Inspection on 15/02/07 for Lawfords House

This inspection was carried out on 15th February 2007.

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

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

Other inspections for this house

Lawfords House 19/08/08

Lawfords House 22/08/07

Lawfords House 19/06/06

Lawfords House 14/03/06

Lawfords House 05/10/05

Lawfords House 20/01/05

Lawfords House 02/08/04

Lawfords House 28/03/04

Lawfords House 05/02/04

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

CARE HOMES FOR OLDER PEOPLE Lawfords House Walford Road Ross-on-Wye Herefordshire HR9 5PQ Lead Inspector Denise Reynolds Unannounced Inspection 15th February 2007 13:10p 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 Lawfords House DS0000024721.V330689.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. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lawfords House Address Walford Road Ross-on-Wye Herefordshire HR9 5PQ 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) 01989 566811 01989 566811 Miss Mary Eileen Wilson Mr Peter Donald Vine Mrs Jill Madley Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: The Home may accommodate 3 named service users who have needs that fall outside the scope of the registration category OP. This is conditional on regular review by the Registered Persons to ensure the Home is able to meet all needs without detriment to other service users. Key inspection – 19/06/06 Date of last inspection Random inspection – 02/10/06 Random inspection – 21/11/06 Brief Description of the Service: Lawfords House is registered for 15 people over the age of 65 who do not have significant needs other than those due to the physical ageing process. They may not accommodate people whose main needs are due to the effects of dementia illnesses or mental health problems. The accommodation is provided in a medium sized period house about a mile from Ross on Wye town centre. The house is a converted building and is in need of refurbishment and upgrading. Two of the bedrooms have been set aside for use as an office and an on call room for staff. This means that no more than 13 residents can be accommodated at present. 1. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report on a key inspection. This was the second key inspection during 2006/07; the other was in June. In between these two inspections we did two random inspections, one in October and the other in November. A random inspection looks at specific issues where we have concerns. The reason for the October and November visits was to review progress with requirements made following the June inspection and to attempt to make progress with outstanding shortcomings in the premises. Officers from Herefordshire Council Environmental Health, Herefordshire and Worcestershire Fire Service and a specialist nurse from the Health Protection Agency took part in these inspections with us. The reports we write after a random inspection are not published on our website but copies can be provided on request. The inspection in February involved one unannounced visit to the Home starting at just after 1pm and ending at 6.25pm. During the visit, staff were observed as they spent time with residents, two residents were spoken to privately and others spoken to in the dining room. Care records for three people were looked at as well as a sample of other records and documents. There was discussion with the manager about the way the Home is managed and the care provided. Information provided in the June 2006 pre inspection questionnaire states the current range of fees for Lawfords House is from £325 to £395. Additional charges are made for hairdressing, chiropody, magazines and newspapers. What the service does well: Lawfords House is a relaxed and friendly Home. People living there like the staff and manager and feel well looked after. The staff are welcoming and do their best to make life pleasant for people living at the Home. People are able to visit the Home as often as they want before making a decision and are made welcome by staff. The relative of a new resident said – “the girls are bending over backwards to help her feel at Home”. The care plan format is now well established and helping staff make sure the residents have the care they need. The format of these is clear and easy to use. Previous improvements to the way medication is managed have been kept up. This means that medication is dealt with safely. The menus offer residents a choice and are displayed on the tables so that people can read what is being served beforehand. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 6 Staff are receiving training in essential topics such as fire safety, first aid and adult protection. The manager and staff are working hard to make the Home a nice place to live. What has improved since the last inspection? A number of concerns identified at the last inspection have been dealt with, for example – • • • • • • The kitchen and the rest of the building are being kept cleaner due to changes in the cleaning arrangements. An inspection of the electrical wiring has been done and remedial work completed. Steps have been taken to make sure the rechargeable torches are kept in working order in case there is a power cut or fire during the night. New towels and bedding has been purchased. Piles of disused walking frames and commodes have been removed from the garden. The information displays in the entrance hall have been completed. Other safety matters have also been dealt with, for example a step has been replaced with a ramp and a handrail installed alongside a staircase. There has been a longstanding issue regarding the location and lack of privacy in the office. This was in a room that is the only way