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Inspection on 24/07/07 for Lancum House Care Home

Also see our care home review for Lancum House Care Home for more information

This inspection was carried out on 24th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

The homes Statement of Purpose and Service User Guides are documents that the home must make available to people using the service by having the documents available this enables prospective residents and their representatiives to assess how far the home`s claims to be able to meet resident`s requirements and expectations. Within the front entrance to the home the statement of purpose and service users guides were availavble together with copies of the most recent inspection reports, and there was also other information available for residents and visitors to access such as minutes from residents meetings and the homes newsletter. The care plans on the resident health and personal care needs are detailed and records available of when residents had received treatment from their general practitioner, optician, dentist and chiropodist, and there were records available of ongoing assessments of mobility, nutrition and pressure area care. Pressure area care was well managed there was records of turn charts being in place and pressure relieving equipment being in use. Records are kept of one to one and group activities that residents participated in. There is a very active residents committee called the `street committee` who meet regularly to discuss forthcoming activities and social events. Residents spoken with said that opportunities available to have a say in decision-making, through these regular residents meetings and through participating in satisfaction surveys that take place. The resident`s health, safety and welfare is promoted and protected through rigorous staff recruitment policies being followed and a commitment to ongoing staff supervision and training. The home has exceeded the national minimum standards expectation that 50% of staff hold a National Vocational Qualification (NVQ) level 2 in care. Health and safety and management and administration audits take place on a regular basis.

What has improved since the last inspection?

The requirements made following the previous inspection have been met.

What the care home could do better:

There was evidence that the care plans are being regularly reviewed, however following the reviews taking place the changing needs of the residents had not always been fully reflected within the care plan and risk assessment documentation.

