Inspection on 11/10/06 for Lingdale Lodge

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lingdale Lodge 07/11/08

Lingdale Lodge 03/12/07

Lingdale Lodge 01/08/07

Lingdale Lodge 01/03/07

Lingdale Lodge 08/01/07

Lingdale Lodge 27/10/05

Lingdale Lodge 20/04/05

Lingdale Lodge 23/11/04

Lingdale Lodge 21/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Lingdale Lodge Lingdale East Goscote Leicestershire LE7 3XW Lead Inspector Keith Charlton Unannounced Inspection 11th October 2006 09:35 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 Lingdale Lodge DS0000001730.V314982.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. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lingdale Lodge Address Lingdale East Goscote Leicestershire LE7 3XW 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) 0116 2603738 0116 2603738 Mr John William Nunn Mrs Barbara Elsie Nunn Vacant Care Home 48 Category(ies) of Dementia (9), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (10), Old age, not falling within any other category (37), Physical disability (8), Physical disability over 65 years of age (8) Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one under the age of 55 years may be admitted to the home. Service user numbers - PD & PD(E) No one falling within the categories PD or PD(E) to be admitted to the home when there are already 8 persons falling within categories/combined categories PD or PD(E) already accommodated within the home. To be able to admit the person of category MD(E) identified in correspondence from the previous registration authority dated 5/4/2000. To be able to admit the named persons of category DE named in variation application number 55170 dated 10th September 2003. To be able to admit the named persons of category DE(E) named in variation application number V11211 dated 25th August 2004. October 2005 3. 4. 5. Date of last inspection Brief Description of the Service: The home is owned by the Registered Providers Mr and Mrs Nunn and is part of fifteen homes owned by the Broadoak Group of Care Homes. Lingdale Lodge is a large 48 bedded home set in a modern building on one level. The home is set back off the main road in a quiet location of East Goscote but is accessible to shops, and other amenities. The home is situated next to Primrose Residential Home, also owned by the same Providers. The weekly fees range from £275 to £420 approximately - this information was provided prior to the inspection. There are additional costs for individual expenditure such as hairdressing, newspapers, outings and private chiropody. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting four service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Acting Manager was on her day off for the first day of the inspection so it was conducted with the Senior Care Assistants in charge. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report. There have been three complaints made to the Commission for Social Care Inspection since the last inspection. One of three concerns was upheld regarding the lack of proper employment checks in the first complaint. Three of four concerns were upheld regarding the lack of proper mobility equipment, lack of appropriate food supply and lack of personal care in the second complaint. None of five concerns were upheld in the third complaint. The Inspection took place between 9.35 and 13.55 and included a selected tour of the home, inspection of records and direct and indirect observation of care practices. The Inspector spoke with nine service users (though this was limited for some owing to the difficulty with communicating with service users with a high level of mental frailty) five staff members, and two visitors. Comment Cards were received from three service users and three medical personnel. There were a mixture of positive comments regarding care practices, activities and facilities but also a number of negative comments regarding the lack of senior management to consult regarding service users medical conditions, lack of staff working in partnership with medical authorities, staff not understanding service users care needs, staff and relatives complaining to medical authorities regarding care, service users not receiving a contract, they had a poor food supply and the home is not always fresh and clean. The Inspection was concluded on 16/10/06 with the Acting Manager. To her credit she had identified a number of issues raised by the inspector and positively stated that they would be firmly put into place so that service users quality of life improved to a good standard. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that Inspection Report Requirements are attended to as soon as possible, and that the welfare of service users is protected at all times, as at this inspection the hot water temperature continued to be a risk to service users, and there were staff without statutory Criminal Records Bureau and identification checks, which meant service users were exposed to staff who may have posed a risk to them if they had criminal convictions or cautions. The Commission for Social Care Inspection issued an Immediate Requirements Notice for the Registered Provider to rectify this situation. Staff must always be aware of service users care needs; this would include ensuring a full assessment of needs on admission, detailed Care Plans agreed with service users and frequently reviewed, service users with head injuries following falls always being referred to medical authorities, speaking to service users in a friendly fashion at all times and speaking to them whenever possible and not standing behind them and observing, and ensuring that service users are always helped to eat and are kept in a hygienic condition,. Care Plans need to have full details of the care requirements of service users and staff being aware