CARE HOMES FOR OLDER PEOPLE
The Lakes Nursing Home Off Boyds Walk Dukinfield Tameside SK16 4TY Lead Inspector
Tracey Rasmussen Unannounced Inspection 6th March 2007 07:00 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 The Lakes Nursing Home DS0000025440.V332247.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. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 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 elaine@lakescare.co.uk 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.V332247.R01.S.doc Version 5.2 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. 10th October 2006 Date of last inspection Brief Description of the Service: The Lakes Nursing Home 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 a private company called Blackcliffe Limited. 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 provides accommodation for service users who require personal care only. Most 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 that may take place within the home. The current weekly fees range from £343.66 to £500 dependent on the package of care required. Further details regarding fees are available from the
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 5 manager. Additional charges may also be made for hairdressing, chiropody and other personal requirements. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors undertook this ‘unannounced’ 2nd key inspection site visit on the 6th March 2007. The home was not told beforehand of the inspection visit. The inspection included a review of all available information received by the Commission for Social Care Inspection (CSCI) about the service provided at the home since the last inspection. This included a spot inspection check in October 2006 which looked at medication practices in the home and a meeting to discuss improvements with the responsible person (owner) and manager in November 2006. All key inspection standards were assessed at the site visit and information was taken from various sources which included observing care practices, talking with residents; talking with visitors; interviewing the manager and other members of the staff team. A tour of the home was also undertaken and a sample of care, employment and health and safety records seen. Five resident’s care needs were looked at closely (case tracking) to determine the quality of service provided in the home. This means the care service provided to these residents was looked at and this included talking with the resident (where possible) to seek their opinions and looking at their records. A brief explanation of the inspection process was provided to the manager of the home at the beginning of the visit and time was spent at the end of the visit to provide verbal feedback to the manager and the responsible person for the home. What the service does well:
Residents and relatives all spoke positively about living in the home. Comments from residents included; “Staff treat me very well I am very glad I came here”; “staff treat me very well” and “When you ask you normally get what you want. On the whole it’s not too bad here”. Comments from relatives included; Staff are very friendly”; “Staff always involve me in care planning” and “The care my mother gets is amazing”. The home does provide care services to people with different cultural and religious backgrounds. The manager said the home worked hard with community services and families to ensure individual lifestyle needs were met. Areas of the home environment were benefiting from being redecorated and spacious well maintained garden areas were available to residents with pleasant areas to sit out.
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 7 Staffing levels in the home were appropriate to meet the high dependency levels of the residents. Staff were trained and more than half the care staff team had a NVQ 2 qualification. Resident’s personal monies are maintained safely by the home. Some general maintenance records for the home were available and these were up to date. What has improved since the last inspection? What they could do better:
It was clear from this visit that the manager, responsible person and staff had worked hard to improve the service they provided. Many areas had improved and the manager needs to ensure that improvements continue and are sustained. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 8 Two areas of improvement must as a priority improve and requirements have been made at this inspection and at previous inspection about the same issues. Employment checks were not completely safe because staff were working in the home before the necessary police check (CRB or PovaFirst) had been received. The home used bedrails to help protect residents from falling out of bed but the necessary checks to make sure the resident was safe from injury from the bedrails had not been done. Bedrails have been known to cause serious injuries so they should only be used following a detailed risk assessment to make sure the resident is safe. The resident (or their representative) should give written agreement to the use of bedrail. Some care plan documentation needs to be further improved and developed, in particular detailed wound care plans should have photos or information that lets the staff know if the wound is getting better or not. Care plans on the Derwent and Conistan units need to be more ‘person centred’. This means that information about the resident’s personal wishes and preferences should also be included. Evaluation of the care plans should also be undertaken so that the effectiveness of the care provided to residents is reviewed and changed if necessary. The home should look at ways to provide stimulation to high dependent residents. The same complaints procedure needs to be available and records of the actions the home has taken when they get a complaint could be better. Comment cards about the quality of service provided should be sent to relatives and professionals and staff need to have regular ‘supervision’ or personal support and development meetings. 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. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 9 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.V332247.R01.S.doc Version 5.2 Page 10 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were assessed before they moved into the home and the home confirmed they could meet the needs of the resident on admission. EVIDENCE: Five resident care files were seen, two from Derwent suite , two from Conistan suite and one from the Kendal suite. The care records had information that indicated that the home had made preadmission assessments or checks on the resident’s care needs before they came into the home. This enabled the manager of the home and the unit manager to assess whether the new resident’s care needs could be met properly by the services provided in the home, and provide information on the home to the prospective resident or their family. Some of this information recorded for resident’s care needs was quite basic