CARE HOMES FOR OLDER PEOPLE Lancum House Care Home Bush Close Hardwick Road Wellingborough Northants NN8 3GL Lead Inspector Irene Miller Unannounced Inspection 24th July 2007 14:00 24/07/07 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 Lancum House Care Home DS0000060026.V341232.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. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancum House Care Home Address Bush Close Hardwick Road Wellingborough Northants NN8 3GL 01933 442440 01933 443404 Lancum.House@shaw-homes.co.uk www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd 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 Michael Scott Care Home 35 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (35), of places Physical disability over 65 years of age (12) Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. All re-development work detailed in the refurbishment plan submitted to the Commission on the 25.04.04 must be completed by March 2009 The home may continue to accommodate 1 named service user who falls within the registration category LD (E) No one falling within the category of DE (E) may be admitted into the home where there are 12 service users who fall within the category of DE (E). No one falling within the category of PD (E) may be admitted into the home where there is 10 service users who falls within the category of PD (E) already accommodated within the home No further residents may be admitted to the home in the category of old age (OP) when there are 35 residents in this category already accommodated in the home. Variation number V000029394 allows 2 DE residents to be accommodated in OP beds. To be able to admit a named person named in Variation No. 35928 in the category DE can be admitted to an OP bed. To admit the resident named in variation number V38086 in the category DE (E). To admit the resident named in variation V38840 in the category DE (E). 12th July 2006 Date of last inspection Brief Description of the Service: Lancum House is a purpose built residential care home for the elderly, formerly owned by the Northamptonshire County Council Social Services Department, and now owned by Shaw Healthcare. The accommodation for service users is set out on the ground floor. The first floor accommodates the manager’s office, and an area used for training and as a staff room. Service users rooms are divided into small individual areas called flats. Each flat has a small lounge and dining area, and the service user’s bedrooms. All rooms are single occupancy. There is a communal lounge area and a larger foyer area where service users frequently choose to sit. The home has a wide corridor that is called the street, where tables and chairs are placed for the service users use. There is also a shop and a licensed bar in this area. The home is surrounded by pleasant gardens and is situated in a residential area close to the town centre and other local amenities. The home caters for elderly residents of both sexes with both physical and dementia related illness. The current fees are in the region of Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 5 £450 per week according to resident’s assessed needs. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for people using the services and their views of the service provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. The care of two people living at the home was looked at in depth this involved looking through written information available on their care, such as the residents individual care plans (a care plan sets out how the home aims to meet a residents personal, healthcare, social and spiritual needs). Sample checks were carried out on the homes policies and procedures, staff recruitment records, and the homes medication and quality assurance systems, in addition health and safety records on the general maintenance and upkeep of the facility were viewed, and general observations on the environment were made. The Commission for Social Care Inspection sent out to the home an Annual Quality Assurance Assessment form (AQAA) for completion by the registered manager, the AQAA had been returned to the Commission for Social Care Inspection prior to this visit, and provided information the care provided at the home and the management, administration and quality assurance processes. Time was spent prior to the visit reviewing the AQAA, the previous inspection report and the homes service history, (the service history details all contact with the home including notifications of events reported by the home, telephone calls, letters, and details of any complaints and concerns received). The manager Michael Scott was unavailable at the home on the day of the visit. What the service does well: Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 7 The homes Statement of Purpose and Service User Guides are documents that the home must make available to people using the service by having the documents available this enables prospective residents and their representatiives to assess how far the home’s claims to be able to meet resident’s requirements and expectations. Within the front entrance to the home the statement of purpose and service users guides were availavble together with copies of the most recent inspection reports, and there was also other information available for residents and visitors to access such as minutes from residents meetings and the homes newsletter. The care plans on the resident health and personal care needs are detailed and records available of when residents had received treatment from their general practitioner, optician, dentist and chiropodist, and there were records available of ongoing assessments of mobility, nutrition and pressure area care. Pressure area care was well managed there was records of turn charts being in place and pressure relieving equipment being in use. Records are kept of one to one and group activities that residents participated in. There is a very active residents committee called the ‘street committee’ who meet regularly to discuss forthcoming activities and social events. Residents spoken with said that opportunities available to have a say in decision-making, through these regular residents meetings and through participating in satisfaction surveys that take place. The resident’s health, safety and welfare is promoted and protected through rigorous staff recruitment policies being followed and a commitment to ongoing staff supervision and training. The home has exceeded the national minimum standards expectation that 50 of staff hold a National Vocational Qualification (NVQ) level 2 in care. Health and safety and management and administration audits take place on a regular basis. What has improved since the last inspection? The requirements made following the previous inspection have been met. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 8 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. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 9 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 Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 10 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 1 & 3 (Standard 6 is not applicable to this service) Quality in this outcome area is excellent. Information is available on the services provided and prospective residents will only move into the home once it has been established that the home can fully meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the front entrance of the home there was copies of the most recent inspection report from The Commission for Social Care Inspection and there was a copy of the homes Statement Of Purpose and Service User Guide, which set out the facilities and services offered in the home. There was also other information available for residents and visitors to access such as minutes from residents meetings and the homes newsletter. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 11 Within the care plans viewed there was records of pre-admission assessments having been carried out prior to admission to ensure that residents needs had been fully identified prior to moving into the home. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 12 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 & 11 Quality in this outcome area is adequate. The care plan reviews do not always reflect the residents changing needs and therefore people using the service could be at risk of their needs not being fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed there were records of daily notes which provide an overview on the changing health, social and emotional needs of residents, one of the daily notes looked at had records of the resident having frequent disturbed nights, however the care plan stated that the resident ‘did not wake through the night’. On checking the monthly care plan reviews the changing needs of the resident in this area had not been reflected within the care plan. The care plan of a resident living with dementia had several entries within the daily notes of episodes when the resident had left the home unescorted by Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 13 staff, on speaking with staff they were aware of the times of day when the resident was most likely to leave the building, however this was not reflected within the care plan or the risk assessment, there was a statement that ‘the staff were to observe the resident at all times’, this was an unrealistic expectation as the resident was not on constant one to one supervision. There were records of residents of when residents had received treatment from their general practitioner, optician, dentist and chiropodist, and there were records available of ongoing assessments of mobility, nutrition and pressure area care. Pressure area care was well managed there was records of turn charts being in place and pressure relieving equipment being in use. The medication held within the home was sample checked and the medication records were in good order. There was a medication policy in place, the team leaders hold the responsibility for the administration of medication and training was provided from the dispensing pharmacy. The staff on duty were witnessed to knock on doors before entering, and to speak courteously with residents and visitors. Comments from residents were complimentary to the staff such as ‘the staff are very experienced and know what we need’ ‘we get along very well, I feel well cared for’, ‘its good to be involved and have our say’. Visitors spoken with were in the main very complimentary saying that the staff do a terrific job, there was only one area of concern which was in relation to the as to the cleanliness of the bathrooms and an individuals bedroom, the areas were sample checked during the visit and found to be clean and odour free. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15 Quality in this outcome area is excellent. People using the service are encouraged and facilitated to exercise choice and control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a very active residents committee called the ‘street committee’ who meet regularly to discuss how individual and collective lifestyle needs are being met in the home and to plan social events. Residents spoken with said that they liked having an active part in choosing what happens within the home in terms of leisure and entertainment activities. There were minutes available of the ‘street committee’ meetings that included what social activities had taken place and those that were planned to take place. These included a Narrow boat trip, and visits from outside entertainers such as bell ringers, singing and musical entertainment. A party was planned to take place to include a pig roast, karaoke and disco to mark the closure of the home whilst refurbishment takes place. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 15 The home employs an activity person and there were records within the individual care plans on the resident’s life history, such as special events, important people in their lives, family contacts and previous occupations, hobbies and interests. There were records of when residents had been engaged in individual activities appropriate to their likes and residents spoken with said that that their individual wishes were respected. Representatives from the local churches visit the home to give the opportunity for residents to participate in religiouse services Relatives and visitors are welcome in the home at any time and records were available of meetings having taken place to ensure that all relatives and visitors were kept informed of the homes development plans and other issues. Residents spoken with about the move to another home whilst refurbishment works take place said that they understood the reasons why and where happy that the staff were going to be still caring for them, one residents said ‘I know that the staff will help us all through this, I’m sure that we will be well cared for’. The food supplies and weekly menus were viewed, and there was records available of residents daily menu choices that verified that residents were given choices of lunch and tea time meals, some of the residents required specialised diets such as diabetic, soft or pureed diets which were provided. Food safety audits are carried out by representatve from the conmpany and there was records of the audits avialable. When asked about the choice and quality and quantity of the meals provided residents said that the food was good and if they didn’t like what was on the menu that the staff would provide something that they do like as an alterntive. Lancum House Care Home DS0000060026.V341232.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): Standards 16 & 18 Quality in this outcome area is good. People that use the service may be assured that their concerns will be listened to and acted upon and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure was available to all residents and visitors and there was a comments box avaialble within the front entrance to the home. Five complaints had been received by the home since the last inspection visit , no complaints had been received by the Commission for Social Care Inspection in relation to the home since the last inspection. All staff have received training on Safegurading Adults and in discussion with the staff on duty they had an awareness of their resposibilities in this respect. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. People using the service are provided with a clean and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is due for a major redevelopment and refurbishment in the near future which will greatly enhance the facilities provided. Areas of the home viewed during the visit included some of the residents bedrooms, bathrooms, toilets, communal lounges, main kitchen and Laundry. Residents bedrooms viewed were clean and tidy and personalised with individual ornaments, pictures and small items of furniture. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 18 Records were available ogf the building upkeep and maintenance, and a new fire panel had been installed as the previous fire panel had developed a fault. Cross infection control measures were seen to be in operation, there was sanisitizing hand gel available at the front entrance to the home for use by visitors to the home. Clinical waste was manged effectively, disposable gloves were available at stations outside the unit bathrooms, the need for some consideration to be given to having risk assessments to be in place for individuals in this respect was discussed with the senior in charge. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is excellent. People using the service can be assured that there is robust staff recruitment and training systems in place to ensure that they are protected and that the staff are competent to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of staff recruitment files seen demonstrated that full checks are carried out the on the employment histories of new staff and that clearances are obtained from the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults register (POVA) on all staff taking up employment at the home. Staff employed at the home are from both sexes and efforts are made to ensure that staff deployment meets the individual cultural and personal preferences of the residents living at the home. There is a commitment to ongoing staff training and development, there is a comprehensive induction training programme in place and staff are encouraged and supported in gaining a National Vocational Qualification (NVQ) in Care levels 2 and 3. Staff spoken with said that therer was always lots of opportunities to do more training, staff said that they had recently been Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 20 offered training course on Dementia Care. Staff members spoken to confirmed that they are well supported by the senior staff in the home and that they receive regular supervision at which their training needs and progress in the home are discussed. The homes administrator explained that upon employment all staff embark upon a four day induction programme and training records verified that there was a training programme in place that covered mandatory training such as Fire, health and safety, moving and handling,food hygiene, first aid and safeguarding adults. In addition there was records of ongoing training having been provided to meet the specifiic health, social and welfare needs of the residents living at the home. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 & 38 Quality in this outcome area is good. Individual risk assessments need to fully reflect the level of support required protecting individuals from foreseeable risks; this should further protect the health, safety and welfare of the people that use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager holds a National Vocational Qualification (NVQ) Level 4 and the Registered Manager’s award, and has the skills and experience to efffectively manage the home. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 22 Regular audits take place on the management and administartion and health and safety processes in the home, and the outcomes of these audits are made available to all residents and visitors to the home through a newsletter. The homes quality Assurance policy was viewed within the policy there was reference to using dementia care mapping as a quality assurance tool to be used for people living at the home with dementia who lack the capacity to express their feelings verbally. However in discussion with staff they were unaware of the dementia care mapping tool for observation. Residents and relatives meetings are held regularly and have provided the forum for residents and visitors to be kept up to date on the progress of the building development and plans on how this is to be managed. Recently there had been a problem with the fire alarm system this had been rectified and was back in working order, staff said that weekly fire alarm test are carried out and information provided through the annual quality assurance assessment documentation demonstarted that records were maintained on the maintenance and upkeep of the building and equipment. The health, safety and protection of residents was in the main well managed, the care plans and risk assessments regularly reviewed, however following the review taking place the changing needs of the residents had not always been fully reflected within the care plan and risk assessment documentation. It was evident in one of the care plans viewed, that the residents had left the home unescorted by staff on several occasions and had been brought back to the home by passing neighbours, on speaking with staff they were aware of the times of day when the resident was most likely to leave the building. However based upon this knowledge the care plan and risk assessment did not reflect this knowledge or specify what action to be taken by staff to monitor the whereabouts of the resident to protect them from further harm due to the risk of leaving the building unescorted. A sample check of the residents cash accounts demonstarted that money held on behalf of residents was well managed to protect as far as possible from financial abuse. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13 (4) (c) 15 (2) (b) Requirement The care plans and risk assessments must reflect the changing needs and current objectives to ensure that health, safety and welfare needs can be fully met. Timescale for action 31/08/07 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 Refer to Standard OP33 Good Practice Recommendations The use of dementia care mapping to gain an insight into the well being of people living with dementia who use the service who lack the capacity to communicate verbally, should be considered within the quality assurance framework. Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Lancum House Care Home DS0000060026.V341232.R01.S.doc Version 5.2 Page 26 - 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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