Inspection on 03/01/07 for Laxton Hall

This inspection was carried out on 3rd January 2007.

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

Laxton Hall 20/11/07

Laxton Hall 04/01/06

Laxton Hall 11/07/05

Laxton Hall 11/01/05

Laxton Hall 25/05/04

Laxton Hall 23/02/04

Similar services:

London Road Neurological and Specialist Care Unit

Carlton Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Laxton Hall Laxton Corby Northants NN17 3AU Lead Inspector Keith Charlton Key Unannounced Inspection 09:55 3rd January 2007 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 Laxton Hall DS0000012842.V321433.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. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laxton Hall Address Laxton Corby Northants NN17 3AU 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) 01780 444292 01780 444574 Polish Benevolent Fund Housing Association Limited Sister Teresa Sabok Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No person falling within the category Older Person can be admitted to the Home where there are already 29 persons of category OP already accommodated In the Home. The Total number of Service Users in the Home must not exceed 29 The Home may continue to care for 5 existing named Service Users with Dementia or Mental Health Problems 4th January 2006 Date of last inspection Brief Description of the Service: Laxton Hall is a care home providing personal care and accommodation for 29 older people with a special condition for 5 existing, named residents who also have mental health needs. The Home provides care for Polish people of retirement age whose main language is Polish. The Polish Benevolent Fund Housing Association Limited owns the Home. The Registered Manager is Sister Teresa Sabok. A Religious Order of Nuns provides staffing in most part. The Home is located in a rural environment within its own grounds of approximately one hundred acres near the village of Laxton in north Northamptonshire. Nearest towns are Corby, Peterborough and Stamford. The Home was opened in November 1975 and consists of a large listed building offering 27 single bedrooms and 1 double room. There are 3 large day rooms on the ground floor and additional communal space in the large entrance hall. The building has its own Chapel and residents have access to the extensive grounds. There is a passenger lift. The weekly fees range from £329 to £348 per week - this information was provided on the Pre Inspection Questionnaire, that the Registered Manager provided prior to the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, etc. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. The Inspection took place between 9.55 and 15.10 and included a selected tour of the home, inspection of records and direct and indirect observation of care practices. The Inspector spoke with seven service users, three staff members, and three relatives. The Inspection was concluded the next day with the Registered Manager, and a Polish interpreter so that service users and staff whose first language was Polish could be included in the inspection. What the service does well: Service users said that staff were friendly and helpful towards them, reported that staff welcome visitors and they thought the food provided to them was good. Staff were observed to be generally friendly towards service users. Service users needs were well covered regarding medical authorities being involved where necessary following illness or injury. Care Plans contain the past life history of service users if service users/their representatives agree to supply this information. This helps staff see service users as people with a valued past and assists in talking with them. Residents said they were comfortable with raising any concerns that they might have and were satisfied that the concerns would be listened to and acted on by staff and management. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 6 There are flexible visiting arrangements in the home and relatives and visitors are made welcome. Residents generally spoke positively about the activities arranged by staff, which provided interest and stimulation for them. Staff thought they were valued in their performance of their jobs and staff training is encouraged by the Registered Manager in order to equip staff to meet service users needs. The Registered Manager has a positive attitude in seeking to improve the care standards in the service and was receptive to ideas as how to improve the service for residents. The manager and her staff run this home so as to create a relaxed and homely atmosphere. Four Comment Cards were received from visiting professionals, which were very complimentary about the care the staff provide: ‘Best care home I have had dealings with’. ‘Excellent care given’. ‘The staff at Laxton Hall are professional, kind and caring’. The Registered Manager has submitted a detailed Improvement Plan to deal with the requirements and recommendations stated in this inspection report. What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of residents is protected at all times, as there were staff without statutory Criminal Records Bureau checks in place prior to employment commencing, which meant residents were exposed to staff who may have posed a risk to them if they had criminal convictions or cautions. Staff must always be aware of residents care needs; this would include ensuring that staff being aware of all the Care Plans, and the Policies and Procedures of the service (which also need to be available in Polish so that all Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 7 staff can understand them, as a large number of staff cannot presently read English). Providing signs to facilities would assist residents who have dementia, in that they can identify facilities clearly. It was also recommended that staff be trained on how to provide suitable activities for residents with dementia, so as to provide proper stimulation. Also to set up memory boxes for residents with dementia, which can be used for reminiscence and interest for them. At the last two inspections the registered provider was asked to provide a contract on employment for all staff in line with the employment legislation. This is still outstanding, in that it has been drawn up but not yet been signed by the Registered Provider representative. Legal advice needs to be sought to ensure that it complies with Employment law, e.g. the clause on working more than a 48 hour week, staff supplying ‘voluntary’ unpaid hours etc., and staff working excessive hours. There needs to be a more thorough review of safe working practices, including the need to protect residents from burning from hot radiators without covers. 