Inspection on 29/06/06 for Lennox Lodge

This inspection was carried out on 29th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 26/04/07

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 29th June 2006 10:45 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.V296877.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.V296877.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 222966 Mr Guy Haddow Mandy Marie Donno Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Lennox Lodge DS0000021407.V296877.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 over fifty five (55) years 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. 27th September 2005 Date of last inspection Brief Description of the Service: Lennox Lodge is a care home registered to provide accommodation for up to nineteen residents 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. At the time of the inspection extensive building works were in process to provide 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 entrance of the home. Lennox Lodge DS0000021407.V296877.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 management review meeting was held in respect of the serious concerns raised during the inspection. This was held at the CSCI office and attended by the proprietor of Lennox Lodge during which the proprietor was informed that Statutory Requirement Notices would be issued in relation to poor medication procedures, poor recruitment procedures and a poor environment in the home. Unannounced visits were made to the home on 1 December 2005, 12 January 2006, 20 March 2006 and 27 April 2006 to monitor compliance with the Statutory Requirement Notices when compliance with medication and recruitment issues was evidenced. But there was slow compliance with the Statutory Requirement Notice in relation to the poor environment. This unannounced inspection took place over seven and a half hours on 29 June 2006. 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, rotas and care records were inspected. Thirteen service users were resident, due to communication difficulties it was not possible to speak to all the service users individually but four service users were spoken with individually in their bedroom or communal areas and four service users as a small group in the designated smoking room. Of these eight for four 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 three came back completed. The proprietor, the Registered Manager, the administration assistant and three care staff were all spoken with. Six staff questionnaires were sent out prior to the inspection and three completed questionnaires were returned. A relative and two friends visiting one service user were spoken with on the day. A regular visitor of a further service user was subsequently spoken with on the telephone. Three General Practitioners comment cards were sent out and one completed comment card was returned. A Community Physiciatric Nurse who also visits service users in the home was spoken with on the telephone after the inspection. 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.V296877.R01.S.doc Version 5.2 Page 6 from the service users included ‘This is the best care home in Bexhill’, ‘it’s a home not an institution’ and ‘if there is a vacancy here I recommend it’. 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: 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 Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Lennox Lodge DS0000021407.V296877.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.V296877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with adequate information about Lennox Lodge in advance of their admission to the home. The pre-admission paperwork has been developed to ensure there is adequate information prior to an admission to ensure each service users care needs can be met in the home. EVIDENCE: The Statement of Purpose, the Service Users Guide and a copy of the last inspection report were available to view in the entrance to the home. The three service users surveys stated that enough information about the home was available prior to moving in. One relative confirmed they had received information prior to admission but due to the quickness of the admission there had been no opportunity to visit the home prior to this. There is a written contract/terms and conditions in place. The three service users surveys all stated that a contract had been received and the sample of service users documentation viewed also evidenced these were being used. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 10 The pre-admission assessments were viewed for the last two service users admitted to the home. The format used to record the assessment has now been further developed as had been required and both were detailed. Intermediate care is not provided in the home. Lennox Lodge DS0000021407.V296877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a detailed individual plan of care being in place, where their personal, social and health care needs are identified at the start of their stay and which informs staff of the care which needs to be provided. Medication procedures in the home have improved. EVIDENCE: Individual service user documentation is well structured in files for easy reference. Four 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. 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. Supporting risk assessments were also recorded, but where a service user goes out independently from the home a supporting risk assessment was not in place. An Immediate Requirement Form was left to address this issue. Not all service users had a photograph and a system should be in place to ensure a photograph of the service users is taken as part of the admission procedure. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 12 All the service users stated they always received the care and support they needed and that staff listened and acted on what the service user said to them. Medication policies and procedures are in place and the administration of medication was observed at teatime. The storage and a sample of the recording of the administration of medication were also viewed and were adequate. The Manager confirmed that since the last inspection staff are in the process of completing medication training and that although the records were not available to view, that a pharmacist regularly visits. Where medication is held in a refrigerator it is recommended that the temperature should be regularly checked. Feedback from visiting healthcare professionals was that they were satisfied with the overall care provided and that the home worked in partnership with them. The three service users surveys stated they always received the medical support they needed. 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 Manager stated that service users could use the office telephone for more privacy. Staff were also observed using the telephone and it should be ensured that confidentiality is maintained. The visitors and where asked service users commented that they were pleased with the overall care provided in the home. One visitor did comment they would like to be kept better informed of important matters affecting the service user they visited. Comments from the service users included ‘This is the best care home in Bexhill’, ‘it’s a home not an institution’ and ‘If there is a vacancy here I recommend it’. Lennox Lodge DS0000021407.V296877.