of Care Plans and the Policies and Procedures of the service. Some comments were made by service users and staff that should be more activities such more bingo, singing, music and movement, etc. It is recommended that an Activities Programme is set up and an Activities Organiser is employed to Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 7 ensure activities are consistently carried out. All complaints need to be recorded and acted upon and shown to be acted upon. Staff always need to be sensitive, friendly and caring to service users, have full training on all essential care issues, and receive on going supervision to ensure they receive support to provide a consistent and friendly service, and have a full understanding of the Vulnerable Adults procedure and the fire procedure. Staff were not always seen to use proper Moving and Handling procedures to ensure safe practice for service users. There needs to be a review of the menus with these being drawn up based on the preferences of service users, that vegetarian service users receive wider choices and that cooks are asked to attend service users meetings and carry out food surveys with service users. The premises need to be kept in an odour free condition. It was therefore recommended that the Registered Provider provides proper cleaning equipment rather than the current arrangement of periodically arranging this, as this has meant odours are not swiftly dealt with. It is also strongly recommended that a maintenance person is employed specifically to cover this site, as currently this person covers multiple sites so cannot always respond swiftly to maintenance issues. If a new Manager is appointed the Commission for Social Care Inspection needs to be informed as to the experience and qualifications of this person so this arrangement can be looked at. 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. Lingdale Lodge DS0000001730.V314982.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 Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process is managed so that service uses receive a satisfactory assessment, thereby ensuring that their main health and welfare needs are being met, though this could be more thorough in terms of assessment and information provided to the person. EVIDENCE: There was no Statement of Purpose available in the home to inspect, which was odd as this document was subject to comment in the last Inspection Report and it needs to be available for service users and visitors to refer to as it contains essential information as to the services that residents can expect. There were comments that not every service user has received a contract – the Acting Manager is to follow this up. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 10 No service users could remember anyone from the home coming to see them prior to admission to discuss their care needs. The Acting Manager stated that prospective service users will be seen in their own setting prior to admission and can visit the home to see whether it suits their needs. An assessment was inspected though this appeared to be part of the Care Plan and did not include all aspects of the needs of service users, as per the National Minimum Standard. The Acting Manager said the form would be reviewed to cover this standard. There were more comprehensive assessments on file from Social Service Departments. The home does not offer intermediate treatment facilities. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 11 Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not always well looked after in respect of their health and personal care, or always treated with respect. EVIDENCE: Service users care plans were inspected and included records of the service users care needs. Risk assessments were kept and set out within a risk assessment framework. Care Plans were not always accurate, e.g. one said there was no sight impairment when the service user wore glasses. They also did not clearly set out dental needs as regards routine dental checks, or whether the service user needed a chiropodist. One Care Plan had a number of gaps regarding daily living wishes, social activities and religion. Another plan was a month behind for its reviewing process. No Care Plan seen by the inspector had a signature of a service user agreeing to its contents. The Acting Manager stated that she had inherited some Care Plans, which were patchy, and these would be Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 13 reviewed and upgraded with service users/representatives involved to participate in drawing them up. Service users generally said that if there was a medical problem then staff would call a GP to see them though one service user said that she wanted to see a GP the night before but staff had ignored her. The Acting Manager said this complaint would be followed up. The inspector observed Moving and Handling practices whereby the service user was being inappropriately lifted. The Acting Manager said that she had observed some staff not carrying out proper procedures and is taking this up with them and organising refresher training. Accident records were viewed. Generally the GP was called if there had been a head injury though there was one instance noted when this had not been carried out. The Acting Manager said that she would again stress this procedure needs to be followed so as to fully protect service users. Staff were heard to say that a number of wheelchair footplates were broken. The Acting Manager stated that this is being currently followed up. A relative complained that her mother’s hair was not being taken care of properly by care staff and that service users were clothes were not always clean as clothes were often stained. The Acting Manager said this would be monitored, though some service users refused to have a wash and this