Inspection on 07/09/05 for The Lakes Nursing Home

This inspection was carried out on 7th September 2005.

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 17/01/06

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 Off Boyds Walk Dukinfield Tameside SK16 4TY Lead Inspector Fiona Bryan Unannounced 7 September 2005 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 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 F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Lakes Address Off Boyds Walk, Dukinfield, SK16 4TY Telephone number Fax number Email 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 A Forrest CRH - Care Home 75 Category(ies) of DE - Dementia (36) registration, with number DE(E) - Dementia over 65 (36) of places OP - Old Age (72) PD - Physical Disability (39) PD(E) Physical Disability over 65 (39) The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 8:00am and 9:00pm. One registered nurse to be on duty between 9:00pm and 8:00am. The manager to be supernumerary to (3 and 4) above for 13 hours per week. Rooms: 4, 5, 6, 7, 8, 9, 10, 11, 15 and 16 on Kendal Suite cannot be used to accommodate service users in the category PD (Physical Disability). Date of last inspection 17 March 2005 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. 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 F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors, who spent time talking to residents, visitors and staff. Four residents were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of staff and residents’ records were examined including records of care, staff duty rotas, employment and maintenance records, and a tour of the building was carried out. Comments cards were left at the home for residents and relatives. Ten residents and six relatives had responded at the time of writing this report. What the service does well: What has improved since the last inspection? Since the last inspection a new carpet has been laid in the dining room on Derwent suite and the hallways have been redecorated. Continuous improvements have been made to the environment and fittings. A large number of new high profile beds and mattresses for Derwent and Coniston Suites have been provided. One member of staff felt that staffing levels had improved over recent months. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 More rigour is needed to ensure that all the necessary information about residents is obtained so that the home can be sure it can meet residents’ needs. EVIDENCE: Four residents’ care files were examined from Derwent and Coniston Suites. (The care files on Kendal Suite were not examined on this occasion, as they had been consistently satisfactory at previous inspections). Each file had individual care plans from the resident’s care manager but assessment details were not completed for one of the four residents. Some files had scant information regarding the residents’ social history, family contacts and leisure interests. Two staff interviewed were vague about how individual residents liked to spend time and what measures were in place to provide social and mental stimulation. Staff did not know anything about some residents’ previous jobs and life histories although one resident was very talkative and able to communicate well and another had information about these areas written in the care file. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 9 Four residents said staff knew them well and understood their care needs. Staff said that prior to the admission of a new resident the manager would explain their care needs, and a handover was given at the start of each shift so they could be updated about any day to day changes to the residents’ needs. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Care plans do not fully identify the needs of the residents, leading to the potential risk that health care needs may not be met. The majority of residents felt that they were treated with respect and their dignity was maintained. EVIDENCE: The care plans for four residents were examined. Care plans were sometimes vague, for example stating to “make sure appropriate aids are used” for one resident who is incontinent, without stating what the aids were and “ensure necessary treatment is carried out to treat infection” for one resident with MRSA, without stating what the treatment was and the timescales for action. One care plan for a resident whose main problem was the risk of poor nutrition was vague, although there was evidence that staff were taking the correct actions to ensure that their nutritional intake was properly monitored. One resident who was prescribed strong painkillers had no care plan to ensure that the effectiveness of the medication was properly monitored. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 11 The care plans for one resident who had previously stayed at the home for respite care had not been reviewed until a week after they were readmitted. The care plan for one resident with epilepsy was very good with detailed information about the actions to be taken. Three residents said they did not feel that they were always kept informed about any changes that were being made to their care. However, two residents felt they were kept informed about changes and one relative said the care needs of the resident had been explained by staff. Although the home has a key worker system residents could not identify who their key worker was and key workers were vague about what the role entailed. Residents had attended out patient appointments at the hospital and had been seen by other health care professionals such as GP’s, chiropodists and opticians. Wound care plans contained limited information regarding the size and grade of wounds and the progress of treatment, with evaluations only stating “dressing renewed to leg” or “plan ongoing”. Wounds had not been photographed and no wound mapping had been undertaken. Nutritional risk assessments had been undertaken for one resident, which may have been inaccurate as they were not weighed at the time of the assessment. Five residents and one relative said staff were pleasant and kind, but one said some staff were very good whilst others were reluctant to do anything and had refused to help because they were about to go off duty. One relative said the resident they visited always looked smart and presentable. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 14 and 15 Further consultation is needed to ensure that the home satisfies all of the residents’ social and recreational needs and their wishes in respect of their daily routine are taken into account. Visitors are encouraged and welcomed in to the home. A significant number of residents were not satisfied with the meals provided by the home. EVIDENCE: Nine of the ten residents who returned comments cards said the home provided suitable activities. The home produces a newsletter, which gives details of past and forthcoming social events for the residents. Residents had enjoyed a VE celebration and some residents had attended the mayor’s party at Dukinfield town hall. A summer fair and barbecue had been held and some residents from Kendal suite had been out for a potato pie supper at the local pub. Further trips were planned once a month until the end of the year. Three residents said they were able to choose what time to get up and go to bed. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 13 Two residents said they had enjoyed going out in the mini bus for a pub lunch. One resident said they liked to spend time in the garden. One resident said they liked to read and watch TV but otherwise there was not much to do. Another seven residents said there was not much to do to pass the time, four saying they mainly watched television and two saying they got bored. Two residents said they sometimes played skittles and one resident said they occasionally played bingo. Three residents said they would like to go out more. One relative who visited the home regularly said there did not seem to be many activities provided. The manager disagreed with the comments that the provision of activities was limited but was unable to produce evidence of social events and activities that residents had participated in because the activities organiser was on holiday and there was no access to her records. Possible expansion of the key worker system for those residents who are not satisfied with the activities provided at the home may allow them further opportunities for preferred leisure interests. One resident was under the impression that they had to stay in the lounge all day and were “not allowed” to go to their own room. Discussion with the unit manager indicated that restrictions had been placed on the resident due to concern that the resident would fall and sustain an injury walking up the stairs. The unit manager felt that staffing levels were such that it would be difficult to accommodate the estimated amount of time it would take to supervise the resident going up and downstairs. The use of risk assessment and the involvement of the family and the resident in the decision making process was discussed. Seven residents said that they could receive visitors whenever they wished and one relative said staff made them welcome. Of ten residents’ comments cards returned, four residents said they only sometimes liked the food and one did not like the food provided at the home. Five residents stated that they liked the food. Residents that were spoken to said that the food was “not so bad”, “Ok”, “satisfactory”, “variable” and “adequate”. Some residents did not think a choice of meal was offered whilst others said sandwiches were provided as an alternative. One resident said they did not like the meals but were offered jacket potatoes or omelettes as alternatives. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 14 One resident said the menu was displayed on the wall outside the dining room but it was too high up to read from a wheelchair. Another resident commented that what was stated on the menu was not what was always served in reality. Two people commented that meal portions were quite small. Residents confirmed that hot and cold drinks were served between meals and some residents said supper was provided on request. Lunch was corned beef hash. A small board outside the dining room, next to the main menu stated that alternatives could be ordered before 10.30am for lunch and before 2.30pm for tea. Alternatives included omelettes, salads and jacket potatoes. Most residents asked did not know what was being served for tea. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 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 standard(s) 16 and 18 Lack of information in the home’s complaints procedure and the way in which some complaints have been handled have resulted in some relatives losing confidence that their complaints are investigated properly or used to improve practices in the home. Further training and stricter adherence to recruitment procedures are required to ensure that residents are protected from abuse. 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. One relative said they had complained to the manager in the past and the problem had been resolved. The complaints procedure is displayed in the reception areas to Kendal suite and the main building. However, 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. Two complaints have been made known to the CSCI since the last inspection, as the complainants were not satisfied with the response from the registered provider. A discussion was held with the manager about how the home dealt with complaints, as responses the home had made to complainants, that had been copied to the CSCI appeared to be confrontational and dismissive. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 16 The home’s complaint’s policy and it’s stated ethos in dealing with complaints did not appear to have been followed in these cases. The manager disputed this and stated that other complaints had been handled well and complainants had been satisfied. As the record was not available it was not possible to verify this. In house training is provided to staff regarding the recognition and reporting of abuse and the local authority procedure was available for staff to read. Two staff said they would report suspected abuse to the manager but were unsure of the role of the CSCI or social services in the protection of vulnerable adults. Some staff had not received training in topics such as dealing with challenging behaviour. The registered person must ensure that staff receive training in dealing with challenging behaviour in order to ensure that they have the skills and knowledge to manage service users who could be at risk of abuse. As discussed elsewhere in this report shortfalls in recruitment procedures lead to a possibility that unsuitable staff may be employed to work at the home. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 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 standard(s) 19, 20, 24, 25 and 26 The home is well maintained, safe, clean and pleasant to live in. EVIDENCE: Throughout the home there was lots of evidence of ongoing maintenance and refurbishment. On Kendal suite the unit manager said that new carpet had been ordered for the hall, stairs, landing and sun lounge, which was to be fitted in the near future. As this was a requirement at the last inspection a new timescale has been agreed for completion. New cushion flooring has also been ordered for the dining room and a timescale agreed for completion. Residents in three rooms had chosen new carpets for their rooms. A new gas fire had been purchased for the lounge. Radiator guards had been fitted and one of the hallways had been redecorated. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 18 Twenty-nine new high profiling beds had been purchased for Derwent suite and four beds had been purchased for Coniston suite. Coniston lounge was in the process of being redecorated. Bedrooms were personalised to residents’ individual choice and to suit their needs. The décor throughout the home was attractive, homely and comfortable. 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 door locks for some of the residents’ rooms on Derwent suite were not suitable as the residents could be at risk of locking themselves in and staff not having access to the room in an emergency. One lock had been taped over by the resident’s family to avoid this. A small kitchen is provided off the main reception area for the use of residents and visitors. All laundry equipment was in good order and the laundry is operated for up to 11.5 hours per day. Six residents and one relative said they were happy with the laundry and cleaning services provided by the home. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Staffing levels are usually sufficient to meet the needs of the residents. Residents are not protected by the home’s recruitment practices. EVIDENCE: Examination of staff duty rotas indicated that staffing levels were generally satisfactory. One relative’s comment card stated she felt there were not always sufficient staff on duty. One relative commented that staff were always very busy. Three residents felt there were not always enough staff as they sometimes had to wait for long periods of time to go to the toilet especially after breakfast and at other busy times of the day. Another three residents commented that staffing levels were sufficient. Two staff members felt that staffing levels were satisfactory but one member of staff felt that on occasions staff had difficulty meeting residents’ needs due to the high dependency of many of the residents and the challenging behaviour of a small number of residents that sometimes required staff to provide more individual attention. Four staff personnel files were examined. In some cases the employment histories of the employees were not fully completed. References had been obtained but it was not clear in all cases how long the referee had known the applicant and it what capacity. One employee had only one reference on file. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 20 Some staff had started employment at the home without first having been checked for inclusion on the POVA register and without an up to date criminal records disclosure certificate. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Further staff training is needed to ensure that the health, safety and welfare of residents and staff are protected. EVIDENCE: A maintenance person is responsible for carrying out weekly health and safety checks of the building and these are recorded. Staff could not recall when they last had fire training and the last available records were dated September 2004. Staff at the home do not participate in fire drills and are therefore at risk of not fully understanding or forgetting their role and the procedure to follow in the event of a fire. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 22 The member of staff working in the laundry was unsure about which residents in the home had MRSA. Systems within the home should identify to all staff which residents have infections so that adequate infection control measures can be maintained. The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 2 3 x x x 3 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 2 The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 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 3 Regulation 14 Requirement The registered person must ensure that a full assessment is undertaken for all residents prior to their admission to the home. The registered person must ensure that a care plan is written for each service user, which sets out in detail the action that needs to be taken to ensure that all aspects of the health, personal and social care needs of the service user are met. The registered person must ensure that the treatment and outcome of pressure sores is recorded in the residents care plan. The registered person must ensure that so far as practicable residents are able to make decisions about the care they receive and their health and welfare. 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. The registered person must Timescale for action 31/10/05 2. 7 15 31/10/05 3. 8 15, 17 31/10/05 4. 12 12 31/10/05 5. 16 22 31/10/05 6. 16 17 31/10/05 Page 25 The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 7. 18 13 8. 19 23 9. 20 23 10. 25, 38 13 11. 29 19 12. 38 23 13. 38 13 14. 19 23 ensure that a record is kept of all complaints made that includes details of any investigation and action taken. The registered person must ensure that staff receive training in handling challenging behaviour. The registered person must ensure that the stair carpet on Kendal suite is replaced. (Timescale of 30/4/05 not met). The registered person must ensure that the flooring in the dining room on Kendal suite is replaced. The registered person must ensure that a restrictor is fitted to the window in the dining room on Kendal suite. (Timescale of 31/5/05 not met). 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. The registered person must ensure that staff receive fire safety training and participate in fire drills and a record is kept of each drill and which staff members attended. The registered person must ensure that systems are in place to ensure that all staff in the home are aware of infection control procedures. The registered person must ensure that the ceiling in the toilet on Kendal suite is repaired. 28/2/06 31/10/05 1/12/05 31/10/05 31/10/05 30/11/05 31/10/05 30/11/05 The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 8 12 15 Good Practice Recommendations The registered person should ensure that photographs are taken of residents wounds, in order to assist in assessing the effectiveness of treatment. The registered person should ensure that residents who are not satisfied with the arrangements for activities are consulted with to ensure their needs are met. The registered person should ensure that residents are aware of the choices on offer at meal times and should regularly review the meals with residents to ensure their satisfaction. The registered person should ensure that door locks on the residents rooms are suitable for their purpose. 4. 24 The Lakes F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, 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 F54 F04 the lakes U s25440 v248131 070905 stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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