CARE HOMES FOR OLDER PEOPLE
Lapal House & Lodge Lapal Lane South Halesowen West Midlands. B62 OES Lead Inspector
Jean Edwards Announced 11 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Lapal House & Lodge Address Lapal Lane South Halesowen WEst Midlands. B62 OES 0121 503 0326 0121 550 1562 admin@care_@_lapal.co.uk Mr. A. Billingham Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Michelle Upperdine Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability over 65 years of age (5) of places Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Date of last inspection 18/02/05 Brief Description of the Service: Lapal House & Lodge is located in an attractive area of Halesowen. Although it is not far from the A456 from Birmingham to Kidderminster, it can only be accessed via a minor road. A link to the M5 motorway is nearby. The home is set in acres of land, giving picturesque views from most windows. There is a farm to the rear. Service users who have bedrooms at the back of the home have the benefit of views of the farm and surrounding countryside. All the grounds are maintained to a high standard. The home is operated in two sections, the House and The Lodge. There is a registered Manager who has overall responsibility for the two areas. There are lift facilities in The House and a stair lift in The Lodge. There are separate dining and lounge facilities in both areas. The home operates a no-smoking policy for service users. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection visit was undertaken by the inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection in February 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home. The visit commenced at 9:05 am and lasted until 4:20pm. During the visit the inspector spoke to the majority of the 40 residents who are currently living at the home. There were longer discussions with the residents whose care was looked at in depth. The Registered Manager, Proprietor, Senior Staff and the homes administrator took an active part in the inspection process. Survey comment cards were sent to the residents and relatives from the Commission for Social Care Inspection (CSCI), 22 have been returned. Comments are generally very positive, for example making favourable comments about the social events, catering, the environment and caring staff team. The inspector toured the building, looking in particular at the general environment, gardens, bathing facilities, communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well:
The registered manager, supported by the organisation, has responded to the previous inspection report with a comprehensive action plan, which gave dates for the required improvements to be put into place. The majority of required improvements from the last inspection visit are now in place. Information about the home and the service it provides is readily available on the premises and on its Internet site. People visiting the home have positive comments about the informative documents on display. These include information about the facilities provided and activities offered by the home, resident survey results and inspection reports commenting on the homes performance.
Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 6 The registered manager and senior staff undertake very thorough assessments of each persons needs before they come to the home to make sure all their needs can be met. People commented that, staff are very welcoming, and very informative. The manager and staff make sure that each resident and if appropriate their relatives, are involved in the plan of how their care is to be provided. The home also has excellent relationships with the local GP and district nursing services, which provide support for the residents at the home. Residents are encouraged by staff to treat Lapal House & Lodge as their own home and to be as independent as possible. Residents are able to make their own choices and can take an active part in meetings and surveys. Views can be freely aired about the running of the home. Comments are, its a wonderful home, in a beautiful setting. and this place is the best, I have my own room with a view and I can sit out on my own patio to watch the birds and squirrels. People are encouraged to spend some of their time with a range of stimulating activities supported by the activities co-ordinator and staff. There are organised activities and outings, such as shopping trips and pub lunches. On Sunday 10th July 2005 the home held a wartime jazz picnic in the grounds to celebrate the anniversaries of World War II. There was a marquee, entertainment, champagne and strawberries. From comments residents, relatives and staff, who dressed in period costumes, thoroughly enjoyed the event. Twenty people recently went to Weston Super Mare, accompanied by staff, for a damp, but enjoyable day trip. Some people may choose not to be involved in organised activities, decisions that are respected and fully supported. The meals are thoughtfully and well prepared, and the menus, displayed on each table, offer a range of options for each meal. In addition members of staff ask residents what they prefer at each mealtime. Members of staff sensitively offer people help and assistance, as they need it. The dining rooms provide attractive environments in which to eat, though people can choose to have meals served in their own rooms if they wish. The food is of an exceptionally high standard and the home has been given the gold award by Environmental Services and NHS. Lapal House & Lodge has a stable group of staff, many of whom have worked at the home for many years and know the residents well. They are caring, committed and flexible, often willing to work extra shifts, especially to support residents with outings in trips away from the home. Residents and visitors describe the home as ‘happy’, ‘friendly’, ‘ welcoming’ and ‘well run’, with staff described as friendly, professional, caring and very good. The home follows a rigorous system to select and recruit new staff. The home demonstrates a strong commitment to training and currently 95 of care staff have achieved the NVQ level 2 or 3 award.
Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 7 There was a lot of friendly banter between staff and residents throughout the day. During the visit staff demonstrated a dedicated approach to their work; they clearly know residents’ likes and dislikes and how to meet their needs. They are keen to share views and answered any questions in an open and honest manner. Lapal House & Lodge maintains excellent standards of cleanliness. The home is tidy, homely and comfortable. People commented that they are very impressed with the standards of hygiene. The home has achieved the Investors in People Award and has implemented its own surveys to obtain the views of residents, relatives, and visitors as to how they think the home is performing. The home has an active group of Friends of Lapal House & Lodge. A monthly newsletter is produced to advertise forthcoming events. This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
There are detailed care plans devised for each person, further information has been included to cover all areas of care needed. The home has improved information about each persons medication regime, making sure there are clear written instructions, as part of each persons plan of care. Any medicines, such as creams, in residents bedrooms, are now stored in locked cupboards or drawers for improved security. All risks involved with any use of bedrails are now considered and well controlled by the home, with recorded checks undertaken on a regular basis. The home has a new summerhouse in the grounds, donated by visiting relatives and very much appreciated and well used by a number of residents. A discreet and attractive dining area has been created in the quiet lounge, with spectacular views across grounds, where visitors can book a meal either from the residents menu or a separate menu by request. New carpets have been provided in two residents bedrooms since the last inspection visit in February 2005. In addition attractive new carpeting has been ordered and is due to be fitted throughout the communal areas of the Lodge.
Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 8 There are plans to extend the existing building to upgrade the access to the first floor in the Lodge, replacing the stair lifts with a passenger lift; and to provide additional en suite bedrooms. 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. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Information about the facilities, running and performance of the home is made proactively available. There are up-to-date contracts/terms and conditions of occupancy; this has the effect that residents and their representatives have good information regarding their rights and entitlements and any agreed restrictions. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that identified care needs will be met. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. This home does not provide intermediate care; therefore standard 6 is not applicable. EVIDENCE: The home has an up-to-date statement of purpose and service user guide, which are now produced in an attractive format. There are copies in the reception area and there is evidence from discussions with families that information about the home is given to them.
Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 11 Each person has a contract / terms and conditions, which is appropriately signed and dated. The contract / terms and conditions has been revised and updated taking account of the Office of Fair Trading publication Unfair Terms in Care Homes Contracts, as is good practice. Examination of a sample of residents’ case files demonstrates that the registered manager has obtained the referral agency’s assessment of needs or has used the homes comprehensive assessment tool, which is comprehensively completed with all relevant information. Evidence from informal discussions with residents and families is that the home does offer an opportunity to visit before an admission takes place. Most prospective residents do not take the opportunity to visit; they rely on their relatives to make the choice. The documentation relating to introductory visits is generally on each persons case file, though for the most recent admission this was completed at this visit. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents needs. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The home has robust arrangements for the administration of medication, which safeguards the well being of people living at the home. EVIDENCE: There is a detailed care plan in place for each person, based on his or her assessed needs. There is good evidence that care plans are developed in conjunction with the resident and their relatives, with signatures in place to indicate agreement. The manager has made improvements to care plans for people with Diabetes and other more complex needs. The plans give staff explicit guidance about the monitoring arrangements for diet and skin care. On the sample of residents’ care plans there are records of the persons preferences for their daily routine, for example rising, retiring, and bathing. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 13 There are generally good risk assessments in place and appropriately recorded health care screening assessment tools completed for each person. There is generally satisfactory evidence that residents are weighed on admission and regularly weighed each month. Documentation relating to the health care checks provided for older people are satisfactory to demonstrate that all regular checks have been offered, whether or not they had attended or what the outcome has been. Record sheets for health review, dentist visits, optician visits, chiropodist visits, medication reviews are available on the sample of residents case files assessed. There is a comprehensive medication policy and procedure. As good practice this is regularly reviewed and updated, with staff signatures to demonstrate their awareness and compliance. Observation of the staff administering medication during the visit demonstrates this is done in a professional and sensitive manner. Completion of medication records (MAR sheets) and monitoring arrangements of stock levels demonstrates continued good practice. There is ample evidence that support is given to residents to be appropriately groomed and dressed. There are records of each person’s preferred name, and all members of staff address residents in a respectful manner. Each person is supported in ways, which maintain their personal dignity. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 This home makes planned and spontaneous activities available on a regular basis; these are well advertised so that all residents are able to take advantage of socially stimulating opportunities. Good contact is maintained with family and friends for the majority of residents. The meals at Lapal House & Lodge are very good, offering both choice and variety and catering is extended to relatives on request. EVIDENCE: Residents spoken to confirm that they feel that there are sufficient numbers of staff on duty and that they have time to spend talking to them and to enable them to enjoy regular activities and outings, according to choice. The home employs an activities co-ordinator and there is a weekly activities programme, which is published, in addition to the monthly newsletter advertising forthcoming events. There is a range of social and spiritual stimulation available, such as a monthly church service at the home. Entertainers and therapeutic practitioners, for activities and aromatherapy are brought into the home on a regular basis each month, as well as social events, such as the recent wartime picnic. In addition people are able to enjoy trips and outings using the homes minibus service, examples are the recent trip to WestonLapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 15 super-Mare, local shopping trips to the Lickey hills, Blackheath, and Wombourn, often sampling local pub lunches. There is evidence available to demonstrate that staff consult with all residents as to their preferred activities, hobbies, and outings, with documented preference and the comprehensive activities programme. It is also recognised and respected that some people prefer not to involve themselves in structured activities. There is a visiting policy, which welcomes visitors. A considerable number of people visited during this visit. Everyone expressed their appreciation of the efforts made by the home and the way care is provided. The home has an 8-weekly menu, which offers a wide and varied choice of meals. The menus are displayed on each table in the dining room and care is taken to record each persons daily preferences. Although there is currently one vacancy for catering staff, these duties are covered by care staff working extra shifts, with appropriate food hygiene training. Catering staff take pride in presenting the food to look and taste appetising, and the home is proud to have received a gold standard award from Dudley Environmental Services/ NHS. Care staff were seen to offer sensitive assistance to people needing help or feeding. There was ample evidence seen at the visit that people are able to choose to have their meals in their own rooms if they wish. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a satisfactory complaints system with good evidence that residents and relatives feel that their views are listened to and acted upon. Arrangements for protecting residents are satisfactory safeguarding them from possible risk of harm or abuse. EVIDENCE: The Home has a complaints procedure, which is displayed in the reception area and is also contained in the service user guide. The home has not had any complaints in the past twelve months. The Home has a copy of the Local Authority multi-agency Protection of Vulnerable Adults policy and procedure. The Home has developed its own policies and procedures relating to the protection of vulnerable adults, dealing with aggression, use of physical / non-physical intervention; whistle blowing, dealing with residents finances and there is a copy of the Public Disclosure Act available. The manager continues to regularly raise staff awareness of non-physical intervention strategies through supervision sessions and training. There are records to demonstrate that all members of staff have attended a one-day training course relating to abuse. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 standard(s) 19,21,24,25,26 The manager has a good understanding of the areas in which the home needs to improve with effective planning in place for improvements to be resourced and managed. The standard of the décor within this home is very good with evidence of improvement through continuous maintenance. This is a very attractive and comfortable environment for residents. EVIDENCE: Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 18 Lapal House and Lodge are set in approximately 4.5 acres of land and landscaped gardens. There are attractive views from communal rooms and bedrooms of the grounds and surrounding countryside. The Proprietor has discussed proposed extensions to the home with the CSCI satellite office, Halesowen. The plans are now submitted for planning approval from the Local Authority. There is a rolling programme of redecoration and renewal. This includes the on-going re-decoration of identified bedrooms and areas of the Lodge. The programme of work to provide radiator covers is continuing each cover has to be custom-made due to the size and age of the radiators. However these must now be completed as a priority. The décor, fixtures and furniture are provided to high standards. The grounds are well maintained and are well used by residents and families, especially in the summer months. There is ample car parking in the grounds. There are four assisted bathrooms and 6 communal toilets in addition to the 24 en suite bedrooms, which include toilet and wash hand basins. These facilities are clean, attractive and well maintained. A small number of toiletries left in one of the bathrooms, removed on request during the visit, to prevent communal use. During the tour of the premises a sample of residents’ bedrooms were viewed, with their permission. These are furnished appropriately according to the needs of each person. The bedrooms are tastefully decorated and it is evident that people are encouraged to personalise their rooms with their own possessions, pictures, mementos and furniture. There is an inventory in place documenting personal possessions, furniture etc., brought into the Home, held on each person’s case file. The kitchen and laundry areas will be fully inspected at the next visit. During the tour of the premises on this visit, it is evident that high standards of cleanliness continue to be maintained and there are no discernable malodours. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 This home continues to maintain stable substantive staffing levels and residents receive good and consistent care. The standard of vetting and recruitment practices is good, with all appropriate checks being carried out. Staff morale is high resulting in an enthusiastic workforce working positively with residents to improve their whole quality of life. Good progress is being made to provide all staff with training, which provides safeguards for residents. EVIDENCE: Assessment of staffing rotas demonstrates that the home continues to maintain satisfactory staffing levels. The registered manager reviews staffing levels on a regular basis, using Department of Health Residential Forum Staffing Tool, taking account of the occupancy and dependency levels of residents accommodated, as is good practice. The Home has a very stable staff team of 39 people including 30 care staff, 1 catering staff, (there are currently 2 vacancies) 2 domestic staff, 1 activities co-ordinator, 3 gardeners, 1 maintenance staff, 1 administration staff, the Registered Manager. Three members of staff have left the home’s employ in the past 12 months, for valid reasons. The Home has made excellent progress to ensure that there is a strategy to achieve of the standard of 50 of care staff trained by 2005. Currently 95 of care staff have achieved the NVQ 2 care award or above.
Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 20 The Home operates robust recruitment practices. Random samples of staff files examined are satisfactory. Interview questions and answers should be retained on staff personnel files as a matter of good practice. The home does not currently hold evidence of the hairdressers CRB clearance. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,37,38 The registered manager is supported well by the senior staff in providing clear leadership throughout the home, with staff demonstrating an awareness of their roles and responsibilities. The systems for resident consultation at Lapal House and Lodge are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: Mrs Michelle Upperdine is the Registered Manager and she has worked at Lapal House and Lodge for 19 years. She has extensive experience and she achieved an NVQ level 4 care / management award in 1999. In addition she has completed the Registered Managers Award (RMA). It is evident that she continues to update her training and personal development. There are clear lines of accountability within the home, and she is in day-to-day control of the
Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 22 Home, with the Mr Billingham, the Proprietor providing supervision, support and monitoring through Regulation 26 visits, which are now conducted on a more consistent basis. There is an annual development plan for the Home, with continuous self monitoring, evidencing the involvement of residents, representatives and other community stakeholders. The Local Authority has approved this quality assurance system. The home has the Investors in People (IiP) Award. Record keeping at the home continues to improve, achieving high standards, with only very minor improvements required at this visit. All personal information is held, stored and disposed of in accordance with the Data Protection Act 1998. A sample of mandatory training records, fire safety and maintenance documentation examined is satisfactory. The Manager ensures that all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. The accident records examined are satisfactory. There have been 54 accidents involving residents since the inspection visit on 18 February 2005. The Manager undertakes a regular documented accident analysis each month, which is used to identify trends and instigate reviews / reassessments and corrective action as required. Minor health and safety issues raised are: although the pharmacy has supplied oxygen, there are no warning notices relating to the use and storage of compressed gas. The homes risk assessment and West Midland Fire Service must be updated regarding the use of oxygen on the premises. Although the home undertakes a range of health and safety checks, these do not include regular visual checks of slings used with hoists. Sling checks must be added to the schedule of regular documented checks of equipment. Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 4
COMPLAINTS AND PROTECTION 2 x 2 x x 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x 3 2 Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 13(1) Requirement To seek advice from the continence service regarding the most appropriate continence aids for each person To replace the old style draw sheets with Kylie sheets To obtain and display compressed gas warning signs for oxygen in use (or stored) Timescale for action 31/08/05 2. 9 38 13(2)(4) 31/08/05 3. 21 13(4) 16(2)(j) 4. 29 35 17(2) Schedules 2 and 4 To add information relating to location of oxygen to the homes fire risk assessment and inform the West Midland Fire Service of the location of oxygen on the premises To remove any items, which may 31/07/05 be used communally from communal bathing facilities, ensuring that these areas remain free from such items 1) To provide copies of job 31/08/05 descriptions on each persons personnel file 2) To revise and update staff contracts to include references to abuse / gross misconduct and the potential for referal to the POVA Registers Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 25 5. 25 38 13(4) 6. 38 13(4) 3) To obtain evidence of the hairdressers and any other therapists CRB clearance. The Registered Provider must complete the provision of low surface radiators or radiator covers to reduce the risk of burns. This must now be prioritised. (Timescale of 31/10/04 - Not Fully Met) To undertake regular and documented visual checks of slings 31/10/05 31/08/05 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. Refer to Standard 29 29 Good Practice Recommendations That interview questions and answers are retained on staff personnel files That reciept of individual copies of the General Social Care Councel Code of Practice and Conduct is added to the induction checklist, which is signed Lapal House & Lodge E55 S24965 Lapal House V231845 110705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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