Inspection on 07/09/06 for Lehmann House

This inspection was carried out on 7th September 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

Lehmann House 14/08/07

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 Jan Davies Key Unannounced Inspection 7th September 2006 10:30 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 DS0000037712.V311414.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. DS0000037712.V311414.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) DS0000037712.V311414.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. 27th February 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 GP surgery and shops. The home is a large building, divided into four groups or units, each of which has its own bathroom, toilets, lounge, dining and kitchenette facilities. In total, it caters for 38 service users. Three of the units cater for older people with people with special needs, 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. DS0000037712.V311414.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. This unannounced inspection of Lehmann House took place over six hours and was the first statutory inspection visit in the inspection programme for 2006/7. All core standards were assessed. Nine requirements and five recommendations were set at the last full annual inspection. All requirements have been fully or partly addressed and two have been restated in this report with a new timescale for compliance. The home’s two team leaders and the manager were present during the inspection. Their assistance during the inspection was appreciated. A tour of the home was undertaken, including a visit to all units and individual residents’ rooms with their permission. Records were viewed during the inspection, which included care plans, medical and health records, training records, staff records and menus and the home’s policies and procedures and related information. What the service does well: What has improved since the last inspection? The home was only admitting service users within the conditions for which it is registered and had sought a variation to comply with registration requirements. DS0000037712.V311414.R01.S.doc Version 5.2 Page 6 Fire safety precautions have been tightened. Service users’ doors have identifying features. Daily notes are more robust generally. 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. DS0000037712.V311414.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 DS0000037712.V311414.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. Prospective service users can expect that they will be provided with the information they need to make an informed choice about where to live, that they will have their needs assessed and met and that they will be provided with the opportunity to visit the home before they decide to move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s statement of purpose was appropriate in content and included the required information. The service users guide was in an accessible format, which included information including service users comments about the service. DS0000037712.V311414.R01.S.doc Version 5.2 Page 9 The statement of purpose and the service users guide both include contact details of CSCI. The home’s statement of purpose explains that prospective service users will be encouraged to visit the home prior to moving in. Service users spoken with said that they had had the opportunity to do this. Others have visited the home for a meal while they were deciding where they wished to live. Four service users records were viewed and each contained a written contract. Four residents care plans viewed all contained assessments of their needs, and care plans explaining how these needs will be met. Risk assessments were completed by senior staff or the home’s manager and were detailed and comprehensive. Staff training records were viewed, these evidence that staff are trained appropriately and have sufficient qualifications to meet the needs of service users. Comprehensive care plans were available to staff working with service users in each service user’s bedroom. One staff member spoken with said that staff use them so they are aware of the care they require and what assistance staff are required to provide. DS0000037712.V311414.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. People who use this service can expect to have their care needs documented and met most of the time, but more consistent recording of medication will ensure quality of care for every resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans and associated records, such as the daily statements, relating to four residents were examined. These were discussed with staff; the manager and two residents about their own care plans. Each plan had several elements to the care plan including communication, being safe, personal care, dressing, eating and drinking, sleeping, mobility and DS0000037712.V311414.R01.S.doc Version 5.2 Page 11 recreation needs. All these care plans were clear and easily understood. There was evidence of monthly review and continuous assessment of risk. One resident’s care plan tracked demonstrated a good account of care given by the home from initial assessment to the current arrangements. The resident in question had been given a diagnosis of dementia and was totally dependent on admission to the home from hospital. The medication protocol was examined. All carers who administer and record medication have been appropriately trained and the medication was kept secure. The home operates a monitored dosage system (MDS). There was a record of all medication coming into the home, a record of medication administered and a record of medication returned, therefore it was possible to audit medication at random. The stock and administration was correct. Whilst auditing medication on one unit it was observed that there were gaps in the medicine administration record for two residents and no explanation written or offered for why this was the case. The manager spoke with the senior