through from the communal areas to some of the bedrooms. Converting a bedroom into an office has rectified this. This makes it safer for the affected residents to walk to and from their rooms and has given the manager a safer, private and more efficient working environment. Another bedroom is in use to provide an on call bedroom for staff; this means that the person who is ‘sleeping-in’ does not have to sleep on a sofa in the sitting room as in the past. What they could do better: The manager needs to get better support from the providers and they need to be better at noticing things that need to be done and dealing with them quickly. A structured quality assurance framework would help them with this but they must also make better use of the monthly visits that the law requires them to make. Now that the new care plan format is well established, the manager needs to make sure that they are regularly reviewed and that the information in them is detailed enough to guide staff in the care they need to give people. Overall Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 7 the care records are good but there were some gaps that could lead to a care need being overlooked. The cook should be more closely involved in the assessment and care planning for people with specific dietary needs. New staff are recruited properly with all the required checks done to help the manager make sure they are suitable but the manager needs to keep a record to show that gaps in information provided in application forms have been discussed at interview and resolved. She also needs to make sure that she has written evidence that she has satisfied herself that references are authentic. General upgrading and refurbishment of the building and furnishings is needed and the long awaited improvements to the laundry facilities must be carried out to minimise the risk of cross infection and to provide staff with a safe working environment. This work has been the subject of negotiation with the providers for more than five years. The providers have delayed starting the work a number of times while deciding whether or not to build an extension. This means that general refurbishment work has also been delayed. Herefordshire Council granted planning consent for an extension on 7th June 2006. Since then the service providers have decided to build a smaller extension and submitted a new planning application in January 2007. In their improvement plan they told us that the planned start date for the laundry, subject to planning consent, would be 5th March 2007. They have given dates for work to start before and this has not happened. This shows a lack of regard for the professional advice given by Environmental Health officers and an infection control specialist from the Health Protection Agency. We expect them to proceed without any further delay or otherwise make alternative arrangements for the laundry to be done. They must consult fully with environmental health officers and with the Health Protection Agency to make sure the new facilities will meet legal requirements for hygiene, infection control and a safe working environment for staff. Because the service providers have allocated two former bedrooms to be used as an office and a staff on call bedroom, the maximum number of residents that can be accommodated is 13. The service providers need to request a variation in their registration to reduce the number of places accordingly. 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. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home to help them decide if it is the right place for them to live. People are able to visit the Home as often as they want before making a decision and are made welcome by staff. EVIDENCE: During the last key inspection we gathered information to show that people are given clear information to help them decide whether to move in to Lawfords House. At this inspection a new resident and her relative told us that they had been given a large print copy of the service user guide and had received a contract. Both of them had visited the Home more than once before making a decision. They were both very pleased with the reception the resident had and said, “ The girls are bending over backwards to help her feel at Home”. Lawfords House DS0000024721.V330689.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): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication is securely stored and records are generally well maintained. The care plan format is now well established and helping staff make sure the residents have the care they need. This could be strengthened by making sure enough detail is included and that reviews are kept up to date. People who live at the Home are treated with consideration and respect. EVIDENCE: A new care plan format was introduced in 2006 and staff use different sections to record the different aspects of each persons’ care. There are particularly good moving and handling assessments. The format being used means that there is not one chronological daily record for each person as is usually the case. Staff use various sections of the care plan alongside a diary that ‘signposts’ them to entries in the plan they need to be aware of. This is working well and the inspector was able to cross reference the entries sampled to find out what was happening about specific issues. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 11 There were some examples of gaps in the records and care plans that the manager was able to explain when asked about them; these included a nutritional assessment that did not contain much information and gaps in the records about a person’s weight. There was also a four day gap between entries about a health problem that a member of staff had noticed. It is important that records are kept up to date to provide a full picture of the care being given and to help the manager monitor that any concerns have been followed up and dealt with. The involvement of residents in deciding on the content of their care plan is an area that still needs to be developed. Reviews of care plans need to be firmly established now that the basic framework has been put in place. One entry seen referred to a GP’s comment - “ GP said that he was quite pleased with X as he did not expect (him) to pick up as well as he has, continue with the good work.” Improvements in the management of medication during the last 18 months have been sustained. The medication is stored securely secure and is well organised and managed. Apart from one oversight, which was explained satisfactorily, the medication records were up to date. Lawfords House DS0000024721.V330689.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): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home is small and has a settled team of staff, this has created a friendly atmosphere that residents and visitors appreciate. People are treated as individuals and feel at Home. The introduction of activity information into each person’s care plan will help develop the overall programme of activities. The introduction of new menus has improved the choice of food for residents; this could be further improved by involving the cook more closely in the assessment of people’s nutritional needs. EVIDENCE: General observation during this and previous inspections has shown that staff and residents get on well. Staff are always polite and residents spoken to appreciate the attention they are given. It is clear that each person is treated as an individual. The manager has put the new menus into use and these provide a choice of food at all meals. The menus are placed on the tables so that residents can look to see what the days meals are going to be. The meal provided on the Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 13 day of the inspection had been enjoyed by residents who told the inspector that they like the food and always have plenty to eat. There is insufficient evidence that the cooks know about nutritional information mentioned in residents’ assessments. This could be resolved by involving the kitchen staff in the nutritional aspects of assessment and care planning. The manager is about to introduce an activity section to the care plans; this should address the current lack of information about what individual pastimes people might enjoy as well as providing a record of activities people have taken part in. Lawfords House DS0000024721.V330689.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have regular training so that they understand how to recognise abuse and neglect and how to use adult protection procedures to report this. Residents and their relatives are given clear information about how to raise concerns with the Home. EVIDENCE: There were no complaints in the complaints file and the manager confirmed that none have been received. No complaints have been made to CSCI since the current manager has been at the Home. The relative of a resident said they have had a copy of the complaints procedure. The manager has put a comments book in the entrance hall next to the visitors’ book; so far no one has taken the opportunity to write anything. Staff have all had training about adult protection and a refresher has been arranged in May 2007. Residents spoken to said they feel safe; one person who had heard about a documentary about abuse in care homes said that he was sure the manager and staff at Lawfords House would never allow people to be treated badly. Lawfords House DS0000024721.V330689.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): 19, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A programme of redecoration and refurbishment has begun but considerable work is still needed to provide an acceptable standard of furnishings and décor throughout the house. The laundry does not provide a safe working environment for staff or the space or layout to minimise the risk of cross infection. EVIDENCE: A new housekeeping team has been established and the inspector spoke with the senior housekeeper and housekeeper who were on duty. They spoke with pride about the improved cleanliness in the home. A carpet cleaner has been purchased and although they were not sure if it would stand up to regular use (because it is a domestic model) the housekeeping staff said it is helping them Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 16 keep the Home cleaner and fresher. They had been very pleased when a visitor commented on the lack of odour in the Home. The Commission has now been sent evidence of the most recent check of the electrical installation of the Home which the service provider arranged in response to a requirement by us in 2006. Steps have been taken to make sure that the rechargeable torches are kept plugged in and tested regularly. Work on painting the outside walls has not been finished and some window frames still need to be renovated and painted. It is important for this work to be completed not only to prevent further deterioration but also to improve the first impression gained when looking at the building from outside. Inside, three bedrooms had been redecorated and had new carpets laid since the last inspection in July 2006. An awkward change of levels in the house has been solved by the installation of a ramp and handrail. This is effective and easier for residents and staff although the carpet that has been used to cover it shows early signs of fraying and does not match the surrounding carpets. Further work is needed to improve the standard