Inspection on 09/12/05 for Lehmann House

This inspection was carried out on 9th December 2005.

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

Lehmann House 14/08/07

Lehmann House 07/09/06

Lehmann House 27/02/06

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 Mary Jeffries Unannounced Inspection 9th December 2005 09:30 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 Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 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.V272485.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lehmann House Address Lehmann House Church Terrace Wickham Market Suffolk IP13 0SG 01728 746322 01728 748212 jennifererodger@socserve.suffolkcc.gov.u 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 (28), 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.V272485.R01.S.doc Version 5.0 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. 24th March 2005 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. Social Care services have a base at night time for their domiciliary care service in the home. Staff recruited for this also have domestic relief duties for Lehmann house written into their contracts of employment. A day care unit is within the same building. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection focused on the frail elderly unit. The inspector met all service users on Moore Unit, and tracked three of them who were spoken to at some length. Service users on the most recently converted special needs unit were observed and spoken with more briefly. Two carers assisted with the inspection, and the inspector met with the home’s manager at the end of the inspection. The inspection took place one morning in December 2005, and lasted four and a quarter hours. What the service does well: What has improved since the last inspection? What they could do better: The home must not admit service users outside of the conditions for which it is registered and a variation must be sought to address the current situation. Fire safety precautions must be tightened. Medication administration and quality control requires improvement. Information of staff on duty must be correct, particularly on dementia care units where misinformation can add to confusion, and all service users’ doors should have identifying features. Daily notes require some enhancement. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 6 A worker who is experienced or training in working with learning disability should be involved in the care of the one named service user with learning disabilities. A good standard of décor should be maintained throughout. 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. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 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.V272485.R01.S.doc Version 5.0 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): 2,3,4 Service users can expect to have been fully assessed prior to moving into the home, and to receive a written contract. Service users can expect the home to be able to meet their needs. EVIDENCE: Two of the three service users tracked had been admitted in the previous twelve months and both had compass (Social Care Services) single assessments on file. Service users’ files had contracts on them; one of these was not yet signed by all parties, they had not yet had their 6 weekly review. One service user had been admitted into the home onto the mainstream unit with a diagnosis of dementia. The home was able to meet this service users’ needs on the unit, however, in admitting them the home had gone over the number of people with dementia they are registered to provide care for. There were two other service users with some confusion on Moore, neither had been diagnosed with dementia, and both had been in the home for over a year. Their needs were discussed with the carer, and care plans inspected. The home was able to meet their needs. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 9 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 Service users can expect to have a comprehensive care plan, based on their assessment, which is regularly reviewed. They can expect to receive care in accordance with their care plan, and to be treated with respect and dignity. Although a Quality Assurance system is in place for the administration of medicine, this had not been fully complied with and therefore service users are potentially at risk. EVIDENCE: Plans were found to include those areas identified in standard 3 and were found to be detailed with respect to individuals personal care needs. Details of personal preferences and choice were recorded. Service user records provided evidence of both the initial six-week review involving the service user, relatives and appropriate professionals and of ongoing monthly care plan reviews. Individual care plans were very clearly presented and well organised. Details of appointments with health services including opticians and chiropodists, GP and District nurse appointments were on service users’ files inspected. A service user who had been recently admitted to the home was Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 10 seen to have received a new client medical check, and also to have had their ears syringed. One service user spoken to had been to the G.P.’s the previous evening. They advised that the young lady who was on duty had taken them, and they were “ever so kind and ever so nice.” Ongoing daily notes showed some gaps of up to three days. They were supplemented by records of activities and night time notes. This was discussed with the manager who advised that if there has been nothing notable to report then staff are not expected to make an entry every day. Good practice was seen to be observed in the administration of the lunchtime medication. The carer got down to the service user’s level to speak with them, had a good manner and waited to establish medication given had been taken. Five service users’ medication administration records were filed under their previous unit name and room number. One did not have a photograph. Medication records for all service users on Moore unit were checked. A quality assurance (QA) system was in place, and the carer advised that a new system had been instigated so that the person handing in the medication