staff member with responsibility for the administration of medicine in the unit and no further clarification could be offered. During a tour of the building, it was observed that all residents have a copy of their individual care plans in their bedroom, a member of staff stated that these are used on a daily basis by staff to meet the needs of the service users effectively. Four service users care plans were viewed; these include all dayto-day care and support they require. Service users care plans contained evidence that staff members review them regularly and that the service users signed their care plans. Care plans viewed included the service user’s preferred name. Some bedrooms contained information for staff reminding them about individualised personal care duties to be done. The placing of this information around the room and above the beds of residents detracted from the ‘homeliness’ aspect and could contravene privacy for residents when their visitors accessed their room. All bedrooms at Lehmann House are for single occupancy and service users may choose to keep their bedroom door closed for privacy if they wish to. Service users files seen contained risk assessments for room keys. Staff were observed to knock on service users’ bedroom doors before entering and were discreet when assisting service users to access toilet facilities. One service user who needs help to access bathroom facilities told the inspector how ‘kind and gentle’ the carers were when helping them. This service user had had a different experience elsewhere, and was in a good position to judge good practice. DS0000037712.V311414.R01.S.doc Version 5.2 Page 12 One service user was observed being given assistance from two staff members with getting out of their chair. This was done with professionalism and patience from care staff who encouraged the resident to a greater degree of independence while offering continuing support. DS0000037712.V311414.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Service users can expect that their social, cultural, religious and recreational interests and needs are met and that they are helped to exercise choice and control over their lives. Service users can expect that they receive a wholesome and appealing balanced diet and that they maintain contact with others who are important to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service user records viewed identified family and the significant others in the service users lives and the usual contact arrangements, records evidence when service users have maintained contact with others. DS0000037712.V311414.R01.S.doc Version 5.2 Page 14 At the time of the inspection two relatives were visiting the home and were made welcome in the home. One relative was spoken with and told the inspector that she had been made welcome and offered a cup of tea. A number of service users seen had had their hair done, by the home’s hairdresser who is based on the first floor, on the day of the inspection and obviously were pleased with the results and compliments given them by staff. All of the ten service users on Moore unit were dressed, up, and out of their rooms. All had had their breakfast where they preferred to be, including one service user who prefers to stay in their room, and another who likes to stay in their room until mid day. A number of service users were in the lounge, three of whom were dozing, one was having had their hair done by the hairdresser, and one was out visiting, but returned later. Later during the inspection one service user was seen knitting, one reading, and others watching television. Activities were recorded centrally in which service users on Moore participated with staff. Service users spoken with were very satisfied with the food. A member of staff circulated the units in the morning, asking service users what choice they would like for the day. Resident’s bedrooms were viewed during a tour of the building. All bedrooms contained service users individual belongings including memorabilia and photographs. Some service users bedrooms contained their own furniture, a member of staff confirmed that service users could bring their own furnishings to the home if they choose to. The home has a designated activities coordinator and four service users records viewed show service users likes and dislikes and what they enjoy doing, and a central record of activities is maintained. Activities undertaken by individual residents would enhance their personal care plan recording. Two service users spoken with said that they go out for walks if they want to and often go out with their families. Another resident said that the staff entertain and provide activities. The home’s statement of purpose and service user guide explains how visitors are welcomed at the home, examples of activities service users may choose to participate in, how their religious needs would be met, and what services are available in the local community. The week’s menu was viewed, which provides a well-balanced and varied menu. A member of staff said that the menus are changed regularly. A member of staff spoken to said that the cook asks service users each morning DS0000037712.V311414.R01.S.doc Version 5.2 Page 15 if they want an alternative choice to the menu, which is provided. The inspector observed this to be happening. During the inspection a meal was prepared, which looked and smelt appetising. A resident was observed telling the staff member that the food was very good. One service user said that staff brings them ‘lots of cups of tea’. The home has communal kitchens where service users can prepare their own drinks or snacks if they wish throughout the day. Three service users were observed enjoying tea and biscuits and ‘chatting’ with staff in the kitchen area which the member of staff said was a ‘favourite place’ for residents to enjoy a sit down and cup of tea. DS0000037712.V311414.