Inspection on 11/09/07 for Lime Tree House Residential Home

This inspection was carried out on 11th September 2007.

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 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

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

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 Lime Tree House Residential Home Lewes Road Ringmer East Sussex BN8 5ES Lead Inspector Elizabeth Dudley Key Unannounced Inspection 11th September 2007 09:00 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 Lime Tree House Residential Home DS0000069746.V346820.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. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lime Tree House Residential Home Address Lewes Road Ringmer East Sussex BN8 5ES 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) 07801 225549 Zeenat Nanji Salim Nanji Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Lime Tree House Residential Home DS0000069746.V346820.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 17. Date of last inspection New Service Brief Description of the Service: Lime Tree House provides personal care for 17 residents. It is in a rural location approximately half a mile from the village of Ringmer. Local bus services from Lewes and the surrounding areas serve the home and there is ample parking for around fifteen cars. The residents’ accommodation is over two floors and residents can reach most areas of the building by shaft or stair lift. One area has a mezzanine level with a few steps to it and therefore only suitable for ambulant residents. There are seventeen single rooms, nine of which have an ensuite facility consisting of a washbasin and toilet. The remaining rooms have a washbasin only. There are four general bathrooms; three of these have assisted bathing facilities. The home is surrounded by a large well-maintained garden, which residents may use, and other communal accommodation consists of a large lounge and dining room with a small conservatory type area leading off the lounge. The fees range between £450 and £525 per week with extra services such as chiropody, hairdressing and newspapers being charged separately, these charges are available from the manager (this information is correct as of the 11th September 2007) Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 11th September 2007 and was facilitated by Ms J Norris, appointed manager, and Mrs Z Nanji Home owner. Prior to the inspection ten questionnaires were sent to residents, ten to visitors to the home and two to health care professionals. At the time of writing this report none have been returned. Any responses received will now be addressed at the next inspection. During the inspection four members of staff, six residents and two visitors to the home were spoken with. Positive comments about the home and the staff were received from residents and their visitors: “ This is a nice place to live, the staff are very polite and kind”. “ The home keeps me informed of any concerns, it is always clean and the food seems very good, she (the resident) has put on weight and is eating well”. Over the course of the day a tour of the home was undertaken and records which included care plans, health and safety documentation, personnel files, policies used in the home and training files were examined. The inspector thanks all residents, staff, visitors and the manager and owner for their courtesy, hospitality and help during the day. What the service does well: The service provides a pleasant, clean and homely environment for residents. Recent redecoration has proved popular with residents, visitors and staff, all commenting on the improvement to the home. The large gardens are well maintained and residents can use these as they wish. There is a good programme of activities and staff supplement this by ensuring that residents are occupied or by talking or singing with residents. Staff also go to individual rooms to talk to residents and take them out for walks. The manager has produced a newsletter for the residents and this is distributed. Residents spoke of the good standard of catering and the choices available saying ‘ the food is lovely and you can choose what you want’. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 6 There was evidence that staff promote the dignity of the residents and two residents said that the staff always ask their opinions, knock on doors and are “ charming and so very polite”, “ always make sure we are private when we need to be”. The manager sends out questionnaires on a three monthly basis to gain resident’s views and collates all information received into a graph to inform visitors and residents in which areas the home needs to improve. The manager uses the information to improve the service offered in the areas indicated. What has improved since the last inspection? What they could do better: The manager is not yet registered with the CSCI and an application for this must be commenced. Care plans need some attention to ensure that they address the actions to be taken to meet peoples assessed needs and that the care planning procedure is commenced on admission. The preadmission assessment should address all areas of a residents needs for social, physical and mental health. The manager should ensure that mandatory health and safety training has been updated for all staff as soon as possible. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 7 Areas around health and safety included risk assessments being put in place regarding access to the kitchen area by residents and ensuring that those who may wander into this area are safeguarded and ensuring that upper floor windows had restricted opening or the Environmental health authority contacted regarding advice on risk assessments relevant to these. It was also noted that there was no fire risk assessment in place for a specific resident. 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. Lime Tree House Residential Home DS0000069746.V346820.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 Lime Tree House Residential Home DS0000069746.V346820.