Inspection on 31/10/05 for Lennox Wood

This inspection was carried out on 31st October 2005.

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 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 Wood 04/12/07

Lennox Wood 16/01/07

Lennox Wood 24/07/06

Lennox Wood 10/05/05

Lennox Wood 17/01/05

Lennox Wood 24/11/03

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

CARE HOMES FOR OLDER PEOPLE Lennox Wood Petham Green Gillingham Kent ME8 6SY Lead Inspector Sue McGrath Announced Inspection 31st October 2005 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 Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lennox Wood Address Petham Green Gillingham Kent ME8 6SY 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) 01634 869880 Kent Community Housing Trust Glynis Margaret Bingham Care Home 50 Category(ies) of Dementia - over 65 years of age (50) registration, with number of places Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Fifty (50) Older People with a Mental Infirmity 60 years of age and over. 10th May 2005 Date of last inspection Brief Description of the Service: Lennox Wood is purpose built on two floors with a basement that is used as separate offices and for training. There is a courtyard garden in the centre of the quadrangle building, which houses a sensory garden. The home is situated in a residential area close to local shops and amenities. There are local bus routes nearby. Gillingham and Chatham town centres are approximately 2 miles away where there are main line stations. The service also benefits from its own transport. The home has 46 single rooms and 2 shared rooms, none have en-suite facilities. To support care staff there are additional staff employed to undertake regular activities with service users. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection under the terms of the Care Standards Act 2000 and was carried out by one inspector who was in the home from 10.00 to 15.30 on the 31st October 2005. During the inspection the Manager was in attendance. Documentation and records were read, including care plans. A tour of the premises was undertaken and time was spent talking with residents and some staff. The main focus of the inspection was on the progress of the home in meeting with requirements made at the last inspection, the general environment and the well being of the residents. There had been considerable improvements to the environment including the provision of a very pleasant sensory garden. Staff had clearly taken on board all the requirements made at the last inspection and had worked hard to comply and improve the living conditions for the residents. What the service does well: What has improved since the last inspection? New flooring has been provided in the entrance hall, some corridors and some bedrooms. Ten new beds have been provided and some new bedroom furniture has also been provided. The home now has a sluice facility and the procedures in the laundry have improved. New lighting enhances the hallways, some of which have been newly painted. The home appeared generally cleaner at this inspection. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 6 The cleanliness of the home is now monitored better. Care plans were also improved but it is advised that work continues in the development of these. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-6 Prospective residents are fully assessed prior to moving into the home to ensure assessed needs can be met. A written statement of terms and conditions protects Resident’s legal rights to occupancy. Prospective residents benefit from being offered trial visits to admission so as to ensure that the home will be suitable for them. EVIDENCE: The Statement of Purpose and Service User Guide were seen, which provided comprehensive and detailed information about the service as required by the regulations. Both documents were presented in a clear and concise format. Copies of both documents were given to all residents prior to admission and were readily accessible via the manager. The home is currently still in the process of updating the Statement of Purpose to include the amended staff structure. As seen during the inspection, the last inspection report was available on the resident’s notice board. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 9 Evidence seen in resident’s files confirmed that each resident was provided with a statement of terms and conditions. A relative or representative had signed the ones seen. The manager explained how each resident was fully assessed prior to admission to ensure the home could meet the needs of that resident. These assessments were seen of the residents file. Information gained from both care management and from the assessment process formed the basis of the care plans. Families were also involved in the information gathering process. The manager confirmed that trial visits were encouraged and these were an opportunity for the prospective resident and their family to identify how appropriate the home was for them in meeting their needs. The home does not provide intermediate care. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents benefit from having clear care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and residents’ benefit from having full access to all professional health care services as required. The Residents welfare is protected by the home’s policy and procedures with regard to the handling and administration of medication. Residents are treated with respect and can be assured the home will handle the issue of illness and ageing sensitively. EVIDENCE: The care plans had been reformulated since the last inspection and were much improved. They contained comprehensive pen pictures of the resident, which is very helpful when caring for residents with dementia. The risk assessments had also improved and gave good in depth information for staff. Each care plan had a daily log with events such as GP visits written in red to highlight them. It was recommended that such events be also recorded on a separate sheet to make cross-referencing and listing visits easier. The manager agreed this would help if at any time she needed to retrace visits and outcomes etc. The Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 