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 11 and could be developed more. Some of the care files were also supported by a community care assessments and these included detailed and varied information. The residents whose care files were reviewed were also spoken with or observed as part of the inspection process (case tracking). A number of residents were unable to comment on the assessment process before they came into the home but other residents said their relatives came to look around before admission. An information booklet that explained the services provided at the home was available at reception and a copy of the home’s last inspection report was also available. Comments from different residents included; “Staff treat me very well I am very glad I came here”; ‘I’m comfortable’ and ‘the staff do the best they can’. Relatives also spoke positively about the home. Intermediate care (standard 6) is not provided in the home. The Lakes Nursing Home DS0000025440.V332247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive care and support on the whole in the manner in which they wish to be supported. Some of the care planning documentation was not always sufficient to demonstrate how the staff meet the personal and specialist health care needs of residents. Medication recording practices were safer so residents got the right medication at the right time. EVIDENCE: Residents spoken with in all parts of the home had positive comments about the quality of care and service they received. Resident’s appearance were appropriate and respected personal preferences and choices about dressing respected. The hairdresser was working in the home. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 13 One relative said “Mum is always presentable” and “I am very happy with the care”. Residents said, “They look after you”; “staff treat me very well” and “Staff are very nice to me and always bring my medication”. One visiting nurse professional “It is absolutely brilliant. I am happy with service here”. Staff were busy throughout this visit attending to resident’s care needs. Staff spoken with were positive about working in the home. Staff said they were trained and supported to do their job and several had achieved a NVQ 2. Records of contact with community health services such as GP, community nursing services, chiropody and optical support were available. The home was also part of a pilot project to provide palliative care to residents in the home. Feedback from residents and relative receiving this specialised ‘end of life’ care was all positive. Five care plans were reviewed in detailed. The manager said she and her team of unit managers had been reviewing and improving the quality and content of the care planning records in the home. The sample of care records did indicate some work had been undertaken to update these. Care plan records on the residential Kendal suite were clear, concise and person centred and explained simply how care was to be offered in accordance with the residents likes and preferences. This is good practice. Care planning records on Derwent and Conistan suites which also provide nursing care had been improved however, more work is needed to make sure they provide a clear picture of what care each resident needed and how this was to be provided. For example one care plan asked staff to monitor for signs of low and high blood sugar but did not explain what these might be, another care plan said catheter care was to be provided but did not explain what this meant. Evaluations of the care plans were not always good enough because they did not give any information about the benefit the resident was getting from the care service. Concerns identified at previous inspection about inadequate wound care recording (wound mapping and photographing) had not been addressed. This is important because it ensures staff can see improvement and deterioration in any wounds and respond quickly. Bedrail assessments in accordance with health and safety legislation had not been undertaken. This must bed done as a priority. The home has got to make sure that any bedrails used in the home do not pose a health hazard to the resident. Following the last key inspection, an unplanned inspection (random) visit by a pharmacist inspector was undertaken where a number of areas of
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 14 improvement were noted. In response to the issues identified the manager had put into practice systems to audit medications in the home. This visit did identify improvements with the medication service. Records had been maintained correctly and administration practice was safer. The Lakes Nursing Home DS0000025440.V332247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Lifestyle preferences and social activities were available to meet the diverse needs of the residents. Residents are offered a choice at mealtimes and the quality of the food was good and nutritious. Visitors were made welcome. EVIDENCE: Since the last inspection visit, the home had employed an activities person. The activities person was observed throughout the day. She was active and involved with the residents. In the morning she took residents (who wished to join in) on Derwent off to another lounge to undertake an activity. In the afternoon the activity person supported residents to play bingo in the Conistan lounge. The activity person was also very active with individual residents throughout the day a resident was supported to visit the dentist in the afternoon and another resident was supported to walk about in the home. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 16 The activity person said she had found a rigid activity plan not to work because it didn’t allow her to adapt and change what she did with residents according to their needs and preferences. The activity person said she was enjoying her role but was very conscious that for every resident she provided some stimulation and support there were other residents who could or would not join in. The activity person also acknowledged that she needed to get better at maintaining accurate and up to date records of the activities residents benefited from. Residents spoken with said that their preferences regarding joining in activities were respected. Many residents spoken with also said their wishes regarding rising and retiring times were respected. One resident said, “I am going to play bingo this afternoon” and “I go to bed when I want, about 9.30pm staff help and leave my light on for me so I can read.” Visitors said staff were friendly and they felt welcome in the home. Positive comments were received about the quality of the meals provided in the home. These included “Food is alright, truthfully, it’s great actually. If you don’t like it they’ll get you something else”; “Food is good, I could with a bit more sometimes” and “I have a good breakfast – egg, bacon, toast and a banana.” The home is currently updating it’s menus to offer choices more proactively. The home offered the menu of the day with a list of alternatives. The new menu offers a choice of two meals and in future staff will ask the resident their preference the day before and order the meal from the kitchen. The catering manager said he joined in a resident and relative meeting recently and used the feedback to develop the new menus. This is good practice. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training in the home ensures that residents are protected from abuse. Residents were confident they would be listened to and taken seriously in the event of making a complaint. EVIDENCE: Appropriate information was given to residents on how to make a complaint and the timescales for action. However, policies and procedures in the home need upgrading to reflect the same information and provide an up to date guide for staff reference. One resident said “I find it very satisfying living here but if I did not I would feel comfortable making a complaint to staff or management.” Another resident said, “If I were not happy I would see the manager she is very helpful.” The home had received three complaints since the last inspection one of which is still under investigation. The complaints related to lack of care, issues with medication and privacy and dignity. Examination of the recording of complaints in the home found there was not enough detail relating to how the home investigated the complaints and what action had been taken to address the issues. The owner of the home was able
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 18 to discuss how these had been investigated and what action had been taken. However, records must be maintained to show a clear audit trail. There was evidence that staff had received training in the protection of vulnerable adults, which is also addressed during NVQ training. At interview staff demonstrated a good knowledge of how abuse may present and their role in its prevention. They were aware of their responsibilities in reporting any such instances. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well maintained and properly equipped home that was clean and odour free. EVIDENCE: The home employed housekeepers and these were observed to be busy throughout the home. Communal areas in the home were clean and tidy. A continuous programme of redecoration and re-carpeting of bedrooms and communal areas was being undertaken. The manager said that a new ergonomic bath was going to be purchased for the benefit of residents. Resident’s bedrooms had been personalised with individual possessions and shared rooms had privacy screening. Residents said they were satisfied with their rooms and the laundry service. Comments included, “My bedroom is
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 20 very comfortable and the laundry is good” and “The laundry is good”. And a relative said “Laundry comes back like new”. The lounges benefited from large wide screen TVs which allowed most residents to watch TV should they wish. The maintenance man was observed working in the home. His duties included attending to the day to day repairs, general maintenance of the home and monitoring health and safety. Service reports were available which detailed the ongoing maintenance in the home and this included fire safety records. A variety of equipment was available in the home to ensure the physical care needs of the residents could be met. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels, training and skill mix were appropriate to meet the needs of residents and promote health and safety. Some recruitment and vetting procedures were not followed as well as they should be to ensure that only suitable staff are recruited to work at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were appropriate to meet the needs and numbers of residents at the time of this visit. Some of the comments received from relatives included “ My mother is amazingly looked after,” “The care is good here because staff do not change very much” and “ They keep me involved in everything I am very much involved in care planning.” One relative was visiting the home for a review of care and said, “ I am very satisfied with the care here.” The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 22 Staff training has increased since the last inspection. There was evidence that since January 2007 nine staff had completed protection of vulnerable training, five moving and handling, four first aid and three the care of residents who required specialist feeding. All staff had taken part in the gold standard award for administrating care to those residents who are at the end of their life. The manager said that 62 of staff had now completed NVQ training. There was evidence that the home had put into practice Skills for Care induction procedures for new staff. Three newly recruited staff personnel files were examined. Shortfalls were noted in that criminal record bureau checks had not been obtained before commencement of employment. This issue has been identified at previous inspections. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36,36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of the home has improved with issues relating to quality assurance being addressed. Resident’s finances are safeguarded by the financial systems in the home. Staff receive training in health and safety ensuring residents needs are met. EVIDENCE: The manager is a qualified nurse who continues her professional development through attending short courses in line with residents needs. An example of