book at the end of their shift shouldn’t leave until any gaps in recording had been had been clarified and signed for. A number of omissions in recording were noted, having been picked up by the QA system. Amongst these, the QA system had identified that no teatime medications on the 8th December had been recorded, and that this had been reported to a team leader. The other omissions noted on the QA system were mainly individual gaps, on 4 occasions since 11/11/05, 2 gaps on one occasion and on the 19th November, no 9pm medications had been signed for. The records for teatime on the 8th November were inspected, and despite the system in place, this had not been appropriately addressed. Service users either had x (six service users) or no entry (three service users) marked in the medication administration record for this occasion. There were no supplementary notes on the reverse of the records. One service user had run out of a prescribed cream, which they applied themselves, and said that they had been asking since the beginning of the week to see a doctor. The handover book recorded that this was the third day that they had asked. The member of staff on duty advised that they had become aware on the day of the inspection that the service user had run out of cream the previous day. The carer made an appointment, an appointment was given for the following week. This was discussed, and the carer was asked to contact the surgery to prevent the service user being without the cream, which would result in irritation. The home’s manager advised that there had been an issue of over use of a steroid cream, and the doctor would not re-prescribe without seeing the service user, who self medicated for creams. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 11 The carer on duty on Moore had a good knowledge of all of the service users’ needs, and had a good rapport with service users. A service user with dementia spoken with on Smythe said, “ I love it, they are so good to me. They understand me and they love me. I know they like me and that makes me happy.” This service user receives assistance with bathing and they were asked if they felt they were in safe hands, their response was, “wonderful”. 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, and in addition to the service user who chose to lock their room during the day, another service user was seen to have a room key which they mislaid but found during the morning. 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 is occasionally incontinent described how sometimes they were incontinent at night: “the girls come and they don’t make a fuss, they don’t make it a problem.” This service user had had a very different experience elsewhere, and was in a good position to judge good practice. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users can expect to be free to spend their time as they chose, and enjoy considerable flexibility within the routines of the home. They can expect to be well satisfied with the quality of everyday life. EVIDENCE: 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. Eight of the ten service users on Moore unit were dressed, up, and out of their rooms by 9.30. All had had their breakfast, 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 in the morning, one service user was seen knitting, one reading, and others watching television. Activities which service users on Moore participated in with staff were ere recorded. 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. One service user advised as soon as they saw the worker; “ I’ll Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 13 have fish, peas and chips, jelly and ice cream and a banana, and tonight I would like poached eggs, one round of white bread and butter.” The member of staff advised the inspector that the main meal was beef stew, but that this service user knew what they wanted and that was fine. This service user said that they had had prunes, rice crispies and hot milk for breakfast. Their opinion of the food was, “ It’s lovely, you can have what you want when you want, the fish is lovely and soft. I have a roast dinner on a Sunday, I had chicken last week, gravy, sprouts, potatoes.” A service user on Smythe, the newly converted special needs unit described their food that day as “ a nice ordinary Suffolk dinner- you can’t beat it.” Fresh fruit was available on service users’ lounges. Visitors are welcomed at Lehmann House and the visitor’s book evidenced frequent visits. Lehmann House offers a range of communal spaces in which service users can entertain relatives and friends in private. The home’s Christmas pantomime, which staff participate in was advertised in the home. The December newsletter, included photographs of outings, and activities in the home, including marmalade making. The home employs an activities worker 5 hours a day, who does various forms of arts and crafts, games and competitions with service users. A service user advised that we have quizzes and bowling and such like downstairs on Thursday evenings, but that they had visitors all weekend and liked being on their own so didn’t bother to go down. They went on to say that the activities worker had brought the Christmas puddings up to the unit for service users to make. This service user said that they are taken out to the local shops by a carer, and so they were able to get things for a relative. Another service user said that they did enjoy going down to Thursday evening activities, and that a worker comes and takes them downstairs. They said that otherwise, they did not like going out of their room, because one service user on the unit made a constant muttering/ murmuring noise. This was observed on the day of the inspection, and the carer on duty confirmed that this was something the service user did most of the time, and they were aware that the other service user found this annoying. A very nice atmosphere was observed on the dining room on Smythe unit. Christmas decorations were being put up on Smythe and there were individual fumble boxes in evidence. A worker confirmed that a lot of service users from the special needs unit wandered onto Moore, and that the staff try to keep an eye on what is happening. One service user said she had taken to locking her room, as she had had problems with service users from Smythe going in, another said, “ last Tuesday one stuck her head round here 5 times, and she chucked my cushion at me. It is frightening.” Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Service users can expect any complaints they may have to be dealt with in a appropriate and timely way, within the Social Care Services complaints procedure. EVIDENCE: Copies of the home’s complaints policy, which is the Social Care Services complaints policy had the address of the CSCI on them. A complaint received by the CSCI since the previous inspection had been put to the home to investigate and they had done this is in a timely and appropriate way. Notices in the home regarding complaints included advice that complainants could refer to the CSCI. “I’ve never had anything to complain about.” This service user had previously lived in another home which they had moved from as they had not liked the care. The service user who had spoken about their medication running out was very worried that they would get someone into trouble, and stressed that they didn’t want to do that, several times during the morning. The carer advised that this service user is generally anxious, and there was nothing else that would indicate that service users would not be able to raise concerns and have them addressed in a positive way. One service user said, “If I have any worries I just ask someone. I haven’t got any worries. ” The manager advised that no member of staff was allowed to commence work without a PoVA First check, and this was confirmed separately by another member of staff. Staff files were not checked on this occasion; they will be at the next inspection. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,24,25,26 Service users can expect to have a comfortable homely environment. Notices and information are not currently presented in a way to make them accessible and relevant, particularly for service users with dementia. EVIDENCE: The home was found to be generally in good decorative order and to be homely, but wallpaper on the corridor in Moore was noted to be tatty and ripped in paces, and the plasterwork damaged. The manager confirmed that this was scheduled to be addressed. Service users were seen to have free access to both units on the first floor. The staircases had been identified as high risk for persons with dementia, and digital locks, linked into the main fire system had been provided. Those who are able to go downstairs independently, can do so in the lift. The lift was working at the time of the inspection. It has a heavy door, which must be pulled across manually, and which some service users may find difficult to use without assistance from a carer. One service user confirmed that they could Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 16 use the lift without help, but said that they were worried that it could go wrong, They advised that it had “got stuck” some time ago, and had been out of action. They knew how to call for help should this happen. The manager confirmed that the lift had broken down several times, and on one occasion a service user who uses a wheelchair was unable to make a meeting with a relative outside of the home. A requirement had been made at the previous inspection that the Responsible Persons must provide a report regarding the passenger lifts fitness for purpose, with regard to the standard, the Regulation and The Disability Discrimination Act and any necessary remedial action required. This had not been provided; the manager drew attention to a report that had been forwarded previously. It was subsequently established that a certificate of examination of the list dated 15/04/2001 had been forwarded previously to the CSCI. But a recent report had not. A five-year inspection will be due in April 2006. The temperature of two baths on Moore was checked and found to flow at approximately 43 degrees. The hoist on Moore unit had been repaired since the last inspection. Bathrooms were seen to be clean and tidy by 9.45 am on Moore unit. Soiled laundry was seen being transported correctly in a tied yellow bag, and a member of domestic staff was able to explain the procedure. Service users’ files contained records of equipment cleaning. The service user with a diagnosis of dementia on Moore unit had a pressure mat, to alert staff to when they got out of bed. The home had a number of provisions within the environment to assist service users with their understanding and orientation that were not being maintained. Posters and photographs of who is on duty were on both units, but the wrong photographs were displayed. On Moore the carer was correct, but the wrong domestic worker’s photograph was displayed, on Smythe a picture of a carer who was not on duty was displayed. A crowded notice board on Smythe was not user friendly for service user with dementia, although there was a very clear large clock. The general notice board on Smythe contained a lot of information and was not tidy. The home has a call bell system with alarms positioned in all communal rooms and service user bedrooms. A worker advised that one service user rings theirs up to 15 times a day. When asked how they respond to this they advised that they have to respond the same as to any other alarm call, as it may be a matter of importance or urgency. The majority of doors to individual service user’s rooms on Smythe had photographs of the occupant on them, two did not. One of these was a newly admitted service user, the carer advised that the other had been a very unflattering photograph and they were seeking to replace it. A significant number of the individual rooms Moore unit were missing an identifying picture. Three service users were spoken with in their individual rooms, which were well equipped and personalised. One service user described how their room Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 17 had been decorated for them when they moved across from another unit, and how they helped choose the colour. This service user was very satisfied with their new room. A small reading lamp had been provided for this service user who enjoys reading. The majority of the rooms on the unit were just under 10 square metres, and accepted by CSCI, however these rooms are not suitable for wheelchair users. The home has fitted radiator covers, and all bedrooms are individually ventilated. One service user complained they were hot, the carer explained that the service user liked to keep their windows closed and refused to have their radiator turned off. A fan had been provided in this service user’s room, and was turned on during the morning of the inspection. The home was generally found to be clean and tidy, with no problems of unwanted odours on the two units on the first floor, but the a corridor on a special needs unit on the ground floor had an unpleasant odour. The manager advised this was due to a service user having repeated “accidents”. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Service users can expect staffing levels to meet their needs, and for staff to have a good knowledge of them. EVIDENCE: There was no floating carer on duty on the morning of the inspection, however the carer on Moore unit managed the routine well. They advised that many of the service users were independent in terms of personal care, or only needed some assistance or prompting. Only one service user needed full personal care, and none needed two persons to assist them. Two carers were on duty on Smythe unit. The carers felt they were able to manage their work, and had achieved good progress with two service users in developing their mobility, including a service users who hadn’t been mobilizing when they were admitted. This service user was seen, and confirmed they were pleased with themselves and their progress. Staff had a good knowledge of service users’ needs and care plans, and service users spoke well of care staff. The home has a key worker system, however, of the four staff that normally covered Moore, one had left and another was on sick leave. Relief staff were being used to cover shifts, and between them staff had ensured that the key worker duties in terms of Christmas shopping for service users had been covered. A recommendation had been made that the key worker for the named service user with learning disabilities received some training in learning Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 19 disabilities. This worker had since left, and a key worker with experience in learning disabilities appointed, but they had also left. The carer with responsibility fro the unit on the day of the inspection advised that nether she nor the other worker who covered this unit had received any specialist training in learning disabilities. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 37, 38 Practices around the closure of fire doors were not satisfactory; this exposes service users to unnecessary risk. EVIDENCE: The home awaits action to connect all fire doors to the automatic alarm; currently individual room doors are not on automatic closures. A large number of bedroom doors and other doors, on Moore Unit were propped open. These had been dealt with by a risk assessment, however, at least two were propped open when there was no service user in the room to justify this. The fire risk assessments stated that where rooms had been risk assessed to be propped open, the home’s fireboard must show this. The fireboard for Moore was seen, but did not have any markings to denote the rooms where doors might be propped open, so that staff would take necessary planned action in the event of a fire. One door to a service users individual room at the end of dead end corridor was propped open. This had not been risked assessed and the Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 21 manager understood that this must be closed. They understood that the service user had left this open, although advised they must not. The manager had fully considered how one service user with dementia who regularly hid paper money could be assisted better, and had arranged for them to be provided with coins, rather than notes for small cash. The filing cabinet containing service user’s files on Moore unit was unlocked, with the key in it, it was checked again later and still found to be unlocked, but without the key in it. A copy of the home’s Statement of Purpose was available on Moore Unit. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 X Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 4 Requirement The home must not admit service users outside of the conditions for which it is registered and a variation must be sought to address the current situation. Medication must be administered and recorded accurately in accordance with prescriptions and reasons for omissions recorded. The risk assessments for a service user who self medicates creams must address their over use of a prescribed cream, and precautions put in place to avoid this service user who self medicates running out of prescribed medication. The Responsible Persons must ensure that a good decorative standard is maintained. The passenger lift must be maintained so that it is fit for purpose. The home must be kept free of unpleasant odours. Service user’s records must be kept securely. DS0000037712.V272485.R01.S.doc Timescale for action 09/12/05 2 OP33OP9 13(2) 09/12/05 3 OP9 13(2) 21/12/05 4 5 6 7 OP19 OP19OP22 OP26 OP37 23(2)(b) 23(2)(n) 13 (3) 17(1)(b) 31/03/06 21/12/05 21/12/05 21/12/05 Lehmann House Version 5.0 Page 24 8 OP38 23(4)(a) 9 OP38 23(4)(a) Fire risk assessments for fire 09/12/05 doors must be reviewed, to ensure they minimise risks and actions identified to minimise risks taken as determined. Fire doors that do not have a risk 09/12/05 assessment must be kept closed. 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 3 4 5 Refer to Standard OP7 OP9 OP19 OP19 OP27 Good Practice Recommendations Daily notes should contain at least one entry during a 24hour period to ensure that an ongoing record of the service user’s needs is maintained. The medial administration records should be organised so that the correct unit and room number is with the MARs sheets. Photographs displayed of staff on duty should be correct. Service users’ rooms should have identifying features. It is recommended that relevant training be provided for at least one carer regularly working with the named service user with learning disability. Lehmann House DS0000037712.V272485.R01.S.doc Version 5.0 Page 25 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. 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