Inspection on 29/05/06 for The Laleham

This inspection was carried out on 29th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Laleham 16/05/08

The Laleham 31/05/07

The Laleham 03/10/05

The Laleham 23/05/05

The Laleham 17/01/05

The Laleham 09/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Laleham 117/121 Central Parade Herne Bay Kent CT6 5JN Lead Inspector Mark Hemmings Unannounced Inspection 30th May 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 Laleham DS0000023571.V293732.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 Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Laleham Address 117/121 Central Parade Herne Bay Kent CT6 5JN 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) 01227 363340 Kent County (Residential Homes) Limited Mrs Doris Elizabeth Robertson Care Home 75 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (1), Old age, not falling within any of places other category (73) The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residential care for people with a learning disability is restricted to one (1) person whose d.o.b is 29.06.1946 Residential care for people with dementia is restricted to one (1) person whose date of birth is 04.05.1922 3rd October 2005 Date of last inspection Brief Description of the Service: The Laleham (the Home) is registered to provide accommodation and personal care for up to 75 people. Of this number 74 can be older people (service users) who are 65 years of age and above. There is also provision for one younger adult who has a learning disability and one older person who experiences a dementia-like condition. The premises are five older properties, which have been converted into one building. The accommodation is arranged on three floors. There is a passenger lift giving step-free access to each of the levels. There are 43 single occupancy bedrooms and 15 bedrooms, which can be shared by two people. At the time of the inspection visit, all of the latter were being used as singles. It is understood that this will continue to be the case. There is a call bell system which is designed to assist service users to request assistance from most locations in the accommodation. The Home is located close to the centre of Herne Bay. To the front, there are views across the promenade and the sea. The Laleham is operated by Kent County (Residential Homes) Ltd (the Registered Provider). This is a private company for which there are two Directors. The Registered Manager now has retired and her place has been filled by the current Acting Manager. The Registered Provider supplies information to prospective service users through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure which outlines the principal features of the facilities and services available in the Home. Also, the Registered Provider ensures that a copy of the most recent Inspection Report from the Commission, is available for reference in the Home. The current range of fees charged by the Registered Provider runs from £303.25 to £360.00. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Report has been based upon a number of sources of evidence. These included a review of the correspondence in relation to the Home received by the Commission since the last inspection. Another source of evidence involved any written information received from service users and from their relatives. Also, the Inspector completed an unannounced site visit to the Home. This took about seven hours to complete. During this time, the Inspector spoke in some detail with nine of the service users. Most of these discussions were in private. The Inspector also joined a number of the service users for lunch. The Inspector spoke with one of the two Directors of the Registered Provider. In this Report, she is referred to as being the “Responsible Individual”. Also, he consulted with the Acting Manager. The Inspector spoke with three of the care workers, with one member of the housekeeping staff and with the cook. In addition, the Inspector spoke with two relatives who were visiting service users in the Home and who asked to meet with him. The Inspector examined various parts of the accommodation and he reviewed a selection of the key records and documents. The Inspector concludes that the Registered Provider operates generally the Home in a suitable manner to enable the needs of the service users in residence to receive the support and assistance required. A limited number of omissions was identified which the Registered Provider has been required to rectify. What the service does well: Service users said that the Home provides them with a relaxed and generally comfortable setting within which to make their home. They observed that they received all the assistance they need. Also, that the care workers are attentive and kind in their manner. The Inspector considers that the provision of personal care services takes place within a prudent assessment of potential risks to health and safety. The Home’s catering service provides the service users with meals which they consider to be enjoyable and sufficient. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The Registered Provider has not yet submitted to the Commission an application to register someone in the post of Registered Manager. This is a significant omission. The Registered Provider has not taken a proactive approach to identifying and rectifying the inadequate heat level noted by the Inspector in Lounge A and Lounge B. The Registered Provider has not completed a suitably detailed assessment of the risks constituted by unguarded radiators, so that an appropriate management plan in relation to each can be adopted. This is important because a considered response needs to be made so that the likelihood of a service user being burnt accidentally is reduced to a reasonable minimum. The Registered Provider has not yet completed the discrete improvements in the kitchen which have been required by the local Department of Environmental Health. This is important because the items in question once in place will better enable staff to clean and to operate the kitchen in accordance with good food handling methods. There are omissions in the present internal quality assurance system operated by the Registered Provider. This is important because service users are the experts on what it is like to live in The Laleham. Consequently, it is essential that their views about the Home’s adequacy are incorporated into the Registered Provider’s ongoing development plan. The Registered Provider does not yet have in place a suitable system designed to ensure that all members of staff are competent demonstrably to operate reliably the Home’s fire safety regime. This is important because the actions taken by staff determine largely the level of protection enjoyed by everyone in the Home. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 7 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 Laleham DS0000023571.V293732.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 Laleham DS0000023571.V293732.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): 3, 4 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. Service users’ needs for assistance are assessed suitably before admission. Service users are confident that their needs for personal care will be met when they enter the Home. Suitable provision is made for people who are admitted to the Home for shorter periods of time. EVIDENCE: The Acting Manager said that she completes an assessment of each prospective service user’s needs for assistance before a decision is made about whether or not the Home is a suitable place for the person’s residence. The Inspector spoke with several service users about their experience of having moved into the Home. They said that the Acting Manager had established their needs for assistance and about their preferences in relation to day to day things. They observed that the care workers had been prepared in advance to respond to their requirements at the point of their admission. Care workers The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 10 told the Inspector that the Acting Manager briefs them about the needs of new service users and that this constitute a useful introduction upon which they can build as they get to know someone better with time. The Acting Manager is aware of the range of specialist resources which is available in the community and which can be accessed should a service user need additional help. The Inspector reviewed evidence which showed that some of these resources had been used in a timely manner since the completion of the last inspection visit. The Inspector noted that some service users are admitted for shorter periods of time. This might be in order to allow some free time for relatives who provide care at home for the person, or it might be to enable someone to leave hospital before they are quite ready to return to their own home. The Inspector noted that the Acting Manager has a suitable understanding of the need to ensure that these service users are assisted to leave the Home again when their stay has elapsed. This is done so that short term periods of care do not slip into periods of accommodation which are longer than might be necessary. The Laleham DS0000023571.V293732.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their present and future needs for personal care will be met in a reliable and consistent manner. They are suitably consulted about the assistance they receive. Service users’ health care needs are met fully. Service users consider that members of staff are respectful and that they appreciate their needs for privacy. EVIDENCE: Service users said that the care workers offer them all the assistance they need and that this is provided in a reliable and consistent manner. The Acting Manager said that there is a plan of care for each of the service users and that these are designed to support care workers when responding to individual requirements. The Inspector examined a selection of these documents. The items he sampled were found to be present in adequate detail, given the related systems in use which inform care worker’s orally about the provision to The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 12 be delivered. The care workers were noted to be conversant with a selection of the information in question. The Inspector observed care workers when providing elements of assistance to some of the service users. He noted this provision to be appropriate and to be broadly consistent with that described in the respective plans of care. The Acting Manager is aware of the need to ensure that service users are assisted to maintain their health. She said that care workers are alert to the need to identify occasions when someone is becoming unwell. This is so that medical assistance can be sought promptly. Care workers confirmed this account. Service users said that they are confident that their family practitioner will be called should the need arise. The Inspector reviewed evidence which showed that since the last inspection visit, the Acting Manager had indeed requested assistance from a range of medical personnel as and when the need had arisen. Service users said that the care workers assist them with managing the medicines which have been prescribed by their family practitioner. They said that the care workers retain these medicines and that they dispense them reliably. The Inspector examined a selection of the administrative arrangements overseen by the Acting Manager to support this operation. He noted that the systems in use were reasonable and should function to ensure that each service user receives medication in the manner intended by their family practitioner. Service users said that care workers are cordial in their manner towards them, while at the same time being respectful of their individual preferences. The Inspector saw plenty of examples of this with care workers being kind in their manner and attentive in their approach. Also noted, was the way in which care workers varied their response depending upon the known preferences of the people concerned. For example, some people wanted to spend quiet time in their bedrooms, while others wanted to be in the company of others in the lounges. The Laleham DS0000023571.V293732.