was being documented to prove that there were such refusals. Some service users said staff were friendly but others said that staff were often abrupt and unfriendly. The inspector observed that in general staff were friendly though there was an instance where a staff member was abrupt. There were some concerns from service users that they could not always understand what was being said to them and when some staff spoke to each other they did not always speak in English, so service users felt left out. The Acting Manager said that staff were instructed to speak in English and she would follow up the concern regarding service users not being able to always understand staffs accents and put in place an Action Plan to deal with this. A service user said that a staff member had repeatedly shouted at her. Action was then taken by management regarding this staff member. The Acting Manager confirmed this. Some gaps in medicine record sheets were noted. The Acting Manager agreed to take this matter further with the staff. A Senior Care Assistant confirmed that only senior staff issue medication and have undertaken medication training. It was noted that a service user was able to self medicate some of his ointments and inhaler, which assists him to maintain his independence. The Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 14 Acting Manager confirmed that it was the practice of the service to promote self medication if the service user was able to safely carry this out. There were positive comments made by a GP regarding the care provided by the service but also a number of negative comments were received from a health care professional regarding: lack of senior management to consult regarding service users medical conditions, lack of staff working in partnership with medical authorities, staff not understanding service users care needs, and staff and relatives complaining about poor care provided by the service. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not always have the opportunity to lead full and active lifestyle though can generally exercise choice. EVIDENCE: Some service users said that there were not enough activities (this was also referred to in the minutes of service users meetings) and they would like more, e.g. more bingo, sing a longs, music and movement sessions, staff sitting down to speak with them etc. Service users are able to take part in Residents Meetings thought here has only been one in the past year. The Acting Manager said meetings would now be held frequently and that there were outings and ‘one off’ activities but there had been a problem with on going activities, which she was following up. Service users and staff said staff escort service users to the nearby shops. Service users have recently been to a barge trip and trip to Skegness. Some service users complained about their perception of the ‘high cost’ (£15) of the trip to Skegness. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 16 No activities were observed to be on though a staff member offered a small number of service users the chance to play a game of dominoes. It was noted that the radio played pop music in lounge areas, the TV (that no one was looking at) and radio were on in one lounge, and staff appearing to ‘patrol’ the main lounge area, by standing behind and looking at service users, rather than sitting down and speaking to people. Staff training regarding the provision of activities for service users with dementia was discussed with the Acting Manager who said this would be followed up. It is strongly recommended that an Activities Organiser is appointed and sets up a daily programme based on service users wishes, especially as the home’s literature promises that there will be daily activities. Both service users and relatives stated that visitors are always welcomed to the home and no one reported any restrictions. Service users said that there were no rules apart from any smoking in bedrooms – they said they could rise and retire when they wanted. Some stated that they could go out if staff had time to take them. One service user was seen to be going out to attend a church session. There were a variety of views regarding the food. Whilst some service users said it was either good or satisfactory, others complained about it: ‘There is not enough variety’. ‘Its ok but there could be a lot more variety.’ ‘We get too many mince meals.’ ‘The custard is white and tasteless.’ ‘We want more proper roast meat and two vegetables meals’. ‘We want the cooked breakfast to be there seven days a week, not just for two days’. Menus were inspected and found to have choice though the menus for service users only eating vegetables was limited and needs extending to provided proper variety. Food records need to be more detailed to include the vegetables served so this can be properly monitored. The cook was spoken with. She does not currently attend service users meetings. This is recommended. It is also recommended, as part of the Quality Assurance Survey, that service users are asked on a one to one basis what meals they want and for menus to be provided based on their choices. Service users have in the past requested a menu wipe board to be displayed so that they know what food is on the menu that day, which the Acting Manager said would be provided. The food was tasted and was broadly satisfactory though the chicken burger was a basic processed food and the mashed potato had flavour though was lumpy. Lingdale Lodge DS0000001730.V314982.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints need to be strengthened with staff training provided, to result in the full protection of service users rights. EVIDENCE: Service users generally said that they thought that if there was a problem then the Manager or Senior staff would sort it out, though some service users said that they would not bother, as nothing would be done about it. Regarding the service user who had complained about night staff repeatedly shouting at her, there was no record of this in the Complaints Book. A previous complaint was recorded and appropriately followed up by Management. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the Commission for Social Care Inspection at the initial stage, as per the National Minimum Standard. The Acting Manager said this would be followed up. Policies and procedures for Protecting Adults have are in place for Vulnerable Adults but the care staff spoken with were unaware of the full procedure regarding which Agencies to contact if the in house arrangement failed. Lingdale Lodge DS0000001730.V314982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is satisfactory. This judgement has been made using available evidence including a visit to this service. Facilities are seen to be satisfactory by service users and have seen some improvement but odour control needs to be improved. EVIDENCE: Service users said they were satisfied with their rooms, which were seen to be personalised with items of resident’s furniture, pictures and photographs. Decorators were seen to be working in a lounge area. The Acting Manager said the programme is to repaint all areas. This is welcome, as the home looks somewhat gloomy in a number of areas, due to strong darker colours of furniture and carpets. A curtain had fallen down in the window opposite room 2. TV reception in some lounges was poor as the picture was fuzzy. A call bell in the smoking area is to Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 19 be mended, and the noisy ventilator in one bedroom is to be repaired according to the Acting Manager. Staff said that maintenance is not always followed up quickly, e.g. the kitchen fryer has needed repair for some months. It is strongly recommended that a maintenance person is employed specifically to cover this site, as currently this person covers multiple sites so cannot always respond swiftly to maintenance issues. There were a number of areas where carpets were odouress – the main and west wing lounges and bedroom 3 (this was also reflected in the minutes of staff meetings) Staff said they had to wait for the central office to authorise carpet cleaning. This is not a good arrangement as it means that the home continues to be odouress for some time and it needs to be odour free. It is strongly recommended that a proper carpet cleaner is available for staff to use when necessary. The Acting Manager stated that there are to be carpet replacements in two bedrooms owing to in grained odours. Seating arrangements in the main lounge are of a large square that results in limited contact between service users. It is recommended that this is reviewed and service users asked if they would prefer a more homely arrangement. Some locks to WCs/bathrooms were not operational. A ground floor bathroom flooring was stained around the WC, there was no soap to the washbasin, the bin was overflowing and the bath was being used as an incontinence pad store. The Acting Manager said these issues would be followed up. Lingdale Lodge DS0000001730.V314982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels were criticized by service users and relatives though appear adequte when they are maintained to the rotered level. Staff response, staff training and recruitment procedures need to be in place to meet service users needs and properly protect them. EVIDENCE: There were a number of complaints from service users and visitors that often there were staff shortages and they had to wait too long for staff to attend them (‘they always say ‘wait a minute’, then you don’t see them for ages’) and they were kept waiting for meals after being taken to the dining room. The Acting Manager said there was often a problem with staff ringing in late due to sickness but she was attempting to sort this out. The staffing rota demonstrated sufficient staff on duty when it is fully covered. It is recommended that staffing is reviewed to ensure that service users needs are met within a reasonable period and staff explain why there is to be a delay and for approximately how long. Staff said there had been little training in the last twelve months. This was reflected in the inspector observing blank staff training records. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 21 The Acting Manager said that she had identified this as being an issue and would be formulating and implementing a training plan and matrix to identify key issues that staff need training in (to quickly access who needs training in any relevant issues) – e.g. first aid, challenging behaviour, moving and handling, health and safety, medication, dementia, service users rights etc. In contrast she stated that the National Minimum Standard regarding of 50 of care staff with National Vocational Qualification level 2 had been met. The Acting Manager also said she was looking into developing the current staff induction to meet the Skills for Care recommended training, as the current induction information needs to have more detailed training. Recruitment records were inspected and found to be poor with Criminal Records Bureau /Protection of Vulnerable Adults checks, references and Application forms not in place. An Immediate Requirements Notice was served for this to be quickly rectified by the Registered Provider. Staff recruitment files also need proof of a person’s identity, including a recent photograph. This was referred to in the last Inspection Report so should have already been followed up. Lingdale Lodge DS0000001730.V314982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of service users. EVIDENCE: The Acting Manager has been in post for over a month but the Registered Provider had not informed the Commission for Social Care Inspection of this appointment. The Commission needs to be informed as to the experience and qualifications of this person so this arrangement can be approved. Service users said that they thought the Acting Manager had made a good start and that she was approachable and thoughtful as to the running of the home. Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 23 The Acting Manager stated she is going to be working towards a Registered Managers Award. There was again no evidence that staff are appropriately supervised and supported. The Acting Manager said she was at the point of setting up formal supervisions and induction foundation training with the staff group. There is a Health and Safety folder with Risk Assessments for safe working practices though this appears basic. The Acting Manager is to check whether this is satisfactory with the Environmental Health Officer. There was no record of hoist maintenance for over two years of wheelchair servicing. The Acting Manager said this would be followed up. A Quality Assurance system was not in place for 2006. This needs to be carried out on a yearly basis and the results included in the Statement of Purpose. The Registered Provider is making statutory visits to the service and writing Regulation 26 Reports. These need to be sent to the Commission for Social Care Inspection to be monitored as to the proper running of the service. Service user monies records were generally found to be properly kept with running balances, though two signatures are always needed so that transactions are witnessed. Two service users amounts of monies were checked and found to be in order. Fire Precautions: fire doors were found to be propped open in the main lounge and a corridor area. Staff then closed these doors to preserve fire safety. Two staff were asked the fire procedure but were not fully aware of the whole procedure. All system testing was on required schedules for emergency lighting, though fire bell testing was a week behind schedule, and there had only been one fire drill between July 2005 and July 2006 when three monthly drills are required. The Acting Manager noticed this and is now ensuring this frequency is met and is to check with the Fire Officer as to whether his non compliance letter, issued in April 2004, regarding the fire risk assessment and other issues, has been followed up. The hot water temperature was checked in a bathroom and found to be 48c, when the National Minimum Standard is 43c. Staff were directed to reduce this to a safe level on 11/10/06. However this had not been carried out by the second inspection visit only five days later and an Immediate Requirements Notice was issued to require the Registered Provider to rectify this. Lingdale Lodge DS0000001730.V314982.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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 X 2 X 2 Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP8 OP10 Regulation 12 12 Requirement That the Registered Provider ensures that service users health needs are met at all times. That the Registered Provider ensures that service users are always shown respect by staff and any concerns are properly followed up. That all staff receive Adult Protection Training and are aware of this procedure. Systems must be put in place to ensure that the home is odour free. That staff are employed with all necessary checks in place prior to their employment commencing, which is outstanding from the inspection of 20/05/05. A suitable staff training and development programme must be put into place, to include the training in first aid, which is outstanding from the inspection of 20/05/05. This needs to be sent to the Commission for Social Care Inspection. The Health and Safety systems DS0000001730.V314982.R01.S.doc Timescale for action 16/10/06 16/10/06 3. 4. 5. OP18 OP26 OP29 13 16 19 16/11/06 16/11/06 18/10/06 6. OP30 18 16/04/07 7. OP38 13 17/10/06 Page 26 Lingdale Lodge Version 5.2 in the home must protect the welfare of service users from harm. This includes protection from fire, hot water and unsafe Moving and Handling practices. 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. Refer to Standard OP1 Good Practice Recommendations Information to be included in the Statement of Purpose: The arrangements for service users to engage in social activities, hobbies and leisure interests. The Statement of Purpose and Statement of Terms and Conditions should include who meets the costs for any organised trips as they are currently above those included in the fees. Service users paying costs for some trips should be discussed further at a residents meeting. Care Plans need to be reviewed with service users and updated to meet all identified needs. Medication records need to be complete to show it has been properly administered. An Activities Programme needs to be devised to provide on going activities based on service users preferences. The food supply needs to be reviewed to meet service users preferences. The choice of vegetarian meals needs to be extended and food records have more detail. All complaints need to be recorded and the Complaints Procedure amended to meet the National Minimum Standard. 2. 3. 4. 5. OP7 OP9 OP12 OP15 6. OP16 Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 27 7. OP27 Staffing levels need to be reviewed so ensure that sufficient staff are available at all times to meet service users needs. Ensure that there is an ongoing Quality Assurance system in place to include the views of service users and other relevant stakeholders. Ensure staff receive regular formal supervision. This is outstanding since the last inspection of 20/04/05. 8. OP33 9. OP36 Lingdale Lodge DS0000001730.V314982.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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