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Residents can expect that their complaints will be listened to and that they will to be fully protected from abuse. The home has systems in place to ensure that all staff members are appropriately trained in protection of vulnerable adults and aware of all the risks of harm to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure was viewed, which was appropriate in content, and reference is made to CSCI with contact details and why service users may choose to contact CSCI. CSCI contact details are also included in the service users guide and the statement of purpose, with explanations of how service users can contact them with any concerns about the service they receive. There have been no complaints received by the home or CSCI since the last inspection. A local authority leaflet was viewed ‘compliments, complaints and concerns’, this contained details of CSCI. DS0000037712.V311414.R01.S.doc Version 5.2 Page 17 Two service users spoken with said that they knew what to do if they were unhappy about something in the home, and said that they knew the manager would always listen to them and ‘do something about it’. The home has a policy for the protection of vulnerable adults and a whistleblowing policy. Records of staff training did not show recent up dated training for staff on the protection of vulnerable adults and a whistle-blowing policy. Staff spoken with were able to identify appropriate action to take in the event of an allegation being made but training needs should identify how all staff can receive updated training on this. The home actively addresses the need for respecting each other and promotes anti-bullying attitudes. There was evidence of discussion in staff meetings and residents’ meetings about this. From discussion with the manager ‘minor’ complaints and discontentment from residents are appropriately progressed and resolved without becoming formal complaints. However there should be a system within the home to monitor and record all issues raised ,including those that could be described as ‘low-level’ complaints as part of the overall quality monitoring arrangements for the home. DS0000037712.V311414.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. Service users can expect that they have access to safe and comfortable communal and private facilities, the home is clean, pleasant and hygienic and that they have specialist equipment they require maximising their independence. However they cannot always use the only passenger lift allowing access for residents and their visitors to the first floor as this can be ‘out of action’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During a tour of the building it was observed that the home has three communal kitchen, dinning and lounge areas, which service users can use if they choose. The communal areas are comfortable, light and well furnished. DS0000037712.V311414.R01.S.doc Version 5.2 Page 19 The home has attractive garden areas with garden furniture where service users can sit if they choose and also have gardened and grown vegetables. Some bedrooms have washbasins and there are several bathrooms and toilets in the home, which service users can use and which are sufficient in number for the numbers of service users living at the home. There are no en-suite facilities that include individual showers and toilets for residents. Bathrooms have been made more homely with clever use of decoration. All bathrooms are equipped with grab rails and bath and shower seats for service users safety and comfort. The home has a store cupboard where wheelchairs are stored; there are sufficient hoists available. Two service users were observed using walking frames in the home. All rooms are provided with call systems, including communal areas, bathrooms and bedrooms. All bathrooms are provided with hand wash gel and disposable towels. Service users bedrooms have appropriate furnishings and fittings, including lockable storage areas, bedroom doors have locks, which service users may use if they choose to. The home has appropriate sluicing facilities. There is a laundry room, with sufficient washing machines and a large dryer. There is storage for clean laundry until it is returned to service users and an ironing area. The rooms contain hand-washing facilities including hand wash gel and disposable towels. The home was observed to be very clean and tidy and without any offensive odours. Storage cupboards were observed to hold protective gloves and aprons for staffs use. However the only passenger lift is central to the smooth operation of the home and choice of access for residents and their visitors and this is regularly ‘out of action’. DS0000037712.V311414.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Service users can expect that staff that are trained and competent to do their jobs supports them and service users are supported and protected by the homes recruitment procedures. They cannot expect that staff will always be supervised on time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s statement of purpose included information on staffing of the home and their qualifications. The home has exceeded the 50 (and are in excess of 80 ) requirement of care staff to achieve NVQ (National Vocational Qualification) level 2. This was confirmed by staff training records, which were viewed. One staff member spoken with had recently completed their NVQ level 3 Care; they spoke of how they had enjoyed the process and the good support they had received from their manager in achieving the award. DS0000037712.V311414.R01.S.doc Version 5.2 Page 21 Members of staff spoken with said their experiences of the recruitment process were positive. One new member of staff has been recruited since the last inspection. There was only one reference on file at the time of the inspection. (A copy of the missing reference was later faxed to the local CSCI and was seen to be satisfactory.). Training records were viewed, the staff team are provided with a comprehensive training programme. (However as referred to above, updated adult protection training should be available at least annually in addition to