11 care plans also need to be signed by the resident or by their relative to ensure they agree with the care offered. Oral hygiene had been addressed as had weight loss or gain. Some nutritional assessments had been undertaken but only if a problem with feeding had been identified. It is recommended that all new residents undertake a full nutritional assessment on admission and then at regular intervals. Residents with dementia can be particularly at risk of poor nutritional intake if not regularly monitored. Generally these plans were much improved and only required a few minor changes. It will be important to ensure that these plans are reviewed regularly to ensure they remain current. All of the residents were registered with a local GP and had full access to other professional such as opticians and chiropody. One member of staff specialises in the maintenance of hearing aids. Discussion took place over the length of life the batteries had in standard hearing aids. Staff were advised to regularly check the batteries in residents hearing aids. The aids were obtained mainly from the local audiology department at the local hospital via a GP referral. None of the residents had been assessed as being able to self medicate, so senior staff were responsible for the safe administration of medication. All staff that administered medication had completed a recognised course that was accredited and safe. A further 11 members of staff were awaiting the same training. The home is experiencing major problems when ordering repeat prescriptions from one particular surgery and the assistant manager had put a safe system in place to ensure that all prescriptions were ordered early and were correct before being sent to the Pharmacist for dispensing. Several meeting had taken place with the surgery but the problems remain. The assistant manager is closely monitoring the situation. Staff practise seen on the day indicated that residents were respected at all times and that preferred terms of address were used. Good interaction between staff and residents was observed. In the shared rooms privacy curtains were provided. The home is currently purchasing a mobile phone for residents to use or if the family agree residents can have individual phones installed in their rooms. This would be done at the resident’s own expense. With regard to clothing the manager confirmed that all residents wore their own clothes and that the home does not have a ‘spares wardrobe’, which is good practise. Families are encouraged to ensure all clothing is named prior to it coming into the home. The organisation had a policy on death and dying and relevant information was seen on individual care plans and on the residency contract. At such difficult times relatives can stay with their loved ones for as long as possible. If necessary a bed could be made available. Comments from relatives confirmed this is very much welcomed at such difficult times. If the home is to provide palliative care then formal training must be provided. Some staff are going on training but many more have requested the course. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 12 Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 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): Where possible residents enjoy a high level of organised activities. Residents benefit from being encouraged to maintain contact with families and friends. Where possible residents are encouraged to exercise choice over their daily lives. Residents also enjoy a good balanced and wholesome diet with special diets being well catered for. EVIDENCE: The homes cares for people with varying degrees of dementia and lifestyles can be very challenging for some. Designated activity staff work very hard to endeavour to stimulate and entertain the residents. It can often be difficult to ensure recreational interest and needs are addressed for residents with dementia but the staff do achieve a wide range of activities and entertainments. Several outside outings were arranged throughout the year. Relatives spoken to confirmed that they often see residents engaged in meaningful activities. Many residents were spoken with and those that could communicate were mainly happy to be at Lennox Wood. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 14 Visiting relatives confirmed that they could visit at any time and were always made very welcomed. Visitors praised all staff highly for the homely atmosphere in the home. Some of the residents go to a coffee morning held at the local church and were also invited to other events arranged by the church. Local schools and Brownie packs also visited from time to time and the local junior school had ‘adopted’ Lennox Wood and had regular contact with the home. These visits by the children were very much appreciated by the residents. With the levels of dementia within the home was not always easy to ensure that full choices were given at all times, however staff were seen to offer choices where possible and where not possible gave full support and consideration. The menus seen on the day and the ones submitted to the commission indicated that a well-balanced and nutritional diet was offered. Specialist diets were well catered for. Several residents stated that the food was good and that there was plenty of it. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 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): 16-18 The home has a clear and effective complaints system in place and residents are protected by robust adult protection policies and procedures. EVIDENCE: The home had a complaints procedure in place, which included all the information required by this standard. Discussion with the manager confirmed that the home tries to resolve issues informally in the first instance. Evidence was seen of appropriate recording of complaints. There had been no recorded complaints this year. The home had an Adult Protection Policy, including Whistle Blowing, which complied with the Public Disclosure Act 1998 and the Department of Health’s Guidance No Secrets. Staff spoken with were able to demonstrate a good understanding of Adult Protection issues. All of the Team Leaders had received training on Adult Protection and the rest of the staff had mainly covered this within their NVQ’s. It will be recommended that all staff have some formal training in Adult Protection. Staff are also trained in managing physical and verbal aggression and some staff have completed a NAPPI course. Discussion with the manager confirmed that if wished arrangements could be made to assist residents to vote but due the level of confusion amongst the Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 16 majority of the residents this was not done routinely and currently only one resident actually exercised his right to vote. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Residents now benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. Residents’ benefit from improved procedures for infection control. EVIDENCE: The last report was critical of the environment at Lennox Wood and the organisation had clearly taken notice, at this inspection several improvements were noted. Corridors that were dark and unappealing had been painted in a lighter colour and were more pleasant. New lights had been fitted in the hallways and this had also enhanced the home. The dusty curtains noted at the last inspection had been cleaned and the home generally appeared much cleaner and tidier. New net curtains were seen throughout the home. A new cleaning schedule was now in place as required from the last inspection and was monitored monthly by senior staff. Radiators had now been covered and some items of bedroom furniture had been replaced. Ten new beds had been provided. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 18 The entrance hall had been improved with the old carpet being replaced with laminate flooring to reduce odours. Some of the corridors had also been recarpeted. The last two reports had mentioned lack of access to the garden. The home can now boast was delightful sensory garden for the residents to enjoy. Staff had clearly worked very hard to achieve such a good result. The manager confirmed that all of the work had been undertaken by staff and volunteers and they are to be congratulated for turning an untidy, unused area into a very pleasant environment for the residents to enjoy. Wind chimes and written poems were hung in the trees and the garden had been planted with flowers and shrubs that were highly perfumed. Another area of improvement was the laundry. This was tidier and more organised that at the last inspection. Discussion took place around the movement of clean and dirty clothes around the room. It will be recommended that a door be added to the clean laundry storage area to ensure clean clothes are not transported through the ‘dirty area’. The very old ‘Butler sink’ still needs to be replaced. It will be very important that this standard is maintained in the laundry. It was noted that an extra half an hour a day in domestic hours had been allocated to the laundry. The home has also installed a dedicated sluice machine. One of the rooms had been dedicated as a hairdressing room, but is in need of some refurbishment. The home has applied to a special fund that is used with in the organisation for a grant. Should this not be successful, some improvements to this room will be required. This will be assessed at the next inspection. The bedrooms viewed were well personalised, particularly with nameplates that had been made by the residents in their craft sessions. Some of the bedrooms still had sinks that were badly cracked, however the inspector was aware that work to replace these sinks was being undertaken and six new sinks were on order. Again this issue will be assessed at the next inspection. Seven of the bedrooms had been decorated since the last inspection. All of the bathrooms and toilets were airy, clean and fresh smelling. The manager discussed a basic maintenance programme that was now in place as required from the last inspection. The airing cupboards criticised at the last inspection were much tidier and items were no longer stored on top of the boiler. The wheelchairs that were seen to be dirty and had missing footplates were now cleaner and stored in a specific area. They were now all regularly checked and serviced. The visitors/residents smoking room had bee moved and was now much improved. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 19 The home has also recently purchased a professional type carpet cleaner, so this should make keeping the carpets clean and fresh much easier. The kitchen was also criticised at the last and previous inspections as needing a refurbishment. Following an inspection from the Environmental Health Department, who agreed that work was needed, the manager confirmed that new kitchen units had been ordered and should be fitted in the very near future. The kitchen ceiling had also been painted and fly screens fitted to the windows. One area that needs to be considered for future maintenance planning are the window frames. These will soon need either re-painting or re-placing as they are starting to show signs of wear and tear. This is not currently urgent, but should be taken into account when planning future budgets etc. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Residents are supported by a staff team who are interested and motivated to provide a good standard of care. Residents are protected by robust recruitment procedures. EVIDENCE: Following the requirement made at the last inspection, designated staff were now found on the high dependency unit at all times. Seven extra care hours a day had been provided. The manager stated that some hours were still in the process of being recruited to. These figures must be maintained at all times. Advisory figures given by the Department of Health via the Residential Forum indicate that the home is just within the required staffing levels, however the home has only assessed ten residents as high dependency and this needs to be reviewed. All the residents have dementia and this dependency assessment needs to reflect that. The residents are well protected by the homes robust recruitment procedures that ensure only suitable staff are employed. All staff had current CRB checks. All staff follow and induction course plus a five day basic foundation course in care. They then shadow other staff for one week or until they are competent. Training records were viewed and found to be comprehensive. Staff spoken with said that training was readily available and that they were encouraged to attend. Training needs were identified during supervision and appraisals, or by observing work practises. The mandatory trainings were mainly up to date. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 21 The home currently has 51 of its care staff qualified to NVQ level two or above. Staff who administered medication had completed accredited training. Twentythree members of staff had completed first aid training. Several members of staff stated they would like further training in the care of service users with dementia including ‘Leadership in Dementia’ courses. The home enjoys a stable workforce and had only lost three members of staff in the last year. Good interaction was seen throughout the home between staff and residents. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30-37 The residents’ benefit from having a manager who is supported well by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. Residents’ benefit from a service which is safe and well managed. Sound financial procedures protect residents from abuse. EVIDENCE: The Registered Manager has worked at Lennox Wood for a considerable length of time and has the necessary qualifications and experience. She is strongly supported by her Assistant Manager and senior team. Following the last inspection she has identified areas of concern and worked to improve these areas. The outcome is that the majority if the requirements made at the last inspection have been complied with. The challenge now will be to maintain and improve on the existing level and to continue with a clear sense of direction and leadership. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 23 Staff spoken with confirmed that the management team is approachable dialogue is good between staff. Comment cards received from many relatives confirmed that they were very happy with the level of care and commitment that staff deliver to their relatives. Comments like ‘I feel my Mother is well cared for’ and ‘her room is always tidy’. One relative commented that her Mother seemed to have an improved lifestyle. Other comments complimented the home on providing the most excellent care. One relative commented that ‘the staff are always very kind and helpful to myself and all the residents, you could not wish for a better place’. Other relatives confirmed that they were always kept informed of their relative’s condition. Some concerns were expressed about staffing levels. KCHT organises quality assurance surveys, although the results of these were not seen during the inspection. The homes financial procedures were assessed and found to be thorough and well maintained. There was a clear line of responsibility within the financial structure with regular internal and external audits carried out. The home had designated budgets to work to in all areas. Resident’s personal money was well managed. Families were encouraged to handle financial affairs but the home did deal with minimal amounts of personal monies for use within the home, such as hairdressing and chiropody. These accounts were seen to be well maintained and accurate. Two accounts checked were found to balance. The home does have a small safe and correct procedures for the receipt and storage of items were maintained. Staff benefit from regular staff meetings although these did tend to occur separately for different groups of staff. The Senior Team meet regularly on a monthly basis. The home also organises a Residents Forum for residents and their families. The last one was held in August 05 and full minutes were available. Staff supervision was taking place every two months but when staff were asked if they received supervision, many said not. However, when discussed with the manager it became clear that it is not called supervision and staff seemed a little confused. The manager was awaiting a new format from head office and was expecting this area of confusion to be dealt with then. Supervision or catch up notes were seen on some staff files. Although the manager stated that residents rarely ask to see their files they could do so if they wished. All of the records seen were secure and mainly in good order. The Registered Manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff by maintaining and servicing equipment and systems. Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 24 Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 2 2 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 26 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. 2. Standard OP26 Regulation 13(3) Requirement Timescale for action 31/12/05 6. OP27 18 The Registered Person shall make suitable arrangements to prevent infection; toxic conditions and the spread of infection at the care home in that the laundry be refurbished to the required standards. Although this has been carried on from the last inspection, it is recognised that considerable work had been completed. Action plan required. The Registered Manager shall 31/12/05 ensure that staffing numbers and skill mix are appropriate to the needs of the residents, particularly in the high dependency unit. This has been carried on from the last inspection. Dependency levels need to be assessed. Action plan required Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 5 6 Refer to Standard OP38 OP26 OP30 OP30 OP19 OP7 Good Practice Recommendations It is again recommended that consideration be given to replacing the kitchen units in the near future It is recommended that a door is provided in the clean laundry area to access the main corridor and prevent clothing being taken through the ‘dirty laundry’ area It is recommended that further training in dementia be provided for all staff. It is also recommended that staff receive Adult Protection training. It is recommended that training be provided in Palliative care It is recommended that future maintenance planning takes into consideration the poor state of the window frames in some areas of the building. It is recommended that care plans continue to be developed Lennox Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Wood DS0000028942.V262740.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!