Inspection on 08/06/06 for Lindhurst Lodge

This inspection was carried out on 8th June 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 but made no statutory requirements on the home.

Other inspections for this house

Lindhurst Lodge 04/12/06

Lindhurst Lodge 19/07/05

Lindhurst Lodge 05/04/05

Lindhurst Lodge 07/07/04

Lindhurst Lodge 01/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lindhurst Lodge Lindhurst Road Athersley Barnsley South Yorkshire S71 3DD Lead Inspector Christine Rolt Key Unannounced Inspection 8th June 2006 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindhurst Lodge Address Lindhurst Road Athersley Barnsley South Yorkshire S71 3DD 01226 282833 01226 282833 none None Mr Azad Choudhry 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) Post Vacant Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Lindhurst Lodge is a purpose built care home providing personal care and accommodation for 37 older people. The home is a two-storey building with a passenger lift. It has 33 single bedrooms and two double bedrooms. There is a small car park to the front, and large, private gardens to the rear. All areas of the home are accessible to people in wheelchairs. Lindhurst Lodge occupies a central position at Athersley North, and there are shops, pubs, a post office and other amenities within the vicinity. The home is approximately three miles from Barnsley town centre. The weekly fee was £315 per week. Hairdressing, chiropody, toiletries and non-emergency taxi service were not included in the weekly fee and were charged separately. The acting manager supplied this information in the PreInspection Questionnaire dated April 2006. The home produces a Service User Guide and a Statement of Purpose. Copies of these together with the inspection report were displayed in the entrance foyer. The home also produces a newsletter. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.20 am to 5.40 pm th The acting on 8 June and from 9.45 to 11.00 am on 12th June 2006. manager, Ms. Elaine Murfin was present and provided assistance throughout the two days. The Area Manager, Mrs. Pat Smith, was present for some parts of the first day and the owner Mr. Choudhry made a brief visit on the first day. Four residents were tracked throughout the inspection. The majority of the residents were seen and chatted to during the site visit, and of these, five residents were asked detailed questions about their opinions of the home. Two members of staff who were key workers for two of the tracked residents were interviewed. During the site visit, two relatives were asked for their views and a further three relatives were contacted by telephone. Comment cards were sent to ten residents and of these nine were completed and returned. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff, residents, relatives and stakeholders for their assistance and co-operation. What the service does well: The home had a welcoming atmosphere. Residents were satisfied with their care and said that they made their own decisions of how to spend the day. Residents who were capable went out for walks and visited local shops. Others were observed to be following their own routines. Some sat outside, others sat in the lounges and conservatory and others preferred to stay in their bedrooms. Relatives were satisfied with the home. One relative said that the home had not been his first choice for his parent but conceded the he was “Glad she’s here now. It’s more convenient and staff have more time for her”. Other comments from residents and relatives were “He’s happy”, “Very pleased”, “Definitely advise it to others”, “Very good”, and “Couldn’t wish for anything better”. A choice of menu was offered at all meals and special dietary needs were catered for including soft, liquidised, vegetarian and diabetic diets. The variation in meals was observed and residents were satisfied with their choices. One relative said, “He can’t wait to get down for breakfast”. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Lindhurst Lodge DS0000018262.V298921.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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service The home does not provide intermediate care. Residents only moved into the home after their needs had been assessed and been assured that the home could meet their needs. Residents had written contracts/terms and conditions with the home to ensure that they were aware of what was and was not included in their fees. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 9 EVIDENCE: The acting manager and staff said that she visited prospective residents to assess their needs to ensure that the home could meet their needs. Copies of the assessments were seen on residents’ files. In the main, residents’ families chose the home. Relatives said that they had been given all the information they required about the home and questions had been answered to their satisfaction. A copy of the inspection report, service user guide and statement of purpose was displayed in the entrance foyer. Their reasons for choosing the home were locality and the welcoming atmosphere of the home. “Its easy for us to visit”, “They made us welcome”, “It wasn’t my first choice but I’m glad she’s here now, visiting is easier and I think the staff are better – make a fuss of her”. Residents’ said that they were satisfied with the choices made and their comments were “I came here for a trial visit and liked it”, and “Couldn’t wish for anything better”. Residents had contracts with the home and copies of these were seen on residents’ files. The contracts had been updated to provide information of what was not included in the fees. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ health, personal and social care needs were set out in individual care plans and their changing needs were also reflected in their care plans, but there was insufficient recording of residents’ day to day routines. Residents’ health care needs were, in the main, met. Medication procedures did not ensure that residents were protected. Residents’ privacy and dignity was respected. