Inspection on 03/04/08 for Lennox Lodge

This inspection was carried out on 3rd April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lennox Lodge 26/04/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Lennox Lodge 37 The Highlands Bexhill-on-sea East Sussex TN39 5HL Lead Inspector June Davies Unannounced Inspection 3rd April 2008 10.00 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.V361086.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.V361086.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 27 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 27. Date of last inspection 26th April 2007 Brief Description of the Service: Lennox Lodge is a care home registered to provide accommodation for up to 27 Older people. The home is a large detached property situated in a quiet residential area of The Highlands, approximately three and a half miles north of Bexhill on Sea. Accommodation is provided over three floors with level access only to the front of the home. There is a shaft lift that serves all floors in the home, enabling easy access to bedrooms for the residents. Residents have a choice of communal areas where they can sit, including a comfortable conservatory, that opens onto the back garden. The village Sidley is approximately half a mile away, which can be accessed via the local bus service. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection took place on Thursday 3rd April 2008 over a period of six hours. The inspector spoke with the registered provider, appointed manager, residents and staff. A tour of the home took place, and all relevant documentation to the key standards inspected was viewed. There was an observation of a medication round at lunchtime together with a partial audit of medication. What the service does well: What has improved since the last inspection? A new manager has been appointed, and is in the process of applying to CSCI for registration. The manager has worked hard to improve many of the systems in the home, although she recognises there are still many more improvements to be made. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 6 The new extension to the home has been completed, and the whole home has undergone a refurbishment programme. All communal areas, and residents’ bedrooms are presented to a high standard. Residents now have a passenger lift to all floors. The cleanliness throughout the building was very good, and there were no offensive odours. The central heating system has been appropriately maintained and all residents have access to a good heating system and thermostatically controlled hot water. The home operates a rigorous recruitment procedure and all staff are POVA first checked prior to taking up employment in the home. Where possible the manager tries to obtain a CRB check prior to employment starting. All new staff receive initial introductory induction and a ‘Skills for Care’ based induction. What they could do better: Some requirements and recommendations were made for improvements that need to be made. Personal hygiene care was not reported in detail on the resident daily record sheets, and there was no recorded evidence of chiropody, dentist or optician visits. While medication was well managed, the refrigerator for storing fridge medications was not suitable for purpose and was not keeping fridge medication at the right temperature. The manager needs to obtain the ‘Sussex Multi-agency Policy and Procedures for Safeguarding Vulnerable Adults.’ The back garden of the home at the present time is not safe for the residents to use independently. There is a built up lawn area with a flat surface to a wall that falls approximately two feet to the back pathway, and there are tripping areas in several areas of the garden. In three bedrooms visited it was observed that there was no call bell available for the residents use and one call bell was not accessible from the bed. The manager must ensure that she keeps staffing levels under constant review as new residents are admitted into the home to ensure that staff are able to meet the assessed needs of the residents, as well as complete domestic duties. While the home operates a stringent recruitment process, the inspector noted that the application form does not require a full employment history, and there was evidence that the manager does not always obtain two forms of identification. Not all staff have received mandatory training, and none of the staff have received infection control training, there was very little evidence that staff have Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 7 received training in worked related issues. There was no evidence that staff receive recorded formal supervision six times per year. The appointed manager has done a lot towards developing a good quality assurance monitoring system but further work still needs to be done, to ensure that all interested parties are involved in the satisfaction questionnaire, and that systems used in the home are monitored on a regular basis to ensure the home is offering the best quality of care. There was no evidence that an appropriate Legionella check has been carried out on water systems in the home. The inspector found that for one resident who had two falls reported in her daily record there had been no accident forms completed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lennox Lodge DS0000021407.V361086.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.V361086.