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Inspection on 16/02/07 for Lindale Residential Care Home

Also see our care home review for Lindale Residential Care Home for more information

This inspection was carried out on 16th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a warm, comfortable and homely environment for the residents. The views of the residents were regularly sought and the views incorporated into the running of the home. Residents were involved in the recruitment process. Each of the residents had their own bedrooms that had been personalised to suit their personality. There were good care plans in place ensuring that the needs of the residents were being met. All the residents spoken with said that they were happy at the home. Residents were involved in drawing up their care plans and a copy was kept in their bedrooms. Residents were supported with their medical needs including the administration of medicines. The residents were encouraged to be involved in the day-to-day tasks in the home. There were very good relations between the staff and the residents based on mutual respect and understanding.

What has improved since the last inspection?

Since the last inspection some of the bedrooms have been repainted and the residents were able to choose the colour of the bedroom. The manager had worked consistently at meeting the requirements madeat the last inspection and contracts had been amended, daily entries were being made in residents care notes, risk assessments were being regularly reviewed, health action plans had been developed and person centred plans were being set up for all residents. Staff had been provided with training in epilepsy, dementia care and challenging behaviours.

What the care home could do better:

Although care plans included some good details they could be further improved by including details of the care tasks that residents could do for themselves and when staff needed to intervene. Risk assessments could be crossreferenced to the care plans. Any information provided by ancillary health care professionals relating to how care needed to be provided must be available to staff for their information. The manager needed to ensure that there was a record kept of the food actually eaten by the residents. Foods needed to be dated on freezing to assist with stock rotation and quality assurance of the food. There needed to be protocols in place for the administration of `as and when required` and `as directed` medicines with the MAR charts to ensure that staff were consistent with regard to what indicators were to be seen before this medication was administered. It is good practice for staff to use both initials when signing for the administration of medicines to minimise any confusion with the codes that could also be used on the MAR charts. Staffing levels were maintained at minimum levels and could not allow for individual activities where residents needed a level of supervision. There were periods of the day, for example, in the evenings when the staffing levels could be increased. Health and safety was generally well managed in the home. The only areas that needed addressing were the need for staff to have fire training every six months, to ensure that the moving and handling training had a practical element to it and to ensure that soiled bedding was changed promptly.

