Inspection on 25/05/06 for Lea House

This inspection was carried out on 25th May 2006.

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

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

Other inspections for this house

Lea House 16/09/08

Lea House 27/07/07

Lea House 20/09/05

Lea House 19/04/05

Lea House 12/10/04

Lea House 10/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Lea House Lea House Rest Home 40 Terminus Avenue Bexhill on Sea East Sussex TN39 3LZ Lead Inspector Jenny Blackwell Unannounced Inspection 25th May &1st June 2006 10:00 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 Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lea House Address Lea House Rest Home 40 Terminus Avenue Bexhill on Sea East Sussex TN39 3LZ 01424 220968 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) Mrs Sadna Seesarun Mr Baldeo Seesarun Mrs Sadna Seesarun Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is fifteen (15). Service users must be older people aged sixty five (65) years or over on admission. 20th September 2005 Date of last inspection Brief Description of the Service: Lea House is a detached property situated in a quiet residential area of Bexhill on Sea. The town centre with its shops and access to bus and rail services is approximately one mile away and local shops are on a short level walk. Accommodation is provided in 13 single and one double bedrooms and a shaft lift is fitted to assist service users to access first floor accommodation. The home is registered to accommodate up to fifteen older people and the owners are Mr and Mrs Seesarun. Resident’s accommodation is provided on two floors; a lift assists service users to access first floor rooms. The home has large front and rear gardens. The fee range for Lea House is £310-£375 per week. More detailed information about the services provided at Lea House can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are kept in the home’s office. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Lea House are referred to as “residents.” People working at the home will be referred to as “staff” or by their job title. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and visiting professionals and an unannounced and follow up announced site visits which lasted a total of nine and a half hours on Thursday 25th May and Thursday 1st June. The site visits included a tour of the premises and an examination of medication, care and staffing records. The Inspector joined residents for their lunch. Throughout the inspection process, the Inspector spent time with the majority of the residents, two residents individually and observed the way the people were supported in communal areas. Time was spent with the staff at the home collectively and as individuals. Written feedback was received from five relatives. The manager was met with during the site visit. In addition two staff was interviewed individually and two others together. A relative was met with during the visit, as was a visiting health care assistant. What the service does well: The inspection process has identified that the home is performing good in one area and adequately in others. Residents were supported by a team of staff who are committed to meeting their needs. During the site visit, staff were observed to be assisting residents in a sensitive and respectful manner. The atmosphere was friendly and relaxed. Some residents spoken to through out the visits were asked about the staff. One resident said they were “lovely and always willing to help” and another said, “We are in safe hands.” The visiting professional commented that the manager and staff always made the home have a welcoming and relaxed atmosphere. Some residents were spoken with about their experience of living at the home. Three residents said they were happy with the home and that it suited the Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 6 needs. They all liked the fact that they were able to spend the day as they wished and called open support from the staff when they needed. The manager has been responsive to previous requirements and recommendations and had improved many of the systems operating in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 7 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 Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 8 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): 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides good in house admission assessments although did not ensure community care assessment was in place for one resident. There is no provision for intermediate care at Lea House. EVIDENCE: The night before the inspection at the home a resident was admitted to the home on an emergency basis. The resident had come from the hospital. The manager visited the person in hospital and had undertaken a pre-admissions assessment. The records were viewed at the home. The homes assessment forms contained information about the resident’s medical history mental health and personal care needs. Information was recorded about the resident’s communication skills. A section on the form noted that the resident’s first language was English and that there were no barriers to communication. This was noted as a good piece of assessment recording, as the manager could then have the information to put in place methods that would help the newly assessed residents communicate with staff. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 9 In addition the forms recorded the resident’s religious beliefs and cultural background, interest and hobbies. The information gathered for the new resident was of a good quality and provided the staff enough initial information to support the resident. The resident’s relative was spoken to at the home about the admissions process. The relative said that she had look at a few homes when her relative was in hospital but had decided to have her relative move to Lea House temporarily as it was welcoming, clean and tidy. She had been given information about the home when she visited. During checks on other resident’s documents it was noted that a resident, who had lived at the home for a year, assessment did not contain enough information relating to his mental health needs. A discussion took place with the manager about ensuring that prior to admission, assessments are obtained from professionals overseeing or funding the placement such as social workers or community psychiatric nurses. It is required that the manager obtains full and satisfactory assessment information prior to admitting residents. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the health and well being needs of the residents were set out in their individual plans and their health care but not in all records examined. Medication procedures protected people from errors in medication. Through observation, discussion and viewing documents residents were seen to be treated with respect and their privacy was upheld. EVIDENCE: Three residents individual plans were looked at. Each contained information about their interest and support needs. Information had been recorded about the individuals needs their physical and mental well being. At the last inspection a requirement was made to improve the individual plans to ensure they contained detailed information and guidance for staff about all areas of daily support. The three plans viewed did contain detailed information on the support needs of the individuals. Additions risk assessments had been included for the residents that assessed their risk of falling and of developing Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 11 pressure areas. The manager had ensured that the plans were reviewed monthly. However some information was still lacking in one plan and not updated in another. It was required that individuals plans contain adequate information on residents support needs and are up to date. Some good information was written in one residents plan that described the after care support she needed after an operation. Information about the resident’s interests was transferred from the assessment forms. During the visits to the home time was spent with staff discussing the support needs of the residents. The staff were able to describe their routines during their shifts and talk about particular tasks that they supported individual residents needs. An example was given of a resident’s particular health care need. This was checked in the residents plan and found to be accurate. The manager demonstrated good knowledge of the health care needs of the residents and had ensured that some information for residents had been updated when their health care had changed. The residents have access to their own G.P’s and community health care professionals. Four G.P’s who provide services to the residents were sent survey cards to comment on the homes performance. At the time of the report two had been returned. The comments were positive about the home both agreeing that the home communicates clearly and work in partnership. During the first visit to the home a community health care assistant was spoken to about her involvement with the home. She had been visiting the home for the past 15 years providing health care support to the residents. She found that the manager and staff were always welcoming. She said the new manager had continued to provide an relaxed and homely atmosphere. The staff always ensured the notes of the resident she was due to see were available and that if she needed any help during her visit she would always get it from the staff. Visit to residents were always conducted in private in their rooms. A check of the resident’s medication was conducted with the manager. All the residents rely on the staff to help them with their medication. The medication was stored administered and recorded correctly. The staff were asked about the medication procedures and were able to describe the process in accordance with the homes policy. The current group of residents were fairly independent of the staff for their daily living. Some people required help from staff with memory prompts and some levels of personal care. The resident were seen to choose what they wanted to do throughout the visits. Staff approached them with respect and used appropriate language with them. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported to experience their preferred lifestyle as much as possible, including maintaining contact with family and friends. Mealtimes were relaxed and the meals well prepared. EVIDENCE: The home provides accommodation for up to 15 residents. At the time of the visits to the home there were 10 residents. The home had a welcoming and had a relaxed atmosphere. Some residents were spoken with about their experience of living at the home. Three residents said they were happy with the home and that it suited the needs. They all liked the fact that they were able to spend the day as they wished and called open support from the staff when they needed. The individual plans recorded the religious and cultural backgrounds of the residents. None of the current residents practice a particular faith. The residents social needs appeared were supported by the home. Relatives were able to visit the residents at reasonable times and some residents went for walks around the local area. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 13 It was noted that some residents had struck up friendships with others living at the home. Two residents spoke about their daily routine of meeting up in one persons bedroom to have supper together. The staff have supported the friendship by ensuing the meals are served as the residents have requested in the room. At the last inspection a requirement was made for the manager to consult with the residents about a programme of activities. A programme was seen on the visits to the home on this occasion. It was placed on the notice board in the hall area of the home. Each week day afternoon an activity was written up. On the day of the visit the board games where available to be played by residents. One staff member played several games of draughts with a resident in the lounge. Another member of staff went around to residents asking if they would like to play scrabble. One person took the offer up and time was spent with her and the staff member as they played during the afternoon. It was noted the scrabble set had large tiles that helped people with reduced eyesight see the letters better. Both games were played in good spirits, the staff and residents engaged in friendly banter during the games. Another resident joined sat in the dining room and observed the game; although she did not want to take part she enjoyed the chatting. Lunch was taken with the residents. The meals are prepared by the care staff at the home. It was noted that this was arranged formally with the shift hours split in 8-10.00am personal care support and 10.00-2pm-lunch preparation and cooking. The staff member had a food hygiene certificate and demonstrated an awareness of food safety. Some individuals chose to have their meals in their rooms, however most people came to the dinning room area for lunch. The lunch was well cooked and presented nicely. Some residents were asked if they new what they were having for lunch. Several people said they did not know what they were having. It was noted that a menu board was displayed in the dining area. Although the people asked did not raise any concerns about not knowing what was for lunch it was recommended the staff provide a menu board to inform the residents what was on the menu. The group of residents was also asked about choice of meals. They said that they didn’t choose lunch meals but were able to choose from options of the supper menu. Again this did not seem to course concern for the residents as they said they would be offered another choice if they didn’t like what was offered. They went on to say that the food was very good and they had good size portions. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives are enabled by the homes policies and procedures to have the complaints dealt with. Systems and some training was in place to reasonable protect people from abuse although all staff needed to be trained. EVIDENCE: The Commission for Social Care Inspection had not received any formal complaints about the services provided at Greenaways. The home had received two complaints from a resident at the home. The complaints were recorded in the homes complaints log, they were dated and the actions taken and outcomes of the complaints recorded appropriately. The visiting health care assistant was asked about if she had any concern who would she go to. She said she was happy to raise any concerns with the manager of the home if needed and felt that her concerns would be taken seriously. The manager had completed her Registered Managers Award training in April ’06 and described the training she had received in identifying and reporting suspected abuse. Three of the staff team were undertaking the N.V.Q level 2. Two staff present were asked about the qualification. Both said that they covered the protection of vulnerable abuse during their training. This included “what is abuse”, signs and reporting. They were confident in reporting suspected abuse. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 15 It was noted that those staff not undertaking N.V.Q training had not undergone training in adult protection. It was required that all staff are trained in identifying and reporting suspected abuse. Conversations with staff and observation of the interactions between the staff and residents indicated that the home operates in a manner that reduces the risk of abuse in the home. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 adequate. This judgement has been made using available evidence including a visit to this service. The home was not fully safe. It was well maintained and a homely environment, clean and hygienic. EVIDENCE: A tour of the building took place at several points during the two visits. The home was presented in a clean and homely way. It was noted that several of the fire doors in the corridors had been propped open to help the residents move through the corridors without opening the doors. The manager was required to close the doors immediately and to fixed approved fire safety door closures if the resident wished to have the doors remain open in the future. The homes had two lounges one at the front of the house the other quieter lounge at the back. Both were presented well and contained comfortable furniture. The lounge at the front had a large TV and was the lounge most residents chose to gather. One resident used the quiet lounge during the visit and she said she liked to sit there to do some reading. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 17 The inspector was invited into some resident’s rooms during the visit and showed around. They all were personalised bright and clean. The residents said they liked their rooms and were able to bring furniture or personal items to the home. The rooms were varied in size but all were light, well ventilated and tidy. One resident said he loved his room as he had good views out from the large windows. All the bedrooms have ensuite facilities. The bathroom facilities met the needs of the residents and they had assisted seating facilities that enabled the resident easy access in and out of the baths. The home has a garden to the rear of the property that the residents spoken to said they didn’t use very much. The garden to the front of the property was also large and were the residents gathered in good weather to socialise. The drive to the home was made of shingle. The residents who went out for walks were asked in the surface caused them any difficulty. The confirmed that it didn’t and that they had not had any falls or near misses on it. The laundry facilities at the home were appropriate for the needs of the residents. The manager said that some laundry was sent out to a laundry service cutting down on the laundry the staff do. The home was clean and tidy and a cleaner was employed in the home for 21 hours a week. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a team of staff who are committed to meeting their needs. Staff were generally well trained although not all staff and recruitment procedures were adequate with more work needed on complying with criminal record checks. EVIDENCE: Throughout the two visits to the home the staff were seen to interact well with the residents. The staffing levels appeared reasonable through the day, as many of the residents are mainly self caring. Usually two staff are on shift through out the day with the manager working at the home week days on early shifts providing extra support when needed. One member of staff works a waking night shift each night. Those residents spoken to said they always felt staff were available to then and answered their call bells when used. It was noted that some staff work long hours and in one case more than seven days in a row. Those staff were asked about the long hours and shift patterns. They said that they had chosen to work those hours and it did not cause them any difficulties. One person said she had plenty of opportunity for breaks at the home, as certain times of the day were quiet. It is required that the manager check that she employs staff in accordance with working time guidance. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 19 Some residents spoken to through out the visits were asked about the staff. One resident said they were “lovely and always willing to help” and another said, “We are in safe hands.” The staff were seen to be respectful to the residents using and appropriate language when addressing them. Staff were asked about their work during the visits and all spoken to were knowledgeable about the individual residents support needs and interest. Two staff were spoken to individually about working at the home. They were asked about training that they had undergone. One person was current studying the N.V.Q level 2 and had undertaken mandatory training such as a food hygiene certificate. The other staff member had not completed any training other than induction training provided by the manager. She had been offered the training but had not taken it up. It was required that the manager ensured that all staff undertake training appropriate to the work they perform. The recruitment records were viewed for two staff and the criminal records check were viewed for all staff. The manager had ensured that the all contained written references one form previous employers, a copy of the application form supervision and induction information and training records and certificates. Criminal Records checks had been undertaken for all staff however two had been undertaken by previous employers and as the checks are not portable, it is required that the manager ensures that all C.R.B checks are undertaken by the home. This was also found to be the case at the previous inspection and therefore the manager needs to ensure she fully understands the correct procedures she should be operating to. Records were seen of 1:1 supervisions the manager holds with the staff on every other month. Each member of staff has an annual appraisal to assess their work skills and training needs. These forms were not always dated and signed. It is recommended that the manager date the sessions and have the supervisee sign the record for agreement. The staff spoken to confirmed that they had met with the manager for supervision. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has improved since the previous inspection and the home is run in the interest of the residents. Health safety and welfare of the residents is generally protected, improvements are needed in training of staff and fire protection. EVIDENCE: Since the previous inspection the manager has completed the Registered Managers Award. As required form the last inspection the manager will send evidence of the modules in the Award were see trained in care planning and risk assessments. The manager has implemented the majority of improvements that needed to be made at the home. She had used the training in the R.M.A to develop some new systems for the home. She is a registered nurse and has good knowledge in supporting the resident’s health care needs. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 21 The staff that were spoken to said they found the manager to be supportive and approachable. Residents were also complimentary about the manager saying she was friendly and helpful. The manager was co operative through out the visit to the home and demonstrated a good knowledge about the residents needs. The home is set up to accommodate the needs of the individuals. The current group of residents appear to have their needs met by the management of the home and the care staff. Staff were aware of changing needs of some individuals and adapted the ways in which they worked. At the previous inspection a requirement was made to re distribute a questionnaire to residents asking about their views of the home. The manager has since appointed a staff member to review the forms. She has also included an activities audit in the form. A discussion took place with the manager about expanding the quality assurance tool to evidence that the home monitors the quality of service it provided to residents. Further work needs to be done on the system to fully meet the standard. It is required that the manager implements a quality assurance system for the home. The manager has written risk assessments for all areas of the home looking at were the home presents a risk to the current resident group. These were checked and seen to be appropriate. The manager will continue to review the assessments and update them when needed. Health and safety records were checked on the visit and found to be in order generally. The staff undertook check on the fire detecting system weekly. A day after the visit a new fire detector board was being installed. The manager had responded to a fire safety company’s visit recommendations to update the fire board. The manager had produced a fire risk assessment for the home in ‘04 that covered each room in the home and rated its risk level. The manager said that this was checked by a visit from a fire safety officer in September ’05 and deemed to be appropriate. Gas and electrical certificate were examined and found to be in date and in order. The manager and staff record accidents and incidents in the home. These were looked at and again were recorded appropriately. The manager has improved reporting incidents and significant accidents to the Commission. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 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 X 2 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 23 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 OP3 Regulation 14(1) (a-d) Requirement It is required that the manager obtains full and satisfactory assessment information prior to admitting residents. It was required that individuals plans contain adequate information on residents support needs and are up to date. It was required that all staff are trained in identifying and reporting suspected abuse. It was required that the manager ensures the fire doors are kept closed at all times or are propped open by approved devises. It is required that the manager checks that she employs staff in accordance with working time guidance. It was required that the manager ensured that all staff undertake training appropriate to the work they perform. It is required that the manager ensures that all C.R.B checks are undertaken by the home. (From previous inspection Sept. 05) DS0000047969.V290840.R02.S.doc Version 5.1 Timescale for action 25/05/06 2 OP7 15 (1)(2) 30/12/06 3. 4. OP18 OP19 13(6) 23(4)(c) 30/12/06 25/05/06 5. OP29 18(1)(a) 30/12/06 6. OP30 18(1)(c) 30/12/06 7. OP29 19(5)(d) 25/05/06 Lea House Page 24 8. OP33 24(1-3) It is required that the manager implements a quality assurance system for the home. (From previous inspection Sept. 05) 30/12/06 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 OP15 OP27 Good Practice Recommendations It was recommended the staff provide a menu board to inform the residents what was on the menu. It is recommended that the manager date the sessions and have the supervisee sign the record for agreement. Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI Lea House DS0000047969.V290840.R02.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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