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are enabled to exercise choice and control over their lives whist resident in the home, with some opportunities to participate in social and recreational activities, support to maintain contact with family and friends and with the provision of a varied diet provided. EVIDENCE: There were no activities arranged on the day of the Inspection, but it was a very hot day. Some service users were watching the tennis on the television and a couple were in the garden, one of who regularly liked to help with the gardening. The Manager and staff stated that there were now more opportunities for service users to go out either for a walk, or for an activity and that activities were also more frequently offered in the home. Feedback from the service user survey was varied and stated activities were always or usually arranged. Visitors had not been in the home at a time when an activity had been organised, but one did confirm their friend participated in a local yoga class and swimming. A further comment received was that it would be nice to see the garden used more. Service users spoke of some activities they had participated in. One stated the activities provided were not always ones they would want to join in with. Two spoke of a recent trip to a local pub and the Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 14 lunch they had had. Records viewed also detailed some of the activities provided. Some service users attend local day care facilities or go out from the home independently. The range and frequency of activities provided should continue to be developed. Visitor’s spoken with and the service user who had had visitors commented that there was flexible visiting and that staff are very welcoming. The care and support provided was observed to enable service users where possible to exercise choice whilst at Lennox Lodge. The four service user files viewed and feedback received confirmed this. There was no cook working on the day of the Inspection and the Manager was preparing the meals in the home on the day. The Manager stated that this was unusuall and due to the necessity of both cooks having to take the same time off work. There is a rotating menu in place and this was available for service users to read in the home. Although this does not detail a choice at all meals, the Manager and staff stated that alternatives are always available and where asked service users spoke of choices available. Lunch on the day was homemade soup, chicken salad and fruit flan, which was different from the planned menu but had been changed slightly due to the particularly hot weather on the day. Where two service users did not want the main meal both had had the alternative meal they had requested provided. Tea was also observed and again service users were seen to have chosen a number of different meals. Special diets are catered for. Records had been maintained of individual food consumption to ensure service users had an adequate diet, but the recording should be developed to also include breakfast. The service users survey feedback stated that they always or usually liked the meals. All service users spoken with on the day stated they enjoyed the food provided. Lennox Lodge DS0000021407.V296877.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate systems 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 complaints policy and procedure in place. The pre-inspection questionnaire detailed that no complaints have been received since the last inspection. The CSCI have been informed of one complaint received about Lennox Lodge being investigated under adult protection procedures. The three service users surveys stated they always know how to make a complaint and knew who to speak to if they were not happy. All but one of the service users stated they would fell comfortable raising any concerns with the staff. One service user spoken with stated they had raised a concern with the Manager, had felt listened to and was happy with the outcome. Visitors confirmed that they would feel comfortable raising any concerns with the staff or the Manager. There are policies and procedures in place in relation to the protection of vulnerable adults and a whistle blowing policy. The three completed staff questionnaires all confirmed they had an awareness of adult protection procedures. One member of staff spoken with on the day did not demonstrate an awareness of the procedure to be followed and this was passed to the Manager during the inspection for a resolution. The Manager also stated that further training for staff was to be arranged. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 Quality in this outcome area is poor. 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 always provide service users with a safe, attractive and homely place to live. But building work is in progress to improve and develop communal facilities for service users in the home. EVIDENCE: At the time of the inspection there was extensive building work being undertaken in the home, to provide further bedrooms, a new kitchen and improved communal space. During the tour of the home the décor, carpeting and furnishings in the home was observed to be variable. The proprietor stated this would be addressed as part of the work and changes being undertaken in the home. An action plan as to how the environment will be improved has been requested. Due to the work being completed this it was not possible to fully inspect the facilities in the home. The proprietor and Manager both stated a maintenance plan is in place in the home. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 17 There is a separate lounge and a dining area. Again due to the building work there was temporary arrangements in place to provide communal space for service users to access. The proprietor stated that it is intended to improve the communal space available as part of the building work and provide improved lighting in the existing lounge area. A new kitchen has also been built. There is not a passenger lift between floors, but the proprietor stated that he is looking in to options to have a passenger lift fitted in to the home between all floors. There are eleven single bedrooms and four double bedrooms which all meet the minimum space requirements. At the time of the inspection one single bedroom was being used as a smoking room, following the loss of the conservatory area usually used by service users, due to the building works in the home. All bedrooms have an emergency call bell system. A selection of the service users bedrooms were viewed and were found to be clean, comfortable and personalised. Five of the single bedrooms have en-suite facilities, none of the double rooms have en-suite facilities. There are also shared toilet and bathroom facilities in the home. All the areas of the building are heated by a central heating system. Two service users stated that they were not always warm enough during the winter. This should be reviewed during the winter months to ensure adequate heating is provided. Records of the routine checks of the hot water temperatures were viewed. Hot water in a sample of seven of the wash-handbasins and baths used by service users were tested, and were not all close to the