Inspection on 09/08/07 for Lambspark Residential Home

This inspection was carried out on 9th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Lambspark Residential Home 08/08/08

Lambspark Residential Home 23/05/06

Lambspark Residential Home 11/11/05

Lambspark Residential Home 10/05/05

Lambspark Residential Home 24/11/04

Lambspark Residential Home 19/05/04

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

CARE HOMES FOR OLDER PEOPLE Lambspark Residential Home 38 Merafield Road Plympton Plymouth Devon PL7 1TL Lead Inspector Margaret Crowley Unannounced Inspection 9th August 2007 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lambspark Residential Home DS0000003538.V340958.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. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lambspark Residential Home Address 38 Merafield Road Plympton Plymouth Devon PL7 1TL 01752 330470 01752 345126 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) Mr Richard Wraighte Mrs Tracey Elizabeth Wraighte Care Home 36 Category(ies) of Dementia (36), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (36), Old age, not falling within any other category (36), Physical disability over 65 years of age (36) Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The following person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category, aged 60 years and over on admission- Code OP Mental disorder, excluding learning disability or dementia, aged 60 years and over on admission- Code MD(E) Dementia aged 60 years and over on admission- Code DE 2. Physical disability, aged 60 years and over on admission- Code PD(E) The maximum number of service users who can be accommodated is 36. 23rd May 2006 Date of last inspection Brief Description of the Service: Lambspark is a detached, three storey property situated in the residential area of Merafield in Plympton. The home is registered to provide residential accommodation and personal care, for a maximum of 36 persons over the age of 60 who may also have dementia, a mental disorder and/or a physical disability. The home has 2 double and 32 single bedrooms with en suite facilities situated on three floors. A shaft lift provides access from the ground floor to the 1st and 2nd floors. The dining room is situated on the ground floor and has a lounge area attached. There is a small separate lounge with a conservatory attached available for use by people living in the home who wish to smoke. A large, non-smoking lounge is situated on the 1st floor. There is a call bell system throughout the home. Outside there is an attractive and spacious garden at the rear. Fees currently range from £280 to £520. Written information is available for people considering going to live at Lambspark and for those who are resident. A copy of the most recent CSCI inspection report is available. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 13 hours on 9th and 13th August 2007. Mrs Wraighte, the current registered manager, and Mr Wraighte, the registered provider, were present in the home on both days. In addition the acting manager also provided assistance. An application is to be submitted to CSCI for the acting manager to be registered as the manager. An Annual Quality Assurance Assessment of Lambspark was completed by the management and sent to the Commission for Social Care Inspection prior to the inspection. There were 30 people resident in the home during the inspection. Many were spoken with, including 6 in more depth regarding the lifestyle in the home and the care services they receive. Staff were observed and spoken with in the course of their daily duties. Two relatives were also spoken with during the inspection and one via the telephone. A tour of the premises was made. Records were inspected, including care, medication and staff records. Surveys were received from 2 people who live in the home, 7 relatives and 4 staff. Feedback was also received from a district nurse and a general practitioner. What the service does well: What has improved since the last inspection? Improvements have been made to the décor, furnishings and facilities to upgrade the home and make it more comfortable and attractive for people who live there. The main lounge and dining room have been decorated and new Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 6 carpets and chairs provided. Three new en- suit bedrooms and a new communal shower room have been created on the second floor. All staff are now attending the Protection of Vulnerable Adults training in rotation. Risk assessments have been completed on all windows above ground floor level, and restrictors fitted where a risk has been identified. 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. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information to assist them in choosing to live at Lambspark and admission procedures ensure that their needs can be met. EVIDENCE: A relative commented, “my aunt has settled in well in the short time she has been at Lambspark. I am sure this is attributed to the care she is receiving” The relatives of another person who had been admitted to the home in recent months said that staff were kind and welcoming and that good information was available in helping them to choose the right home. A person who had come to stay at Lambspark for a trial period was spoken with and said that although the accommodation was very good, the person had decided to seek an alternative home which would be more suited to her needs. The statement of purpose and service user guide was available and covered all areas as required. It did not include the increase in the registration for three Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 9 additional persons, and the new accommodation, because the confirmation of the variation in the registration was awaited. Care records were inspected and showed that the acting manager visited prospective residents and undertook a thorough pre-admission assessment. Additional assessment information was available from health and social services staff. A letter was sent to the person, or their relative or representative confirming that their needs could be met. A contract or statement of terms and conditions is usually provided, but none was available for people admitted recently. The acting manager said that there had been delays in these being issued, but the matter would be addressed. Lambspark does not does not provide intermediate care. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are met and they are treated with respect. EVIDENCE: People who live at Lambspark said that staff were kind and helpful. Many people living in the home have dementia and some are significantly confused and were unable to express their views clearly. Most relatives who responded to questionnaires, or who were spoken with were pleased with the care provided, although two relatives said there was not always sufficient attention given to the cleanliness of people’s fingernails. Staff were described as “dedicated, helpful and caring”. Comments were made that the home understands the needs of people with dementia and cares for them well. This was echoed by a district nurse who also said that Lambspark is very good at looking after people at the end stage of their life. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 11 The inspector observed staff interacting with people living in the home in a warm, friendly and appropriate manner. People said that staff assisted with personal care sensitively. Records inspected contained risk assessments and care plans, providing information about health, personal and social care needs. Care plans include details about daily routines, preferences regarding how people like to be supported and specific guidelines for staff where necessary. Dietary preferences and needs are noted in the care plans and people’s weight is monitored on a monthly basis. Care plans and risk assessments are reviewed regularly. There is a key worker system in place. Daily records and handover meetings demonstrated that people’s care is monitored and concerns are recorded and dealt with. Medication records and procedures were inspected. A monitored dosage system is in use. Medication is secondary dispensed prior to mealtimes into named, lidded pots. The inspector was informed that this is to assist with the administration of the medication. Controlled drugs were appropriately stored, administered, and recorded. The administration of prescribed creams kept in people’s bedrooms was not always recorded. The registered manager and the acting manager have received external training in the administration of medicines, but none of the care staff have. Staff who administer medicines receive in-house preparation and are supervised and assessed as competent by one of the managers, prior to carrying out the task unaided. In discussion, the management were advised to seek refresher training for staff from the pharmacist. The community pharmacist has visited the home recently and provided a risk assessment for the manager to complete. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported in making choices in their daily lives, but there are limited opportunities for stimulation through leisure activities, which are linked to people’s needs, interests and capacities. The content of meals does not always provide an appealing, balanced diet. EVIDENCE: People who live at Lambspark have a range of support needs. The more able people said they are able to make choices about their daily living routines such as getting up when they like and go to bed when they like. Some choose to stay in their rooms and follow their own interests such as reading or watching television. They said they enjoy contact with relatives and talking to staff when staff time allows. There is no set activities programme provided. The manager said that activities are provided in an ad hoc way according to what people choose to do. Musical entertainment was provided by external entertainers during the inspection and is provided three mornings per week. There was little evidence of any other activities. One relative commented on the lack of stimulation provided and another said that “quiet residents can be overlooked Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 13 and should be given more attention”. The inspector observed that staff had little time to spend talking with people. or in providing small group occupations. A resident and a relative said that people would like to have trips out in the home’s minibus. The registered provider said that few people have show interest in these recently. The home has a large attractive level garden with seating that is situated at the rear of the premises. No one was seen to use the garden during the inspection although the weather was sunny and warm on both days. The garden is not accessible to most people who live at Lambspark without assistance and support. In discussion, the management confirmed that the garden is not used often and said many people do not wish to go outside. The inspector reminded them of the importance of older people having access to sunlight. People who live in the home and relatives said that visitors are always made welcome. A relative spoken with said that she had appreciated being able to stay overnight with her mother when she was unwell. People’s dietary likes, dislikes and specific dietary needs are recorded in their care plans, although there was no record of this information kept in the kitchen for easy access by those preparing and serving meals. The menu showed that convenience foods are included with low nutritional content. Main courses at lunchtime provided on both days included ready prepared pies and pastries served with baked beans and mashed potatoes on the first day and frozen mixed vegetables and potatoes on the second day. There were no fresh fruit or fresh vegetables available on the premises other than a very minimal amount of salad. The proprietor said that fresh vegetables are served with the Sunday roast and that fresh fruit is not routinely available because people do like it. People said that the meals were satisfactory, but some made comments about the quality of the cooking. These included that sometimes the meat was tough, the potatoes and vegetables were hard, and they disliked having a pastry dish for main course and pudding in the same meal. During the inspection people were served tea and coffee and biscuits between meals. Although it was a hot, sunny day and the temperature in the home was very warm, there was a lack of attention to ensuring that people received adequate hydration. Water and diluted fruit drinks were not regularly offered between meal times and water was not available in communal rooms. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 14 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): Standards16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure and most people feel their views are listened to and acted on. EVIDENCE: The home has a written complaints procedure, which is contained in the statement of purpose and the service users’ guide, and was on display. People living in the home and relatives indicated that they knew how to complain, or said a relative would raise concerns with the management on the person’s behalf. Two relatives commented that any concerns are addressed promptly, but one relative said they hadn’t been entirely satisfied by the manner in which issues had been addressed. The registered providers said that no complaints had been received since the last inspection and none were recorded in the complaints book. The Commission for Social Care Inspection has not received any complaints since the last inspection. The home has an adult protection policy and a copy of the local adult protection procedures. All staff attend multi- agency training in safeguarding adults. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 15 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): Standards 19,22,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at Lambspark benefit from a programme of continual improvement to the premises, but the lack of attention to some maintenance tasks and infection control matters could place service users at risk. EVIDENCE: A tour of the premises took place and most rooms were seen. Since the last inspection improvements have been made to the décor, furnishings and facilities to upgrade the premises and to make the home more comfortable and attractive for people who live at there. Improvements include redecorating the main lounge and the dining room and providing new carpets and chairs. Three new en suit bedrooms and a new communal shower room have been created on the second floor. Bedrooms are personalised to people’s tastes and rooms have been redecorated when they become vacant. The carpets in three rooms identified needed attention to prevent trip hazards developing and two were stained. The Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 16 armchairs in one room did not have covers on the seat cushions. A black polythene bag covered one seat cushion. The home has two shower rooms and a bathroom with an assisted bath. There were various aids such as grab and handrails and raised toilet seats. There was no mobile hoist available. The inspector was informed that the hoist was awaiting servicing and was stored in the basement, but that none of the people currently living in the home required the use of a hoist for transfers. Temperature control valves have not been fitted to hot water outlets accessible to people living in the home to prevent the risk of scalds, as required at previous inspections. The registered provider said that the plumber was due to undertake this imminently. The central heating and hot water boilers have been upgraded as part of the refurbishment programme. He said that window restrictors have been fitted to windows where a risk assessment has identified a significant risk. The home has a small lounge/conservatory that is designated as the smoking room and was being used by people who live in the home and staff who wish to smoke. The door to this room was held open by a magnetic device and cigarette smoke drifted up the corridor and permeated through the atmosphere of the ground floor. A relative commented that the smell of smoke was unpleasant. Ventilation in the smoke room was limited and the room does not have an extractor fan. The home was clean and free from unpleasant odours of urine, other than in two bedrooms. The walls in a toilet on the ground floor were dirty. The inspector was informed that the room was due to be redecorated. The ground floor shower room contained a commode that required emptying. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 17 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): Standards27,28,29,30, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are looked after by caring staff, but staffing levels are not always sufficient to ensure that people’s needs can be met at all times. EVIDENCE: Communication seen between staff and people living in the home during the inspection was friendly and caring. People said that staff were kind and helpful, and relatives confirmed this. However, the inspector observed during the inspection that there no visible presence of staff in the main lounge on the first floor for periods of approximately 45mins on both days of the inspection. The layout of the building on three floors presented some difficulty for monitoring people who live in the home, including in the two lounges on the ground floor and the lounge on the first floor. Most of the people living at Lambspark have dementia. Care staff had limited time to spend with people, other than when undertaking personal care or serving meals. On the days of the inspection there were 30 people living at Lambspark. The staff rota was examined for the day and it was confirmed that the acting manager, the registered manager who works directly with residents as part of the care team, and four care staff were on duty from 8.00 to 2.30. Four care staff, including the deputy manager were on duty from 2.30 to 9.30 pm, assisted by a tea-time assistant from4.30 to 8.00pm.There were two night staff employed from 9.30pm to 8.00am who are awake. In addition a cook, domestic, and laundry assistant were available from 8am until 2.30pm and Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 18 there is a handyman employed. The registered provider and registered manager said that the staffing complement was sufficient to meet the needs of the people currently living in the home. There has been a high turnover of staff since the last inspection with 18 staff having left in 14 months. The registered provider said that there have been difficulties in recruiting staff. A sample of staff files was seen, including records of staff recently employed in the home. There was evidence of a recruitment procedure in place and Criminal Records Bureau disclosures are applied for in a timely manner. However, there was only one reference for a member of staff recently employed and no work permit had been seen or full enquires made in respect of a non-UK member of staff from outside the European Community. The management has a commitment to staff undertaking the National Vocational Qualification in Care. There are currently 60 of staff who hold the qualification at level 2 or level 3. Six staff are currently undergoing the training. Staff have received some mandatory training in safe working practices including moving and handling, first aid and fire safety, but no one has attended training in infection control. The acting manger said she is due to attend training in this in November and will devolve it to staff. Only 4 staff have attended health and safety training. There was no training plan available. Evidence was seen that a system of staff supervision takes place and staff meetings are held on a regular basis. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 19 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): Standards 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lambspark has a management team who are committed to providing a good standard of care, but the lack of attention to some health and safety matters could place people at risk. EVIDENCE: People value the active involvement in the home of Mr Wraighte, the registered provider, and Mrs Wraighte, the current registered manager. They live in the house next door to the home and are present in the home each weekday and at weekends, if necessary. Mrs Wraighte is intending to relinquish her role as the registered manager as she prefers to working directly in the care of people living in the home. An application is to be submitted to CSCI for the acting manager to be registered as the manager. She is currently responsible for Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 20 admissions processes, care records, training and other management tasks. She holds the registered the Registered Managers Award and the National Vocational Qualification in Care at level 4. Lambspark is now owned by a limited company. Mr Wraighte, the current registered provider and director of the new company, said he had obtained an application to re-register the home and would be submitting it to CSCI. Quality monitoring surveys take place periodically and are distributed to people who live in the home, relatives and visiting professionals to obtain their opinions of the care and services provided at Lambspark. The home offers support to people living in the home who are unable to manage their finances. Records were inspected and showed that all money held by the home is recorded and where payments are made on behalf of individuals, receipts are kept and records are maintained. A monthly statement is sent to the person’s relative or representative, if appropriate, to keep them informed of any expenditure. A relative said he valued this process. Three people do not have their own bank accounts and their personal allowances are held in cash by the home, and the amounts have accrued over time. The registered provider was advised that people’s money should be held in an interest bearing bank account, separate from the home’s business accounts. He was advised to speak to their social services care managers. He was reminded of the need to ensure that money is stored safely at all times, which was a requirement at the last inspection. Health and safety in the home is covered in policies and procedures for safe working practices. However, mandatory training in safe working practices is not systematically provided and no one has received training in infection control. Concerns regarding some practices were identified in the Environment Section. Evidence was seen which confirmed regular maintenance and checks of gas and electrical appliances in the home. However, a relative had recently provided an electric fan for a person’s bedroom, but there was no risk assessment for its use or any indication that it had been safety tested. Accident records and the Fire Log were inspected and records of fire safety equipment tests and drills were maintained up to date. The fire escape at the side of the building was rusty. The registered provider indicated that this is going to be replaced within the next 12 months. He should meanwhile undertake a fire risk assessment and ensure that the fire escape provides a safe means of escape which complies with the Regulatory Reform(Fire Safety)Order 2005. The “Safer Food Better Business” diary record was inspected in relation to processes in the kitchen. This had not been completed for the previous week. The registered provider was reminded that the home must comply with the requirements of the Smoke Free (Premises and Enforcement) Regulations 2006 He was advised to seek information regarding this from the Smoke Free England website, or the environmental health department. The designated smoking room should be used only by residents and steps taken to ensure smoke does not permeate outside the room. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 21 Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x 2 x 2 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 2 Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 23 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 OP25 Regulation 13(4)(a) Requirement Design solutions must be in place to ensure that water is stored at a temperature of at least 60 C, distributed at 50 C and provided close to 43 C. from bath taps/showers. Risk assessments must be completed for all other hot water outlets including wash hand basins. The Registered Provider must ensure that design solutions are in place to restrict water temperatures to all hot water outlets accessible to residents who are at risk due to confusion. Previous timescales of 31.03.06 And 30/09/06 not met. Any monies held in safekeeping for people must be is stored securely at all times. The money of people identified elsewhere must be held in an interest bearing account to ensure their financial interests are protected. Carpets and cushions in bedrooms identified should be DS0000003538.V340958.R01.S.doc Timescale for action 09/10/07 2. OP35 16(1), 20(1)(a) 09/11/07 3 OP24 16(2)c 09/10/07 Page 24 Lambspark Residential Home Version 5.2 4 OP26 OP38 13(3), repaired or replaced so that people have a safe, comfortable environment. Commodes must be emptied appropriately. The walls in the ground floor toilet must be re-painted. All staff must receive training in infection control. These are measures to prevent the spread of infection so that people’s health is protected. The number and deployment of staff on duty must be reviewed to ensure that there is always sufficient staff available so that people’s needs can be met. References and necessary documentation must be obtained for all staff before they commence work, to ensure that people living in the home are safe. 09/12/07 5 OP27 18(1)(a) 09/11/07 6 OP29 19(1) Schedule 4 09/08/07 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 2 3 Refer to Standard OP12 OP15 OP30 Good Practice Recommendations People should have more stimulating activities available, which are linked to their needs, interests and capacities. People should have a more varied nutritious diet, with fewer convenience foods provided and more attention given to monitoring their hydration. A staff training plan should be devised that includes mandatory training in safe working practices to ensure people’s health and safety is protected. Lambspark Residential Home DS0000003538.V340958.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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