Care Home: Lakelands

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What the care home does well In the absence of the registered manager, the acting manager has managed the home effectively ensuring a high standard of care for the people living there, has been maintained. Residents have access to everything they might need to live a comfortable life. If something is needed, relevant to a person`s health and well-being arrangements are made for it to be obtained. The premises are clean and safe and the standard of the accommodation is good. There have been few staff changes, so residents are looked after, by people they know and can trust. Staff are well trained and show commitment towards giving good care to the residents. Records are kept to a good standard. There are additional checks and procedures in place to ensure everything is properly accounted for. Relatives are made welcome and are always consulted and involved. What has improved since the last inspection? The information in the service user guide had been reviewed and updated. The times of the medication round had been changed so as not to interrupt mealtimes. The home has purchased a computer for any resident who wishes to use it. What the care home could do better: Information stated on the AQAA indicates that the home is planning to make further changes as a result of listening to people who use the service by introducing life plans and diaries, by involving residents in interviews of new staff, and redecoration of first floor lounge and bedrooms. The home would also like to utilise the first floor kitchen for residents to promote their independence. CARE HOMES FOR OLDER PEOPLE Lakelands Grizedale Drive Higher Ince Wigan Greater Manchester WN2 2LX Lead Inspector Judith Stanley Unannounced Inspection 30th January 2008 09:20 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 Lakelands DS0000005775.V358341.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. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakelands Address Grizedale Drive Higher Ince Wigan Greater Manchester WN2 2LX 01942 323154 01942 826199 margaret.bennett@clsgroup.org.uk www.clsgroup.org.uk CLS Care Services Limited 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) Mrs Margaret Bennett Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (40), Physical disability over 65 years of age (8) Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include:up to 40 service users in the category of OP (Older People) up to 8 service users in the category of PD(E) (Physical Disabilities over 65) up to one female service user in the category of DE(E) (Dementia over 65) up to 2 service users in the category of MD(E) (Mental Disorder over 65) The service should employ a suitably qualified and experienced manager who is registered with the CSCI. One named service user (GH) may be accommodated in the category of DE(E) (Dementia over 65 years of age). Two named service users (LG and HS) may be accommodated in the category of MD(E) (Mental Disorder over 65). 12th September 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Lakelands Care Home is part of the CLS group of Homes. The home is situated on a housing estate set in its own grounds with car parking facilities. The home is close to some local amenities and public transport runs close by. Lakelands is a purpose built two storey home, which offers accommodation for up to 40 residents who require assistance with personal care and support. All rooms are single, there are no rooms with en suite facilities, however all rooms are fitted with a hand basin and bathrooms and toilets are close by. There is a passenger lift to the first floor. Lounges and dining areas are available on both floors. There is outside garden space with suitable seating available. At the time of the inspection the current scale of fees ranges from £274.38 to £305.00 per week. Additional charges are made for hairdressing, newspapers, toiletries, holidays, trips and transport. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection which included a site visit which the home did not know was going to happen, was conducted over a six-hour period. At the time of the inspection the registered manager was on sick leave, the acting manager was available to assist with the inspection. Part of the time was spent in the office looking at the information the home holds on residents (care plans) and other records the home needs to keep to ensure that the home is being properly run. The rest of the time was spent talking with residents, a relative and staff and looking around the home. Prior to the inspection the home was sent an Annual Quality Assurance Assessment form (AQAA). This was completed and returned to the CSCI. This information tells the inspector about how the home is meeting the National Minimum Standards, what they do well at, and in what areas they need to improve. To gather more information about the home and the services provided comment cards were sent to residents, relatives and staff and to other people such as doctors and district nurses. Six residents, two relatives and nine staff completed comment cards. One resident said, “ There is always a good selection and plenty of food”, the resident went on to say, “ I am as happy as I can be here.” Residents added no further comments however the responses indicate overall satisfaction of the home and the services provided. One relative said, “ The home creates as much of a homely feeling as possible. They are always kind and caring with everyone, they are cheerful and nothing is too much trouble. I can only express my thanks to all the staff at Lakelands”. Staff response to comment cards was good; they indicated that the training they receive was relevant to their role. One member of staff said, “ My induction was very thorough and I have been offered many different training courses”. With regard to what the service does well, one member of staff has written, ‘ the home is very person orientated, it’s very friendly and we all pull together as a team’. During a conversation with a resident who was on a short term placement, initially for one week, the resident told the inspector he was delighted with the care he had received and was extending his stay for two more weeks. Complements were made about the dedication of all the staff working at the home and the overall services provided. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 7 Information stated on the AQAA indicates that the home is planning to make further changes as a result of listening to people who use the service by introducing life plans and diaries, by involving residents in interviews of new staff, and redecoration of first floor lounge and bedrooms. The home would also like to utilise the first floor kitchen for residents to promote their independence. 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. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4 were assessed. Standard 6 does not apply, as Lakelands does not offer an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents and their supporters with up to date information about the services provided that helps them in making a decision about moving in to the home. EVIDENCE: The home has a statement of purpose and a service users guide. This is available to prospective residents and it was noted that the information was available in a presentation folder in the residents rooms inspected. The information is clear and concise and informs people of the services and facilities available, about the staff and their qualifications, results of annual surveys and the last CSCI inspection report. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 10 We inspected three care plans. Each care plan contained a pre admission assessment to ensure that the resident’s health, personal and social care needs could be met. The assessment was detailed and covers areas of personal care, physical well-being, risks, diet, sight and communication, foot care, oral hygiene, pain, nutrition, continence, mobility, past and present medical health care, social care and interests. This assessment provides staff with the information they need to ensure the home and staff can meet the individual needs of the resident. Assessments are carried out at the most convenient place for the prospective resident, which could be in their own home or in hospital. All residents are provided with a written contract (statement of terms and conditions) regardless of how their care is purchased. Contracts were kept in a separate file in a secure location. The contacts of the three residents care plans examined were looked at and contained all the relevant information as required. A fourth contract for a resident on respite was also examined and the dates had been extended due to the residents extended stay at Lakelands. The home is providing care for some residents with a dementia related illness and for residents with mental health problems. The staff have undertaken training in dementia to ensure that they have an awareness and an understanding of the different types of dementia and can provide the necessary care. The staff have worked exceptionally well in ensuring that some residents with mental health problems are receiving the level of care required and that the input from the appropriate outside agencies had been obtained and their advice acted up on. This has enabled the residents to remain at Lakelands where they appeared to be happy and settled and had formed good relationships with staff. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 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. 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. Care plans are clear and concise and provide staff with the information they need to meet the needs of the residents. Personal support is offered in such a way as to promote resident’s privacy and dignity. EVIDENCE: Inspection of the three care plans showed the information contained in the plans gave staff detailed information about the care each resident required. The plans are written in a person centred manner, for example, ‘ I am able to’ or ‘ I need help with’. Care plans written in this way include the resident in building up the plan and informs the staff so they know what the resident can do for themselves and what they need assistance with. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 12 The care plans contained activity pursuits such as times of rising and retiring, naps during the day and the desired time of breakfast. General activity preferences were seen in care plans which included what the residents liked to do during the day such as cards and other games, arts and crafts, exercise, watch television, listen to music, going on trips out, gardening, spending time chatting with people etc. Each file contained a social profile, which gives staff some background about the residents they are caring for and about their life experiences, for example where they were born, different addresses lived at, family members and friends, school days, work places, memories (war service), social interests and hobbies. What would be their perfect day and any aims or aspirations that they may have. Other information of daily living includes risks assessment for example the risk of falls and mobility, nutrition, pressure care and moving and handling. Regular monitoring of weights and bathing was also noted. Accident reports were seen in care plans and the daily progress notes were completed by staff. Files contained information and consent forms for the use of homely remedies such as paracetamol and for the taking of the resident’s photographs. The care plans had been updated monthly as required and where possible signed by the resident. There was evidence to demonstrate that outside agencies had been contacted such as the doctor, district nurse, chiropodist, the mental health team and continence adviser who all visit the home as required. Observations throughout the inspection showed that the personal care needs of the residents were being met. Attention to all residents was given to personal grooming, residents were seen to be clean and clothes nicely washed and ironed and were coordinated. On the day of the inspection the hairdresser was visiting and ladies were seen having their hair done. Staff were seen knocking on bedrooms doors and toilet doors and waiting for a response before entering. Staff were heard speaking with residents in a friendly and respectful manner. It was evident that good relationships had been formed. One resident told the inspector, “I have no complaints, the staff are great, the food is good, I would recommend this home to anyone, the way you are treated is first class.” The senior carer gave out the lunch medication; this was done swiftly and efficiently. Residents were given tablets in an appropriate manner and offered a drink to help them swallow them. Medication given was immediately recorded on the individual’s drug sheet. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a wide and varied range of activities to meet their capabilities and expectations. Residents are provided with well-cooked food, which they like, in good portions and times that suit them. EVIDENCE: The home has designated staff members that, with the help of residents plan and deliver a wide range of activities. The activity programme is displayed so that residents and relatives know what’s going on. Activities include bingo, quizzes, dominoes, gentle exercise, range of movies and trips out. The home has also purchased a computer should any resident want to use it; staff are available to assist if needed. The home has a residents monthly magazine with quizzes, word searches and information re birthdays, celebrations etc. Relatives are welcomed and encouraged to join in with any of the activities or outings if they wish. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 14 Visitors are welcome to the home at any time; there are no restrictions as to when people can visit. Residents can meet with their visitors in the communal areas or in the privacy of their own rooms. Only one visitor was available to speak with the inspector and the relative was very complementary about the way the home was managed and the quality of care provided. The returned relatives comment cards expressed satisfaction of the standard of the home, the commitment of the staff and facilities provided. The manager has acknowledged on the retuned AQAA form that home would benefit from more involvement with community links, and with more input from advocacy services. Where possible residents go out to local shops and the home has regular visit from the local clergy. Residents are encouraged to make their own choices about what time they get up and what time they wish to retire. When asked about who decides what clothes to put on each day a resident confirmed that it was her decision she picked what she wanted to wear. Another had informed staff that he did not want to get up; he was having a day in bed. Staff respected the resident’s choice but checked on a regular basis to make sure he was alright and took his meals and drinks to his room for him. A flexible breakfast is served to allow residents to get up at their leisure. The inspector observed that breakfast was still being served mid morning. There is a choice of hot and cold breakfast dishes served including cereals, porridge, bacon, eggs, toast and preserves and choices of drinks are available. At lunchtime residents were offered choices of corned beef hash with beetroot, bread and butter, soup and sandwiches, followed by fairy cakes. The main meal is served early evening and residents were to be offered steak and kidney pie, potatoes, broccoli and carrots, followed by a dessert of cherry crumble and ice cream. Residents spoken with after lunch confirmed that the food was very good, that there was plenty to eat with choices available at every meal. The menus were clearly displayed for residents and relatives to see what choices were available on a daily basis. The inspector noted that the tables were nicely set for each meal with appropriate cutlery and crockery, condiments and napkins. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their supporters can have confidence in knowing that any concerns or complaints will be listened to and appropriate action taken. EVIDENCE: A complaints procedure exists and any records of complaints are kept properly and recorded along with the outcome. Since the last inspection there have been no complaints made to the manager of the home and no complaints have been brought to the attention of CSCI. There has been one adult safeguarding issue reported by the home since the last inspection. However this was not reported immediately to the appropriate agencies. The acting manager addressed this matter and spoke with staff. Staff had received training in the protection of vulnerable adults and refresher training is planned to reiterate the procedures that must be followed and to ensure that staff are confident in reporting any protection incidents or concerns they may have. Up to date policy and procedures are available and accessible to staff. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 16 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, 24 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Lakelands is maintained to a good standard making it a homely, comfortable, clean and pleasant home for residents to live in. EVIDENCE: From a tour of the premises, it was evident that the home is maintained to a good standard both internally and externally. In the last twelve months several of the bedrooms had been decorated. The kitchen on the first floor had been upgraded and new flooring had been laid on the lounge/dining area. On the ground floor new curtains had been purchased. The lounge/dining areas were clean and comfortable. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 17 Several of the bedrooms were looked at. These were seen to be clean, tidy and comfortable, and residents had personalised their rooms with some of their own possessions brought from home. There are no en suite rooms at Lakelands, however bathrooms and toilets are available on both floors and in close proximity to bedrooms and communal areas. Bathrooms and toilets were seen to be clean and tidy and well equipped with paper towels and liquid soap. The outside of the home is well maintained and the grounds were neat and tidy. There is suitable seating for resident to sit out, weather permitting. The laundry was well equipped and is sited away from food preparation and food storage areas and does not intrude on the residents. The inspector spoke with the domestic staff, who took pride in her work ensuring that the home was clean and free from any offensive odours. Systems were in place to reduce the risk of cross infection. Good practices were observed. Staff were seen wearing protective clothing as required for different tasks. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 18 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 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their needs are met by good levels of staff who are competent, committed, experienced and well-trained. EVIDENCE: On the day of the inspection there were sufficient numbers of staff on duty. Staff rotas were available for inspection. There is two waking night staff on duty throughout the night. As discussed at previous inspections the manager or acting manager should regularly review staffing levels mainly at weekends and nights to ensure that any changing needs of the residents can be met. Domestic and kitchen staff are employed in sufficient numbers to cater for the needs of the residents and to support care staff. Several of the staff had worked at the home for a number of years, This provides residents with good, consistent, reliable care from people they know and can trust. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 19 From the inspector’s observations, staff morale appeared to be good and the staff seemed genuinely happy to be working at the home. The atmosphere on entering the home is warm, friendly and inviting. A full copy of each members of staff’s employment file is kept in the home in a secure location. The file for the last most recently recruited employee was looked at and was complete and up to date. Another two files of longer standing members of staff were also examined and found to be up to date. Files contained an application form, interview questions and responses, two written references, job descriptions and contracts. Other forms of identification were seen on files. A separate record of Criminal Records Bureau checks disclosure numbers was available for inspection. Staff supervision records and some training certificates were also available in the staff files inspected Staff undertakes a full induction programme on commencement of work, a copy is kept on the staff file. Training for staff is on going with 75 of staff having achieved NVQs in care. The home has three NVQ assessors working there and the home has been awarded the Investors in People Award. Staff have completed mandatory training in, for example moving and handling, infection control, fire and health and safety and protection of vulnerable adults. There was evidence to show that staff had also received training in dementia, continence and prevention of pressure sore training. Several staff holds a current first aid certificate ensuring there is a qualified first aider on every shift. Domestic and kitchen staff had also completed NVQs and was involved in fire training etc. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 20 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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure their best interests will be the central focus, with a positive and inclusive approach to making the service better. EVIDENCE: The registered manager has been on sick leave for some time. The acting manager currently running the home has a considerable amount of experience in working with the elderly and is very capable and competent in continuing to manage Lakelands ensuring that high standards are being sustained. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 21 The way in, which the home is managed, and run is open and transparent. The home operates an ‘open door’ policy so that the acting manager can be approached at any time by staff, residents or relatives. The office is well organised so that staff have access to all the paperwork and contact information they need during a shift. The home usually has administrative support. Unfortunately the administrator was off sick and help and support is being provided as needed by administrators from other CLS homes. There are good systems of continuous self-monitoring within the home, which includes home audits, consultation and meetings with staff and residents, surveys and satisfaction questionnaires. Some residents living at Lakelands have handed over the responsibility for their financial affairs to their families but keep a small amount of money with the acting manager for safekeeping. We checked the money of the residents whose care plans we had examined and found it to be in order and matching the written records of transactions. Records kept and required by regulation were seen to be in good order and up to date. All records are kept securely stored. The records showed that staff are trained in safe working practices and training is updated at regular intervals. Equipment and systems used in the home are serviced and maintained, and records were available. Repairs are carried out by the company (CLS), and other maintenance and service contracts are in place. The home benefits from the services of a handyman. Information provided on the returned AQAA form indicates that the following checks had taken place: Portable electrical equipment – August 2007 Lift – October 2007 Gas – May 2007 Fire detection – May 2007 Hoists – May 2007. The inspector randomly checked some of this information and certificates were seen to be up to date and valid. Other maintenance checks on fire alarms, water temperature etc are carried out on a regular basis and recorded. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 22 Any accidents, injuries and incidents are recorded properly and the CSCI are notified as required. Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Lakelands DS0000005775.V358341.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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