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, 13, 14 and 15. Quality in this outcome area is good. This judgement is made using available evidence including a visit to this Service. Service users have access to a suitably varied range of social activities. Service users are assisted to maintain normal contacts with family and friends. Service users are enabled to exercise suitable choice in their everyday lives. Service users are offered a suitably healthy diet. EVIDENCE: Various social activities are convened in the Home. Service users consider themselves to be occupied suitably. The Inspector noted that the record of attendance which should be completed, sometimes gets overlooked. This means that the Registered Provider does not have as detailed an understanding as might be the case, of which activities are proving to be popular and which are less so. The Responsible Individual said that this record would be completed in future, so that the information in question will be to hand. Service users said or indicated that the pace of daily life in the Home is relaxed and unhurried. They used various examples such as the fact that they can retire to their bedrooms whenever they wish. Also, they observed that it is up The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 14 to them to decide when to get up, when to go to bed and how to spend their day. Service users say that they receive good quality meals and they always have enough to eat. The Inspector joined service users for a meal. He noted the food to be adequate in quantity and to have been prepared well. The meal time was a relaxed experience with people dining at their own speed without any sense of being rushed along. The Inspector examined the record of food served in the Home. He concluded that it indicated that the service users are offered the opportunity to have a normally varied diet. The cook said that there are sufficient provisions in the Home to enable all the meals listed on the planned menu to be prepared. The Laleham DS0000023571.V293732.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. Service users consider that their views are listened to and that as necessary they are acted upon. Arrangements are in place which are designed to protect service users from abuse, neglect and self harm. EVIDENCE: There is a complaints procedure which explains how service users and other stakeholders can make a complaint about any aspect of the facilities and services provided in the Home. Service users say or indicate, that they are confident that any matter they raise will receive serious attention and if possible will be addressed. The Responsible Individual said that the Registered Provider had not received a complaint in relation to the Home in the time since the last inspection visit. The Inspector noted that the Commission also had not received a complaint in relation to The Laleham. The care workers have a sound understanding of what constitutes good care practice. As part of this, they are aware of the need to be alert to instances which might jeopardise the well-being of a service user. Also, they are aware of the various agencies external to the Home to which reference can be made should they become concerned about a service user’s wellbeing. Service users said or indicated that they feel safe living in The Laleham. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 16 Care workers said that they had not witnessed any incidents which caused them to be concerned about a service user’s wellbeing. The Laleham DS0000023571.V293732.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, 22, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Service users are provided with a generally satisfactory environment. Suitable provision has been made to assist service users who experience a measure of reduced mobility. There are two omissions in the arrangements used to heat the service users’ accommodation. Suitable arrangements are in place to achieve a normal domestic standard of cleanliness. EVIDENCE: Service users said or indicated, that they are comfortable living in The Laleham. They consider the accommodation to be homely and welcoming. The Inspector did not identify any significant defects in the general presentation of the accommodation. However, he has noted to the Responsible Individual that some of the toilets and bathrooms look to be a little bare. She said that this matter would be reviewed and that as necessary it would be rectified. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 18 The local Department of Environmental Health has identified a limited number of defects in the kitchen. The Responsible Individual said that the Registered Provider has made plans to enable all of these matters to be addressed. The Inspector reviewed evidence which confirmed this account. The Inspector noted that the regulator in question has yet to finalise a timescale within which it expects the work in question to be completed. There are various items of equipment in place to assist care workers when helping those service users who experience a measure of reduced mobility. These include things such as a hoists in the bathrooms and banister rails along hallways. Service users said that they received all the assistance they need to enable them to move around in comfort. Care workers said that enough provision has been made to enable them to undertake safely this aspect of their work. Service users said that their accommodation