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): Standards 1, 3 and 6. People using this service experience good quality outcomes in this area. The homes, statement of purpose and service user guide provides prospective residents with the information they need to make a decision about moving into the home. Residents move into the home knowing that their needs can be met and that their independence will be maximised and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide have been updated to reflect the new category of the home, both documents give prospective residents Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 10 clear information they would need to make a decision about moving into the home. The inspector viewed three pre-admission assessments and found the information gained would enable the manager to judge if the home could meet the prospective residents needs. The information from these pre-admission assessments is also used as a basis for the individuals care plan. Two of the pre-admission assessment viewed were for private clients and therefore there was no Care Manager, plan of care. One pre-admission assessment was for a funded client and this did contain a care manager plan of care. The home does not offer intermediate care. Lennox Lodge DS0000021407.V361086.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): Standards 7, 8, 9 and 10 People using this service experience good quality outcomes in this area. The care planning system is clear and consistent and provides staff with the information they need to satisfactorily meet the residents’ needs. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. Personal care is offered in a way to protect residents’ privacy and dignity and promote independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 12 Three care plans were viewed. Care plans are well structured and the contents give the staff detailed information on all aspects of care for each individual resident. Risk assessments were in place for each individual resident. Care plan are reviewed regularly and updated to reflect any changing needs of the residents. There were daily records for each day, but staff do need to be more explicit in the care that is given to each resident. There was evidence in each care plan that residents have access to health service relevant to their health care needs. The inspector did note that in all cases personal hygiene care is not recorded in detail, there was no evidence that denture care, nail care, tissue viability, and hair care or in some cases bathing is recorded. The manager confirmed that staff do check tissue viability but do not necessarily record this. If there are any concerns regarding tissue viability this is reported directly to the district nurse. Where there are any concerns regarding a resident’s continence, the manager contacts the continence nurse for advice and assessment. One resident spoke about needing continence aids but said that she has to purchase these herself, the manager will look into this and contact the continence nurse to enquire if these continence aids can be provided by the NHS. There was evidence in care plans that residents have access to the consultant psychiatrist and community psychiatric nurse as and when required. Any concerns regarding the residents’ mental well being, are referred in the first instance to the resident’s general practitioner who will then refer to the psychiatrist. There is provision in the home for residents who wish to take part in aerobic armchair exercises. Nutrition screening takes place on a regular monthly basis, any concerns regarding constant weight loss or gain will be referred to the resident’s general practitioner. All residents have access to outside health care specialists such as opticians, chiropodists, and dentists. None of the care plans or daily records viewed showed evidence of chiropody visits, and the manager stated that she will address this. A partial audit of medication was carried out on the day of this key inspection and the inspector observed a member of staff administering the lunchtime medication. The home uses the Nomad system for the administration of medication. The receipt, administration, storage and return of unused medication are well managed. The policies and procedures for the administration of medications are up to date and give staff clear guidelines. There is a list of all staff who have been trained to administer medication together with their initials, this list also indicates who the medication cupboard Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 13 key holder will be for each shift. The inspector did note that the medication refrigerator is not suitable as it is only meant for keeping cold drinks and on the day of this inspection the running temperature was 10ºC, therefore a suitable medication fridge must be provided. The home does not at the present time have controlled drugs. Throughout this key inspection the inspector observed that staff treat the residents with respect, and ensure their privacy and dignity. Staff ensure that toilet, bathroom and bedroom doors are kept closed during personal hygiene tasks being carried out. All residents are addressed by their preferred name. Staff knock on doors before entering. All residents are able to see relatives, friends and professional visitors in the privacy of their own bedrooms. None of the residents have a private telephone in their own room, but are able to access a call phone in the main hallway, but if they wish to make a more private telephone call they are able to use the mobile phone in the office. While the home does have three double bedrooms these are not shared at the present time. Comments from residents were – ‘I like living in this home, the staff are very good and the food is excellent.’ ‘I had to be sensible and realise I could not look after myself, I like being here, the staff do all they can for me.’ ‘This is a very nice home, everyone is very kind to me.’ ‘I could not wish to be cared for any better in any other home.’ Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13 14 and 15 People using this service experience good quality outcomes in this area. Residents are able to choose activities on a daily basis. Links with the community are good and support and enrich the residents’ social lives. Residents are able to exercise choice and control over their lives, or appoint their relatives or solicitor to do this for them. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets the residents’ tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is no structured activities programme in place for the residents. From observation the inspector noted that staff do spend one to one time with the residents, and on the afternoon of this key inspection residents requested to watch a DVD film on the television with members of staff present. Staff carry Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 15 out manicure sessions for the residents. A variety of board games and craft activities are on offer. Photographs displayed in the main hallway captured residents being involved in making Easter bonnets. There was also evidence that outside entertainers are brought into the home for the residents to join in if they wish to, such as Sitting Aerobics, Music for Health and Motivation and the appointed manager held a quiz recently. One resident was observed playing a patience card game. Residents spoken with stated ‘I am happy here.’ ‘I find things to occupy myself.’ ‘I cannot see very well, but I like sitting in the conservatory with the door open.’ ‘I would like assistance to get out in the fresh air when the weather is nice, that would help to break the day up.’ Some the residents are able to go into town on their own, visiting the local shops and meeting a friend/s for coffee. One resident attends the local Church of England service on Sundays, and is picked up from the home by friends. Both the registered provider and the appointed manager take residents out for a coffee or to a place of interest when the weather permits. One resident has a voluntary visitor each week, and another resident has visitors every three weeks from the Christian Science church. Visitors are welcome into the home at any time and residents are able to choose where they entertain their visitors. The registered provider and appointed manager have no dealing with residents’ personal finances; either residents’ relatives or solicitors have power of attorney. From a tour of the building the inspector noted that residents are able to bring personal possessions into the home with them, to personalise their own bedrooms. From a tour of the building the inspector noted that residents are able to bring personal possessions into the home with them, to personalise their own bedrooms. The home now employs a qualified chef. The chef talks to residents about their likes and dislikes and their choices for the menus in the home. There is a rotating menu in place and this is changed on a seasonal basis. The menus provide a good choice of balanced, and nutritional meals that are presented to the resident in an appetising way. One resident requires a liquidised diet, and each item is separately liquidised. The dining room is decorated in a homely and relaxing way. Tables are nicely laid and look attractive. At the present time the chef caters for low potassium/low phosphate diet and diabetic diets. Other diets can be catered for as and when required. The inspector observed that lunch times are relaxed and unhurried. One the day of this key inspection residents had a choice of starter, main course and sweet. For those residents who require some assistance with feeding this was carried out discreetly by the Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 16 staff. The chef prepares the food for teatime and then staff place into the oven for cooking. Comments from residents were – ‘The food here is excellent.’ ‘There are no complaints about the food, it is all very nice.’ ‘We are given a choice at each mealtime, and the food is very good.’ ‘I really enjoy all my meals in the home, if there is something I do not like the chef always makes sure I am offered something else.’ Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 People who use this service experience good quality outcomes in this area. Residents know their complaints will be listened to and acted on. Staff have knowledge of safeguarding vulnerable adults issues, which ensure that residents are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure has recently been reviewed (March 2008) and is being displayed in the main hallway. This document is also contained within the homes statement of purpose and service user guide. There have been no complaints made to the home since the previous key inspection. One resident said, ‘Yes I do know how to complain should I need to, I would expect my complaint to be resolved within a month.’ The home has it own recently reviewed (April 2008) policy and procedure for safeguarding vulnerable adults. The appointed manager still needs to obtain the Sussex Multi-Agency Policy and Procedure for Safeguarding Vulnerable Adults. There is also an up to date whistle blowing policy and procedure. All staff are appropriately vetted prior to taking up employment in the home. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 18 Safeguarding vulnerable adults training has been completed by 46 of the staff in the home. There have been no adult protection issues since the last inspection. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 People who use this service experience good quality outcomes in this area. Recent investment has significantly improved the appearance of this home creating a comfortable and safe environment for those living there and visiting. The home is clean and free from offensive odours, which helps to prevent cross infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The extension to the home that was underway at the last key inspection on 26th April 2007 has now been completed and provides a further five bedrooms. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 20 The inspector toured the whole building and found it to be presented to a very high standard. All communal rooms are pleasantly decorated, and all soft furnishing are domestic in style. The whole home has a warm homely feel to it. It was noted that at the present time the back garden does present hazards to the residents, but the registered provider is fully aware that this area needs attention to enable the residents to use this garden freely. Should a resident wish to access the back garden a member of staff would at all times supervise them. The inspector did note that some rooms did not have a call bell in place and in one room the call bell was situated away from the bed. This was discussed with the manager, who is in the process of ordering more call bells. Where the call bell was placed away from the bed, this was because the resident in that room had requested that their bed was moved. The registered manager confirmed that she will risk assess this issue, notify the resident of the risks involved an ensure that staff are aware. There is a high standard of cleanliness throughout the home and there were no offensive odours. The laundry room has industrial washing machines with sluicing programmes and industrial tumble drier. There are policies and procedures in place to control the spread of infection, although it was noted that none of the staff have received infection control training. Staff are supplied with disposable gloves and plastic aprons for use when carrying out personal hygiene tasks. Clinical waste is appropriately managed and placed into the appropriate sacks, which in turn are placed into an external clinical waste bin. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 People using this service experience good quality outcomes in this area. Staff at the present time are employed in sufficient numbers to meet the assessed needs of the residents. Staff morale is high resulting in an enthusiastic workforce that works positively with the residents. The standard of recruitment practices have improved, ensuring that all staff are appropriately vetted, that helps to ensure residents are not placed at risk. Staff training needs to improve to ensure that all the staff have the knowledge and skills so that residents are not placed at risk and that their needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is registered for 27 residents, but on the day of this key inspection there were only 16 residents living in the home. At the present time there are sufficient care staff employed to ensure that the assessed needs of the residents are met. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 22 The home does not employ a domestic at the present time. A qualified chef is employed. There is also a part-time administrative assistant. The appointed manager stated that none of the residents are high needs at present, and some of the residents are self-caring. She is well aware that as the home takes more residents then the staffing hours will need to be reviewed and that extra carers and domestics will need to be recruited. Residents commented – ‘Staff are always available when I need them.’ ‘I never had to wait long when I ring for a member of staff.’ ‘The girls work very hard, but they always have time for a chat, and are always around when I need them.’ At the present time 39 of carers have an NVQ qualification with a further three carers that have enrolled onto the NVQ course this will then ensure that 53 of carers working in the home have an NVQ qualification. Recruitment practices have improved since the last key inspection. All prospective staff are POVA first checked prior to taking up employment, and CRB checks are sent off on acceptance of position. It was noted however that the application form used by the home does not at present request a full employment history, and the manager has not obtained two forms of identification from the most recent two employees. The inspector viewed all the training certificates for care staff employed in the home and found that the following staff have completed mandatory training as follows – 100 Moving and Handling, 30 Food hygiene, 38 First Aid, 0 Infection Control, and 53 Medication. Further training must be organised to ensure that all staff have completed their mandatory training, which should take place within the first six months of their employment. The home does use a ‘Skills for Care’ based induction as well as the initial introductory induction. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38 People using this service experience adequate quality outcomes in this area. The manager has a good understanding of the areas in which the home needs to improve. Some further work needs to done to ensure the home has a good quality monitoring system in place, which can accurately test the quality of care that the residents receive. Residents personal monies are managed appropriately by the home. Health and safety in the home is generally well managed but further improvements need to be made to ensure that residents are not placed at risk. This judgement has been made using available evidence including a visit to this service. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 24 EVIDENCE: The appointed manager has completed all her application forms for registration with CSCI, but is awaiting her CRB check this was checked at this inspection. She has been appointed manager since October 2007. At the present time she has a City and Guilds Management of Care qualification and is in the process of finding out about NVQ level 4 and the Registered Managers Award. The manager has an open door policy and residents and staff can speak with her at any time. Residents commented that the manager was very approachable, and that she is very kind and does all she can for them. Staff spoke highly of the manager and her leadership skills. A satisfaction questionnaire is sent out annually to residents and their relatives, at present the home has not developed a questionnaire for external stakeholders such as G.P’s, district nurses, care manager, chiropodists, opticians, dentists, hairdresser and outside entertainers. The manager does carry out a monthly Health, Safety and Fire risk assessment of all rooms in the home. The manager still needs to develop her monitoring of systems used in the home, which will include checking care plans, reviews, daily records, medication, cleanliness, food cooking/presentation and laundry. Small amounts of personal allowances for residents are kept in the home, each residents has their own account sheet, and envelope for keeping money in, all purchases made on the residents behalf have a receipt. The account sheets and personal monies are kept separately and securely in the home. Where residents have solicitors who manage finances on their behalf, the home makes purchases on the resident/s behalf, retains receipts then bills the appropriate solicitors for the expenditure. At this inspection there was no evidence that staff receive regular supervision sessions, the manager is aware that regular supervision sessions need to be organised to ensure that staff receive at least six supervision per year. As mentioned previously not all staff have received training in health and safety issues, and this has been addressed under staffing in this record. The inspector did view the maintenance certificates for equipment used in the home and these were all seen to be in date. There was no evidence that a Legionella check has taken place. Both fire call points and hot water delivery is checked on a weekly basis. The Health and Safety Executive accident book was viewed and while accidents to residents are appropriately recorded it was noted that two Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 25 accidents recorded in a residents daily diary notes, had not had an accident form completed. Some of the homes policies and procedures have been reviewed and others are in the process of being reviewed in the near future. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 26 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 12 (1) Requirement The registered person must ensure that personal hygiene care is recorded appropriately; to record ‘all care given’ is not helpful or adequate. Daily records when well written, help to ensure a consistent approach and good quality of care for the residents. The registered person must ensure that there is an appropriate medication refrigerator that will keep refrigerated medication at between 2ºC and 8ºC. Medication that requires refrigerated storage must be kept at the above temperatures to ensure that they do not ‘go off’ or break down. The registered person must ensure that all resident are provided with a call bell in their bedrooms and that these call bells are accessible for the resident. The registered person must ensure that the staff application DS0000021407.V361086.R01.S.doc Timescale for action 27/05/08 2. OP9 13 (2) 27/05/08 3. OP22 23(2)(n) 27/05/08 4. OP29 Schedule 2 (1) (6) 27/05/08 Lennox Lodge Version 5.2 Page 28 form requests a full employment history, and that any gaps in employment have a full written explanation. The registered person must ensure that they obtain two forms of identification; one must be a recent photograph. The registered person must ensure that all staff receive mandatory training in moving and handling, first aid, food hygiene, fire safety, infection control and training to meet the assessed needs of the residents. The registered person must ensure that all staff receive at least six recorded formal supervision each year. The registered person must ensure that an appropriate Legionella check is carried out on the water system/s in the home. The registered person must ensure that any accident or incident to residents is appropriately recorded into the accident book. 5. OP30 18 (1)(a) (c)(i) 23/06/08 6. OP36 18(2) 27/05/08 7. OP38 13 (4)(a)(c) 17(1)(a) (2) Schedule 3 (j) Schedule 4 (12) (a – f) 27/05/08 8. OP38 27/05/08 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 OP18 OP19 Good Practice Recommendations It is recommended that the appointed manager obtains the ‘Sussex Multi-agency Policy and Procedures for Safeguarding Vulnerable Adults.’ That the registered provider pays particular attention to ensuring that the back garden is safe for residents to use. DS0000021407.V361086.R01.S.doc Version 5.2 Page 29 Lennox Lodge 3. OP27 4. OP33 The level of staff is kept under constant review to ensure that the assessed needs of the residents is being bet, and that the home is kept at its present standard of cleanliness. The manager should continue to develop the quality assurance system to ensure that stakeholders’ views are sought and that she carries out regular recorded monitoring of the systems used in the home. Lennox Lodge DS0000021407.V361086.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone 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.V361086.R01.S.doc Version 5.2 Page 31 - 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!