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. Laxton Hall DS0000012842.V321433.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 Laxton Hall DS0000012842.V321433.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is well managed and meets the needs of residents. EVIDENCE: Residents said that they could visit the home prior to their admission usually by way of a trial period, to give them a good idea of what services the home offered. There was evidence of assessments undertaken by the Registered Manager available on the residents files examined by the inspector. The Registered Manager was asked to incorporate all issues contained in the National Minimum Standard for future assessments. Laxton Hall DS0000012842.V321433.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 good. This judgement has been made using available evidence including a visit to this service. Care plans describe identified care needs to ensure proper care is supplied by staff. Medication is suitably and safely managed - this protects the safety and welfare of service users. EVIDENCE: No residents asked knew they had a Care Plan. The Registered Manager said that residents are always made aware of Care Plan and can participate in setting them up and this would be followed up to see if anyone wanted to see them. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 11 Residents needs are detailed in their Care Plans and all residents case tracked had a plan of care in place. The registered manager stated that care plans are reviewed monthly and this was seen as recorded in the Plans. Plans included records of the service users care needs. Risk assessments also form part of Plans to reduce the risk of harm from identified risks. Some Care Plans did not clearly set out dental needs as regards routine dental checks, or whether the service user needed a chiropodist. No Care Plan seen by the inspector had a signature of a service user agreeing to its contents. The Registered Manager said this would be followed up. It is also recommended that residents personal histories be compiled so that they can be seen as individuals with a valued history. The Registered Manager said she had identified this aspect and was planning to implement this in the near future. Daily records and Risk Assessments were recorded in Polish so that they are only understandable with the aid of an interpreter. There was discussion with Management staff regarding this. There are weekly English language sessions for staff. This needs to fully cover writing skills so that records are recorded in English in the future. Residents said that if there was a medical problem then staff would call a GP to see them. Accident records were viewed and the GP was appropriately called if there had been potentially serious injuries, e.g. a head injury. Residents all said that staff and the manager were friendly. The inspector observed that staff were largely very friendly and respectful and carried out tasks at residents pace. There were a small number of observed occasions where staff appeared to be smiling at what a resident with dementia was saying. The Registered Manager recognised this these acts were not respectful and said she would inform staff of the inspectors observations. It is recommended that management monitor this issue and follow up in training and supervision, as necessary. The medication system was inspected and was found to be well managed and appropriately administered. The Registered Manager confirmed that only trained staff issue medication. Medication training certificates confirmed that this training had taken place. Medication recording was fully complete with no gaps observed. Medication is securely kept in a locked trolley. Laxton Hall DS0000012842.V321433.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 good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to lead full lifestyle and can exercise choice. EVIDENCE: Residents said that there were activities and all except one resident said this was at a good level and frequency. The Registered Manager keeps records of activities that residents participate in and there are photos of events and outings. One resident wanted to go to the theatre and join a local bridge club. The Registered Manager said this would be followed up to see if there were any local services. The inspector recommended that memory boxes, containing valued items, be set up for residents, particularly for residents with dementia, so as to provide valuable reminiscence material and staff training on providing suitable activities for residents with dementia. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 13 They said that there were no rules that they knew of, e.g. no one reported that there were set going to bed and rising times, and all thought the atmosphere of the home was friendly and relaxed. Some residents spoken with were glad staff gave them medication so they didn’t need to worry about keeping it themselves. One resident said she was given the choice of keeping her medication. The Registered Manager said that if residents can do this safely then self medication is encouraged. This situation is commended. Residents also spoke of being able to maintain their independence in other ways – having kettles in their rooms to be able to make drinks (this was seen by the inspector), being able to make their own beds and keep their bedrooms clean, walking in the large grounds of the home etc. One resident said she was able to do digging and growing vegetables. This situation is commended. Inspection of residents accommodation demonstrated that they were able to bring in to the home their personal possessions. Residents confirmed this. However personal choices were not identified in individual care plans. It is recommended that this is included during assessment of potential residents. The Registered Manager said this would be carried out Both residents and relatives stated that visitors are always welcomed to the home and no one reported any restrictions. The visitors spoken to were very impressed with the standard of care provided by the staff. There were positive views regarding the food and a number of comments received: ‘There is good food always. If we want something else they will get us it’. ‘We like proper Polish food and we always get it here’. ‘No one could complain about the food. It is always tasty’. The food was tasted and was found to be well cooked and had flavour, with three courses served followed by coffee. Laxton Hall DS0000012842.V321433.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. Residents are confident in the system of managing complaints and staff have a good level of understanding regarding the prevention of abuse. EVIDENCE: Residents said that they thought that if there was a problem then they were confident that the Manager or other staff would sort it out. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the Commission for Social Care Inspection at the initial stage, as per the National Minimum Standard. The Registered Manager said this would be altered to reflect this standard. Staff members spoken with were aware of the full procedure regarding which Agencies to contact if the in house arrangement failed. The homes records were inspected and there were two complaints recorded in the file for the past year, which were appropriately recorded and dealt with by the Registered Manager. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 15 There have been no complaints regarding the service since the Commission for Social Care Inspection was set up. This situation is commended. Laxton Hall DS0000012842.V321433.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Facilities are seen as homely, clean and well maintained by residents. Odour control is of a very good standard. Some equipment is needed to ensure the protection of the Health and Safety of residents. EVIDENCE: Residents said that they liked the facilities of the home, that they appreciated that the home was always kept clean by staff and there were never any odours, and they could organise their bedrooms in the way they wanted. No one stated that the home was ever cold or chilly. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 17 During a selective tour of the home it was observed that all areas were generally well decorated and furnished, clean and tidy and well maintained. Rooms had been personalised to accommodate personal possessions. The Registered Manager said that there were plans to redecorate residents bedrooms in 2007. This was stated in the home’s maintenance plan seen by the inspector. A number of bathrooms have been renovated and looked attractive and well equipped. The Registered Manager said that the remaining bathrooms were planned to be refurbished in 2007. It was recommended that the Registered Manager investigate a signing system for residents with dementia, e.g. colour coding wc/bathroom doors, having pictures on bedroom doors, having a board to indicate date, weather etc, so as to provide more clarity for residents. The Registered Manager said radiator guards have been fitted to most radiators to minimise any risk of burning to at risk residents, though these have not been fitted to all radiators. The Registered Manager said this would be looked into and completed as soon as possible. The Registered Manager was asked to review lighting levels for the reception/lounge area and this was dimly lit and may need more lighting, e.g. standard lamps to ensure that residents are not at risk from stumbling by not being able to fully see what is in front of them. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 18 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): 27,28,29.30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appear to meet residents needs though recruitment processes are not thorough to ensure the full protection of residents. Staff training needs to be bolstered to meet residents needs. EVIDENCE: No adverse comments were made regarding staffing numbers and that staff always responding quickly to residents needs. The rota confirmed that there appeared to be sufficient care staff on duty during the day. The Registered Manager confirmed that at night there was one awake staff and one staff on call and currently this was sufficient to meet residents needs. However she recognised that if the service accommodates more residents with dementia in the future then there would need to be a minimum of two awake staff on duty at night. There was also discussion regarding if the on call night staff had to often get up then there needs to be a system in place to ensure that person is not fatigued if they are rotered to do a morning shift immediately after the night shift. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 19 Staff have now been supplied with copies of the General Social Care Council Code of Conduct in Polish so that they are aware of their responsibilities in providing care. At the last two inspections the registered provider was asked to provide a contract on employment for all staff, in line with the employment legislation. This is still outstanding. It has been drawn up, as seen by the inspector, but not yet been signed by the Registered Provider representative. A review of a clause is needed, as it states that staff are expected to sign that they will work more than a 48 hour week. The employment requirement is that there is a free choice for staff in this matter, and therefore they should not be compelled to do so. There were also comments received by the inspector that staff work long hours. It was found that there is a current staff practice that staff work rotered shifts but then also supply ‘voluntary’ hours on top of this. The Registered Provider needs to review this practice, as it would appear to contradict employment law, as it is unpaid work. It also may mean staff working excessive hours, potentially causing staff fatigue and impaired staff performance. Two staff files were inspected and contained a Protection of Vulnerable Adults checks that had been received by the Registered Manager after the staff members had commenced employment. The Registered Manager said that she thought that by confirming with Polish Police Authorities (this paperwork was seen by the inspector), before the Polish workers commenced employment as to criminal conviction checks then this would be adequate. However the Regulations have been tightened in this respect. The Registered Manager said that this practice would be changed to follow that statutory checks need to be in place prior to employment commencing. Other information, references etc. were seen to be in place. Staff files contained evidence of training though not all staff had received training on essential care practices – food hygiene, health and safety, fire, first aid, infection control, dementia, training on residents health conditions – stroke, parkinsons disease, diabetes, hearing and sight impairment etc. The Registered Manager said that a number of staff had received training in the past year and she would ensure that all staff were suitably trained. The Registered Manager stated that staff are encouraged to undertake National Vocational Qualification level 2 training and the staff spoken to confirmed this. Discussion with the Registered Manager indicated that the induction programme used for new staff is the National Training Organisation (Skills for Care) Standards, as per the National Minimum Standard. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of service users. EVIDENCE: Residents and staff said that they thought the Registered Manager was approachable and thoughtful as to the running of the home. Staff said they felt valued in their work by the management of the home. The Registered Manager has a National Vocational Qualification level 4 and has also achieved the Registered Managers Award. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 21 There was no evidence on staff records that staff have one to one supervision. The Registered Manager agreed to commence supervision to support staff and ensure practice issues were regularly discussed. Staff Meetings have been held and were recorded. There is a Health and Safety folder with Risk Assessments for safe working. Other Risk Assessments for safe working practices are needed, e.g. use of ladders, any work needed regarding the lift, the need for window restrictors etc. The Registered Manager is to check this issue with the Environmental Health Officer so that it comprehensively covers all workplace risks. There are a number of radiators without covers. The Registered Manager said she would carry out a Risk Assessment and arrange to have covers fitted where necessary, as a number of service users have unpredictable behaviour and could be at risk from burning. A Quality Assurance system was in place for 2006. This had been supplied to service users, with a summary of findings. The inspector recommended that this process is extended to relatives and other stakeholders, e.g. the hairdresser, people supplying activities etc. It is recommended the results are included in the Statement of Purpose. Service user monies records were generally found to be properly kept, with running balances and receipts but no recorded signatures, so that transactions are witnessed. The Registered Manager said this would be carried out. Fire Precautions: System testing was on required schedules for fire bell testing though emergency lighting was only tested on a three monthly, not monthly basis and a recorded fire drill had not been carried out for eleven months – the Registered Manager immediately organised a fire drill (this was evidenced in the records) and said she would also check with the Fire Officer as to the required frequency for drills, as she had been told that six monthly, not three monthly drills were the requirement. There was a fire risk assessment on file. Staff members were asked about the fire procedure – one was fully aware of the whole procedure. The other staff member was not fully aware. The Registered Manager said she would test all staff to make sure they were all fully aware of the proper procedure. The hot water temperature was checked in a bathroom and found to be 42c; close to the National Minimum Standard of 43c, which was fully satisfactory. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 1 Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 2 Standard OP29 OP38 Regulation 19 13 Requirement Statutory staffing checks must be in place before staff commence employment. The Health and Safety systems in the home must protect the welfare of service users from harm. This includes protection from hot radiators; complete Risk Assessments for safe working practices, all staff understanding the full fire procedure and regular fire checks. Timescale for action 03/01/07 03/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP36 Good Practice Recommendations Facilities need to be signed to help orientate residents with disabilities. The Registered Provider needs to ensure that employment Policies and Procedures comply with employment law. DS0000012842.V321433.R01.S.doc Version 5.2 Page 24 Laxton Hall Staff need to have regular one to one supervision to support them in their work. 3. OP30 Staff need to receive more extensive training to meet all residents needs. Laxton Hall DS0000012842.V321433.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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