is kept comfortably warm. However, the Inspector did note that two lounge areas did feel to be rather cool. This was because there was a considerably draft from the windows, the frames of which were fitted poorly. There is a Required Development in relation to this matter at the end of this Report. The Registered Provider has not installed guards in order to shield the heated surfaces of all of the radiators which could result in a service user being burnt in the event of a fall. The Responsible Individual said that those which have not been guarded have been assessed informally as not constituting an undue risk to service users. This was said to be due to various factors such as the heat level they achieve and their location. The Inspector did not identify any information which led him to question further this statement. The Inspector has asked the Registered Provider to formalise the assessment reported above. This will be done by preparing a written document which then should be more easy to keep under specific review. The development should enable the provision in question to be strengthened promptly should a service user’s needs require this to be done. The Registered Provider said that this measure will be completed by 1 September 2006. Service users said that there always is an adequate supply of hot water available for their use. Care workers confirmed this account. The Responsible Individual said that all hot water taps located in areas of the accommodation occupied by service users, are fitted with regulator valves. These help to ensure that the temperature of the hot water service is kept at a level which is not likely to result in a service user being scalded. Service users said that their clothes are adequately laundered and that they are returned promptly to them in a presentable condition. The Responsible Individual and care workers said that the laundry is equipped adequately and that it is orderly in its operation. The Inspector understands that the premises and their use continue to comply with the requirements of the local The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 19 Department of Environmental Health and with other relevant regulatory authorities. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the Service. There is an adequate number of staff on duty to ensure service users’ needs for assistance are met. There is an omission in the security checks completed to ensure that only suitable people work in the Home. Care workers have the competencies they need in order to work effectively. EVIDENCE: There are six care workers on duty to respond to service users’ needs for assistance from early in the morning until the evening shift commences when the number reduces to four. At night time, there are two waking care workers on duty. The care workers are supported in their work by other people who undertake catering and housekeeping tasks. The Inspector considers that there are enough staff on duty to enable service users’ needs to be met in a timely and reliable manner. More than half of the care workers employed in the Home have acquired a National Vocational Qualification (NVQ) in health and social care. This level meets the specification required by the Standards. The Responsible Individual intends to continue to increase the number of care workers who have acquired the Award. Naturally, this is an example of good management practice because The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 21 it provides care workers with additional opportunities to familiarise themselves with the principles of good residential care practice. The Registered Provider completes a number of security-related checks. These are designed to ensure that all members of staff employed in the Home are suitable to be entrusted with access to service users who may be vulnerable. The Inspector noted there to be a category of omissions. There is a Required Development in relation to this matter at the end of this Report. The Acting Manager said that all new care workers receive introductory training. This is designed to ensure that they have the basic competencies necessary to enable them to work without direct supervision. The Inspector noted that aspects of the Registered Provider’s current arrangements can be strengthened further. This will entail refining the range of subjects to be assessed and being more clear about the evidence to be used when completing these evaluations. The Registered Provider is going to consider this matter within the context of a new national model of good practice to which the Inspector has referred it. In addition to the introductory training, existing care workers undertake a number of training courses. These are designed to enhance their capacity to deliver care. The Responsible Individual said that the Registered Provider is aware of the specific responsibility placed upon it to ensure that all care workers are validated as having the competencies necessary to enable them to support effectively the service users currently in residence. In connection with this, the Responsible Individual said that the Registered Provider is going to complete a review of the competencies possessed by each of the care workers. This is being done in order to ensure that there are no omissions. The Inspector understands that this exercise will be completed by 1 May 2007. As noted earlier in this Report, service users consider that care workers are supportive in their manner and that they are competent to deliver the assistance they need. The Inspector observed care workers when they were assisting the service users. He noted this help to be delivered in an appropriate manner. The care workers demonstrated that they were able to respond effectively and reliably to the service users’ individual requirements. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. There is an omission in what otherwise is the suitable management system in place to support the delivery of care and accommodation services in the Home. The internal quality assurance system in the Home needs to be strengthened further. Service users’ financial interests are safeguarded. The work completed by members of staff is supervised. There is an omission in the otherwise suitable provision in place to ensure that the health and safety of the service users and of members of staff is safeguarded. EVIDENCE: There is various direct and indirect evidence to show that the Acting Manager supervises suitably the day to day operation of the Home. However, the The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 23 Registered Provider has not yet submitted to the Commission an application to register someone in the post of manager. Therefore, the Inspector is not in a position to review fully the situation. This development is now overdue considerably. There is a Required Development in relation to this matter at the end of this Report. Service users say or indicate that the Home is run without there being any intrusive rules or routines. This means that they can continue to experience a normal home life of their choosing. The Registered Provider operates a system by means of which service users are invited to comment about their home. The Registered Provider needs to develop this provision further. In particular, the results of each annual round of consultations should be summarised in a written Quality Report. This Report which should explain the Registered Provider’s proposed responses to any suggested improvements, should then be fed back to service users. This is so that people can know what will be done in order to respond to their contributions. There is a Required Development in relation to this matter at the end of this Report. The Registered Provider assists some of the service users to administer aspects of their weekly personal spending allowance. The Inspector examined a selection of the records kept to track the various transactions involved. These were found to be satisfactory in that there was a clear account of the movement of the funds concerned. In conversation with the Inspector, none of the service users voiced any concerns about this aspect of the assistance they receive. The Acting Manager meets with each care worker on a periodic basis to review their work and to resolve any difficulties. Care workers said that they consider the Acting Manager to be supportive and to be knowledgeable about residential care. The Acting Manager in turn is supervised by the Responsible Individual. The Responsible Individual said that all items of equipment in use in the Home remain in good working order. The Inspector reviewed a selection of items such as maintenance and servicing documents. He did not identify any information which led him to question further this statement. The Inspector reviewed evidence which supported the Responsible Individual’s report to the effect that the Kent Fire and Rescue Service has not recommended the introduction of any fire safety equipment additional to that which already is in operation in the Home. The Inspector noted that the Registered Provider since the last inspection visit, has completed all of the various checks which are designed to ensure that the Home’s fire safety equipment remains in a suitable operational condition. The Registered Provider does not operate a system which is designed to validate regularly that all members of staff are competent to operate effectively the Home’s fire safety regime. This is important because the actions The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 24 taken by members of staff, determine largely the level of fire safety protection provided in the Home. There is a Required Development in relation to this matter at the end of this Report. The Responsible Individual said that the Registered Provider has completed a review of the premises in order to identify any potential hazards which might compromise the health and safety of both the service users and members of staff. She reported that no such hazards had been found. The Inspector examined various parts of the premises. He did not notice any obvious hazards which led him to question further the Registered Provider’s assessment. The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 25 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 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 X X 3 X X 2 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 2 X 2 X 3 3 X 2 The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 23 Requirement Timescale for action 01/09/06 2 OP31 19 The Registered Provider should ensure that all future appointments made to the staff team as necessary are supported by a suitably detailed employment history. The Registered Provider should 30/05/06 submit to the Commission a duly completed request to register an appropriate person in the post of Registered Manager. The Registered Provider should ensure that it operates a suitable internal quality assurance cycle in the Home. This should comprise an annual round of consultations with service users, the results of which should be summarised in a written Quality Report. The material in this document should be fed back to service users and should form the basis of the next annual cycle of the internal quality assurance function. 01/07/06 3 OP33 8 The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 27 4 OP38 23 The Registered Provider should ensure that all members of staff are included within a suitably detailed system which is designed to validate their competency to avoid the occurrence of a fire safety emergency and to respond effectively to one should the need arise. 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Laleham DS0000023571.V293732.R01.S.doc Version 5.1 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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