CARE HOME ADULTS 18-65 Lindale Residential Care Home 81- 85 Wharfdale Road Tyseley Birmingham West Midlands B11 2DB Lead Inspector Kulwant Ghuman Key Unannounced Inspection 16th February 2007 09:30 Lindale Residential Care Home DS0000047064.V328494.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 Lindale Residential Care Home DS0000047064.V328494.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. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindale Residential Care Home Address 81- 85 Wharfdale Road Tyseley Birmingham West Midlands B11 2DB 0121 706 3273 0121 624 5334 genesishomes2003@yahoo.co.uk 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) Genesis Homes (Essex) Limited Adenike Adebukanla Adenuga Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nine residents with a learning disability under the age of 65 years. The home can accommodate one named service user over 65 years. The details regarding how the specific needs and social needs of people over 65 years will be met must be included in the service user plan. 23rd February 2006 Date of last inspection Brief Description of the Service: Lindale provides care and accommodation to nine adults who have a learning disability. The home is privately owned and had a change of owner/manager in May 2003. The home is in Tyseley, Birmingham and is a corner property, which blends in well with local housing and industrial buildings. To the front of the home there are walled gardens and to the rear there is off road parking. To the rear at either side of the property there are two small gardens. The interior of the home is decorated and furnished to an adequate standard. On the ground floor there is a communal dining room, TV lounge, quiet lounge, separate WC, a large bathroom and toilet, a kitchen, hairdressing salon, laundry and two ground floor bedrooms. On the first floor there are seven bedrooms and two bathrooms and toilets with shower facilities. The home is situated off the main A41 Warwick Road and is well served by public transport. Trains run frequently from Tyseley station to Birmingham city centre and Solihull. The home is near to local shopping facilities as well as places of worship, parks, adult education centre, library, restaurants, a leisure centre and pubs. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over one day in February 2007. As part of the inspection the inspector was able to speak with one carer and the manager of the home and six of the nine residents. A tour of the building was undertaken and records relating to the management of the home, food menus, medication and health and safety were sampled. The care files of three residents and one member of staff were also sampled. Prior to the inspection the manager had provided the CSCI with some information that the inspector was able to use as part of the inspection process. No complaints or adult protection concerns had been raised about the home since the last inspection. What the service does well: The home provides a warm, comfortable and homely environment for the residents. The views of the residents were regularly sought and the views incorporated into the running of the home. Residents were involved in the recruitment process. Each of the residents had their own bedrooms that had been personalised to suit their personality. There were good care plans in place ensuring that the needs of the residents were being met. All the residents spoken with said that they were happy at the home. Residents were involved in drawing up their care plans and a copy was kept in their bedrooms. Residents were supported with their medical needs including the administration of medicines. The residents were encouraged to be involved in the day-to-day tasks in the home. There were very good relations between the staff and the residents based on mutual respect and understanding. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although care plans included some good details they could be further improved by including details of the care tasks that residents could do for themselves and when staff needed to intervene. Risk assessments could be crossreferenced to the care plans. Any information provided by ancillary health care professionals relating to how care needed to be provided must be available to staff for their information. The manager needed to ensure that there was a record kept of the food actually eaten by the residents. Foods needed to be dated on freezing to assist with stock rotation and quality assurance of the food. There needed to be protocols in place for the administration of ‘as and when required’ and ‘as directed’ medicines with the MAR charts to ensure that staff were consistent with regard to what indicators were to be seen before this medication was administered. It is good practice for staff to use both initials when signing for the administration of medicines to minimise any confusion with the codes that could also be used on the MAR charts. Staffing levels were maintained at minimum levels and could not allow for individual activities where residents needed a level of supervision. There were periods of the day, for example, in the evenings when the staffing levels could be increased. Health and safety was generally well managed in the home. The only areas that needed addressing were the need for staff to have fire training every six months, to ensure that the moving and handling training had a practical element to it and to ensure that soiled bedding was changed promptly. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. Lindale Residential Care Home DS0000047064.V328494.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 Lindale Residential Care Home DS0000047064.V328494.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to information informing them of what services they could expect from the service and were able to make an informed choice about where they wanted to live. EVIDENCE: No new service users have been admitted to the home. The residents had all lived there for several years and had good relationships with each other. There was a new contract in place that stated the fees to be paid and that the organisation would pay £300 towards the staff wages during a holiday. The cost of the holiday (accommodation/travel/etc) would have to be born by the residents. The service user guide was not assessed at this inspection. This had been met but the home had been recommended to have formats such as DVD or cassettes available to the residents at the last inspection. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are monitored on an ongoing basis and they are supported and consulted in all areas of life. EVIDENCE: The residents told the inspector that weekly meetings were being carried out. The meetings enabled the residents to decide on the coming weeks menus including packed lunches and what activities they had done the previous week and how they had met the residents needs. Discussions also looked at what holidays the residents wanted to have and how they wanted to celebrate events such as Christmas and birthdays and whom they wanted to invite to these celebrations. Consultation with the residents was further facilitated in the monthly meetings, key worker sessions and daily contacts with the residents. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 11 The care files for three residents who were at home on the day of the inspection were sampled. There were some very good details included in the care plans for the residents and they had been encouraged to sign them where possible. If they were not able to sign them this was recorded on them. Copies of the care plans and person centred plans that were being developed were kept in the residents’ bedrooms. Care plans included details regarding personal hygiene, diet, health, mobility, routines of daily living, social activities and holidays. Some of the care plans could be further improved to include details of what tasks the residents could do for themselves and guidance on how much time they should be allowed to do them before the staff intervened. There were several risk assessments in place for residents. It was recommended that these risk assessments were numbered and cross-referenced to the care plans. Where it had been identified that residents could become aggressive a risk assessment and guidelines for staff handling any challenging behaviours needed to be put in place so that consistency in response could be achieved. For one of the residents the care plan referred to guidelines from speech and therapy advisors however this guidance was not kept accessible to staff who would be reading the care plans and risk assessments and therefore could be unaware that they needed to ensure crusts were cut off the bread and so on. Care plans were being reviewed every six months and daily entries were being made regarding the residents daily lives. The observed interactions between staff and residents were found to be calm, supportive, reassuring, warm and respectful. Residents were very relaxed in their home and approached the staff for advice for things such as what to wear to go out to the club in the evening. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were experiencing enjoyable and meaningful lives that were based on individual needs and preferences. EVIDENCE: On the day of the inspection three residents stayed at home during the day. One of the residents spent the majority of the day sleeping in a chair. The staff were aware of the difficulties being experienced at the present time both at home and at the day centre due to the residents inability to be as involved in daily activities as had been the case in the past. This could be due to the ageing process or there may be something more organic underlying the behaviour. This situation needed to be monitored by the manager. One resident spent the majority of the day practising writing and although several efforts were made to assist her by the staff it was evident that she did Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 13 not want this assistance but readily took a break from this activity to assist the staff in preparing lunch and drinks during the day. There were a variety of activities ongoing during the day with residents attending day centres, work and college. Some of the residents spoke to the inspector about friends outside the home and contact with their families. Residents told the inspector that some of them visited their families at their home, or the families visited them at Lindale and some had telephone contacts arranged. It was pleasing to note that families were invited by the residents to attend celebrations throughout the year if they wished. Some residents went shopping with the staff. Residents were escorted to appointments in the community and some attended church. Some residents used the ring and ride service and others used a taxi service. Residents attend social activities in the evening and go out for meals, to the pub and bowling. Residents were asked what they wanted to eat on a weekly basis. The menus indicated a variety of meals were on offer during lunchtimes and evenings. There was no specified supper but the inspector was informed that residents could have a sandwich, toast or biscuits and cheese if they wanted. The manager needed to ensure that a record was kept of the actual food eaten by the residents as this could be different to what they had planned to eat at the beginning of the week. The dining room was large enough for the residents and was comfortable and well decorated. Fresh fruit and vegetables were available. Examination of items in the fridge and freezers indicated that some meat items had not been dated on freezing and there were items such as turkey drumsticks, pork joints, corned beef and Cornish pasties that were past their use by dates. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were meeting the personal hygiene, physical and emotional needs of residents in a caring and supportive manner. EVIDENCE: Residents were assisted to have annual health checks with the GP and a number of other appointments were regularly organised to deal with sight, dental, chiropody, mental and psychological needs for the residents. One resident was being appropriately supported at a time when a relative was not in the best of health. Health action plans had been put in place for the residents. Residents were being weighed on a regular basis at the home and residents were assisted if they required assistance with losing or putting on weight. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 15 The residents were being supported with their personal care needs appropriately. They had made individual choices about who was to assist them with personal care needs. The residents were aware of who their key workers were. The home utilised a 28 day monitored dosage system for the management of medicines. The management of medicines was good. An audit of the medicines showed a minor discrepancy with some paracetemol tablets. It was recommended that the staff should use two initials to identify who had administered the medicines to avoid any confusions with the codes identified at the bottom of the MAR (Medicine Administration Record) charts and in the event that there are two staff with the same initial. There were copies of the prescriptions kept on the file so that medicines could be checked against those being provided by the pharmacist. Where medicines were to be given PRN (as and when needed) or ‘as directed’ a protocol needed to be put with the MAR charts to ensure that staff were consistent with regard to what indicators were to be seen before this medication was administered. The manager indicated that discussions had been undertaken with the residents regarding dying and funeral arrangements however, some of the residents were upset about this and did not wish to discuss it further. It was entirely appropriate to go at the pace of the residents’ understanding. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ welfare is safeguarded and they are safe from abuse, neglect and their concerns are listened to. EVIDENCE: There have been no adult protection issues or complaints since the last inspection. Staff had received training in the protections of vulnerable adults. There were policies in place for the residents celebrating birthdays and going on holiday and these highlighted the residents’ contributions. The appointee ship for the service users is held in the company name of Lindale. Records are kept of the expenditures carried out by the residents and receipts were available. The records were held on the computer but could be printed off for access. There was a discussion about the amount of money spent by some residents on taxis and attending appointments and college. There were some instances where public transport could be utilised by the residents but on some occasions sharing a taxi between several of the residents was cost effective. There was one instance where a new wheelchair had been purchased for a resident because of problems arising at the day centre. The manager must ensure that decisions made on behalf of residents are in the best interests of Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 17 the residents and alternatives explored such as having the appropriate safety belts fitted to the wheelchair used previously. Residents stated that if they were unhappy with anything they would speak to the manager and were quite aware of who the manager was. Lindale Residential Care Home DS0000047064.V328494.