Inspection on 21/09/06 for 98 Beeches Road - Lyndel Homes

This inspection was carried out on 21st September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

98 Beeches Road - Lyndel Homes 12/02/08

98 Beeches Road - Lyndel Homes 09/01/06

98 Beeches Road - Lyndel Homes 26/07/05

98 Beeches Road - Lyndel Homes 07/02/05

98 Beeches Road - Lyndel Homes 31/08/04

98 Beeches Road - Lyndel Homes 18/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 98 Beeches Road - Lyndel Homes 98 Beeches Road West Bromwich West Midlands B70 6HJ Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 21 September 2006 9:30 st 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 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 98 Beeches Road - Lyndel Homes DS0000004850.V311875.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 Adults 18-65. 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. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 98 Beeches Road - Lyndel Homes Address 98 Beeches Road West Bromwich West Midlands B70 6HJ 0121 580 0759 0121 515 2544 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 Delores Matadeen Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two service users identified in the variation application dated 30 September 2005 may be accommodated at the home in the category MD(E). This will remain until such time that the identified service users placements are terminated at which time the category will revert to 9 service users in the category MD only. 9th January 2006 Date of last inspection Brief Description of the Service: 98 Beeches Road is a residential home providing 24-hour care and support for 9 people experiencing mental ill health. The property is an extended 3 storey, mid-terrace, Edwardian building forming part of the Lyndel Care Homes Company. It is situated in a residential area close to West Bromwich town centre and has good transport networks. On the ground floor there is one single bedroom, lounge, kitchen, shower room including a toilet and wash hand basin, two toilets, and a two-roomed conservatory used as a dining and smoking area. Access from the conservatory leads to a secure paved area. On the first floor there is one double bedroom, three single bedrooms, one bathroom with bath, toilet, wash hand basin and the staff office. Finally on the second floor there is three single bedrooms, one shower room with toilet and wash hand basin. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 21st September 2006. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults (18-65) and report on the progress made to address previous requirements. The inspector’s findings are based on the information received by the Commission for Social Care Inspection, examination of relevant records and documents kept at the home, discussions with the responsible individual, acting manager, staff, service users and a tour of the premises. The home has fully met seventeen of the twenty-two requirements made at previous inspections. A further twelve requirements were identified as requiring action. Service users who expressed an opinion to the inspector stated they were pleased with their living environment and satisfied with the level of support and care being provided to them by staff. The fees charged by the home for their service is currently ranges from £235 £335. What the service does well: The home ensures relevant information is on display in the home. Good arrangements are made for introducing prospective service users to the home, staff and other service users. Staff provide personal care to service users in the way preferred by them. Suitable arrangements are made for managing service users’ medication and for supporting them to attend health care appointments. Appliances and equipment are regular maintained and serviced to ensure service users safety. More than 50 of the home’s staff have attained National Vocational Qualification Level 2. Training has been recently provided on health & safety issues. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 The overall outcome for this group of standards is judged to be good. Prospective service users are provided with relevant information to enable them to make an informed choice about where to live. Arrangements are made with individuals to visit and ‘test drive’ the home. The home has adequate procedures for ensuring prospective service users’ needs and individual aspirations are fully assessed. EVIDENCE: The home’s Statement of Purpose and Service User Guide has been reviewed and is on display in the home together with a copy of its Aims & Objectives. A revised copy of the Statement of Purpose and Service User Guide is to be forwarded to Commission for Social Care Inspection (CSCI). Two service users discussed their individual experiences of being introduced to the home. Both confirmed they had received written information, were visited by a senior staff member to discuss their individual needs and how these could be met by the home. Arrangements were made for them to visit the home and have overnight stays prior to moving in. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 10 The home has recently reviewed its referral and admission process. Some service users’ Contract/Terms & Conditions have been revised. However, files examined did not yet contain a copy of these. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9 & 10 The overall outcome for this group of standards is judged to be adequate. The home is reviewing care plans and risk assessments with service users to ensure their needs and personal goals are identified. Care plans must be reviewed with the service user and significant people at least every six months. The home needs to demonstrate through its records how it consults with service users on all aspects of life in the home. Service users are provided with assistance and support from staff. However, current administrative arrangements need to be reviewed to ensure service users’ privacy and confidentiality is fully respected. EVIDENCE: Service users’ files contain care plans, risk assessments and supplementary information. One service user is experiencing mobility difficulties. The home has made interim arrangements to address this while waiting for a comprehensive assessment of his needs to be carried out by a relevant 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 12 professional. Staff were able to described how his needs are currently being met. However, this has not been identified in his care plan or individual risk assessment. There is no record of discussions held with the service user in respect to the changes made. An internal reviews of care plans and risk assessments are being carried out with service users and their link workers. There is little evidence to demonstrate reviews are being carried out with the service user, their relatives/advocates (where applicable) and significant professionals at least once every six months. Three service users expressed satisfaction with the support they receive from staff, especially in respect of enabling them to make informed decisions. Staff stated regular meetings take place with service users to discuss common issues. Minutes of recent meetings were not available for inspection. Service users, whilst at home, spend a lot of time together in the lounge engaged in various activities such as listening to music and watching television. As well as spending time with service users, staff also use this room to write up records and make and receive telephone calls. The home needs to review this arrangement to ensure service users’ confidentiality is maintained at all times. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 The overall outcome for this group of standards is judged to be good. Service users are encouraged by staff to maintain positive relationships with family and friends and are supported in accessing local amenities and services, wherever appropriate. The home needs to provide service users with more opportunities for personal development. Service users’ rights are generally respected. However, issues brought to the attention of the home by service users should be addressed in a timely manner. Service users are provided with a healthy diet and varied menu. EVIDENCE: Staff call service users by their preferred form of address and this information is recorded on their files. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 14 Some service users attend day centres during the week, other service users said they organise their own activities, such as shopping or visiting family and friends. Service users who expressed a view stated they did not feel they had developed any special links within the local community, preferring to spend time with their own family and friends. The home provides them with opportunities to use local amenities and social venues, as a group or individual basis with their link worker. The inspector was informed of the new weekly activity programme. This includes short breaks away from the home. Three service users commented on how they enjoyed a recent trip on a narrow boat. Service users are provided with a key to their bedroom door. One service user stated he had lost his key sometime ago and had spoken to different staff but nothing had been done. The responsible individual was made aware and will ensure the matter is promptly dealt with. Suitable arrangements need to be identified for dealing with lost/missing keys to avoid similar incidences in the future. There is unrestricted access to all communal areas in the home. For health and safety reasons staff provided service users with supervision when using the kitchen to prepare drinks or wash up. The menu for the day is displayed in the dining room and a record of meals taken by service users’ is also kept. This enables any concerns about an individual’s dietary intake to be identified at an early stage. The menu appeared adequate in respect of nutritional content and variety. One service has specific dietary needs and is aware what foods to avoid. The inspector was invited to share the mid-day meal with service users. They stated the meals provided by the home were very good. There was little social interaction between the service users or service users and staff during the meal. The home needs to look at arrangements for enabling service users to maintain and develop their social and communication skills in such settings. The inspector was informed that service users are encouraged to participate in preparing meals, however, little evidence of this was available on their files. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The overall outcome for this group of standards is judged to be adequate. Staff support service users to manage care and personal needs in the way they prefer. However, the home must ensure these needs, how they are being met and any associate risks are fully detailed in the individual’s care plan. Service users are protected by the home’s procedures and arrangements for managing their medication. EVIDENCE: Service users require varying levels of support with their personal care. Staff described to the inspector the different levels of support required by individuals. The support required ranges from prompting some service users to maintain good personal hygiene routines to assisting others with bathing. As previously stated, one service user’s mobility needs are being re-assessed, in the meantime the home has made temporary arrangements for him to share the ground floor bedroom. Although both service users are agreeable to this arrangement, there are no records of the discussion that took place with them about this. (See Individual Needs & Choices). 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 16 The inspector observed a service user being supported by the staff on duty in his attempt to give up smoking. The service user said he appreciated this support. As previously stated risk assessments needed to be provided/improved upon, especially in respect of concerns expressed by staff about service users who do not always comply with the home’s smoking policy. (See Individual Needs & Choices). The service users’ files contain appropriate contact details of the external care co-ordinators, usually a social worker from the mental health team or a community psychiatric nurse. The records demonstrate staff provide support to service users in attending their healthcare appointments. Senior staff are responsible for ensuring service users’ medication is appropriately managed. A list of prescribed medication is available on the files and medication administration records were completed to a satisfactory standard. Training in the safe handling of medication is provided to staff, which was described by one staff member as being “very detailed”. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The overall outcome for this group of standards is judged to be good. Systems are in place to for service users to express their views about the home. The home has suitable procedures in place to protect service users from abuse. EVIDENCE: A copy of the complaints procedure is displayed in home for easy access to service users & visitors. The home informed the inspector that they have received no complaints. No complaints about this service have been reported to the Commission for Social Care Inspection. The home has suitable adult protection procedures and a copy of the local authority’s Sandwell’s Vulnerable Adult Procedures. No such concerns were raised with the home during this visit. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 The overall outcome for this group of standards is judged to be adequate. Service users live in a homely and safe environment. However, improvements need to be made by the home in providing a more timely and planned approach to re-decoration and refurbishment. EVIDENCE: A planned maintenance and renewal programme for the fabric and decoration of the home was not provided. However, since the last inspection the home has replaced some items of furniture, such as the chairs in the lounge and dining. An extractor fan has been fitted in the smoke room for the comfort of the service users. The home has a paved patio area at the rear of the premises for use by service users. This is accessed via the dining room and smoke room. Garden chairs and potted plants provide a pleasant environment for service users to sit during fine weather. Two service users stated they took responsibility for looking after the plants. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 19 The lounge is suitably decorated and furnished. As previously stated, staff carry out some administrative tasks here. There is a small office located on the first floor. This is mainly used for storing files and has no natural light. As previously stated, this arrangement needs to be reviewed. (See Individual Needs & Choices). Service users’ bedrooms reflect their individual personalities and interests. A temporary arrangement has been made for a service user to share the ground floor bedroom. However, his clothes and personal possessions remain in the upstairs bedroom. Staff stated these are provided to the service user on request and returned to the first floor room after use. Arrangements are to be made this service user’s possessions to be transferred to the room he is using. Some bedrooms required attention in respect of decoration and furnishing. For example, the ceiling in bedroom on the first floor is flaking, the service user’s chair in a room on the second floor is in a poor state. The inspector was informed some service users do not wish to have certain items of furniture in their rooms. In such cases, a record needs to be kept of their wishes and reviewed with them on a regular basis. This was reported on at the previous inspection. The home has sufficient bathing facilities and service users are able to choose whether they wish to take a shower or bath. The temperature of the hot water outlets for wash hand basins and bathing facilities are regular checked for safety. Staff stated they do all the service users’ laundry. Discussions were held with the responsible individual and acting manager about encouraging and supporting service users to carry out some of these tasks themselves, depending on their individual abilities. (See Lifestyle) Cleaning materials are kept locked in the laundry when not in use. Service users who expressed a view stated they were happy with their living environment. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 33, 34, 35 & 36 The overall outcome for this group of standards is judged to be good. Service users are more fully supported and protected through the revised home’s recruitment policy and procedures. Staff are supported by the responsible individual. However, the day-to-day arrangements for the management of the home must be appropriately addressed. The majority of staff hold National Vocational Qualifications. Additional training is required to ensure the individual and joint needs of service users are fully met. EVIDENCE: Recruitment records for staff show relevant checks are carried out. The shortfalls identified at the last inspection are being appropriately addressed. The National Vocational Qualification (NVQ) Level 2 is held by 54 of the staff team and 3 staff were identified as working towards achieving Level 3. A senior member of staff confirmed she had recently completed update training in health & safety. Staff training records that were examined show training has been provided in Fire Safety, Basic Food & Hygiene and Manual Handling. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 21 It is evident from the observations made, discussions held and records seen that staff need further training in client-centre issues, risk assessing, care planning and implementation of individual plans to ensure care needs are being fully met. Training in mental health was identified as a need for staff at the last inspection. This has not yet been addressed. A minimum of two staff are on duty at all times, one of whom is a senior member of staff. Staff reported individual supervision sessions cover care planning, record keeping and roles and responsibilities. They commented positively on the value of these sessions and the support provided by the responsible individual. The inspector was informed staff meetings take place on a regular basis, two within recent weeks. Copies of the minutes for these meetings were not available at the time of this visit. Service users commented positively on their relationship with staff and the care being provided. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 & 43 The overall outcome for this group of standards is judged to be adequate. Service users’ interests are safeguarded by the home’s policies and procedure. Suitable arrangements must be finalised for the day-to-day leadership and management of the home. The further development of the home’s quality assurance system will enable the service to identify improvements to the service for the benefit of all its service users. EVIDENCE: The responsible individual is registered with the Commission for Social Care Inspection (CSCI) as the manager. In practice, she has appointed an acting manager to carry out this duty on her behalf. The acting manager is in the process of completing National Vocational Qualification Level 4 and intends to submit an application for registration in the near future. Discussions were held about this with the responsible individual and acting manager. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 23 It was agreed an application for the acting manager would be submitted to CSCI within 3 months. The responsible individual is carrying out an audit on the care plans, record keeping and staff practices. Plans are being put in place to address shortfalls identified through this audit and from comments made by service users. Arrangements are being made to seek the views of stakeholders and other significant people about the service. As part of the quality assurance system the home must produce an annual development plan for the home. The inspector was informed policies and procedures have been reviewed in the last 12 months. Observations made and discussions held indicate staff would benefit from written guidance on valuing privacy, dignity, choice, fulfilment, rights and independence. Service users’ files vary in content and there is evidence of the audit currently being undertaken. The responsible individual has recorded on the files action to be taken by link workers and this is followed up in supervision. During the last 18 months the home has received routine visits from officers from the Environment Health Agency and West Midlands Fire Service. Written reports of the visits are available and no major concerns were raised. Appropriate records are kept of any accidents. These records are monitored regularly and, where identified, action is taken to prevent recurrences wherever possible. Regular inspections and services are carried out on equipment and appliances. However, evidence of the annual tests carried out on electrical portable appliances was not available. The responsible individual confirmed these tests have been carried out and a copy of the report would be kept available on the premises. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 4 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 2 27 3 28 2 29 X 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 2 3 2 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 3 2 3 2 3 3 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 5 Requirement A copy of the home’s current Statement of Purpose & Service User Guide must be forwarded to CSCI. Revised contract/statement of terms & conditions must be available on the service user’s file. Care plans must be reviewed at least once every three months with the service user, significant professionals and relatives/advocate. Changes in service users’ care needs must be recorded in individual plans and, where applicable, risk assessments 4 YA8 16 Written records must be kept of all consultations held with service user/s Risk assessments must be reviewed and updated. These must be used to plan individual actions and interventions. DS0000004850.V311875.R01.S.doc Timescale for action 30/03/07 2 YA5 5 30/03/07 3 YA6 15 30/03/07 30/03/07 5 YA9 17 30/03/07 98 Beeches Road - Lyndel Homes Version 5.2 Page 26 (This is an outstanding requirement from 09/02/06). Any restrictions on a service users daily life must be recorded in their care plan. (This is an outstanding requirement from 09/02/06) 6 YA10 23 Carrying out of administrative tasks by staff in the communal lounge must be reviewed. Service users must be encouraged and supported to maintain and develop their social and independent living skills Arrangements must be identified for replacing lost/missing keys to service users The home must put in place a planned maintenance and renewal programme for the fabric and decoration of the premises with records kept. (This is an outstanding requirement from 01/02/06). The ceiling in the bedroom on the first floor must be redecorated The armchair in the bedroom on the second floor must be recovered or replaced. Service user’s clothes and personal items must be transferred with them when they move bedroom. 13 YA26 23 Where the full range of furniture and fittings specified in the National Minimum standards for Adults is not present in the service users bedroom, the DS0000004850.V311875.R01.S.doc 30/03/07 7 YA11 12 30/03/07 8 YA16 12 30/03/07 9 YA24 23 30/03/07 10 YA24 23 30/03/07 30/03/07 98 Beeches Road - Lyndel Homes Version 5.2 Page 27 home must either provide the required items, or document the service user was offered and did not wish to have certain items, or provide risk assessments if it is considered unsafe. (This is an outstanding requirement from 01/02/06). 12 YA32 18,19 Staff must receive training in mental health. (This is an outstanding requirement from 01/03/06). Staff must be provided with training in relevant clientcentred issues, care planning & implementation and risk assessing. Minutes of staff meetings must be kept available at the home. The manager to be qualified to level 4 NVQ in management and care. (This is an outstanding requirement from 09/01/06) The acting manager must submit their application for registration to the Commission. The home’s quality assurance system must include seeking the views of stakeholders and other significant people and produce and annual development plan for the home. 30/03/07 13 YA32 18 30/03/07 14 15 YA33 YA37 24 8 30/03/07 30/03/07 16 YA37 8 30/03/07 17 YA39 24 30/03/07 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA40 Good Practice Recommendations It is advisable for staff to be provided with written guidance on valuing privacy, dignity, choice, fulfilment, rights and independence. 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 98 Beeches Road - Lyndel Homes DS0000004850.V311875.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!