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): People who use the service experience good outcomes in this area Some documentation provided by the home, whilst informing prospective residents sufficiently to enable them to make a choice of home, has not been reviewed to reflect the current ownership of the home. Existing residents at the home do not have a statement of terms and conditions relative to the parent company. An assessment of prospective residents is undertaken to ensure that the home can meet their needs and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose in place does not reflect the current status in the home and is relevant to the previous provider. The service user guide relates to the new provider and is given to all prospective and current residents but does not meet the regulations due to lack of inclusion of a complaints procedure. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 10 The manager and provider gave assurances that this would be addressed. The ‘Terms and Conditions of Residence’ have not yet been finalised under the new provider but all residents have a copy of the terms and conditions relating to the previous owner. The provider is still awaiting legal advice over this document. All prospective residents are assessed by the manager to ensure that the home can meet their needs, and that the resident’s expectations will be met. The assessment methodology now being used identifies the psychological, physical and to a lesser extent social needs of the prospective residents. Currently the manager is informing residents verbally rather than in writing over the outcome of the assessment, this should be followed with written confirmation. Assessments can take place in the person’s current place of residence, including a hospital, or the individual can visit the home. All prospective residents and their representatives can look around the home at any time. The home admits residents for respite care but not for intermediate care. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People who use the service experience good outcomes in this area The standard of care planning is variable and in some instances does not fully address the actions required to meet the assessed needs of the residents. The general standard of medication administration safeguards the residents, but lack of correct recording of a specific medication may lead to misuse and have implications for the resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection four care plans (20 ) were examined in detail. The implementation of new care planning procedures, which is not yet complete, resulted in the standard of care planning being variable. One resident recently admitted had a full risk assessment but the care plan had not been Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 12 commenced. The pre admission assessment was not sufficiently in depth to inform of the care this resident may require. Whilst the care plans addressed all the health, personal care and social needs of the residents, some of the care plans showed little guidance for staff in meeting these needs. All care plans contained risk assessments which were generally good, and most addressed current and changing needs and had been reviewed on a monthly basis, showing evidence that they had been formed in consultation with the residents. It would be beneficial to residents if their preferences regarding times of rising and retiring, whether or not they wished to have keys to their rooms and what time they preferred breakfast etc were included in the care plans. The home operates a key worker system and the key workers spoken with were fully aware of the needs of the residents in their care. Residents spoken with said that their dignity was upheld especially when personal care was taken place and that staff were polite and treated them with respect. A visitor to the home said that ‘ I am very happy with the care, the staff tell me if there are any concerns and are prompt in calling in the doctor’. Residents said ‘ They get the doctor when you need him’. ‘ The care is good and the staff very polite’. Confidentiality of residents was compromised by the lists of treatment details hanging in the office, which could be viewed by persons looking through the window, but this issue was addressed during the inspection and the details put into the care plans. Some residents have expressed a preference to receive care from female care staff only and whilst at present their care needs can be addressed whilst the day staff are on duty, a female member of staff is available at night on an oncall basis, but the present system of accessing on-call personnel does not ensure that residents needs can be met in a timely manner. The manager has been asked to ensure that this issue is addressed. Medications are administered using a pre-packed monitored dosage system. The administration of these was satisfactory, with signatures in place and the use of a drug trolley. The majority of staff having received the appropriate training. A Controlled Drug had not been recorded correctly for this type of medication, the provider has addressed this, and it is recommended that the staff update their training on medication procedures. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 13 Any medications requiring to be stored at below ambient temperatures are stored in the domestic fridge in a discrete container. The provider stated that a specific drug fridge might be purchased in the future. Residents can remain in the home during their end of life providing that medical needs do not direct otherwise and care is provided by Community and Macmillan nurses. This standard was not fully examined at this inspection. Lime Tree House Residential Home DS0000069746.V346820.