Inspection on 14/08/07 for Lehmann House

This inspection was carried out on 14th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Lehmann House 07/09/06

Lehmann House 27/02/06

Lehmann House 09/12/05

Lehmann House 24/03/05

Lehmann House 18/11/04

Lehmann House 06/08/03

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOMES FOR OLDER PEOPLE Lehmann House Lehmann House Church Terrace Wickham Market Suffolk IP13 0SG Lead Inspector Jane Offord Key Unannounced Inspection 14th August 2007 09:15 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 Lehmann House DS0000037712.V349040.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. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lehmann House Address Lehmann House Church Terrace Wickham Market Suffolk IP13 0SG 01728 746322 01728 748212 Jennie.Rodger@socserv.suffolkcc.gov.uk 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) Suffolk County Council Mrs Jennifer Ann Rodger Care Home 38 Category(ies) of Dementia - over 65 years of age (30), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (10) Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one service user with a Learning Disability, over the age of 65, as detailed in the correspondence dated 4th November 2003. 7th September 2006 Date of last inspection Brief Description of the Service: Lehmann House is owned by Suffolk County Council. The home is well established and located in the small market town of Wickham Market, within reach of local facilities including a GP surgery, church and shops. The home is a large building divided into four units, each of which has its own bathroom, toilets, lounge, dining and kitchenette facilities. In total the service caters for 38 service users. Three of the units offer support to older people with a diagnosis of dementia, Gainsborough and Constable Unit, which are on the ground floor, and Smythe unit, which is located on the first floor. Moore Unit, also on the first floor, provides care for frail elderly service users. The home also provides a number of short-term care beds. There are a number of seating areas around the home as well as the lounges in each unit. The gardens are large, secure and accessed from several ground floor exits. There is also a day care facility on site that is not used every day and offers additional space for organised activities for residents. The fees range between £397.00 and £293.00 weekly and do not cover the cost of newspapers, hairdressing, chiropody and toiletries. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.15 and 16.30. The registered manager was present throughout the day and assisted the inspection process by providing documents and information. This report has been compiled using information available prior to the inspection and evidence found on the day. During the day a tour of the home was undertaken with the manager but all areas were revisited later. A number of residents and staff were spoken with and the serving of lunch was observed. Part of a medication administration round was followed and a check was made on some controlled drugs (CDs) stock. Some new residents’ and staff files were inspected and a variety of documents, certificates and policies were seen. Care practice was observed, the Annual Quality Assurance Assessment (AQAA) and a number of survey forms for residents and staff were received by CSCI prior to the inspection. Residents were using all areas of the building and moving from one part to the other with ease and confidence. They looked relaxed and cheerful. Interactions with staff were respectful and friendly. Activities being undertaken were suitable and the residents participated with enthusiasm. The lunch looked well cooked and presented and residents spoken with said they had enjoyed the meal. The medication administration practice was safe. What the service does well: What has improved since the last inspection? The passenger lift has been replaced and is now accessible by wheelchair users and can be operated by residents independently. There has been a newly appointed activity co-ordinator to replace the previous post holder who left three months ago. The new co-ordinator is enthusiastic and has plans for introducing some new pastimes. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 6 The service has been looking at ways to stimulate the appetites of some residents with dementia and use bread-making machines on a daily basis to offer fresh bread at breakfast. They also offer freshly percolated coffee and have found the aromas encourage residents to eat better. 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. The summary of this inspection report can be made available in other formats on request. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 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 Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6. Quality in this outcome area is good. People who use this service can expect to have a written contract with the home and have their needs assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This service does not offer intermediate care. The files of four recently admitted residents were seen and each one contained a copy of the contract and terms and conditions of residency that had been signed by the resident or their representative. Three of the four files had a pre-admission assessment completed. The fourth file belonged to a resident who had been admitted for emergency respite care when their main carer in the community had been admitted to hospital suddenly. The manager said they had had information from the social worker. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 9 The pre-admission assessments in the other three files contained information about health and social needs of the residents. They covered areas such as past medical history, known allergies, present medication, health professionals involved with the care of the resident and social activities. The amount of involvement from the family and the degree of support required to meet the activities of daily living for the resident were recorded. In two cases the final wishes of the resident had been noted but the third was reluctant to discuss it and that was recorded. Lehmann House DS0000037712.V349040.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 excellent. People who use this service can expect to have an individual plan of care and be protected by the medication practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The four residents’ files that were seen each had evidence that an assessment had taken place on admission and the information used to compile an individual care plan for the resident. There were entries under headings such as communication, continence, diet, personal care, night needs and prevention of falls. One entry under personal hygiene recorded that the resident, ‘prefers an evening bath with lots of bubbles and suds’. Another one said, ‘XXXX struggles to brush their hair but enjoys having it brushed for them’. One file contained explicit instructions in the event of serious illness or collapse with a ‘Do not resuscitate’ (DNR) form completed and signed by the resident. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 11 A number of risk assessments were in the files and related to the activities of the individual resident. There were moving and handling assessments, ones for falls, wandering, management of their own room keys and in one case for smoking. Under likes and dislikes for one resident it was noted that they enjoyed a particular brand of jam that their relatives would ensure they had a supply of. Each file contained a record of the residents’ weight and there was evidence that care plans were reviewed monthly. Contact details of health professionals involved with the resident were noted and included the GP, a dietician, optician, community nurse, dentist, physiotherapist and chiropodist. Records were made of visits to or by these professionals and any out patients’ appointments at the hospital. On the day of inspection a conversation between a resident and the manager was overheard about an appointment with the health centre for the resident to have their ears syringed. A comment card from a health professional received prior to the inspection was positive about the service saying, ‘clients’ personal choices are always considered and individuals treated with dignity and respect’. Each of the four units has a communication and handover book for the staff to know what is happening daily. The information recorded includes visits by the GP and community nurse for residents and other professionals such as the physiotherapist and chiropodist. The daily records include health details like having an influenza vaccine administered by the community nurse. There was evidence that the continence nurse had been to do assessments and that advice had been taken from a dietician about the diet for a resident with swallowing problems. Part of a medication administration round was followed and practice was safe. Medication is kept in locked cupboards in each resident’s room together with the medication administration record (MAR sheet) for that person. The MAR sheets seen were completed correctly with no signature gaps noted. The team leader said they check the MAR sheets on a daily basis to ensure they have been completed fully. The recently received completed Annual Quality Assurance Assessment (AQAA) says that the home made an appointment with the Primary Care Trust (PCT) pharmacist to spend time with staff looking at the medication and MAR sheets being used in the home. The carer giving the medication said that had happened and the pharmacist had been satisfied with the standard of recording. The carer giving the medicines said they had had in-house training to do the medication round and a team leader had done some shadow shifts with them to check their competency before they were allowed to do a round alone. The team leaders will still do spot checks with a carer doing the medicine round to ensure standards are maintained. All carers are given the choice of whether they wish to undertake the medication administration or not. The manager said they and senior carers had recently done the Otley College medication training, this was confirmed by a carer and in the training records. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 12 The controlled drugs (CDs) register and stock were checked and individual amounts tallied with the records. There is a weekly audit of the medication held in the residents’ rooms by a senior team leader. Staff were observed to knock on doors before entering bathrooms, toilets and resident’s own rooms. Residents were given choice about where they wished to sit. Independence was encouraged with gentle verbal guidance. When residents required support or help it was given sympathetically and patiently. Residents spoken with said, ‘the girls are lovely’, ‘you can ask for anything and they do it willingly’. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is excellent. People who use this service can expect to be offered meaningful pastimes and a well-balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently appointed a new activities co-ordinator as the previous one retired three months ago. The co-ordinator is still getting into their new role but talked about plans for future activities and groups. Several residents are to go to Aldeburgh for a fish ‘n chip lunch next week and the co-ordinator is already thinking of plans for celebrating Halloween, Guy Fawkes night and Christmas. Some cooking and flower arranging sessions take place in the day care facility and on the day of inspection some residents were taken to join the day care attendees to have a competitive game of carpet bowls. Daily records showed that residents enjoy hand massages and help with some of the domestic tasks. ‘YYYY has done a lot of washing up today’. ‘ZZZZ has been happily folding laundry this afternoon’. On visiting the units it was noted that some carers were sitting doing jigsaws and knitting with residents. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 14 Each file seen had a social questionnaire that the resident completed to indicate their interests and whether they would be interested in continuing to pursue them or try any new pastimes. They covered a wide range of subjects from television and radio to music, craft, walks, exercises, shopping, gardening, pets, reminiscence and board games to note just some subjects. The activities co-ordinator said they made a point of spending time with new residents and their families to establish any special interests. They were planning to start a gardening club and, with the help of male carers, a male reminiscence group. The contact details and relationship of the next of kin were recorded in the files together with some life history work that was often signed by the resident. The home has open visiting and some visitors were seen to come and go during the day. Lunch was served in the dining rooms in each unit or the resident’s own room as they chose. There were two choices of times for the meal to allow people who wished to take a late breakfast time between meals. The meal on the day of inspection was pork and apple casserole or cheese and potato bake. Individual dishes of freshly cooked vegetables were offered to each resident and dessert was Bakewell tart and custard. The meal was well presented and looked appetising. Residents said they had enjoyed it. The kitchen was visited and was clean and tidy. The cook said they had had the kitchen ‘deep cleaned’ two months ago. Records of temperatures of refrigerators and freezers showed they were all functioning within safe limits for food storage. The menus were seen and showed that each lunchtime there was a choice of two main meals but also an alternative of fish, salad, omelette or jacket potatoes was available. The tea menu offered a choice of hot dishes such as cauliflower cheese or spaghetti Bolognese with a variety of other snacks such as soup and a roll, pork pie and pickle, a ploughman’s and home made cakes. The service has recently looked at ways to encourage people with dementia to take more interest in their meals. They have found that the aroma of freshly baked bread and slices of a new loaf will encourage some people to eat a better breakfast. As a result the service has purchased bread-making machines for all the units and make their own bread every day. To enhance the aromas they have also begun to make freshly percolated coffee for breakfast for the residents that wish for it. They have found that residents with dementia will eat small pieces of cut up fruit rather than a whole fruit so each day a selection of prepared fruit is offered. Comment cards have been introduced after meals for residents to make a comment on the standard of food. Some comments were, ‘nicest piece of fish for a long time’, ‘very good lunch – nice to have beans’. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. People who use this service can be assured that any complaints will be taken seriously and staff knowledge will protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that is included in the statement of purpose information. A number of comment cards were received by CSCI prior to this inspection and of nineteen asked, eighteen residents said they would know how to make a complaint. The complaints log was seen and showed a number of issues had been raised by residents and all had been looked at, actioned and confirmation taken with the resident that they were happy with the outcome. The issues ranged from fried bread that was too crunchy to changing a resident’s room and moving furniture in one of the lounges. The protection of vulnerable adults (POVA) policy is cross-referenced to the guidance from the inter agency committee for protection of vulnerable adults of Suffolk. Staff spoken with were clear about their duty of care and twentythree staff responses, 100 of those returned prior to this inspection said they knew what to do if someone raised some concerns. The training matrix showed all care staff and ancillary staff have had POVA training and staff spoken with confirmed this. Lehmann House DS0000037712.V349040.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. People who use this service can expect to live in a generally clean, wellmaintained and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of all four units and the communal areas of the home was undertaken with the registered manager but all areas of the home were later re-visited. The home was clean and tidy with no unpleasant odours except in one ground floor unit near the toilet and bathroom. The manager was aware of the problem and said it was being addressed but would involve building works as the concrete floor around the toilets had become impregnated and needed renewing. They hoped the work was scheduled to be done in the next few weeks together with a camera check of the drains that seemed to be invaded by tree roots. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 17 The home has had a new passenger lift installed that is easily operated by residents and wheelchair users. The previous one needed a member of staff to open and close the heavy outer doors thus taking away residents’ independence. There is a maintenance/gardener person employed in the home. The secure gardens are accessible from a number of level exits from the two ground floor units. The gardens looked attractive with runner beans and vegetables as well as flowers and shrubs. Some pathways in the garden have been newly re-surfaced to enable residents to reach the centre of the village easily to access the shops, health centre and church. There is an ongoing redecoration programme within the home and a number of rooms have been refurbished as they have become empty. The laundry was visited and had washing machines with sluice programmes. The dedicated laundry worker was on annual leave so the carers were managing the laundry. There was evidence of the use of protective clothing and soiled linen was transported in alginate bags and placed directly in the machines. The home’s infection control policy is comprehensive with guidance on managing infections such as MRSA and clostridium difficule. Lehmann House DS0000037712.V349040.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 good. People who use this service can expect to be supported by adequate numbers of correctly recruited and trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the day the home was staffed by one senior with two carers on each unit and a ‘float’ person. A senior and four carers covered the night shift. An ancillary team that included a cook and kitchen assistant, an administrator, two domestics and a maintenance person supported the care team. The manager was supernumerary and as noted earlier the home has recently employed an activities co-ordinator. People spoken with said the team was sufficient to meet the needs of the residents. During the day it was noted that call bells were answered quickly. The training details that were given by the manager show that of forty-four carers employed by the home thirty-eight have achieved NVQ level 2 or above. This represents an achievement to exceed the recommended level of 50 in standard 28 of the national minimum standards (NMS) for care homes. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 19 The manager said that the staff team was complete at present having just recruited three new relief carers, the activities co-ordinator and a maintenance person. The files of three of the new recruits were seen and all contained evidence of identification checks and two references. They all had a POVA 1st check but only two had a criminal records bureau (CRB) check. The manager said that this check was taking an unusually long time and there was evidence in the file of e-mail requests from the manager about the status of the check. It appeared to be held up at the local police station. The files had documentary evidence of a three-day induction period that covered moving and handling, food hygiene, infection control, fire awareness and POVA. The training matrix showed ongoing training for all staff and included dementia care, care planning, first aid, control of substances hazardous to health regulations (COSHH) and for some care staff, medication training. Senior staff and the manager had recently undertaken I.T. training level 1 2. There was evidence of annual updates for fire awareness. Lehmann House DS0000037712.V349040.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, 38. Quality in this outcome area is good. People who use this service can expect to be consulted and have their finances and welfare protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in care management for a number of years and was appointed manager at Lehmann House five years ago. They have achieved an NVQ level 4 in direct care and a diploma in management of care. They have undertaken a number of courses in dementia care including dementia mapping. Staff spoken with said the manager was approachable and offered leadership. Interactions observed between the manager and residents were friendly, caring and demonstrated knowledge of the individuals. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 21 The residents’ files and care plans seen showed that residents are consulted about the way they wish to be supported to meet their daily needs. Social needs and physical needs are addressed and there was evidence to show that regular reviews take place. The cook consults daily with residents about their enjoyment of the meals offered. To help residents complete the recent comment cards sent by CSCI prior to this inspection the manager had used a member of staff from a sister home, who was not known to residents, as an independent advocate. The team leader on each shift has access to residents’ personal monies. The home has a float that is used to supply residents with cash. The local authority holds other money in a central account and each resident has an individual numbered account within that. Interest is allocated according to the balance and every three months statements are issued to the resident or their representative or filed in their notes. Some statements were seen when the residents’ files were inspected. A number of service certificates were seen including the gas safety certificate issued in November 2006 for a year, a certificate for a major water hygiene inspection that had been done in February 2007 and all the paperwork and risk assessments associate with the installation of the new lift that was commissioned in June 2007. The fire log showed that fire alarms and bedroom fire doors are tested weekly and that staff have regular drills. Lehmann House DS0000037712.V349040.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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 X X 3 Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO. 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP26 Good Practice Recommendations The necessary work to be undertaken in the bathroom and toilet identified should be processed as rapidly as possible to ensure that residents live a pleasant environment free from odours. Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Lehmann House DS0000037712.V349040.R01.S.doc Version 5.2 Page 25 - 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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