Inspection on 18/05/06 for Linden Lodge

This inspection was carried out on 18th May 2006.

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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Linden Lodge 28/06/07

Linden Lodge 12/12/05

Linden Lodge 06/09/04

Linden Lodge 24/05/04

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

CARE HOME ADULTS 18-65 Linden Lodge 38a Linden Way London N14 4LU Lead Inspector Wendy Heal Key Unannounced Inspection 18th May 2006 10:00 Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 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 Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Linden Lodge Address 38a Linden Way London N14 4LU 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) 020 8447 9195 020 8447 9195 www.craegmoor.co.uk Parkcare Homes (No. 2) Limited Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of service users accommodated do not exceed 8 in Linden Lodge, 38a Linden Way and 3 at 38 Linden Way. One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 12th December 2005 Date of last inspection Brief Description of the Service: Linden Lodge is owned by Parkcare Homes Ltd. The home provides care for up to 10 residents with mental health needs. Linden Lodge consists of two adjoining houses and is situated in a pleasant residential area of Southgate. The home is close to local shops and facilities and is near to public transport routes. 38 Linden Way has 3 bedrooms, each with en-suite facilities. There is a lounge and kitchen on the ground floor and a room upstairs for staff where they sleep in at night. 38a has 7 bedrooms, each with a hand basin. There is also a lounge and kitchen/dining room, bathroom and an office used by staff. There is an attractive garden at the rear with a patio area. All residents have their own bedroom. The staff team consists of a manager, 2 senior support workers and support workers. A minimum of 2 care staff are on duty in the daytime and 2 sleep in at night. Residents take part in a variety of activities, both within and outside of the home. The Purpose and Function Document and the last Inspection Report are on the homes notice board for interested parties to view. The organisations fees are approximately £800.00 per person. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards and took approximately 6 hours. The inspector undertook a tour of the building and spoke with service users and members of the staff team. The inspector gained further information by an inspection of the documentation kept in the home, including care plans and health and safety documentation. The Manager and Deputy Manager assisted the inspector throughout the day. The inspector would like to thank the service users present during the inspection, the managers, staff and service users for their openness and participation. What the service does well: What has improved since the last inspection? Service users care plans are now being reviewed on a monthly basis and are signed by service users where possible, which ensures service users needs are met. The staff have received fire safety training, which increases their knowledge in relation to fire prevention and improves the safety and wellbeing of service users. The patio door which was not working effectively in the conservatory and acted as an exit route in the event of fire in this area of the house has now been made safe, which ensures a safe exit is available to service users in the event of a fire. Improvements to the environment have taken place. The cooker hob in flat 38a which, was not safe, has been replaced, which ensures that service users are living in a safe environment. The staff members are receiving regular supervision from the Manager, which ensures a consistent professional approach is maintained by staff in relation to supporting service users. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 7 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 Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 8 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): 1,2,3,4,5 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. Service users are given the information they need to make an informed choice about whether the service is suitable for them and their needs. The service is poor at assessing individual service users aspirations and needs, which means the service users needs may not be met. Service users have an individual contract of terms and conditions, which means they know what the expectations are for them and vice versa. EVIDENCE: Since the previous inspection there has been one new admission to the home. However, there was no written documentation available at the time of inspection regarding the service users admission to the home, which means that the home cannot ensure that this service users needs are met and that a professional, consistent admissions procedure is followed. This requirement has been restated. The home has an up-to-date Purpose and Function Document. The home has a Service User Guide that was updated by the manager in 2006. It clearly specifies the terms and conditions of the home including a four week notice period. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 9 The service users files were inspected. They contained copies of contracts between the home and service users, which set out the terms and conditions on which the accommodation is provided. The care plans are being reviewed on a regular basis and considered areas such as promoting personal hygiene, promoting a healthy and active life style, encouragement to investigate and organise vocational training, smoking and substance abuse. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,78,9,10 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to this service. The service is good at assisting service users to make decisions about their daily lives. Service users are consulted and participate in all aspects of life in the home, which increases their self-esteem and personal development. The service must improve with regard to supporting service users to take risks to develop an independent lifestyle to ensure that service users needs are met and their wellbeing is safe guarded. The service is good at maintaining service user confidentiality and service user information is handled and kept appropriately to protect service users. EVIDENCE: Service users care plans were inspected. They were clear to read. The manager is endeavouring to keep them up-to-date. The care plans in the service users files were inspected and evaluate all aspects of living in the home. The needs are identified as well as the aims to achieve a care intervention and the care plans are being evaluated on a regular basis. The plan specifies the areas in which service users make decisions about their lives Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 11 with assistance. The risk assessments to show potential risks for service users are being reviewed. However, they do not include all relevant areas to ensure that the service users and staff members’ health and safety is safeguarded and the service users needs are met. The inspector informed the manager that areas such as aggressive behaviour, depression, fear of racist comments and Diabetes must be included in the identified service users risk assessments as well as guidance in relation to the signs and action to be taken in relation to experiencing complications such as hypoglycaemia and hyper glycaemia which will ensure that the identified risks to service users are minimised and staff have the written knowledge available to them to take appropriate action when required. There must be guidance available in relation to the signs and triggers to be considered in relation to identifying depression in relation to the identified service user, which will assist staff to identify a decline in the service users emotional wellbeing to allow staff to then take appropriate action. Service users meetings to discuss issues relating to service users do take place. The topics discussed included service users being asked their views in relation to Linden Lodge, which ensures they have the opportunity to express their views about the home. The homes Service User Guide had been given to service users at this meeting to ensure that all service users had access to a copy of the Guide. Service users had discussed their wishes to go on holiday. Service user information is handled appropriately. The main files are kept in the office and information stored on the computer is accessed by a password, which ensures service user confidentiality is respected. The inspector observed the level of confidentiality in the home and is satisfied that the staff working at Linden Lodge keep all information regarding service users secure. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13,14, 15, 16,17 Quality in this outcome area is good. The judgement has been made from evidence gathered both during and before the visit to the service. Service users are supported to develop their skills within the home, which assists their independence. Service users are part of the local community, which enriches their lives. Service users rights are respected, which emphasises they are valued and increases their self-esteem. Service users are assisted to maintain appropriate relationships, which assists their emotional wellbeing. Service users are supported to choose healthy nutritious meals, which assists service users maintain a healthy lifestyle, and promote good health. EVIDENCE: On the day of the inspection a number of service users had gone out to take part in a range of activities in the community. Two service users attend Jewish Day Centres two days per week to meet their specific needs. One service user is due to start an eight-week gardening course, which allows opportunity for personal development. One service user has enrolled to be trained in relation to painting and decorating which develops personal skills and self esteem. Service users enjoy going to shops and cafes, which increases their Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 13 involvement in the community. Service users go out together once a week, for a drink or to play pool. The service users have games such as darts, dominos and bingo available, which ensures they have access to activities within the home. The inspector observed pictures in the lounge of service users having gone to watch ice hockey matches. The inspector is of the opinion that it would be beneficial for some structured activities outside of the home to be researched for the identified service user who has all of his activities planned by the home. A good practice recommendation has been made in relation to this. Care plans are organised and are being updated on a monthly basis and identify how service users are supported to develop their independent living skills. The inspector observed the interaction between staff and service users. The staff interaction was appropriate and service users were treated with respect. Service users contact varies ranging from personal visits to telephone calls. On the day of the inspection one service user was going to stay with his father, he was travelling there independently by train. The service user spoken with said “I am looking forward to seeing my father.” One service user’s father came to see the Manager on the day of the inspection and he said, “I am very pleased with the contact I have with my son.” He went on to explain how his son visits to have breakfast with him in the mornings, and returns to his home or goes out during the day and then returns to have super with him in the evenings. On the day of the inspection the kitchen was clean and tidy, which benefits the health and safety of service users and staff. The menu of food available was wholesome and nutritious, which ensures the service users dietary needs are being met which also benefits their health and wellbeing. The fridge and fridge freezer were inspected and all food was identified as being within its use by date and properly labelled, which ensures that service users health is safeguarded. The inspector observed that one Jewish service user was being provided with Kosher food of his choice which is being stored in a separate compartment in the fridge which has been labelled which ensures that his specific cultural needs in terms of diet are being catered for. Service users benefit from a mixed staff team who bring a range of different ideas to the home in terms of food preparation. This benefits service users as they have access to different types of food than they may otherwise experience. One service user spoken with said, ”the food was good”. Service users privacy is respected, service users have keys to their rooms and permission is sought before entering their bedrooms. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users receive personal support in a way they prefer and require, which ensures their individual rights and choices are respected. There is good support provided to service users to access healthcare appointments. The process for the storage and administration of medication is not effective and does not promote the good health of service users. The wishes of service users in the event of their death are recorded to ensure their wishes are respected. EVIDENCE: Service users all have access to primary and specialist healthcare appointments, which safeguards their health and wellbeing. Service users care plans and records of medical appointments inspected indicated that service users have access to General Practioners, Dentists and other healthcare professionals, which ensures that their healthcare needs are being monitored. The medication was inspected and found to be stored inappropriately in a locked filing cabinet. The medication must be stored in a locked medication cabinet, which is attached to the wall, which will ensure the professional Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 15 storage of medication, which will safeguard the health safety and wellbeing of service users. The temperature at which medication is stored must be recorded which will ensure that medication is being kept within the required temperatures. Requirements have been made in relation to this. On the day of the inspection, one service user who was visiting his father took his medication home with him for his stay. This situation had not been risk assessed at the time of the inspection, a risk assessment must be completed to minimise any potential risks to the service user. This information must be included in the care plan. A requirement has been made in relation to this. The service user spoken with said that he “understood how his medication had to be taken and was happy to do this.” The medication and administration records were inspected. The medication had been appropriately signed for on the MAR sheets. Staff had received medication training to ensure that service users are protected by the homes medication procedures. Service users were appropriately dressed at the time of the inspection. Service users wishes are recorded on their files in the event of their death, which ensures their individual wishes are respected. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is good. The judgement has been made from evidence gathered both during and before the visit to the service. Service users can be confident that their views are listened to and acted upon, since the recording of complaints and action taken is adequate. Service users are protected by trained staff who had an adequate understanding of how to protect service users from abuse, neglect and self-harm. EVIDENCE: At the time of the unannounced inspection the inspector looked at the complaints file. There were no new complaints since the last inspection. The company policy on whistle blowing was satisfactory and staff were familiar with how to use it. Staff had attended Adult Abuse and Protection of Vulnerable Adults training and during discussions with staff they were knowledgeable with regard to the reporting procedures. Service users financial records were not inspected on this occasion. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 17 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): 24,25,26,27,29,30. Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Improvements in the home have been made and further action is needed to ensure the home is comfortable and homely for all service users. Service users bedrooms suit their needs. Service users have the specialist equipment they require to maximise their independence. The home was clean, which promotes the health and safety of service users. EVIDENCE: The home offers an appropriate domestic type environment. Service users bedrooms were inspected and found to be adequate and met their individual needs. The tour of the building showed a reasonable standard of cleanliness, which ensures the health, safety and wellbeing of service users and staff. The patio door, which also acts as a fire door in this area of the building is now functioning correctly which provides a suitable exit in the event of fire for service users. The cooker hob that was a health and safety risk to the service users living in the home has now been replaced. The front garden is very Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 18 untidy and does not provide a pleasant environment for service users. A requirement has been made in relation to this. The washing machine in 38a, which is broken must be repaired or replaced to ensure that it is available to be used by service users. The pebbledash exterior of the building is still unsound. This must be attended to, to ensure that the service users can enjoy living in a home that is safe and well maintained. This requirement has been restated. One service user said, “I am very proud of my bedroom and lounge” and took great pleasure showing the inspector around. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 19 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): 31,32,34,35,36 Quality in this outcome area is adequate. The judgement has been made from evidence gathered during and before the visit to the service. Staff are adequately qualified as they now have access to NVQ assessors. The Manager is not receiving regular supervision so a consistent approach cannot be maintained. Service users are safeguarded by the home’s recruitment Policy and Procedures. EVIDENCE: The staff files were inspected and the manager had not received regular supervision for at least a year, which means that a professional, consistent approach cannot be maintained and it cannot be guaranteed that the Manager is receiving adequate support, which does not assist the development of service users. A requirement has been made in relation to this. Staff records were inspected and were found to contain all the necessary documentation e.g. criminal records bureau checks, staff references and the required staff identification records to ensure that adequate recruitment procedures were followed and that service users are being adequately protected from abuse. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 20 Staff had undergone training in relation to fire safety, which increases the knowledge of the staff team and their ability to safeguard service users in relation to fire prevention has been improved. Staff must undertake training in food hygiene, first aid and infection control, to ensure the health, safety and wellbeing of service users is maintained. This requirement has been restated. A number of staff were undertaking their NVQ Level 2 and Level 3. The Manager has just finished his Registered Managers Award. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 21 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): 37,39,41,42 Quality in this outcome area is poor. All appropriate health and safety measures need to be in place to ensure the safety and welfare of service users is maintained. Service users can be confident that their views underpin all selfmonitoring, review and development of the home. EVIDENCE: The home has two monthly service user meetings. This allows service users to put forward their views and comments in relation to the running of the home. Fire safety measures in the home were inadequate. The fire door closure in the lounge was not effective, and does not promote the health, safety and wellbeing of service users and staff. An immediate Requirement was made in relation to this. The record of fire alarm tests, emergency lighting and fire drills were inspected and found to be in order. During a tour of the building the inspector noted that Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 22 all fire doors were closed. All fire exits were clear and free from obstruction. The fire notices contained all of the information to indicate where service users need to meet in the event of fire, which assist in safeguarding service users from harm in the event of a fire. The COSHH materials are not kept in a locked cupboard and data record sheets are not up to date which does not minimise the risk of harm from these substances to service users. A requirement has been made in relation to this. The company insurance was seen and found to be in order. The boiler and water test certificates were seen and found to be in order, which ensures that the quality of care offered to service users living in the home is improved. The Electrical inspection certificate identified outstanding tasks to be completed which must be acted upon to prevent any unnecessary risk of harm to service users. A requirement has been made in relation to this. One service user spoken to said “the manager is very helpful and supportive.” Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 23 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 3 2 1 3 3 4 3 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 2 25 3 26 3 27 3 28 x 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 x 3 2 x Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 YA2 Regulation 14 (a) (b) Requirement The Registered Person must ensure that written documentation is available regarding tea visits, overnight stays and service user assessments when a new service user moves into the home. This requirement has been restated, previous timescale not met. The Registered Person must ensure that individual risk assessments include sufficient detail to identify how hazards to safety will be minimised; these must cover aggressive behaviour, depression, and fear of racist comments, Diabetes, and excessive drinking. The Registered Person must ensure that staff are provided with comprehensive guidance in the event of service users experiencing complications such as hypoglycaemia or hyperglycaemia as a result of Diabetes. Staff must also have comprehensive guidance made available in relation to service DS0000010565.V287745.R01.S.doc Timescale for action 01/07/06 2. YA9 15 2 (a) 01/07/06 3. YA20 13 01/08/06 Linden Lodge Version 5.1 Page 25 users who are at risk of suffering from depression, which, identifies the triggers related to depression. 4. YA20 13 2 (b) The Registered Person must ensure that medication is kept in a locked cupboard attached to the wall. The temperature at which medication is kept must be recorded. The Registered Person must ensure that a risk assessment is completed for the service user who administers his own medication. The Registered Person must ensure that the front garden is maintained. The Registered Person must ensure the broken washing machine is repaired or replaced. The Registered Person must ensure that the pebble-dash exterior is made good and a schedule for action is sent to the CSCI area local office. This requirement has been restated, previous timescale not met. 30/01/06 The Registered Person must ensure all staff have training in first aid, food hygiene and infection control. The Registered Person must ensure that the Manager has regular supervision at least two monthly. The Registered Person must ensure that the one remaining door closure in the lounge is functioning effectively. Immediate Requirement. The Registered Person must ensure that all chemical DS0000010565.V287745.R01.S.doc 27/06/06 5. YA9 12 (a) 20/06/06 6. 7. 8. YA24 YA24 YA24 23 (2)(b) 23 2(c) 23 2 (b)) 01/07/06 20/07/06 01/08/06 9. YA35 23 01/09/06 10. YA36 18 10/07/06 11 YA42 24 25/05/06 12 YA42 24 10/07/06 Version 5.1 Page 26 Linden Lodge substances are kept in a locked cupboard and COSHH data sheets are kept up to date. 13. YA42 24 The Registered Person must 01/08/06 ensure that the outstanding work identified on the electrical inspection certificate is completed. 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 YA12 Good Practice Recommendations It would be beneficial for some structured activities outside of the home to be researched so that they can be made available to the identified service user who has all of his activities based from the home. Linden Lodge DS0000010565.V287745.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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