The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 24 this is the gold standard award in palliative care and the protection of vulnerable adults training. Two-unit managers have been appointed in order to deal with requirements made on the previous inspection and to raise standards in the home. The manager has an open and relaxed style leaving staff feeling supported in their role. The manager said the home works jointly with relatives to meet the needs of residents from ethnic backgrounds. Special diets are provided with religious and cultural needs being discussed. The manager said all referrals would be welcomed and assessment would be carried out to ensure the resident’s cultural needs could be met. This was particular important with end of life care. The home had made improvements in its quality monitoring systems. Relative’s questionnaires had been sent out. On return the home undertook an audit of the comments made and devised a list that required action. Two items on the list had been addressed. The manager said other items in relation to care practices and communication were being discussed at staff meetings. Although good progress has been made, the home now needs to extend the quality assurance questionnaires to other professionals and residents. There was evidence that residents meetings had begun and the manager said these would be undertaken quarterly. The inspector had the opportunity to interview two professionals visiting the home and both spoke highly of the care provided. Resident’s monies are held in a non-interest bearing account. Records were maintained of all transactions and receipts of purchases were available for inspection. Staff appraisals take place yearly. However, staff supervision needs to be implemented with staff receiving supervision a minimum of six times a year to ensure care practices are monitored in line with staff development and to identify staff training needs. In discussions with the manager they said action had been taken to seek training for the management team in supervision techniques. On completion of this regular staff supervision would commence. Staff said that senior staff observe working practices and comment on any improvements that are needed for the safety of residents. Staff training is provided in safe working practices e.g. moving and handling, food hygiene, first aid and the protection of vulnerable adults. Equipment in the home is checked and maintained by professionals e.g. hoist, gas, electric and fire extinguishers. Records were maintained of professional visits. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 25 Shortfalls were noted in some of the recording systems especially in relation to care planning and staff recruitment. Policies and procedures need to be reviewed to ensure staff have an appropriate reference. The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 2 3 The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 27 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 OP8 OP38 Regulation 13 Requirement Timescale for action 15/04/07 2 OP29 OP37 19 The registered person must ensure that risks to the health and safety of residents are identified, recorded and care practices implemented to reduce identified risks to the minimum. This includes the safe use of bedrails (Timescale of the 31/03/06 not met) The registered person must 30/04/07 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). 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 Good Practice Recommendations
DS0000025440.V332247.R01.S.doc Version 5.2 Page 28 The Lakes Nursing Home 1 Standard OP7 2 OP7 4 5 6 7 8 OP7 OP8 OP12 OP12 OP16 OP37 9 OP33 OP37 OP36 OP37 The registered person should ensure that the improvement and development of the care planning records continues and consideration given to using a clearer recording format on the Derwent and Conistan suites. The registered person should ensure that residents are consulted about their care and care plan interventions are developed further to include more person centred information about each resident’s needs and preferences and explains how these needs are met. The registered person should ensure after consultation with residents that care plans are evaluated for their effectiveness and this is recorded. The registered person should ensure that wound care planning included information detailing the size and depth of the wound and this is reviewed regularly. The registered person should ensure records of activities are maintained up to date. The registered person should consider strategies to support the activity person to meet the social and stimulation needs of the more highly dependent residents. The registered person should ensure the policy and procedure on how to make a complaint is upgraded to reflect information provided to residents. All complaints received should be fully recorded with records stating action taken by the home to address issues raised. The registered person should ensure that the quality assurance system extends to gain the views of professionals and residents. The registered person should ensure that staff receive supervision for a minimum of six times a year. 10 The Lakes Nursing Home DS0000025440.V332247.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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
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