Inspection on 19/06/06 for Lawfords House

This inspection was carried out on 19th June 2006.

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

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

Other inspections for this house

Lawfords House 19/08/08

Lawfords House 22/08/07

Lawfords House 15/02/07

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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lawfords House Walford Road Ross-on-wye Herefordshire HR9 5PQ Lead Inspector Denise Reynolds Unannounced Inspection 19th June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lawfords House DS0000024721.V295501.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.V295501.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.V295501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The Home may continue to accommodate the 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. 2. A minimum of 3 care staff (excluding the Manager) must be deployed on the morning shift. 3. A minimum of 2 care staff (excluding the Manager) must be deployed for the afternoon shift. 4. Sufficient ancillary staffing must be provided additional to these core care staff. 5. The registered persons must inform the Commission without delay if any of these service users move out of the home 6. The Registered Manager will complete the additional training needed to obtain the Registered Manager’s Award - within 12 months of registration. 7. The Registered Manager will undertake moving and handling training at a level that equips her to monitor the competence of staff practice and undertake service users` moving and handling assessments - within 4 months of registration. 8. The Registered Providers will support the registered Manager in achieving conditions 6 and 7 by funding and facilitating attendance at courses and ensuring that suitable management cover is provided at Lawfords House. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 5 Date of last inspection 14th March 2006 Brief Description of the Service: Lawfords House provides a home for 15 people over the age of 65. 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. The registration categories for the service were reduced during 2004 to better reflect the care needs the Home is set up to cater for. This involved the removal of the categories relating to care of people with dementia illnesses, mental health needs and physical disability (other than for people already resident at the Home). An application to enable the Home to accommodate one person with differing needs had been received by CSCI. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the report on a key inspection. This involved one unannounced visit to the Home starting at 11.20am and ending at 5.25pm. Before the visit we sent the manager a pre inspection questionnaire and consultation leaflets for people living at the Home and their relatives. We received five replies from residents and three from relatives. One relative was spoken to on the phone. Information was also obtained from a social care professional and a healthcare professional. During the visit, two staff were interviewed and three residents spoken to privately. Care records for five people were looked at. There were discussions with the provider about the way the Home is managed and the care provided. Information provided in the 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. The Home has a well written service user guide that is given to prospective residents. What the service does well: What has improved since the last inspection? The Care Manager has continued to make improvements to how the Home is run. The content of the care plans needs further development but these are much more informative and detailed than in the past. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 7 Steps are being taken to improve the menus and give residents more involvement in deciding what they have to eat. The choice available at teatime is being increased. This has been made possible because of additional staffing in the kitchen at this time of day. Minor refurbishment had been done in the kitchen. 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. Reports of these visits are not always being submitted to the Commission as the law requires. During this inspection the inspector identified a number of concerns relating to the facilities premises that show a lack of attention to the comfort and safety of people who live at the home – • • • • • • • • • A number of drawers and cupboards in the kitchen were dirty. The Commission has not been provided with evidence of the most recent check of the electrical installation of the Home. A window restrictor has been removed from a first floor window A rechargeable torch on the first floor landing did not work because the charger was unplugged. A raised toilet seat was not securely fixed to the toilet bowl. Old, frayed towels were in use. The seat of one chair lift is held in the upright position when not in use by a coat hanger wrapped in black tape. Piles of disused walking frames and commodes in the garden. An activity display board waiting to be put up since March. The providers should have noticed these things themselves during the monthly visits mentioned above. They should already have taken action to put them right. General upgrading and refurbishment of the building and furnishings is needed and there are some specific shortcomings with the Home that need structural work. Briefly, these are – • • • Provision of suitable laundry. Provision of an office that is private. Suitable accommodation for staff on call at night. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 8 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. The Commission now requires the providers to inform us of their plans for starting this work. A number of requirements in this report relate to things that could have a direct impact on the safety of residents. Other requirements are repeated or relate to longstanding issues. If these requirements are not met by the dates given the Commission is likely to take enforcement action. 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. Lawfords House DS0000024721.V295501.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 Lawfords House DS0000024721.V295501.