of décor and furnishings throughout the building. New towels and bedding has been purchased to replace the old and worn supplies commented on when we inspected the Home in July. The garden has been tidied by the removal of disused equipment and furniture that had accumulated outside. The entrance hall has been used to display information about food and activities in the Home and photographs of the staff with their names. This has been done attractively and helps give an impression of a friendly place on entering. A significant improvement is the provision of an office that offers privacy for discussions and phone calls, improved security for records and a more efficient working environment for the manager. This replaces the previous office which was located in a main thoroughfare through the Home. The old arrangement meant that some residents and their visitors had to use it as a corridor between their bedrooms and the communal rooms. This area has now been opened up to provide safer access for residents and an area where people can sit and rest. Another improvement is the allocation of a former bedroom for staff on call at night; previously they slept on a sofa in a sitting room. An aspect of the premises that is still unsatisfactory is the laundry. There have been ongoing negotiations with the service providers about this for over five years. Between 2003 and 2006 CSCI and Herefordshire Council Environmental Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 17 Health officers accepted temporary improvements as a short-term solution pending the construction of an extension that was to include a new laundry. On 12th October 2006 we did a joint site visit with Environmental Health and the Health Protection Agency because the service providers had not started work on the extension despite planning consent being granted in June 2006. This site visit established that these short term improvements were not wholly adequate to ensure good infection control arrangements and a safe working environment. Environmental Health officers requested the findings of a risk assessment and plans for corrective action by 20th November 2006. The Health Protection Agency report stated that the laundry should not be done on the premises until suitable facilities were provided. On the basis of this we made a requirement stating – The registered person shall make arrangements to prevent infection, toxic conditions and the spread of infection at the care home. (In house laundering should not continue until appropriate facilities are provided) 31/12/06. In response to this requirement the service provider’s improvement plan submitted in January 2007 described further temporary changes to the current laundry and states that work on building a new laundry would start on 5th March 2007 subject to planning consent. During the inspection the inspector learned that the alterations to the current laundry were abandoned due to the manager being concerned that these may not be satisfactory. The laundry is still being done in the Home. The manager told the inspector during this inspection that the providers have submitted a new planning application. She believed that this is for a new laundry but no new bedrooms as was previously planned. The inspector telephoned the planning department and they confirmed that they received a planning application on 10th January 2007. A requirement has been made in this report for the registered persons to consult with Herefordshire Council Environmental Health officers and the Health Protection Agency regarding the adequacy of the further temporary work done to the current laundry and the plans for the new one. This is essential to ensure that all work done complies with relevant legislation. We will be arranging a meeting with the service providers to discuss with them 1) The outcome of the consultations with Environmental Health and the Health Protection Agency. 2) Whether planning consent has been received for the new laundry. 3) The date that work will start on building the new laundry and the anticipated completion date. 4) The arrangements in place for minimising the risk of cross infection in the meantime. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 18 5) What arrangements will be made for laundering while the new laundry is being built. 6) Their intentions for the ongoing refurbishment of the building. Because the service providers have allocated two former bedrooms to be used as an office and a staff on call bedroom, the maximum number of residents that can be accommodated is 13. The service providers need to request a variation in their registration to reduce the number of places accordingly. Lawfords House DS0000024721.V330689.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): 27, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have time to help residents with their personal care. They are respectful, friendly and treat residents as individuals. Recruitment practice is generally sound but some aspects need to be more robust to make sure applicants have given full information about their work history; this helps prevent unsuitable staff being employed. EVIDENCE: Discussion with residents and relatives gave a picture of a good relationship between staff and residents. Observations of staff helping residents during the inspection showed that they were being patient and polite. There was a sense of teamwork among the staff. Staff training has continued to improve with a programme of regular updates for staff in mandatory health and safety related courses such as first aid and moving and handling. Progress with NVQ training was not inspected – this will be reviewed at the next inspection. A recruitment file was checked. These records were satisfactory except that the person had not given the dates of previous employments or schooling and there was no record that this had been explored with the person at interview. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 20 There was no record of steps taken to authenticate her references. These are important checks to ensure the recruitment process is robust. Lawfords House DS0000024721.V330689.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): 31, 33, 34, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager works hard to improve those aspects of the service within her responsibilities. Effective quality assurance measures and financial investment by the service providers are needed to support her in improving the overall quality of service that people living in the Home receive. EVIDENCE: The Care Manager has completed the Registered Manager’s Award and at the time of the inspection was waiting for her results. Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 22 During the last two years the Care Manager has worked hard to improve the overall service. As a result of her efforts there have been improvements in most aspects of the day to day running of the home. She reviewed and updated a number of policies during 2006. She is about to conduct a survey of peoples’ views by asking residents and relatives to complete questionnaires. The results of this survey need to be collated and analysed to gain an overall view of what people think about the service. The survey would be more comprehensive if other stakeholders like doctors and district nurses and other visitors to the Home are involved as well. The development of a robust quality assurance programme is a major area for improvement and the service providers need to take an active role in this process. The providers make monthly visits to the Home as required by regulation. The reports they write about these show that they speak to residents and staff but do not provide sufficient evidence that they are making sure that the Home is complying with the requirements of the care homes regulations. There is no evidence that the service providers have a working business and financial plan that they keep under review to help them prioritise spending. There has been limited spending on the business and when money has been spent on the accommodation and facilities this has been in response to repeated requirements by CSCI. Accident records at the Home confirmed that the Commission has been kept informed of all events that are notifiable under the Regulation 37. There has been a recent inspection of the electrical wiring in the Home following a requirement by CSCI and remedial work has been done. Work required following an inspection by the fire service has also been done. Staff training in health and safety related areas is arranged and most staff are up to date in these topics or have refresher course booked in the near future. Protective clothing and hand gel is provided to staff to help in the prevention of cross infection. Liquid soap dispensers and paper towels are in place in the communal toilets. Issues relating to the inadequacy of the laundry for good infection control and also as a safe working environment for staff are described in the accommodation section of the report but are relevant to this section of the report as well. This is because the service providers have delayed putting this right for so long, indicating a lack of regard for the professional opinions of Environmental Health officers and the infection control specialist from the Health protection gency. Lawfords House DS0000024721.V330689.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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X X X 1 Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 and 17(1)(a) Requirement Timescale for action 31/03/07 2 OP26 13(3) and 16(j) The manager must make sure that care plans are regularly reviewed and that the information in them is detailed enough to guide staff in the care they need to give people. The records must form a complete picture so that care needs do not get overlooked (e.g. if a staff member writes down a health problem they have noticed, the record should show what has been done about it). 31/03/07 The registered persons must consult with Herefordshire Council Environmental Health officers and the Health Protection Agency regarding the adequacy of the further temporary work done to the current laundry and the plans for the new one. This is essential to ensure that all work done complies with relevant legislation. (This is a revised requirement relating to previous requirement that the laundry should not be done in house until suitable facilities are provided). DS0000024721.V330689.R01.S.doc Version 5.2 Lawfords House Page 25 3 OP33 24 The registered persons must establish and maintain systems for reviewing the quality of the service and forward reports about reviews of the service to the Commission and make it available to resident. The first report must be produced by the date given - 31/07/07 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 OP8 Good Practice Recommendations The cook should be more closely involved in the assessment and care planning for people with specific dietary needs. The manager needs to keep a record to show that gaps in information provided in application forms have been discussed at interview and resolved. She also needs to make sure that she has written evidence that she has satisfied herself that references are authentic. 2 OP29 Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lawfords House DS0000024721.V330689.R01.S.doc Version 5.2 Page 27 - 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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