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): 12,13,14,15 People who use the service experience good quality outcomes in this area Staff provide stimulation and activities for residents throughout the day in addition to the activities programme in place. The standard of catering is good and provides a nourishing variety of menus in a pleasant dining area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with said that they had choices in their activities of daily living and that the staff would help them to follow any interests they had and take them into the village or out for walks on occasions. They said there was a varied range of activities which take place at all times of day. There is an activities programme in place, and staff were seen talking and singing with the residents outside of the activities on the programme, with residents saying that this happened all the time, residents were spending time in the garden and staff were seen to be proactive in taking precautions against the sun. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 15 There is an open visiting policy at the home and visitors said that they were always welcome and that staff readily gave assistance if they wished to take their relatives or friends out. Provision for religious worship is provided. Residents said the standard of catering was good with plenty of choices. Menus were seen to be on display in the dining area, tables were laid up in an inviting manner and the care staff inform the residents of the choices of meal available. The menu showed a good variety of meals available and there were fresh fruit and vegetables offered. Breakfast is at 8am but can be at any time to suit the individual’s wishes and snacks and beverages are available at any time. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 People who use the service experience good quality outcomes in this area Staff are aware of their responsibilities regarding the safety of those in their care. No records of concerns were available but residents were sure that any concerns or complaints they may have would be dealt with in an open and transparent manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is displayed in the main hallway; this should be included in the service user guide. The manager stated that there have been no complaints since the last inspection although there have been concerns. Records should be kept of any concerns raised and the manner in which these have been addressed for future reference. There have been no adult safeguarding issues under the new ownership of the home and the majority of staff have undertaken training in safeguarding those in their care. This must be extended to all staff including domestic and catering staff. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 17 Residents all said that they are happy at the home, have no complaints and would know who to go to if they had, they were sure that their concerns or complaints would be dealt with in an open and transparent manner. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 18 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): People who use the service experience good quality outcomes in this area A pleasant, well-maintained and comfortable environment is provided for those that live in the home. Personal items left in bathrooms could be an infection control risk for other residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some refurbishment including redecoration of communal areas and some bedrooms, replacement of furniture and curtains has taken place in the home. The provider is planning to extend the home and other areas will be refurbished and improved at this time. The home has communal areas consisting of a lounge, conservatory area, dining room and a large well maintained garden, which includes seating areas for residents. Residents can access the garden from the ground floor. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 19 There are four bathrooms of which three have assisted bathing facilities and nine of the seventeen single rooms provided for resident occupancy have ensuite facilities, the other eight have washbasins and are within easy reach of a WC. Residents’ accommodation is provided over the ground and first floor, the second floor providing accommodation for staff. All resident’s rooms are for single person use only and residents are encouraged to personalise their rooms with their own possessions. The regular monitoring of hot water temperatures and radiator guards safeguards residents. Residents’ rooms can be provided with a lock if the resident so requires and it is recommended that their wishes relating to this are recorded in the care plan. Lockable drawers or cupboards are provided in most rooms. Outer doors are kept locked to maintain the safety of some of the residents in the home who may wander out. Those residents, who are able, are either provided with their own key or staff open the doors in order for their freedom of movement to be unrestricted. There are wheelchair ramps, hand rails and assisted bathing facilities in the home. Most areas are served by a shaft lift or a chair lift but one area of the home is only accessible by stairs therefore restricting its use to ambulant residents. It is recommended that prior to the refurbishment that the home is assessed by an occupational therapist to ensure that future aids provided meet the range of needs required by residents in the home. The home is clean and free from unpleasant odours. The laundry is done in house and soiled laundry is placed in red bags in the resident’s rooms thus ensuring that other laundry is not contaminated. There were no records to show that staff have undertaken any training in infection control apart from that gained from the National Vocational Qualification level 2 in care and it is recommended that this forms part of the training matrix. Staff should be made aware that leaving personal toiletries in general bathrooms might restrict resident’s choice and provide an opportunity for the spread of infection. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate There are sufficient staff on duty during the day time hours to meet the assessed needs of the residents, insufficient clarity is demonstrated to identify that these can be met at night. Whilst staff receive ongoing training not all staff have completed the mandatory health and safety training, which could put residents at risk. The recruitment system is generally robust but some aspects do not fully safeguard the residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rota and conversations with staff and residents showed that there were sufficient staff to meet residents care, social and safety requirements during the day. Neither the duty rota nor the manager demonstrated sufficient clarity over how these were met at night when there is only one member of staff on duty. The manager stated that one of the care staff living in the home on the upper floor would provide an on call service if required, but the current system in the home would not allow this to happen in a timely fashion. Likewise the preferences of some residents regarding gender of carer would Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 21 not be met if they required care quickly. The provider stated that this would be addressed. Four (33 ) personnel files were examined. These identified that two care staff had been recruited from overseas with a CRB relating to the recruiting agency, the manager has now checked on the status of this with the relevant official body and will be. Seven care staff (60 ) have the National Vocational Qualification level 2 in care or equivalent (two carers are registered nurses from overseas which the City and Guilds recognises as equivalent). Staff receive full encouragement to undertake this course and other training. The manager has produced a clear training matrix which identifies the training requirements of the staff and when up dating is due. This showed that there are some staff still requiring mandatory health and safety training and that care staff that assist with food preparation require training in this area. During discussion with staff they stated that training opportunities within the home were much improved and that they were able to identify their training needs and be confident that these would be followed up. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good The manager has systems in place to ensure that the home meets the expectations of the residents and to monitor that staff are meeting the residents assessed needs. Some areas of the home could put residents safety at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The appointed manager has been in post for eighteen months, having stayed with the home over the change of ownership. She is in the process of finishing the National Vocational Qualification level 4 in care and Registered Managers Award but is not yet registered with the CSCI, and discussions were held with Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 23 both the manager and the provider, the provider states an application will be commenced. Staff, residents and visitors were happy with the home, with residents saying that the atmosphere in the home was good: ‘The next best thing to your own home’. ‘ The manager and staff are excellent- wouldn’t want to leave’. ‘ The staff make a home, these are all so friendly’. There is a quality monitoring system in place, the manager obtains residents and visitors views three monthly by questionnaires and has collated these in a graph, this is displayed in the entrance hall and is available for residents, visitors to the home and the CSCI. Results from the monitoring have informed the service offered; with changes being made to ensure residents expectations are met. Views of staff are gained from regular staff meetings. Business accounts were seen by CSCI during the change over of the ownership of the home. The manager does not act as appointee for residents but personal monies are kept in the home for safekeeping, records of these were available and in order. Staff receive supervision at frequency directed by the National Minimum standards and Regulation 26 visits (visits to the home by the provider) are taking place at the frequency required by legislation with records kept in the home. The manager has not yet received formal supervision. Records in the home were up to date with the exceptions of those discussed in National Minimum Standard 7. Policies and procedures have been updated. Certificates for the maintenance and servicing of utilities and equipment were in place and in date. There were some issues that could implicate the safety of the residents living in the home. Two windows in residents’ rooms were able to open wide enough to allow residents to fall. Residents can walk freely into the kitchen and some residents in the home may be at risk of scalding or burn injury. There was no fire risk assessment on one resident that cannot move without assistance, and an inner bedroom door was wedged open, therefore putting the occupant at risk in the event of a fire. The provider gave assurances that this would be addressed. Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 24 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 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 3 2 2 Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation Reg 15 Requirement That all care plans detail the actions to be taken by staff to ensure that the assessed needs of the service users are met. Care plans must be completed following admission of a resident to enable care to be commenced in a timely manner. That the manager submits application to be registered with the CSCI as manager of the service. Timescale for action 30/10/07 2 OP31 3 OP38 Reg 43 Care Standards Act 2000 Applicatio n to Register Part 2 .11 (1) Reg 13(4) Reg 23(4) 30/11/07 That the manager consults with the relevant authority over the provision of risk assessments for those areas identified in the main body of the report or takes action to ensure that residents are no longer at risk. 10/10/07 Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lime Tree House Residential Home DS0000069746.V346820.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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