induction training given in this area.) All newly appointed staff are provided with TOPSS (now Skills for Care) induction and foundation training programmes. Four staff files were viewed and in one case there was a time span of five months since formal supervision had been given. The member of staff and the manager were spoken with and it was stated that this was due to a period of absence of the senior who was the supervisor. However records did not record this reason and there had been no date planned for the next session. DS0000037712.V311414.R01.S.doc Version 5.2 Page 22 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): 31,32,33,34,35,36,38 Quality in this outcome area is good. Service users can expect that the home is managed by a person who is fit to be in charge of the home and that their health and safety will be promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager has the registered manager award and NVQ at level 4 and is a ‘fit’ and appropriate manager. She has a ‘hands on’ approach to managing the home and is clearly well thought of by residents who were pleased to see her when she went around the home. A number of staff were DS0000037712.V311414.R01.S.doc Version 5.2 Page 23 spoken with were very positive with regards to the management of the home and of the staff group. In terms of safe working practices there was evidence at the last inspection that records on training for first aid, abuse, fire and manual handling were available and these were assessed as satisfactory. At this inspection the manager confirmed that staff had received updated training in first aid, manual handling and dementia mapping. Residents’ files were sampled and reflected that there are appropriate arrangements made by residents and their families or appointed representatives to safeguard their financial interests. The home’s staff members are not appointees for residents’ money and are not authorised in this capacity. This arrangement reflects good practice and maximises financial security for all residents. The home’s policy and procedures file reflects that staff have the appropriate information about this available to them and induction training information shows that this topic is covered when staff begin working in the home. Risk assessments were in place for individuals in relation to their needs and specifically for their safety in relation to accessing the environment. Health and safety documentation was available and evidenced that the home keeps up to date and appropriate records of maintenance. Residents spoken with spoke highly of the manager and staff and found them helpful in solving matters. At the last inspection the home was given two requirements around the issue of fire doors. During the tour of the home, no fire doors were wedged or propped open. One particular door was the door to the kitchen and when the inspector looked it was closed and remained closed throughout the inspection. The homes handling of resident’s money was checked and the home is keen for all residents to have their own money where ever possible. A computer database is maintained by the home and identifies how much each resident has. The residents with high care needs in some of the dependent units are not able to have their own money and here families take responsibility where necessary. In these situations the families mostly have Power of Attorney and buy the resident anything they might need. The home is well run, all the staff were observed to be working hard. All the staff were see to be aware when residents needed support or directing to where they wanted to go. Hygiene was strictly adhered to and everything was appropriately kept and labelled. All the staff including the domestic, kitchen, admin, care staff, manager and handyman all interacted well with residents. DS0000037712.V311414.R01.S.doc Version 5.2 Page 24 DS0000037712.V311414.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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 2 17 3 18 3 3 3 3 1 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 3 3 2 X 3 DS0000037712.V311414.R01.S.doc Version 5.2 Page 26 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 OP10 Regulation 12 Requirement Personal care information must not be displayed in residents’ rooms in places where this contravenes confidentiality. The passenger lift must be maintained so that it is fit for purpose. This is a repeat requirement from the previous inspection Medication must be administered and recorded accurately in accordance with prescriptions and reasons for omissions recorded. This is a repeat requirement from the previous inspection. 4. OP30 13 Medication training must be available for all staff who administer prescribed drugs with emphasis on a correct and consistent recording system. 01/10/06 Timescale for action 01/10/06 2. OP22 23 01/10/06 3. OP9 13(2) 01/10/06 DS0000037712.V311414.R01.S.doc Version 5.2 Page 27 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 OP7 OP16 Good Practice Recommendations Activities undertaken by individual residents should be included in their personal care plan recording. There should be a system within the home to monitor and record all issues raised, including those that could be described as ‘low-level’ complaints as part of the overall quality monitoring arrangements for the home. Training needs should identify how all staff can receive updated training on adult protection. There should be a system within the home to monitor and record all issues raised, including those that could be described as ‘lowlevel’ complaints as part of the overall quality monitoring arrangements for the home. All staff should have formal recorded supervision where they can discuss personal aspects and development of their career a minimum of 6 sessions a year. 3. OP18 4. OP36 DS0000037712.V311414.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 DS0000037712.V311414.R01.S.doc Version 5.2 Page 29 - 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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