Inspection on 26/04/07 for Lennox Lodge

This inspection was carried out on 26th April 2007.

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

Lennox Lodge 03/04/08

Lennox Lodge 29/06/06

Lennox Lodge 27/09/05

Lennox Lodge 08/04/05

Lennox Lodge 21/12/04

Lennox Lodge 06/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Lennox Lodge 37 The Highlands Bexhill-on-sea East Sussex TN39 5HL Lead Inspector Judy Gossedge Key Unannounced Inspection 26th April 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lennox Lodge DS0000021407.V336718.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. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lennox Lodge Address 37 The Highlands Bexhill-on-sea East Sussex TN39 5HL 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) 01424 215408 F/P 01424 215408 Mr Guy Haddow Vacant Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is nineteen (19). Service users must be aged fifty-five (55) years or over on admission. Service users with a past or present mental disorder are only to be accommodated. That the home accommodates one named service user with a dementia type illness. 5th October 2006 Date of last inspection Brief Description of the Service: Lennox Lodge is a care home registered to provide accommodation for up to nineteen service users aged 55 or over on admission who have a mental disorder. Lennox Lodge is a large detached property situated in the residential area of The Highlands, approximately three and a half miles north of Bexhill-on-Sea. The nearest village Sidley is approximately half a mile away, which can be accessed via the local bus service. The home has eleven single bedrooms, five of which have en-suite facilities and four double bedrooms without en-suite facilities. Accommodation is provided over three floors and there is no passenger lift, with level access only to the front of the home on the ground floor. This restricts access to the building by those with mobility needs. But at the time of the Inspection extensive building works were in process to provide a passenger lift, further bedroom accommodation and communal facilities. Fees charged at the time of the inspection are £370.00 a week. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. The Statement of Purpose, Service Users Guide and a copy of the last inspection report are available to read in the home. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Following the last inspection a further unannounced inspection was made to the home on 5 October 2006 to review compliance with requirements made at the previous inspection. During this visit a Notice of Immediate Requirement was made to ensure that suitable arrangements were in place for the safe storage of medication, that a safe environment was maintained which ensured that the parts of the home to which service users had access are free from hazards to their safety whilst building work was in progress in the home and that service user documentation was securely stored. The CSCI received a satisfactory response to the issues highlighted. This unannounced inspection took place over five hours on 26 April 2007. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. This was returned and information detailed is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Eleven service users were resident, due to communication difficulties it was not possible to speak to all the service users, but three service users were spoken with individually and service users in the communal areas were spoken with as part of the inspection process. Of these, for three of the service users the care they had received during their stay was reviewed as part of the inspection process. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys were sent out and four came back completed, a relative having completed one on behalf of the service user. The Acting Manager, the deputy manager, two night-care assistants and four care staff were all spoken with. Three relatives were spoken with on the telephone, either prior to the inspection or subsequently. A Community Psychiatric Nurse who also visits service users in the home was spoken with on the telephone after the inspection. Since the last inspection the Registered Manager has left the home and temporary management arrangements are in place with Mrs Heidi Haddow, owner of another local residential home working as Acting Manager in the home, whilst more permanent management arrangements are arranged. What the service does well: The care provided was observed to be delivered in a way to ensure service users dignity and respect was maintained. All service user and visitors feedback was that they were happy with the overall care provided. Comments Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 6 from the service users included ‘I have found this home to be friendly, helpful and very supportive to me and the fees very reasonable,’ ‘ in all my experience I have never found found such a good home as this. Since I have been here I have felt much better in myself and am perfectly happy to stay here on a permanent basis.’ The home presents a relaxed and happy atmosphere and all visitors to the home stated that staff were welcoming and all visitors and the majority of the service users felt that they are enabled them to raise any issues of concern if they wished and these would be listened to. What has improved since the last inspection? What they could do better: The standard of the environment varies within the home and there are a number of areas, which require redecoration. Service users will benefit from the completion of current building works in progress in the home and redecoration plans. Service users would also benefit from adequate hot water being provided in the home, an issue that has been highlighted at previous inspections. Some health and safety issues were raised, which the Acting Manager stated would be addressed so requirements have not been made on this occasion. The home has a new fire risk assessment. There was some wedging open of doors to communal areas on the ground floor and this was discussed with the Acting Manager that advice should be sought from the ESCC Fire and Rescue Service about this practice to ensure that all requirements in relation to fire precautions are met. The Acting Manager stated that she would seek advice. Further work had been undertaken to facilitate leisure activities. This work should continue to further develop the range and the frequency of activities. Robust recruitment procedures need to be in place to protect service users. Please contact the provider for advice of actions taken in response to this Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 7 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. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are pre-admission procedures in place to ensure that service users support needs can be met at Lennox Lodge, but it should ensured that all the required information about Lennox Lodge is available to be viewed prior or after any admission to the home. EVIDENCE: The Statement of Purpose, the Service Users Guide are kept in the office, but should be more accessible to service users and their carers/representatives. There was not a copy of the last inspection report available to reference in the home. Both these issues were discussed with the Acting Manager who stated these would be addressed, so a requirement has not been made on this occasion. Two of the four service users surveys stated that they had not had Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 10 enough information about the home prior to moving in, one had and for the other it was not applicable. The pre-admission assessment was viewed for the one service user admitted to the home since the last inspection. This was detailed and there was also supporting information from health care professionals to support the assessment process. Staff stated that prospective service users are invited to move in to the home on a trial basis and the last service user admitted to the home confirmed this. Intermediate care is not provided in the home. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users are protected by detailed individual care plans being in place, which adequately provide staff with the information they need to ensure that service users individual support needs are met and care is provided in a way which respects the service users privacy and dignity. EVIDENCE: Individual service user documentation is well structured in files for easy reference. Three service users files were viewed. The content of the individual care plans were detailed and gave staff guidance on all areas of care as required and had been reviewed. All feedback received was that service users health care needs are met in the home and their was evidence on the service users files of contact with health care professionals. Staff spoken with confirmed they were aware where the care plans were kept, that they were accessible and that there was good communication between the team if there are any changes to the care plans. The Acting Manager stated that she was Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 12 looking at implementing a key worker system in the home. Supporting risk assessments were also recorded. For one service user who accesses parts of the home and gardens affected by the current building work there were no supporting risk assessments in place. This was discussed with the Acting Manager who stated that the risk assessment in place would be further developed with immediate effect to ensure the health, safety and welfare of this service user, so requirement has not been made on this occasion. The last service user admitted to the home did not have a photograph in place. This issue was raised at the last inspection and had been addressed during the follow up Inspection. A system should be in place and maintained to ensure a photograph of the service users is taken as part of the admission procedure. Three service users surveys stated they could do what they wanted to do during the day, evening and weekend, the fourth was not completed. All the service users spoken with stated they received the care and support they needed. Medication policies and procedures are in place and the administration of medication was observed at lunchtime. None of the service users were selfmedicating. A sample of the recording of the administration of medication was viewed and was adequate. Where medication is stored in the home the room is also currently also being used to store items from the home whilst the building work was in process. The Acting Manager stated that this was a temporary measure during the building works and that it would become a dedicated medication storage area as soon as it was possible to move the items to another area in the home. All the staff confirmed that they had received medication training during the last year and confirmed procedures in place in the home. A pharmacist regularly visits, but the records of these visits were not viewed on this occasion. Where medication is held in a refrigerator the Acting Manager agreed to seek further guidance as to the frequency the temperature should be checked. The care provided was observed to be delivered in a way to ensure service users dignity and respect was maintained. Currently a telephone is situated in the main hallway. The Statement of Purpose states that service users can use the office telephone for more privacy if required and one service user spoken with confirmed they could use this facility. Staff was also observed using the telephone and it should be ensured that confidentiality is maintained. The service users commented that they were pleased with the overall care provided in the home. Comments from the service users included, ‘I have found this home to be friendly, helpful and very supportive to me and the fees very reasonable,’ ‘ in all my experience I have never found found such a good home as this. Since I have been here I have felt much better in myself and am perfectly happy to stay here on a permanent basis.’ Feedback from visitors to the home also stated they were happy with the overall care provided. Lennox Lodge DS0000021407.V336718.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 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assisted with maintaining independence in their daily living and daily routines, are treated with respect and there is good rapport between staff of the home and service users. The meals on the home are good offering both choice and variety. EVIDENCE: There were no activities arranged on the day of the Inspection. Some service users were watching the television, one was in the garden and who regularly likes to help with the gardening and a couple of service users had been taken down to a local pub. The pre-inspection questionnaire detailed the following activities were provided, motivation classes, an external activities group, manicures-beauty therapist, board games, painting and drawing, DVD’s, clothes parties, trips to the pub, shopping, swimming, yoga, café and gardening which service users attend individually or as a group. Staff spoke of facilitating activities in the afternoon as the morning is busy with domestic tasks to be completed in the home. Visitors spoken with had not been in the home at a time when an activity had been run. Two spoke of taking their Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 14 relative out to enjoy the local amenities. A recent service user survey undertaken in the home detailed when asked about the social activities provided the response was varied between good, fair and poor. Three additional comments were that the activities need improving. One service users survey stated, ‘I read, do crosswords, play cards, crochet and as I want.’ This was discussed with the Acting Manager stated that they were trying to introduce a wider range of activities in to the home and some had proved more popular than others and that the range and frequency of activities provided would continue to be developed. All the feedback received was that there was flexible visiting and that the staff is very welcoming. The care and support provided was observed to enable service users where possible to exercise choice whilst at Lennox Lodge. The three service user files viewed and all feedback received confirmed this. There was no cook working on the day of the Inspection and a care worker was preparing the lunch in the home, who stated she had a basic food hygiene certificate. The Acting Manager stated that there was currently a vacancy for a cook and she was trying to recruit a cook and a tea cook to work in the home. There is a rotating menu in place and this was available for service users to read in the home and which details alternatives are always available. Not all service users feedback demonstrated that there was a choice at every meal. This was discussed with the deputy manager who stated that service users are asked in advance what they would like to eat prior to each meal. Lunch on the day was liver, potatoes and vegetables and apple crumble and custard. Special diets can be catered for. Records had been maintained of individual food consumption to ensure service users had an adequate diet. The service users and relatives stated the food was good. Comments received were, ‘the food is served piping hot and is good class home cooking with large portions,’ ‘ food is very good,’ ‘ I am well fed, the food is well presented and well cooked,’ and ‘ I would like more fresh fruit to be available.’ A recent service user survey undertaken in the home detailed when asked about the food provided that all but one of the responses stated the food was excellent or good. The Environmental Health Officer had recently visited and the Acting Manager stated they were working on addressing requirements made following the visit. Lennox Lodge DS0000021407.V336718.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 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: There is a detailed complaints policy and procedure in place. The preinspection questionnaire detailed that no complaints have been received since the last inspection. The CSCI received one complaint relating to the care provided at Lennox Lodge, which was passed to the home to be investigated. There was no record to view of the investigation undertaken and outcome as required. All service users feedback stated they knew who to speak to if they were unhappy and how to make a complaint. One commented,’ all staff are available at any time, although I do have more of a rapport with a couple of staff with who I can discuss anything and who know me better. Any main queries would, naturally be directed to management.’ Relatives also confirmed that they would feel comfortable raising any concerns with the staff or the Acting Manager. There are policies and procedures in place in relation to the protection of vulnerable adults. All the staff spoken with had an awareness of adult Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 16 protection procedures and stated that they had received recent training/guidance. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 17 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, 25 and 26. People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of the environment varies within the home and does not provide service users with a comfortable and attractive place to live in all areas of the home, but service users will benefit from the building work in progress to improve facilities and the planned redecoration. EVIDENCE: At the time of the inspection there was extensive building work still being undertaken in the home, to provide further en-suite bedrooms. A new kitchen and further communal space has been completed since the last inspection and is being used by staff and service users. It was not possible to evidence as the work is still ongoing, but the Acting Manager stated that the building work has been inspected and met all required building standards. During the tour of the home the décor, carpeting and furnishings in the existing part of the home was observed to continue to be variable, with areas needing redecoration and reLennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 18 carpeting. The Acting Manager stated this was due be addressed shortly following completion of the building works. There is a separate lounge and a dining area and a further new seating area. There is a conservatory off the lounge, which is used by service users who wish to smoke. The Acting Manager stated that it is intended to undertake work in the lounge to provide improved lighting. A passenger lift is in the process of being fitted into the home, which had not been finished at the time of the inspection and on completion will enable access between all floors. There is currently a stair lift to the first floor, but the Acting Manager stated this was due to be removed when the passenger lift is operational. There are eleven single bedrooms and four double bedrooms which all meet the minimum space requirements. All bedrooms have an emergency call bell system. A selection of the service users bedrooms viewed was found to be clean and some had been personalised. Five of the single bedrooms have en-suite facilities; none of the double rooms have en-suite facilities. There are adequate shared toilet and bathroom facilities in the home. All the areas of the building are heated by a central heating system. Records of the routine checks of the hot water temperatures were viewed and detailed that the temperature is delivered at between 36-39°C, lower than the recommended safe temperature of 43° C. This was discussed with the Acting Manager who confirmed that she would look in to this ongoing issue. The home was clean and free from offensive odours. Staff spoken with had not all had training/guidance in control infection and stated there was an adequate supply of disposable gloves and aprons. This was discussed with the Acting Manager who stated she had been made aware of this and was looking in to potential training for staff to access. All feedback received was that the home was always or usually fresh and clean. Additional comments received related to the difficulty in keeping the home clean due to the building works. Recordings of routine fire checks undertaken in the home were viewed. The home has a garden, which is currently not fully accessible due to the building works. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 19 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 and 30. People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures need to be followed to ensure service users are in safe hands at all times. EVIDENCE: The deputy manager and two care workers were on duty during the morning. The Acting Manager and proprietor also arrived at the home during the morning. One care worker was preparing and cooking the lunch and care workers also undertake the cleaning in the home, as there is no domestic staff employed to work in the home. Two care workers work at night one providing waking night cover and one sleeping in and on call. The number of care staff on duty needs to be kept under review and increased as required to ensure that the changing care needs and number of service users accommodated of the all the service users resident continue to be met. Feedback from the majority of service users surveys stated the service users felt the staff always treated them well. When asked if staff listened and acted on what you say all stated always or usually. Comments received were, ‘they are friendly and professional in all their dealings with me,’ ‘ staff are very approachable,’ and ‘I am on the whole happy to be here and cared for as much Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 20 as my needs require. I am very grateful to all the staff and management. I am comfortable, well fed and settled.’ Care workers spoke well of working in the home and one commented ‘ really good teamwork and communication.’ Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care by April 2005. The pre-inspection questionnaire detailed that there are twelve care staff working in the home and currently no care staff hold an NVQ Level 2 in care or above. The recruitment procedure was viewed for the one member of staff recruited to work in the home since the last inspection. There was evidence of an application form, two references and a Criminal Records Bureau check (CRB) /POVA check had been received. But there was no evidence of a POVA First check having been received prior to the member of staff commencing work in the home or of an induction having been completed. Care workers are also working in the home, which had been recruited to work in the Acting Managers home. There were no records to view for these staff to evidence recruitment, induction or training undertaken. The pre-inspection questionnaire detailed that all staff have had a CRB check completed and care workers spoken with confirmed this. It was not possible to evidence the induction that new care workers will be completing. The Acting Manager stated that she would insure that an induction would be put in place, which would meet the requirements of General Skills for Care induction standards. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 21 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, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The temporary management arrangements are satisfactory, quality assurance systems are in place in the home and safety checks and checks of records are kept up to date to ensure that service users are kept safe. EVIDENCE: The Acting Manager currently working in the home stated this was a temporary arrangement and that it is planned to put forward a new Registered Manager for the home shortly. Lennox Lodge has a quality assurance system in place. There are opportunities for service users and their representatives to put forward their views about the home and the care received and the Acting Manager evidenced that feedback is in the process of being sought through a survey from service Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 22 users, their relatives and representatives. Service user forums have not been maintained and the Acting Manager stated that it was planned to reinstate these meetings shortly. The service users care plans are regularly reviewed. The pre-inspection questionnaire detailed that the homes policies and procedures have been reviewed. Where a small ‘float’ of money is held for some service users and the financial records to support this activity were adequate. Staff spoken with and records viewed confirmed that staff has received individual supervision. The Acting Manager stated it is intended to facilitate these meetings each month. A staff meeting was held during the afternoon of the Inspection. The pre-inspection questionnaire, records viewed and staff spoken with confirmed care workers had attended a range of training opportunities including moving and handling, fire safety training and basic food hygiene training. The Acting Manager stated that first aid training is due to be facilitated within the next three months and further moving and handling training and health and hygiene training was also planned. The Acting Manager stated that a detailed check of the environment and fire precautions is carried out monthly and the recording of the last check was viewed. All care workers spoken with confirmed they had attended a fire drill and received fire safety training within the last year. A new fire risk assessment has been written for the home. There was some wedging open of doors to communal areas on the ground floor and it was discussed with the Acting Manager that advice should be sought from the ESCC Fire and Rescue Service about this practice to ensure that all requirements in relation to fire precautions are met. The Acting Manager stated that she would seek advice. The pre-inspection questionnaire detailed that regular maintenance checks had been completed in the home. It was not possible to evidence a current electrical wiring certificate, as work was still in progress in the home following which the Acting Manager stated a certificate would be requested. Accident records were viewed and were detailed. Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 23 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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 1 3 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 24 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 OP25 Regulation 23 (2) (j) Requirement That adequate hot water is provided for service users to ensure they live in a comfortable environment. This issue is outstanding since 29/06/06. That for all staff working in the home the recruitment process is evidenced. That a POVA First check has been completed prior to staff working in the home, to protect service users. This issue is outstanding since 29/06/06. Timescale for action 31/05/07 2. OP29 19 (1) (b) 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Lennox Lodge DS0000021407.V336718.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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