Inspection on 17/01/06 for The Lakes Nursing Home

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

The Lakes Nursing Home 17/07/07

The Lakes Nursing Home 06/03/07

The Lakes Nursing Home 12/09/06

The Lakes Nursing Home 07/09/05

The Lakes Nursing Home 17/03/05

The Lakes Nursing Home 27/09/04

The Lakes Nursing Home 21/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Lakes Nursing Home Off Boyds Walk Dukinfield Tameside SK16 4TY Lead Inspector Mrs Fiona Bryan Unannounced Inspection 17th January 2006 09:30 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 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 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. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Lakes Nursing Home Address Off Boyds Walk Dukinfield Tameside SK16 4TY 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) 0161 330 2444 0161 339 0087 Blackcliffe Limited Mrs Annette Forrest Care Home 75 Category(ies) of Dementia (36), Dementia - over 65 years of age registration, with number (36), Old age, not falling within any other of places category (72), Physical disability (39), Physical disability over 65 years of age (39) The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No service user under 55 years of age can be admitted to the establishment. No more than 38 places can be used for nursing care. Two Registered Nurses to be on duty between 8 am and 9 pm. One Registered Nurse to be on duty between 9 pm and 8 am. The Manager to be supernumerary to (3 & 4) above for 13 hours per week. Rooms, 4, 5, 6, 7, 8, 9, 10, 11, 15, 16 on Kendal Suite, cannot be used to accommodate service users in the category PD- Physical Disability. 7th September 2005 Date of last inspection Brief Description of the Service: The Lakes Care Centre is a large home situated in Dukinfield, with easy access to Hyde, Ashton and Stalybridge. The home provides nursing care for up to 38 service users. Personal care and care for people with dementia can also be provided and the total number of service users is 75. The home is owned by Blackcliffe Limited, which is a private company. The Chief Executive of the company, Mr Jack Meredith, and the registered manager, who is also a registered nurse, manage the home on a day-to-day basis. Accommodation is provided across two buildings, divided into three Suites named after areas in the Lake District. Derwent and Coniston Suites accommodate service users who require both nursing and personal care, whilst Kendal Suite only provides accommodation for service users who require personal care. The majority of rooms are single, although a small number of shared rooms are available. Approximately half of the rooms have en-suite facilities, whilst the others have toilet and bathing facilities nearby. A large number of communal rooms provide a variety of areas in which service users can socialise, dine and participate in activities taking place within the home. The home does not have a communal area within the main building that is specifically for the use of service users who do not wish to smoke. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 17th January 2006 and was the second inspection for the year. During the visit the inspector spent time talking to residents, relatives and staff. Three residents were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of documents was examined, including residents’ care files and medicine records, staff training records and residents’ personal allowance records. Four key standards, which have to be assessed at least once year were not examined at the last inspection, and were therefore considered at this inspection. These standards included how the home dealt with residents’ personal finances and the qualifications and training of the manager and staff. A pharmacy inspector from the CSCI undertook an inspection of the home’s policies and procedures for managing medicines on 12th September 2005. A separate letter was sent to the home detailing the findings of that inspection. The majority of requirements and recommendations made at that time were reassessed and those that still need to be complied with are included in this report. What the service does well: Residents said that staff were hardworking and very nice. One resident said “you get quite a bit of attention – the staff are always coming in and out with drinks and so on”. On the Kendal unit all the residents were cheerful and many were chatty and enjoying banter with the unit manager who seemed to have a good relationship with them. When asked what the best thing was about the home, one resident said she loved the garden and enjoyed sitting outside in the summer and another resident liked his room. Over 50 of the staff have achieved a National Vocational Qualification. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: A number of standards, which were not met at the last inspection, were reviewed again at this inspection to assess if any improvements had been made. These standards related to the assessment and planning of care for residents, the provision of activities and meals, how the home dealt with complaints and staff recruitment practices. Details regarding quality assurance initiatives and consultation with residents were not available as the registered provider was not present, therefore the standard regarding quality monitoring could not be assessed at this inspection. Assessments still need to be more detailed to be certain that all the needs of residents are identified and planned for and staff need to be sure that risk assessments are calculated accurately. Care plans need to be reviewed regularly and updated so they accurately reflect residents’ needs. Although the home has made progress in improving its procedures for dealing with medicines, a small number of areas still need to be addressed. Some records, such as the complaints records were not available for inspection as the manager and the owner were not in the home on the day of the inspection. These records should always be up to date and available for inspection. Furthermore, the CSCI must be informed of any serious injury, illness or incident concerning residents. Some information needs to be updated such as the home’s statement of purpose and the complaints procedure. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 7 Although comments about the food were more positive, further work is still required to ensure that all residents are aware of the choices on offer and to ensure that choices and to ensure that alternative food choices to the main meals are of comparable nutritional content. Some minor repairs and maintenance work is needed to the environment. Staff practices regarding moving and handling residents need to be reviewed. 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 Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 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 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 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 and 3 The home’s Statement of Purpose and Service User Guide require reviewing to ensure residents are clear about the services the home provides. Although assessments are undertaken for all residents, in some cases a lack of detail could lead to needs not being identified. EVIDENCE: A service user guide is displayed in the reception area of the home. However, this needs updating as it contains information about staff who are no longer employed at the home. An assessment was undertaken within 48 hours for one resident who was admitted to the home as an emergency. However, some aspects of the assessment had not been completed, for example, the resident’s weight had not been obtained; therefore the nutritional risk assessment that had been completed may have been inaccurate. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 10 A moving and handling assessment had also not been carried out although the resident had a history of falls. The risk assessments for one resident who had been re-admitted to the home following hospitalisation had not been reviewed. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Shortfalls in the assessment and review process mean that care needs may not always be identified and planned for; therefore health care needs may not be met. The home has made good progress with regard to the arrangements for the administration of medication, but some practices still potentially place residents at risk. Residents were treated in a respectful way by staff and their privacy was maintained. EVIDENCE: On Kendal Suite care plans were detailed and reviewed monthly. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 12 On Derwent and Coniston Suites care plans had generally been developed to address needs identified during the assessment process. However, some shortfalls in assessing residents, as detailed in the previous section of this report, mean that needs may not accurately be identified which presents a risk that no care plan will thus be implemented. One resident who had been hospitalised with swallowing difficulties had not been weighed or had their nutritional risk assessment reviewed on their return to the home. The most recent nutritional risk assessment from November 2005 was inaccurate. The majority of this resident’s care plans and other risk assessments had also not been reviewed on re-admission to the home. Evidence was available that other healthcare professionals were accessed for residents when needed. Many of the requirements made by the pharmacy inspector on 12th September 2005 had been complied with. However, examination of a selection of medicine administration records indicated that where advice and instructions were handwritten by staff, these transcribed details had not been signed, dated or validated by a second staff member. The treatment rooms on Derwent and Coniston Suites were still too warm although the home had made efforts to rectify this. The home utilises resident photographs as a formal system of identification prior to medication administration. On the day of inspection there were a number of resident photographs missing. A group of residents who were spoken to on Kendal unit said staff were very good and they were happy with their care. Residents appeared well presented and comfortable, with clean and neat clothing, tidy hair and clean teeth and fingernails. Staff were observed to be interacting with residents in a friendly and professional manner and took residents to their own rooms or the bathrooms to assist with personal care tasks. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 The home has worked hard to provide a variety of opportunities for social pastimes but still needs to consider how the needs of the more highly dependent residents can be met and ensure that residents are given choices about how and where they spend their day. The provision of meals is satisfactory to most residents, although daily choice of food is limited, which potentially impacts on residents exercising choice and control over their diet and what they eat. EVIDENCE: At the last inspection the activities organiser had been on holiday and was therefore unavailable to describe her role and remit. On this occasion inspectors were able to observe the activities organiser interacting well with a small group of residents playing dominoes. Arrangements had been made for another resident to paint, which she was enjoying. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 14 The activities organiser said that she also took residents out individually on shopping trips and residents confirmed this. Some larger group outings had been discussed at a residents’ meeting in August 2005, which the activities organiser was hoping to arrange for the spring. Several residents had newspapers and books whilst others were watching television. Residents said there were activities to join in with if they wished. Details about activities provided are displayed on each Suite on notice boards. For residents who are more highly dependent and those that do not enjoy participating in group activities, the development of more person centred social care plans may help to identify ways in which staff can maximise social and mental stimulation for them. There was some doubt on the part of the residents as to their freedom to come and go as they wished to their rooms and choose where they spent their time. A number of residents felt that staff preferred them all to sit in one of the lounges “so they can keep an eye on us”. Whilst it did not seem to be a problem to those residents spoken to, the home should ensure that residents are aware of their rights to move around the home freely and spend quiet time in their own rooms if they wish. The residents spoken to were mainly satisfied with the food provided. One resident said an alternative was provided if required, although all residents were observed to be served the same meal of corned beef hash at lunchtime and no one was served an alternative. In addition, the alternatives available were not always comparable nutritionally with the main meal being served. On Derwent and Coniston Suites the menus remain too high up on the wall for residents sitting in wheelchairs to see them very easily. On Derwent Suite the lunchtime meal was served on side plates. The manager was not aware of any reason for this when asked. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents were confident that their complaints would be listened to and dealt with properly. A training programme is in place to ensure that staff are equipped with the skills and knowledge to protect residents from abuse but reference information was not readily available. EVIDENCE: The majority of residents asked said they would bring any complaints to the attention of the manager or the nurse in charge and felt it would be dealt with satisfactorily. The complaints procedure is displayed in the reception areas to Kendal suite and the main building. However, it still requires amending as it does not give timescales by which complainants can expect a response and does not make clear that complainants can refer to the CSCI at any time throughout the process. A record of complaints received by the home was not available at the time of the inspection as the registered provider was not present. These records should be available for inspection by the CSCI at any time. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 16 Training in dealing with challenging behaviour has been arranged for some staff. Staff were aware of POVA procedures to follow within the home and were also aware of their right to contact an external agency such as the CSCI if they were unhappy about how concerns had been dealt with in the home. the majority of staff had undertaken training in the prevention of abuse. The nurse in charge was unable to locate a copy of the local Tameside Adult Protection policy, which should be available to all staff for reference. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 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, 25 and 26 In the main, the home is well maintained, safe, clean and pleasant to live in. EVIDENCE: Since the last inspection the hall, stairs and landing, dining room and conservatory in Kendal Suite have all been redecorated. New carpets have been fitted in all these areas with cushion flooring in the dining room. Residents’ rooms were comfortable, homely and personalised with mementos and small items of furniture. Residents said they liked their rooms. The walls and ceiling in the first floor hallway in Kendal suite need repairing following water damage. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 18 Although a requirement was made at the last inspection, the dining room window on Kendal suite had still not been fitted with a restrictor, and the damaged ceiling in the toilet in the first floor, identified at the last inspection had not been repaired. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staff are provided in sufficient numbers to meet residents’ needs. An ongoing training programme is in place and the home exceeds the standards for the percentage of care staff who have completed NVQ training, providing staff who have the skills and knowledge to care for the residents competently. Although some progress has been made the home’s recruitment practices still put residents at risk. EVIDENCE: Nurses and carers reported that there was little usage of agency staff and that night staff levels have been increased to meet the extra care needs of residents who are highly dependent. Nurses, residents and visitors all felt that staffing levels were sufficient to meet the needs of the residents. Thirty-three of the 49 care staff employed at the home (67 ) have achieved NVQ level 2, 3 or 4. This exceeds the target to meet this standard. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 20 Examination of staff personnel files indicated that recruitment procedures had improved since the last inspection in that there were two references on all files. However, no employment history was available for one staff member and there was no evidence that a POVAFirst check had been made for new employees even though their full Criminal Records Disclosure certificate was issued after they commenced employment at the home. A staff training file provided evidence of an ongoing programme of training. Training planned for 2006 included moving and handling, abuse awareness, safe handling of medicines, First Aid and dealing with challenging behaviour. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 21 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, 35 and 38 The manager has the skills and knowledge to properly manage the home. Procedures are in place to ensure residents’ finances are safeguarded. Although training is provided, failure on the part of some staff to follow procedures correctly creates a risk to the health and safety of themselves and residents. EVIDENCE: The manager is registered with the CSCI and has successfully completed the Registered Managers Award. There are clear lines of accountability within the home and the registered provider is supportive and available on a daily basis. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 22 The majority of residents are assisted with their finances by their families. The home has a bank account set up specifically for the purpose of administering residents’ monies. Separate ledger sheets are maintained for each resident detailing how much money they have in this bank account. The bank account does not attract interest. Records and receipts are maintained of all transactions made on behalf of the residents. Any valuables kept by the home on behalf of the residents are itemised in individual care plans. There was no accident/incident report for one resident who had been hospitalised due to a choking episode. The home also failed to report this incident to the CSCI. Poor practices were observed on Derwent and Coniston in relation to moving and handling residents and although it was reported that equipment such as handling belts was available there was no evidence that they were being used by staff. Records indicated that a fire drill had taken place since the last inspection and staff had received training in fire safety. Further updates have been planned in health and safety topics for the beginning of 2006. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 23 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 2 X STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement Timescale for action 31/03/06 2 OP3 14 3 OP7 15 4 OP7OP8 13 The registered person must ensure that the home’s statement of purpose is reviewed so that it provides accurate details of all the matters listed in schedule 1 of the Care Homes Regulations 2001. The registered person must 31/03/06 ensure that a full assessment is undertaken for all residents prior to their admission to the home. (Previous timescale of 31/10/05 not met). The registered person must 31/03/06 ensure that residents’ care plans are reviewed at least once a month and updated to reflect changing needs in health and personal care. The registered person must 31/03/06 ensure that risks to the health and safety of residents are identified and so far as possible eliminated. The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 25 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. 5 Standard OP9 Regulation 13 Requirement The registered person must ensure that handwritten medication details on the medication administration records are signed and dated and the details are validated by an additional member of staff. (Previous timescale of 26/09/05 not met). Timescale for action 31/03/06 6 OP9 13 7 OP9 13 8 OP16 22 9 OP16 17 The registered person must ensure that photographs of residents used for identification purposes are kept up to date. (Previous timescale of 31/10/05 not met). The registered person must ensure that medicines in the custody of the home are stored at a temperature that does not exceed 25oC. (Previous timescale of 05/12/05 not met). The registered person must ensure that the complaints procedure includes timescales for the process, information that the complainant can contact the CSCI at any time and the address of the CSCI. (Previous timescale of 31/10/05 not met). The registered person must ensure that the record of complaints is kept up to date and is available at all times for inspection by the CSCI. DS0000025440.V278484.R01.S.doc 31/03/06 30/04/06 31/03/06 31/03/06 The Lakes Nursing Home Version 5.1 Page 26 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. 10 Standard OP25OP38 Regulation 13 Requirement The registered person must ensure that a restrictor is fitted to the window in the dining room on Kendal suite. (Previous timescale of 31/10/05 not met). The registered person must ensure that repairs are made to the damaged ceiling in the first floor toilet and the walls and ceiling in the first floor hallway on Kendal suite. The registered person must ensure that all information and documents stated in Schedule 2 of the Care Homes Regulations 2001 are obtained in respect of employees at the home and must ensure that checks against the POVA list are made prior to employment. (Previous timescale of 31/10/05 not met). The registered person must ensure that a record is maintained of any accident or incident affecting the health and welfare of the residents. The registered person must ensure that notice is given to the CSCI of any serious injury, illness or incident affecting residents. Timescale for action 31/03/06 11 OP19 23 31/03/06 12 OP29 19 31/03/06 13 OP38 17 28/02/06 14 OP38 37 28/02/06 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 27 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. 15 Standard OP38 Regulation 13 Requirement The registered person must ensure that staff use safe systems for moving and handling residents. Timescale for action 31/03/06 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP14 Good Practice Recommendations The registered person should ensure that further consideration is given as to how the social care needs of the more highly dependent residents can be met. The registered person should ensure that residents are made aware of their rights to decide how and where they spend their day and should encourage staff to empower residents to exercise their choice in these matters. The registered person should ensure that the menus are displayed on the walls at such a height that residents can easily read them. The registered person should ensure that meals are presented attractively and on appropriate sized plates. The registered person should ensure that options available as a choice to the main meal being provided to residents are comparable nutritionally. The registered person should ensure that Tameside local adult protection procedures are available to all staff and that all staff are able to locate them. 3 4 5 6 OP15 OP15 OP15 OP18 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 The Lakes Nursing Home DS0000025440.V278484.R01.S.doc Version 5.1 Page 30 - 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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