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 (standard 6 does not apply at Lawfords House) 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. EVIDENCE: The survey forms received from residents confirmed that people receive a contract with the Home and have enough information to help them decide if it is where they want to live. One person wrote, “I came to have a look it was very homely. It suited me very well.” A relative confirmed that he had received a contract, service user guide and a copy of the complaints procedure. The manager has written the statement of purpose and service user guide in a friendly and easy to read style. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication is managed safely following hard work to improve this aspect of care. Residents feel well looked after. Improvements to care plans and care records are helping to make sure that health needs are dealt with quickly. Further work is needed to involve residents in planning their own care and to make sure the new process gets firmly established. EVIDENCE: When talking to the inspector residents were very positive about the care they receive. In the five comment cards filled in all the residents answered that they always receive the care and support they need. Four out of five answered that they always get the medical support they need and one said this usually happened but did not give a name so this could be followed up. One person wrote “If I am poorly (and) need a doctor one is sent for.” Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 12 While further work is needed on involving residents in developing their care plans, the organisation and content of these has improved considerably and they now provide a better framework for staff to build on. A social care professional visiting the home gave the inspector positive information about the manager’s awareness of a resident’s needs, the general level of support given to her and the achievements made by the home in helping to improve certain aspects of her life. A relative spoken to was very appreciative of the care received by his mother and had also observed examples of good care given to other people at the Home. For example – he had heard staff trying to persuade someone to have a drink on a hot day. The same person also said that he finds staff very willing to speak with him about his mother’s care. A health care professional gave feedback suggesting that areas for improvement are staff awareness of residents care needs and improved privacy for consultations. Medication practice at the Home has improved – records, training and storage are now satisfactory and a sample of medication was successfully audited. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager and staff know it is importance to provide activities to make life more enjoyable for residents and are developing this. The residents appreciate the relaxed and welcoming atmosphere. EVIDENCE: Not all the residents feel that there is enough to do but enjoy the activities that are provided when staff have time. A range of activities is listed in the pre inspection questionnaire, eg bingo, painting, flower arranging, aerobics, singa-long and video afternoon. One person said they like the music and movement - “I enjoy it very much – good exercise for your body”. It would be positive if opportunities could be made to support residents in taking part in activities specific to them and for this information to be included in more detail in the care plans. Mealtimes are relaxed – people are encouraged to sit at the table to eat but can have meals in their room if they prefer. People said they like the food “very good food.” Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 14 The kitchen was not clean and drawers and cupboards were badly organised and untidy. This meant that a previous requirement about standards of hygiene in the kitchen was not met. A requirement was made for this to be dealt with urgently and the provider has confirmed in writing that this was done. The manager has produced new menus and these were due to be introduced the week after the inspection. These include an excellent initiative where one day each week the cook will use a recipe from a resident for the main meal – it will be interesting to see how this develops. The menu include a good variety of meals with a choice on some days and show efforts to increase the amount of fruit residents eat. The menu also shows a cooked option for tea each day – made possible by the employment of a kitchen assistant for this time of day. The manager plans to display the menus on the tables – this is good practice. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have had training about understanding and reporting abuse and residents feel safe and listened to. EVIDENCE: The survey forms showed that residents know who to speak to if they are not happy and know how to make a complaint. One person wrote, “ If I have a problem I can go to anyone available”. The residents and staff spoken to also said they knew who to tell if they had a concern. The manager said that no complaints have been received. Staff have done training provided by the Adult protection co-ordinator for the County and the staff spoken to understood their responsibilities. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of maintenance and renewal of equipment and facilities mean that service users and staff could be potentially at risk from equipment that may be unsafe. The poor condition of the décor and fixtures and fittings means that service users live in an inadequate environment. EVIDENCE: Residents’ survey forms said that the Home is clean but close inspection of some areas showed that the standard of housekeeping and maintenance is not good enough. A number of drawers and cupboards in the kitchen were dirty (eg dust, crumbs and grease) and untidy (eg drawers containing random contents such as old instruction books, sprigs of artificial flowers and ribbon, an almost empty bottle of vanilla essence with a dirty and encrusted cap). The laundry and utility room were also untidy and not very clean. Poor standards of cleanliness and Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 17 storage arrangements in these areas increase the risk of infection and are unacceptable. The manager said she would do the necessary cleaning herself before the weekend. This would