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was well maintained, bedrooms reflected the residents’ individuality and there were adequate communal and bathing facilities available. EVIDENCE: A tour of the building was undertaken. The home presented as a warm and homely environment that was well maintained. The residents’ bedrooms were individualised and appeared to meet their needs. One resident showed the inspector their bedroom and it was evident that the residents could lock their doors if they wanted. The resident told the inspector that they had been able to choose the colour of paint for the bedroom. There was an ongoing decorating programme for the bedrooms. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 19 There were adequate numbers of toilets and bathrooms around the home. There was a choice of bath or shower for the residents. An extra bedroom was currently under construction would have an en-suite facility once complete. The residents had access to the main lounge, quiet lounge, dining room and bedrooms at all times. The stair carpet was found to be wearing in places. The inspector was told that the carpet was going to be replaced once the building works had been completed. It was observed that where required residents were provided with equipment such as pressure mattresses, cushions and walking aids. Generally the standard of the furniture in the home was good however, the covering on an armchair in one of the resident’s bedrooms was torn and needed to be replaced and the cupboard housing the boiler in another of the resident’s bedrooms needed to be kept locked. There was also a laundry and hair salon in the home. It was noted that one resident’s bedding was soiled and had not been removed when the bed had been made up. The home was generally clean and odour free. Lindale Residential Care Home DS0000047064.V328494.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a small staff team that knew the residents’ needs and were competent to carry out their duties. The home’s recruitment procedures safeguarded the residents. EVIDENCE: The personnel file for the newest member of staff was sampled. The file was seen to include all the documentation required by Schedule 2 of the Care Homes Regulations. The file indicated that the individual had undertaken induction training however, the documentation to evidence this could not be located on the day of the inspection. The individual had undertaken external training in first aid, health and safety and NVQ level 2 training. Other training undertaken by the individual was fire training, food hygiene, safe guarding adults and moving and handling training. The majority of this training had been covered by watching videos and completing questions at the end of end. The manager needed to be sure that the moving and handling Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 21 training had a practical element to it to ensure that where residents were being assisted for example, in and out of the bath, they were holding the resident in the correct manner. The manager was not clear how the staff had been shown to assist the staff. The file showed that this individual had received two supervision sessions since during the past six months. In addition there were staff meetings where general issues were discussed. On the day of the inspection there was one member of staff on duty throughout the day, the manager who was in and out and another member of staff came in for the late afternoon shift. Since the last inspection a handover sheet for shift changes had been implemented. This level of staffing only allowed for all the residents to be able to undertake activities in the home and outside as a whole group. It is recommended that additional staff are made available at weekends and days when residents are at home to allow for the possibility of individual activities either within the home or in the community. The staff were well aware of the needs of the residents and were skilled in meeting their needs. More than 50 of the staff had undertaken NVQ Level 2 training. Lindale Residential Care Home DS0000047064.V328494.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a generally very well run home, with a consistent management lead where health and safety is managed well and the views of the residents are taken into consideration. EVIDENCE: The manager was well organised and tried to ensure that decisions in the home were made in the best interests of the residents. She was accessible to the residents and had a good relationship with them. Records were well managed and organised. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 23 An audit had been carried out to assess the quality of the service provided by the home. This showed that in most areas the residents were happy with the services provided. It was recommended that an action plan was produced based on this audit to indicate what and how could be improved in the home. Health and safety was generally well managed in the home. Servicing of equipment was regularly carried out. The only issues that the manager needed to attend to was that fire training was carried out every six months with staff and that staff were reminded to ensure that soiled bedding was changed promptly. The manager also needed to ensure that meats were dated on freezing to assist with stock rotation and so that the quality of foods could be managed. Lindale Residential Care Home DS0000047064.V328494.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 X 2 3 3 X 4 X 5 3 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 3 26 X 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 2 X X 3 X Lindale Residential Care Home DS0000047064.V328494.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 YA6 Regulation 15(1) Requirement The residents’ care plans must include the self-care tasks that could be undertaken by the residents themselves and how long they should be left before the staff assist them. Any relevant guidance provided by health professionals in respect of meeting residents’ needs must be made accessible to the staff. There must be a risk assessment and procedure in place on how to manage any challenging behaviours presented by the residents. A record of the food eaten by the residents’ must be kept. Two initials must be used by staff to identify who has administered the medicines. Timescale for action 01/05/07 2. YA9 13(4)(b) 01/04/07 3. 4. YA17 YA20 17(2) Sch 4(13) 13(2) 01/04/07 01/04/07 5. YA24 16(2)(c) There must be protocols in place for the administration of ‘as and when required’ and ‘ as directed’ medicines. The manager must ensure that 01/06/07 the stair carpet is replaced when building works have been DS0000047064.V328494.R01.S.doc Version 5.2 Page 26 Lindale Residential Care Home completed. The manager must ensure that the armchair identified is replaced. 13(3) Staff must ensure that soiled bedding is changed promptly. 16(2)(c)(d) The registered manager should ensure at the earliest opportunity that service users are supported to choose their own furnishings in their bedrooms, like carpets and curtains. This is on going. 8. YA39 24(1)(a) (b)(2)(3) The registered manager must ensure that a report on improvements that could be made following the quality audits is prepared. Staff must be available in sufficient numbers to encourage and enable residents to undertake activities on an individual basis. All foods must be dated on freezing. Staff must receive fire training on a 6 monthly basis. 01/04/07 6. 7. YA30 YA26 07/03/07 23/07/07 9. YA33 18(1)(a) 01/04/07 10. 11. YA42 YA42 13(3) 23(4)(d) 01/04/07 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations Risk assessments should be numbered and crossreferenced to the care plans. Lindale Residential Care Home DS0000047064.V328494.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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