The meal at teatime was lighter and there was always soup and sandwiches and often a cooked option such as on the day of the inspection ‘leek and potato bake’. The home reported that drinks were provided through the day and for those that wanted it supper was available. The night staff was able to provide snacks and drinks throughout the night. The home provided a diabetic menu and provided a soft and pureed diet. Residents that needed food to be thickened were provided with this. The home had responded to one resident’s wish for an Afro-Caribbean diet. Observation took place of residents in the dining room of Thirlmere unit having their lunch. A number of residents needed support to eat their meal and the staff on duty were providing this. Residents were encouraged and promoted to eat and the home had made efforts to provide implements and plates that would help them to be as independent with eating as possible. Three relatives were spoken with they were satisfied with the care their relative received. Each one complimented the staff and their commitment to the job. There were small issues like glasses when broken and the family not being informed for about five days (screw missing). One gentleman who comes in four days each week to feed his wife was not provided with a drink despite the time spent in the home. Residents spoken with (8) were pleased with the care and the staff who provide it. The food was good and there was plenty of it. They could choose to stay in their bedrooms and the staff popped in to see them. They had a selection of activities if they wanted to join in. One resident told the inspector that because of the inspection her bedroom door had been closed; she preferred to remain in her room; alternative arrangements need to be made for this lady to hold her door open (which is a fire door). One of the activity staff had completed the tea round as part of the daily one to one service users contact. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure was in place and residents benefited from receiving timely response to any concerns that were raised. The residents had the protection of an adult protection procedure in place but not all staff had received the necessary training and there had been care practice issues considered under the adult protection procedures over the last year. The surveys received from relatives confirmed that they were aware of the complaints procedure. EVIDENCE: The home had a complaints procedure that was displayed in the entrance hall. The home maintained a record of complaints received and this showed that any complaints received had been responded to. A relative spoken stated that if issues were raised the staff responded to them. The home had a policy for the protection of vulnerable adults and had a training programme in place although the records showed that a number of staff had not received the training. There had been five complaints investigated by the CSCI since October 2005, some had been unresolved and some resulted in change in care practises at the home. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 16 Over the last year there had been several issues of concern relating to care practices that had been addressed under the vulnerable adult protection procedures. Some of these had led to requirements being made regarding reporting of incidents, care records and relative involvement. The home had robust procedures in place for managing and recording residents’ finances. In respect of Thirlmere, the EMI unit, the records did not fully identify behaviours of residents and the methods that staff should employ to respond to any incidents of aggression and violence. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The staff worked as a team to promote good standards of hygiene throughout the home. Numerous physical structural issues within the home were evidenced and identified as not being acceptable. EVIDENCE: Within the four units areas of concerns were identified to the care manager at feedback. The bathrooms in the units with the exception of two/three were clinical in their decoration and did not provide the residents with a homely environment; one bathroom was without a light bulb; bathroom G3 bath seat required a deep clean around the fixtures. The hot water from this bath was unacceptably hot 50 degrees Centigrade. Bathrooms without a window did not have a working ventaxia fan. This report made this a requirement to address. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 18 The carpet in Grassmere/Arthur lounge was badly stained and required changing to provide an acceptable environment for the residents that use the lounge. Identified in this lounge were the exit fire doors with a NO EXIT sign adhered to the door. Following an investigation it was identified that the door was not secured correctly and when opened the censor did not show on the panel. The opening was addressed on the day by the maintenance staff. The firm responsible for the electrics were to be contacted. This fault should have been identified when the weekly fire tests were completed. The inspector requested that the bolt on this door was removed; this was done on request. No fire door should have a bolt fitted to secure the door. The carpets on the Thurlmere corridors remained in an unacceptable condition; they were extremely stained and the red corded type had black marks ground into the pile. This was made an immediate requirement by the lead inspector. The Commission had identified this concern in the two previous inspections but no action had been taken. There had been an improvement in this area with the environment having more homely touches, the staff were proud of their unit and the changes made. The fire door at the top of the stairs on Buttermere had been negated with a hole left where a handle had been removed. This report made this a requirement to change or repair the door after seeking advice from the fire officer as to the best way to resolve the concern. Three/four freestanding heaters were identified in the lounges used by residents these were a concern on the previous inspection. The care manager informed the inspectors that they had been removed but following a request of the residents because of the change in the weather returned. The care manager had instructed the maintenance staff to secure them to the walls. It is suggested that if the lounges are not warm enough for the residents then perhaps the system needs reviewing to eliminate the use of additional heaters. From the information evidenced on some equipment in bathrooms, and on reports, equipment was serviced on a regular basis. Each of the residents had an en-suite facility, one bedroom was visited, this bedroom was near to the toilet that was out of order because of a leak; had paint peeling off the skirting board because of the damp. The bedroom had a damp odour, this resident preferred to spend her day in her room. From the sample of bedrooms seen many personal possessions were displayed in bedrooms making them a homely environment. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 19 A number of bedroom doors and one dining room doors were held open inappropriately by wedges or personal items of the residents. This is not acceptable. Advice and agreement from the fire officer was required before any door guards were fitted to any door. This report made a requirement not to wedge fire doors open. Dining rooms varied in their appearance and provision of furnishings and fittings. The ground floor dining room off the reception area was particularly pleasant. The large dining room/lounge on Thurlmere had clean plastic tablecloths with small flower arrangements in the centre. A number of the lounges were not occupied, as residents prefer to remain in their rooms. It is the inspectors’ opinion that a number of these concerns could have been identified on the monthly audit or as a daily observation by the staff and reported to the person responsible. The inspector had concerns as to the flat sheets provided, while there are no pressure areas identified at the time of the inspection the flat sheets were creased despite the care provided by the laundry staff. The staff did not have the facility or time to press sheets; this had been a concern previously. The staff to improve this situation would require a rotary iron. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service and from the records provided. From the evidence provided there was a need to provide more of the mandatory training required. Staff continued to be supportive of the residents, recognising their particular needs. EVIDENCE: From the information provided each unit had different staffing levels this was based on numbers and dependency levels. The levels were acceptable, each unit had a trained nurse or experienced unit manager responsible to the care manager on a daily basis. It was obvious that the staff on duty at the time of the inspection were committed to the well being of the residents. Records identified that with in each unit there had been no COSHH training provided with the exception of one person. The inspectors were informed that this was in hand but no date had been arranged yet. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 21 The majority of the staff had received Dementia awareness training to meet the diversity of the client group. Some staff were attending a Positive Dementia Course through Wolverhampton college which the care staff were really enjoying. The need for staff to receive Infection control training was evidenced from the records and from a tour of the home. In spite of this plastic aprons and gloves were available. Laundry, housekeeping and maintenance staff were all currently training in COSHH and infection control. This was confirmed from the records and by speaking to the staff. Each unit had three of the care staff with a first aid qualification. Moving & Handling continued. Some current records were not available as the Deputy care manager was not on duty. It is important to confirm records, which should be made available at all times. Three of the staff files were checked; the files were current with all the required information to comply with the National Minimum Standards. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area was poor. The manager who has been in post for 5 months is yet to be registered with the CSCI. Several issues relating to Health and Safety were raised as having shortfalls, which is not acceptable. Financial issues were all satisfactory. EVIDENCE: The managers’ application is in the process of being completed and an interview will be arranged as soon as the documentation is received. Ms Armstrong is fully aware of the task in hand to raise the overall standard of care practices in the home and the wider reputation of the home. Many time scaled action plans have been drawn up and followed. Ms Armstrong has introduced many quality audit systems, which have generally resulted in positive feedback. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 23 The inspector had also received the ‘Have your say’ document, which the CSCI issue to relatives. The general theme of these was that although their relative was happy in the home there had been cause for concern form time to time. No relative or respondent had asked to speak to the Inspector. There was comment that the management were more visible and approachable. Financial issues were found to be in good order due to the robust recording systems in place and positive management. Health and safety issues were inspected. Most systems were satisfactory however the records evidenced that while the weekly tests of the fire system were satisfactory the records for the checking of the emergency lighting were poor. While these records had been seen previously the maintenance person could not locate any current records. There was evidence of fire drill continuing for each unit and including the ancillary staff. This report makes it a requirement to test and maintain records for the emergency lighting. Training issues remain with the need for all staff to attend relevant training to ensure they can fulfil their role appropriately in the home. Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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 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 1 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 1 3 3 3 2 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 2 X 2 X 3 X X 1 Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 25 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 2 3 Standard OP8 OP36 OP12 Regulation 14 (2 a/b) 18 (2) 12(3) 15(1) Requirement Service users needs are to be kept under review and altered as necessary. Staff Supervision must be carried out. To ensure that residents social care needs are identified and recorded and that where residents cannot communicate the home develops a record of residents’ likes and dislikes. To ensure that all staff on Thirlmere Unit are made aware of the importance of providing stimulation and positive interaction with residents with dementia care needs. To ensure that all residents are aware that if they wish they can have a cooked breakfast and to ensure that the menu is displayed. To ensure all staff are fully aware of issues relating to adult protection. Timescale for action 22/06/06 22/06/06 22/06/06 4 OP12 12(5)(b) & 18(I) 22/06/06 5 OP15 12(2) 22/06/06 6 OP18 13 (6) 22/06/06 Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 26 7 OP21 23 (b)(p) 8 OP18 5 The registered person shall ensure that the premises to be used as the care home are kept in a good state of repair internally. Ventilation, heating and lighting suitable for the residents is provided in all parts of the home, which is used by the residents. To ensure that that records fully document any potential aggressive and violent behaviour and suitable plans put in place. The registered person shall make arrangements for reviewing fire precautions and testing fire equipment at suitable intervals. The registered person shall have regard to the number and needs of the residents to ensure that bedrooms have adequate furniture within them, including floor coverings. The registered person shall ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. Care Plans must be completed from a comprehensive individual assessment and drawn up with each service user and reviewed at least once a month. The registered person must ensure that all service users individual health needs are recorded and reviewed. The medication room must have systems of safe storage introduced and be kept in a hygienic state. The manager must be registered with the CSCI. 22/06/06 22/06/06 9 OP38 23 (4)(c)(v) 16 (c) 22/06/06 10 OP25 29/06/06 11 OP30 18 (c.)(i) 20/07/06 12 OP7OP 15 22/06/06 13 OP8 13 22/06/06 14 OP9 13 (2) 22/06/06 15 OP31 8 22/06/06 Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 27 16 OP33 24 The quality of nursing care provided at the home must improve. The standards must then be reviewed at appropriate intervals through robust audit systems. 22/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Lakeview DS0000022331.V291352.R01.S.doc Version 5.1 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. 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!