normally be a task that a care home manager would delegate to domestic staff. The manager explained that new cleaning schedules would be implemented next week. She has worked hard to produce new documentation which will give a better framework for the future. It is unsatisfactory that the kitchen has not been kept clean and tidy in the meantime particularly because the kitchen being dirty resulted in a requirement following the last inspection 3 months ago. This requirement, made in March 2006, to introduce a cleaning rota by 31st March 2006 had therefore not been met. The Commission has not been provided with evidence of the most recent check of the electrical installation of the Home. This means that a requirement made in March 2006 to do this by 30th April 2006 was not met. The March 2006 Regulation 26 report states that arrangements for an inspection of the electrical installation were in hand. The manager was not aware of a date having been arranged for this to be done. A window restrictor has been removed from a first floor window because the resident in that room became very distressed by not being able to have the window open wide in the hot weather. No risk assessment had been done about this to make sure any risks to the resident had been identified and dealt with. A rechargeable torch on the first floor landing did not work. Investigation revealed that the charging unit was unplugged and another piece of equipment was plugged in to the single socket. This would cause a problem if staff were expecting to rely on the torch in a power cut or in the event of a fire. A raised toilet seat was not securely fixed to the toilet bowl. This could lead to a resident falling. Requirements were made for all of the above things to be put right or put into action during the week after the inspection (see requirements section of this report for dates). The Provider sent the Commission an action plan confirming that the required action was completed or in hand. In addition to these urgent issues other examples were found of wear and tear to the building and facilities. The exterior paintwork has still not been painted making the house look shabby and creating a very bad first impression when looking at the building from outside. Inside, some rooms have been decorated Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 18 but overall the carpets, décor and furnishings are in need of investment. The providers have previously said they will deal with things like this when they build an extension but this work has been delayed for over 6 years which makes the commission question the providers’ intention to do it. The inspector found old, frayed towels in the wardrobe where they are stored – it is not acceptable to expect residents to use towels in such poor condition. The seat of one chair lift is held in the upright position when not in use by a coat hanger wrapped in black tape. This is not acceptable. In the garden the inspector saw piles of disused walking frames and commodes; this looked unsightly and could present a risk to residents if they go out into the garden. During the inspection in March 2006 an inspector was shown a display board that the manager was going to have put up to show what activities were planned. This board was still waiting to be put on the wall. The manager had not been able to arrange for someone to do this even though the providers retain the services of a maintenance man. One room seen was furnished to an acceptable standard but the resident had purchased all of the furniture himself. The standard of the accommodation is the responsibility of the manager and providers. The concerns identified during this inspection illustrate the lack of effective quality assurance at the Home. It is of concern that the providers have not identified these matters during the monthly visits required by regulation. In addition to the issues identified this time, the following matters have been the subject of lengthy negotiation with the providers and have still not been resolved • Provision of suitable laundry facilities (temporary improvements have been accepted by CSCI and Environmental Health as a short term solution only) to ensure good infection control arrangements and a safe working environment. Provision of an office to replace the current location in a main thoroughfare through The Home. The current arrangement means that some residents and their visitors have to use it as a corridor between their bedrooms and the communal rooms. The space to walk through is limited and at the same time the working space is restricted. There is no privacy for discussion about things that may be confidential and limited security for records. Suitable accommodation for staff on call at night who in the past have had to sleep on a sofa in a sitting room. As a short-term measure while the Home has vacancies, staff are using a vacant bedroom. • • Lawfords House DS0000024721.V295501.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is showing improvement in both the number of staff on duty and training for staff. This will have to be sustained and built on to create a sufficiently well trained staff group to ensure that residents always get the best level of care possible. EVIDENCE: Discussion with residents and comments in the survey forms give a picture of residents getting on well with the staff – “The staff are fantastic” “They are always there for me” “Nothing is too much trouble for them” A relative described the staff as “kind, lovely and very patient”. A member of staff spoken to said she thinks it is a nice home with friendly staff and that residents are well looked after. She showed a good grasp of her responsibilities to report abuse or neglect and had done core health and safety related training. She had not done medication training but told the inspector that she is not one of the staff who gives residents their medication. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 20 The manager is trying to improve the overall level of training staff have had. Half of the staff have now done NVQ 2, this is major progress which is being built on by some staff moving on to level 3 She said that by the end of August all staff will have done first aid (appointed person) and moving and handling training. The manager and two staff have full first aid at work certificates. In September, all staff will be doing a health and safety course. The manager and two staff have done a moving and handling course including an element on moving and handling assessments. The benefit of having an ‘at a glance’ chart showing all the training for each member of staff was discussed. Introducing this will help the manager monitor and plan training. Correct recruitment procedures are now established and the staff files looked at showed that references and CRB checks are obtained before staff start work. However, it was noted that staff contracts are not all signed and the induction checklist forms are not all dated. One to one support and development (‘supervision’) for staff has not been firmly established yet. Although the manager wants to get this underway she feels she has not had enough time to do this in addition to other things that need to be done. It was noted that the staff record for one of the staff is incomplete. She is described on the pre inspection questionnaire as having more than one role – cook and senior care – but her staff record does not confirm this information. There is no record of the training done by this person in her file which only contains two copies of an unsigned contract and no other information. Lawfords House DS0000024721.V295501.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager has worked hard to improve aspects of the service within her scope but oversight of the service by the providers is minimal and the absence of effective quality assurance measures and financial investment by them means that shortcomings in the service are not put right. EVIDENCE: The Care Manager is working towards obtaining the Registered Manager’s Award. 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 Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 22 most aspects of the day to day running of the home. She has reviewed and updated a number of policies during 2006. Accident records at the home confirmed that the Commission had been kept informed of all events that are notifiable under the Regulation 37. A requirement made for the Provider to confirm that the electrical wiring at the home has been checked in the last five years had not been met. A requirement for reports under Regulation 26 to be submitted to CSCI monthly had not been met. A report was sent to the Commission in March 2006 but none have been received since. Some of the concerns identified during this inspection would normally be within the scope of the manager of a Home to deal with. However, it would seem that the manager at Lawfords House has been unable to address all that needs to be done. This appears to be due to a lack of support from the providers – an issue already highlighted in the previous two inspection reports. In addition, the providers are not doing enough to deal with things outside the manager’s control. There are no established quality assurance measures in place and the contents of Regulation 26 reports do not provide evidence that the providers identify and act on shortfalls in the service. Lawfords House DS0000024721.V295501.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 X X X 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 2 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 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 2 1 1 Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 16 and 23 and CSA 2000 section 31(1) 16(2)(c) 23(2)(c) 16(2)(c) 23(2) d Requirement The providers must submit written plans for the refurbishment of the premises including whether they are going to build an extension or not and if so the proposed start date for this. A supply of towels in good condition must be provided for residents. The correct fastening for the seat of the chair lift must be provided. All carpets must be examined for tripping hazards such as frayed areas and remedial action taken. A cleaning rota must be introduced to ensure the kitchen is kept clean. Previous timescale 31/03/06 not met. The kitchen, laundry and utility room must be cleaned and storage properly organised. The Provider must provide the Commission with evidence of the most recent check of the electrical installation at the home. DS0000024721.V295501.R01.S.doc Timescale for action 31/08/06 2 3 4 5 OP19 OP19 OP19 OP15 OP26 31/08/06 31/08/06 31/08/06 26/06/06 6 7 OP26 OP38 13(4) and 23(2)(d) and (l) 23(2) b 26/06/06 31/07/06 Lawfords House Version 5.2 Page 25 8 OP38 13(4) and 23(2)(b) 9 OP38 13(4) (Previous timescale 30/04/06 not met – please see amended timescale and new requirement below) Either, evidence must be provided to CSCI that an electrical safety report has been done within the last 5 years and any necessary work completed or an inspection of the electrical installation by a suitably qualified electrician (ECA or NICEIC registered) must be arranged and a copy of the report sent to the Commission with an action plan for carrying out any work identified. A risk assessment must be done to establish the level of risk involved in not having a window restrictor fitted to the window in LDs bedroom and whether any risks identified can be dealt with. A decision must then be made whether to replace the restrictor or not. Effective maintenance arrangements must be made for small items of equipment such as rechargeable torches. If rechargeable torches are used the charging unit must be kept plugged in at all times. The raised toilet seat referred to above must be correctly fitted. The garden must be cleared of disused equipment. The Providers must supply the Commission with regular monthly reports of visits to the home to show how they are fulfilling their responsibilities to oversee the service. (Previous timescale of 31/03/06 not met) 31/07/06 23/06/06 10 OP38 23(2)(c) 23/06/06 11 12 12 OP38 OP19 OP19 OP38 OP37 23(2)(c) 23/06/06 31/08/06 31/08/06 23(2)(o) 26 Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 26 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 OP19 Good Practice Recommendations Any programme of refurbishment should address the replacement of soft furnishings e.g. suitable height seats, easily cleaned coverings. Lawfords House DS0000024721.V295501.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Office The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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