recommended safe temperature of 43° C. Hot water was not accessible at two of the outlets and an Immediate Requirement form was left to address the issue. Three service users also stated there was not always good access to hot water in the home. The home was clean and free from offensive odours. Two care staff who also undertake domestic tasks in the home were spoken with were aware of procedures in place to control infection and stated there was an adequate supply of disposable gloves and aprons. All feedback received was that the home was fresh and clean. The recordings of routine fire checks were seen and were adequate. There is an attractive garden at the front of Lennox Lodge and several service users were observed enjoying walking or sitting in the garden Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number of staff on duty needs to be kept under review and a robust recruitment procedure needs to be demonstrated to be in place to ensure service users are in safe hands at all times. EVIDENCE: On the day staff in the home appeared to be very busy. The proprietor spoke of continued difficulty in recruiting staff to work in the home and that there is still a high reliance on agency staff to cover the rota. The Manager and two care staff were on duty during the morning. The Manager was also preparing and cooking the meals and the care staff were cleaning in the home as there are no domestic staff employed to work in the home. The number of care staff on duty needs to be kept under review and increased as required to ensure that the changing care needs of the all the service users resident continue to be met. Feedback from the service users surveys stated the service users felt they received the care and support they needed and staff listened to what they say. Staff feedback from the completed questionnaires received were ‘our staff team puts one hundred percent into their work and do their up most to meet service users needs’ and ‘we are provided with as much training as is possible’. Feedback from staff during the inspection indicated a good and supportive Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 19 team and comments received were, ‘I like working here’ and ‘a friendly group of staff’. 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, but that three staff are currently working towards the award. Robust recruitment procedures were not demonstrated to be in place. For two new members of staff working in the home it was found a POVA First check had not been requested and a Criminal Records Bureau check had not been received. One of these members of staff did not have two written references in place and the other had only one written reference in place. An Immediate Requirement Form was left to resolve this issue. Although the Registered Manager was able to state the duties for a member of staff working in the home that under eighteen years of age this should be formalised into detailed job description. The Manager stated and detailed in the pre-inspection questionnaire that it is ensured that all new staff are supported to complete the required induction programme. Two staff spoken with confirmed they had received an induction and for another member of staff their documentation viewed evidenced this had been completed. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the service users expressed satisfaction with the quality of their lives at Lennox Lodge a robust recruitment procedure for staff needs to be in place to protect service users. EVIDENCE: A Registered Manager is now working in the home and is currently working towards NVQ Level 4 in Management. A quality assurance plan is in place in the home. There are some opportunities for service users and carers to put forward their views about the home and the care that they receive through service users forums. Staff confirmed supervision and staff meetings occurred. The Manager evidenced that feedback is in the process of being sought from service users family and representatives. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 21 Where money is held in safe keeping for some service users a sample of the financial records to support this activity was viewed and was adequate. The three staff questionnaires, staff spoken with and records viewed confirmed that staff supervision and team meetings occur on a regular and ongoing basis. The staff questionnaires, staff spoken with and training records viewed confirmed staff had attended some training opportunities. The Manager stated that further training in manual handling, nutrition and use of hazardous substances (COSSH) has been arranged to be facilitated in July 2006. Also that confirmation was awaited of when first aid training was to be provided for staff. The 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. The fire risk assessment for the home was viewed and it is required that advice is sought from the ESCC Fire and Rescue Service that this meets current requirements. The pre-inspection questionnaire detailed checks had been completed on the gas, electrical and fire systems in the home and the Manager stated that all portable appliances had now been checked. Accident records were viewed and were detailed. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 2 1 X X X X X 2 3 STAFFING Standard No Score 27 2 28 1 29 1 30 3 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.V296877.R01.S.doc Version 5.2 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 OP7 Regulation 13 (4) (b) (c) 13 (4) (b) (c) 16 (2) (m) 2 (2) (b) (d) 23 (2) (j) 19 (1) (b) Requirement That where service users are going out of the home independently a risk assessment is completed. That service users photographs are taken as part of the admissions process. That the frequency and range of leisure activities continues to be developed. That an action plan is provided on the works to be completed in the home to improve the environment. That adequate hot water is provided for service users. That it is evidenced that a POVA First check has been completed prior to staff working in the home and two written references are in place. That the Manager confirms how the training requirements as Registered Manager will be met. That confirmation is received that staff have received the required updates in moving and handling and COSHH. Also how first aid training and an update DS0000021407.V296877.R01.S.doc Timescale for action 29/06/06 2. 3. 4. OP7 OP12 OP19 31/08/06 30/09/06 30/09/06 5. 6. OP25 OP29 29/06/06 29/06/06 7. 8. OP31 OP38 18 (1) (a) 18 (1) (a) 30/09/06 30/09/06 Lennox Lodge Version 5.2 Page 24 9. 10. OP38 OP38 13 (4) (a) (c) 13 (4) (a) (c) on the protection of vulnerable adults will be facilitated. That confirmation is provided that the homes fire risk assessment meets requirements. That all hazardous materials are stored in a locked cupboard. This issue is outstanding since 27.09.05. 30/09/06 29/06/06 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 OP9 OP27 Good Practice Recommendations That where medication is stored in the refrigerator the temperature is regularly checked. That a detailed job description is in place for staff working in the home that is under eighteen years of age. Lennox Lodge DS0000021407.V296877.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Lennox Lodge DS0000021407.V296877.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!