Inspection on 09/07/07 for Lee Mount Residential Home

This inspection was carried out on 9th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lee Mount Residential Home 19/08/09

Lee Mount Residential Home 05/03/09

Lee Mount Residential Home 02/09/08

Lee Mount Residential Home 05/03/08

Lee Mount Residential Home 26/06/06

Lee Mount Residential Home 15/02/06

Lee Mount Residential Home 12/07/05

Lee Mount Residential Home 26/01/05

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

CARE HOMES FOR OLDER PEOPLE Lee Mount Residential Home 32 Lee Mount Road Lee Mount Halifax West Yorkshire HX3 5BQ Lead Inspector Lynda Jones Key Unannounced Inspection 11:00 9 , 6th & 19th July 2007 th 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 Lee Mount Residential Home DS0000061575.V342563.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. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lee Mount Residential Home Address 32 Lee Mount Road Lee Mount Halifax West Yorkshire HX3 5BQ 01422 369081 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) Lee Mount Healthcare Ltd Mrs Julia Carling Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user under the age of 65, named on variation dated 12th December 2006, may reside at the home. 26th June 2006 Date of last inspection Brief Description of the Service: Lee Mount is a care home providing personal care and accommodation for eighteen older people. The home is in the Lee Mount area of Halifax, approximately two miles from the town centre and can be easily reached by public transport. There are some local shops and other amenities nearby. The home has been converted into one large house from four terraced properties. There is a small garden at the front of the house. There are eighteen single bedrooms at the home. Four bedrooms are on the ground floor; the remainder are at first floor level which can be accessed by a passenger lift. There are two lounges and a dining room on the ground floor. The home provides care and support, all meals and snacks and a laundry service. The fee of £347.50 per week covers activities and visiting entertainers. People pay for their own personal toiletries, hairdressing and chiropody. Information about the facilities at the home and the service provided is available on request from Lee Mount. A copy of the last inspection report is on display in the entrance of the home. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection took place on 26 June 2006. We also visited the home on 29 May 2007 to carry out a random inspection because we were concerned that the building of a new extension was affecting the quality of life of the people who live at Lee Mount. The new extension has been under construction since September 2006. Our findings were that the health and safety of people who use the service were not being met and the building work was causing disruption to the lives of people living there. The building was not clean; some of the facilities were not in working order, eg. bathrooms and central heating on the ground floor. We found unhygienic conditions in the kitchen and food storage areas where work has taken place. We found that safety precautions were inadequate and that insufficient action had been taken to keep people safe and protected from abuse. We made a number of requirements in the report following that inspection. As a result of concerns about the building work, inspectors from the Fire Service, Environmental Services and the Health and Safety Executive have also visited the home. We decided to carry out this inspection to see if any progress had been made since we last visited. This inspection was carried out by one inspector over three days. On the third visit a second inspector was also present. Total time spent at the home was 11.15 hours. We talked to people who live there and the staff on duty. We observed staff providing care, looked at various records and we looked round the home. The manager completed a self-assessment form and we have used the information that was provided in this report. Surveys were sent to relatives and representatives of people who use the service; these provide an opportunity for people to share their views of the service with us. Information received in this way is shared with the owner without identifying who has provided it. We received responses from ten people who live there; they told us they filled the surveys in with support from staff. Eight relatives, one social worker and one GP also wrote to us with their comments. We have used the information and comments from the surveys in this report. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Staff need to talk to people who live there and their relatives about the care they require. This will give people the opportunity to be more involved in their own care and say whether their needs are being met. The manager needs to make sure the care plans specify what people’s needs are and how these should be met by staff. This should ensure that care is delivered with more consistency. Staff need to pay more attention to people’s personal appearance so that their dignity is maintained at all times. Building work that is taking place in occupied parts of the house must be better managed to make sure that people’s privacy and dignity is maintained. Medication must not be added to the containers dispensed by the pharmacist because this is unsafe and can result in mistakes being made with medication. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 7 Adult protection issues need to be better managed. Staff need more training so that they know how to respond appropriately. This is to ensure that people are safe and protected from abuse. Staff are not being properly checked before they start work. This means that people could be cared for by staff who are unsuitable to work with older people. There are not enough staff on duty in the early evening which means that staff may not be able to provide the care and support that everyone needs. 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. Lee Mount Residential Home DS0000061575.V342563.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 Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5. The home does not provide intermediate care. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The home provides information about the facilities and service provided to help people decide if it is suitable for them. Pre-admission assessments take place to make sure that individual needs can be met at the home. There is evidence that people are encouraged to visit before making a decision about moving in. EVIDENCE: Before anyone moves into Lee Mount they are invited to visit, view the accommodation and meet other people who live there. Anyone considering a Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 10 place there is welcome to stay for the day, have a meal and get some idea of what the home is like. The manager assesses everyone before any decision is made about moving in, this is to make sure that individual needs can be catered for at the home. Everyone is provided with a Service User Guide, which gives information about the facilities in the home and the service that can be provided. A copy of the last inspection report is on display at the home for people to read. Everyone who completed a survey said they had been given a terms and conditions of residence document. This is important because it gives information about their rights and responsibilities of the people who live there and those of the owner of the home. Lee Mount Residential Home DS0000061575.V342563.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The care plans don’t always contain enough detail about the care people need and how the care should be delivered. People are not consulted about their care plans; this means they do not have the opportunity to be involved and comment on their care. Working practices sometimes compromise the privacy and dignity of people who live at the home. EVIDENCE: Everyone living at the home has a care plan that provides staff with some information about what they need to do to meet the needs of each person. I looked at a sample of plans and found that they varied in the amount of detail Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 12 they contained, this means that it would not be possible to know exactly how to meet individual needs based on the care plan alone. Some contained clear instructions and were easy to follow but others were vague. For example, one plan stated, “needs assistance with personal hygiene” but there was no information about the sort of assistance this person needed and how it should be provided. Another plan was “to have hair washed and set weekly; to see chiropodist every six weeks; to see dentist every six months; to see optician yearly”. This is not an individual plan of care, these are general needs that should be taken care of as a matter of course. When the care plan lacks detail it means there is no guarantee that staff are providing care in the same way. If the person receiving help with their personal care can tell staff what they need there is less scope for variation but, if they are unable to let staff know, there is more chance that their care may be delivered differently. Lee Mount is a relatively small home with a small group of staff that communicate well with each other. They seem to rely more on talking to each other about what people need, rather than on what is in the plan. One relatively new member of staff said she got to know about individual needs by watching other staff at work and by talking to people. She was aware of the care plans but had not been particularly encouraged to use them as a means of getting to know about the care and support people needed. Not everyone is aware of what is in their plan and there is no evidence that relatives are involved. People should be consulted about the care and support they receive so that they can say whether it suits them. In the surveys, people told us that they receive the care and support they need, they also said staff were available when they needed them. In their opinion they also receive the medical support they need. 50 of relatives said the home “always” met people’s needs, 50 said needs were “usually” met. The records demonstrate that people have access to a range of health care providers. Details are kept of all health related appointments and their outcomes. The GP said that the staff work in partnership with them and act on the advice they were given. Although attempts have been made to close off the area where building work is going on, there have been occasions when there have been workmen in the areas where people are living and this has affected their privacy. For example, we saw workmen being asked to stop work on one of the bathrooms so that someone could go in to use the toilet. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 13 While we were there, we noticed that some people looked as if they needed assistance with their appearance. These were people who are reliant on staff for help. We saw some people wearing clothes that they had spilled food on; others had food on their hands and faces from mealtimes. Staff didn’t seem to notice these things as they took no action to help people to wash and change. Medication administration records are generally well maintained. The records show that people receive their medication at the prescribed times. All staff that administer medication have received training from the manager and additional external training. The pharmacist provides medication in containers with people’s names on and full instructions for staff to refer to. These containers must not be interfered with. However, a note in the staff communications book indicated that antibiotics prescribed after the container had been supplied had been added to the container by staff. This is called “secondary dispensing”; it is unsafe practice and should not take place. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The building work has caused considerable disruption to the daily lives and routines of people living at the home. Some activities are provided to keep people stimulated. The meals at the home are good. EVIDENCE: The building work that is taking place has disrupted the daily lives of the people who live there. They have had to live with noise, dust and workmen in their home for months. One person said “it’s been like living on a building site, it’s bang, bang, bang, day after day” and “there has been dust and rubble everywhere for months”. The staff have tried to keep disruption to a minimum but the work has had an impact on routines within the home. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 15 Two visitors to the home wrote to us saying “with the work being undertaken on the property, there have been times when privacy has been overlooked”, and “ the environment is relatively chaotic and falls well below the usual standard of the home”. Sometimes staff have not been given advance warning about building work that is about to take place and this has caused serious disruption to daily routines. For example, workmen began to knock down a wall in the kitchen while the kitchen was still in use. While we were there, staff were given very little notice that work was about to begin on changing a lounge into a bedroom. We asked people what effect the building work has had on them. One person said with some resignation, “you just have to put up with it”. Two other people just shrugged their shoulders and said, “what can you do”. In the surveys, people told us the staff were on hand when they were needed. There is a pleasant atmosphere in the home; we were told that everyone gets on well together. We saw staff sitting with people, they joked together and enjoyed some lively banter. Whenever staff walked through the lounge as they went about their work, they always talked to people. Although we didn’t see any evidence of activities, people told us that they do take place and they take part if they want to. One person told us “the staff ask if we want to do anything, it depends how we are feeling, you don’t have to join in”. There is a choice of food available; the menu for lunch is on display. A member of staff usually goes round and tells people what the choice is for tea. People said they enjoyed the meals. People need napkins or paper towels when they are eating and somewhere to rest their plates and cups if they eat in the lounge. There are no trays in the room for people to put their food and drinks on, there are some small, low tables but these are not easy to reach. At tea time, one person struggled to hold a plate and eat at the same time; as a result she spilled most of her food on her clothing and down the chair. As she had nothing to wipe herself with, she had to sit with food down her front. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People are aware of the complaints procedure and feel that their concerns would be listened to. The manager and staff need more training on their role in safeguarding people so that they can ensure that people who live there are safe and protected from abuse. EVIDENCE: Everyone who completed a survey said they knew who they would speak to if they were unhappy about anything. They also said the staff listen and act on what they say. Five out of eight relatives said they knew how to make a complaint if they needed to. Although we were unable to find the complaints log, the manager said one complaint had been received in the last twelve months and it had been dealt with according to the home’s complaints procedure. Staff have had some adult protection training in the past. However, a recent adult protection issue was not well managed by the home. Some staff are already booked onto a course to update their training. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 17 Staff are not always being fully checked before they start work to make sure that they are suitable to work with older people. This means that people living there are not being properly protected. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 18 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): 19,20,21,24,25,26. People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People have been living in unsafe, unhygienic conditions while the building work has been taking place and their movement about the home has been restricted. The choice of bathing facilities has been limited because baths and showers have been de-commissioned before being replaced with other useable alternatives. EVIDENCE: When we visited the home in May we were concerned about the impact the building work was having on the health and safety of the people who live there. We were also very concerned about standards of cleanliness within the Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 19 home. We looked round all parts of the building on this visit to see if there had been any progress in these areas. The heating was still not working on the ground floor. Mobile heaters provided heating in the lounges, dining room and ground floor bedrooms. Fortunately, the weather was good and people said they were warm enough. On our third visit to the home on 19 July 2007 the owner said “the ground floor heating will be working in the next couple of days”. There has been some improvement in the overall cleanliness of the house. An additional domestic has been employed, allowing the day to day dust and dirt caused by the building work to be tackled. There is still need for further improvement in the general standards of hygiene and cleanliness at the home. There are several examples of poor housekeeping and a general lack of respect for people who live there: • • • Two of the duvet covers in the bedrooms had faeces on them, the rooms had been cleaned but staff had not noticed this. Some of the new commodes that were in use still had cardboard taped on the frames; no one had noticed it. In two of the bedrooms, hot water tanks had been removed and the space had been made into wardrobes. Although clothes had been hung in the wardrobes no one had cleaned the space first, the floor was left full of dust and dirt where holes had been drilled in the walls. Radiator covers were not fixed in bedrooms, they were left “hanging” over the radiators and could easily be pulled off causing an accident. • A member of staff showed us two bedrooms which have recently been upgraded. These rooms were described as “the new standard of bedroom”. The walls have been painted and new carpets have been fitted. One of the rooms has a new wardrobe and matching chest of drawers and staff said that additional new furniture that was in storage would be in use as soon as more of the bedrooms were decorated. These rooms looked brighter but some things have been overlooked that detract from the work that has been completed. For example, when the walls were painted the woodwork was not done; there is no grouting around some of the tiles above the wash basin in one of the rooms; dusty, old light shades have been re-hung without being cleaned. On the first visit to the home, none of the bathrooms was useable. One room had no bath in it and the other bathroom had no hot water. The shower room was out of commission because it was going to be changed to a bathroom. Workmen were planning to install a shower in a small first floor room. Two people were upset that they could not have a shower and their routine had been disrupted. We were later told that the shower was working the following day. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 20 By the second visit to the home, the hot water supply had been restored to the bathroom but no one had used the bath because most people could not get in and out of it. The shower had been installed but people said it was too small especially for anyone who needed staff assistance. The narrow passage way to the room also meant that access to the room for wheelchair users was difficult. After this was brought to the attention of the owner, he discussed the matter with staff and proposed to re site the shower room on the ground floor. We were told that an assisted bath was on order that could be used by everyone so that in future they will have the option of a bath or shower. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 21 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. People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Recruitment practice is poor, new staff are not being fully checked before they start work. This puts people at risk of being cared for by people who are unsuitable. There are not enough staff available in the early evening to ensure that people’s needs can be met. EVIDENCE: The recruitment procedures are not robust. There is no evidence that new staff are being properly checked before they start work at the home which means that people are placed at risk of being cared for by staff that may be unsuitable. In previous inspection reports we have expressed concern about staff recruitment not being thorough. In January 2007 we raised serious concerns with the manager and the owner of the home about making sure that all staff had satisfactory Criminal Records Bureau checks before starting work at the home. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 22 On this occasion, we were unable to tell whether appropriate references and checks had been carried out on two staff before they started work because their files could not be found. In the self-assessment that the manager completed and sent to us, it says that all staff that have worked at the home in the past twelve months have had satisfactory pre-employment checks. We are aware that the building work has meant that the office has had to be relocated and this has caused some disruption. However, we asked the manager to locate the records we were looking for and contact us when they were found so that we could verify the checks. We have not been contacted and we regard this as a serious matter as it means that people are still not being properly protected. There are enough staff on duty to meet people’s needs for most of the day and night. However, between 4.30 pm and 8.30 pm, there are only two staff on duty. The cook prepares tea and tidies the kitchen before finishing at 4.30 pm, after that the two remaining staff have to finish the washing up and provide people with the support and assistance they need. Some people who need staff help like to have a bath during this period, this means that one member of staff could be left alone with sixteen people. According to the self-assessment, there are four people who need two or more staff to help with their care, which means that there are insufficient staff available to meet people’s needs at this time of the day. The majority of staff (10 out of 14) have NVQ level 2 or above. The rest of the staff are working towards this qualification. Staff have the opportunity to take part in various free training courses throughout the year. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 23 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): 31,33,35,38. People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The welfare of people living and working at the home has been placed at risk by poor health and safety practices at the home. EVIDENCE: The manager has several years’ experience of working with older people. She has managed Lee Mount since 2002 and has completed NVQ level 4 and the Registered Managers Award. She undertakes regular training alongside the staff at the home to keep her care practice up to date. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 24 There is no regular quality assurance system in operation. People are asked informally about their views on things such as the menus and the activities they would like to take part in. They have been told about the plans for extending the home by the staff. The owner of the home is there most days and he talks to people and tells them how the building work is progressing. The manager holds money for some people who live there and there is a record of all income and expenditure. Receipts are available for all purchases. The performance of the home on health and safety has been extremely poor in recent months placing people who live and work at risk. The owner has now taken advice and has been working to make sure these areas are better managed in future. Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 1 1 X X 2 1 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 27 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must be reviewed to make sure they a) Contain up to date information about people’s needs. b) Indicate clearly the action that staff need to take to meet people’s needs. This will make sure that people’s needs are met appropriately. Medication must not be added to the containers dispensed by the pharmacist. This will mean that medication is managed safely. The building work needs to be better managed to make sure that people’s privacy and dignity is maintained at all times. All staff require adult protection training. This is so that they can ensure that people who live at the home are safe and protected from abuse. All parts of the home must be kept clean and hygienic to protect the health and welfare of people who use the service. (this requirement was first made on 29/5/07) People who use the service must have access to both bath and shower facilities. This will give them the opportunity to use the facility that is most suitable for DS0000061575.V342563.R01.S.doc Timescale for action 21/09/07 2 OP9 3 OP10 13 17/08/07 12(4) 17/08/07 4 OP18 13(6) 31/10/07 5 OP12 162)(j)(k) 17/08/07 6 OP21 23(2)(j) 31/08/07 Lee Mount Residential Home Version 5.2 Page 28 7 OP25 23(2)(p) 8 OP29 19 9 OP27 18 10 OP38 13(3) them (this requirement was first made on 29/5/07) The heating system in all parts of the house must be in good working order to ensure that people who use the service are warm and comfortable at all times. (this requirement was first made on 29/5/07) All staff must be appropriately checked before they start work in the home. This is to make sure that people in the home are looked after by safe and suitable staff. (this requirement was first made on 15/2/06) Staff must be available at all times in sufficient numbers to meet the assessed needs of people who live at the home. This is to make sure that the needs of each person will be met. The health and safety of people who use the service must be protected by making sure the home is as free from hazards as is practicable. (this requirement was first made on 29/5/07) 17/08/07 17/08/07 31/08/07 17/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lee Mount Residential Home DS0000061575.V342563.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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