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 11 EVIDENCE: Residents and their relatives said that residents’ care and health needs were met and relatives would be kept informed. Visitors said that they were satisfied with the care provided to their relatives and that staff were helpful. Comments were “They contact you straight away”, “Home’s good at phoning us”, “Not been in long and no problems but told me they would phone if there was one”. Four care plans were checked and these provided details of individual care and recorded actions to meet physical care needs. However, there was insufficient recording of residents’ day-to-day routines e.g. emotional and social well-being. The activities sheets were not being completed and there was insufficient information of residents’ day-to-day wellbeing. Inventories of residents’ clothing and personal possessions did not provide specific details. Records of accidents were kept on residents’ files, together with 72 hour monitoring sheets. However, there was insufficient information of how residents were checked, the time they were checked and the frequency of checks. There was written evidence to show that care plans were reviewed regularly to meet residents’ changing needs but no indication that residents were consulted. Residents had mobility aids to maintain their independence but one resident with mobility problems had not been referred for assessment by the physiotherapist. This was discussed with the acting manager and the area manager. Staff who dealt with medication had received training, and certificates to verify this were seen on staff files. The recording and storage of medication was checked on a sample basis. There were several discrepancies: the recording procedure for handwritten entries was not being followed, the quantities of two items of medication had not been recorded, a bottle of tablets was out of date and there was insufficient information on one entry on a pre-printed Medication Administration Record and this had not been queried by the staff dealing with medication. The administration of medication was observed and the correct procedure was not being adhered to. These discrepancies were discussed with the area manager and acting manager. Residents and relatives considered that residents were treated with respect and dignity. Residents said “Yes” they were treated with respect and their privacy was respected. Relatives said “Yes, very much so” and “All staff treat her with respect”. Residents were called by their preferred name or title. It was also noted during this site visit that residents were clean and neatly dressed. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ lifestyle in the home, in the main, matched their expectations and preferences. They were encouraged to maintain contact with their family, friends and the local community as they wished and had choice and control over their lives. A good choice of menu was offered and special dietary needs were catered for. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 13 EVIDENCE: Residents were relaxed and said that they were satisfied with the home. There were no organised activities taking place during the site visit, and the home did not employ an activities co-ordinator. The acting manager and area manager said that entertainment was brought into the home, the staff spoke of various activities they’d arranged including painting, “Play Your Cards Right” and oversized board games. Relatives spoke about what they’d observed in the home and named regular bingo evenings, singing sessions, reading to residents and gentle exercise sessions. There was no information on display to inform residents of these activities. The area manager said that residents went out for walks and to the local shops and were accompanied by staff if considered necessary. Observations during the site visit and relatives’ comments confirmed this. The acting manager said that the local vicar visited the home every Sunday and chatted to residents. Relatives said that staff were good at contacting them if they had any concerns about the residents. A relative said, “Yes, they’re good like that” Residents and visitors said that the food was good and comments indicated that special dietary needs were catered for including vegetarian diets, “I’m vegetarian so they do mine separate”, “Mum’s had problems swallowing ordinary food so she’s been on a liquidised diet”. The kitchen also had a list of residents who were diabetic, together with information on whether the residents were insulin dependent or diet controlled. Staff knew residents’ likes and dislikes and there was a choice at all meals. Residents were observed to be eating what they enjoyed and made positive comments about the food, “I like soup”, “Suits me, they know what I like” and “I think it’s lovely”. The dining room was pleasant, teapots were on tables where residents were capable of using them safely, and all tables had condiments available. However, one condiment container was smeared with food and another had been filled with salt but had not been washed after being used for pepper. These were taken to the cook for cleaning. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents and their relatives and friends were confident that their complaints would be taken seriously. Residents were protected from abuse. EVIDENCE: Residents and relatives were aware of who the acting manager was, and said that they would tell her or one of the senior members of staff if they had concerns or complaints. The complaints procedure was displayed on the notice board. The home’s complaint record was seen and this showed what action had been taken to address complaints and concerns. The Commission had received two complaints since the last inspection, which were referred back to the home. One complaint had been resolved and the second was being processed. There were no allegations of abuse. Staff had received some adult protection training and their names had been submitted to attend more detailed training through Barnsley council. Residents and relatives said that they liked the staff and the manager and all comments were positive, “Best lasses in world”. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service The home was clean and comfortable. Some bedrooms were not well maintained. Service users were provided with an environment that was safe, accessible and homely and had the specialist equipment they required to maximise their independence. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 16 EVIDENCE: The home was welcoming and there were no offensive odours. Several relatives said, “Yes” they thought the home was clean and one comment was, “It smells clean”. Their opinions of bedrooms were mixed. Some said that bedrooms were “Lovely” “Nice big room” “Lovely big chair in the bedroom”, whilst others said “It’s adequate”, “It needs decorating”, “She’s been in there four years and it’s never been decorated although they keep promising” and “There’s wallpaper coming loose”. A check of the environment including the bedroom of a recent admission revealed that some bedrooms on the upper floor were drab with loose wallpaper and were in need of redecoration. The acting manager and the area manager said that they were aware that upstairs bedrooms needed redecorating and work was currently underway for plastering and redecoration of bedrooms. This was confirmed by a discussion between the acting manager and a resident who’d moved into another bedroom whilst her bedroom was being renovated. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, adapted baths, mobile hoist and ‘Stand aid’, were provided to enable residents to maintain their independence. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service The numbers and skill mix of staff met residents’ needs. Staff were trained and competent to do their jobs. Residents were not supported and protected by the home’s recruitment practices, therefore residents were not in safe hands at all times EVIDENCE: There was an outstanding requirement from July 2005 relating to staff recruitment records. Six staff files were checked. Files contained employment histories but some did not provide full information and some had gaps in employment. There were no written records on these files to determine whether discrepancies had been discussed. Some files had only one reference and some had none. One reference contained information that required further enquiry, but again there was no written record to demonstrate that this had been discussed and risk assessed. The Pre-inspection Questionnaire recorded the dates when staff’s Criminal Record Bureau disclosures had been received by the home, but on some files there was no evidence that disclosures had been carried out. The home had also accepted CRB disclosures that had been carried out by staff’s previous employers and new disclosures had not been carried out. Therefore residents were not in safe hands at all times. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 18 All service users and relatives spoke positively about the staff’s attitude and care practices. Comments from residents included “Don’t think staff could be any better” and “Lovely lasses”. Staff said there were sufficient staff on each shift to meet residents’ needs. The area manager said that they were advertising for two more carers. Staff training was ongoing. According to the Pre-inspection Questionnaire, 50 of the care staff had attained NVQ Level 2 or above. During the site visit, the acting manager gave the names of seven staff who were undertaking the Induction Training. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service The home was generally run in the best interests of residents but could be improved. The home has not had a registered manager since May 2005. Residents’ financial interests were safeguarded. Residents’ health, safety and welfare were not fully promoted. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home had no registered manager. An acting manager was employed soon afterwards but no effort was made for him to register with the Commission for Social Care Inspection and he left May 2006. The area manager said that she had advertised for a manager. The deputy manager was acting as manager and overseeing the home with the support of the area manager. Residents and their families knew the acting manager. The home had a “Health & Safety” audit book but this was not being used properly and had become an out of date repairs and maintenance book. The auditing of all aspects of the home environment and the home’s procedures, for quality assurance purposes, was discussed with the acting manager. Evidence that Residents Meetings were held was seen and advice was given on how to ensure that these were for the benefit of residents. Minutes from staff meetings were seen and these meetings were held regularly. The area manager carried out visits to the home and produced reports; copies of which were forwarded to the Commission of Social Care Inspection as required by Regulation 26 of the Care Home Regulations. Residents and relatives said that they had not been asked for their views of the home, either at meetings or in surveys or questionnaires. One relative said “The only opinion I was asked was by your lot when I was there (at the home) during an inspection last year”. The majority of residents who were asked said that their families looked after their personal allowances. Relatives said that they either left small amounts of money with the home or gave it direct to the resident for hairdressing, chiropody etc. One relative was asked if they were given receipts for the money handed over. They said “No, but it’s not a problem”. The acting manager was advised to issue receipts for all transactions. The home held some money for three of the four residents who were tracked. There were safe storage facilities within the home. Cash was held separately for each resident and the amounts were checked against the records and were correct. Fire drills were held regularly. The manager was advised to utilise the fire drill matrix, which provided a means to ensure that all members of staff participated in fire drills and were conversant with the procedure. A training matrix was displayed which provided an easy reference guide to the training undertaken by staff. However, dates of training were not available and staff files did not contain all documentation as proof that all mandatory training was up to date. The majority of staff had recently undertaken training in moving and handling and fire awareness and there was written evidence to support this. The need to ensure that all staff had undertaken all aspects of mandatory health and safety training including first aid, basic food hygiene and infection control was discussed with the acting manager. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 21 The Pre-Inspection Questionnaire provided information on the dates that systems and equipment had been serviced and maintained. Since the last inspection, the home’s heating and hot water system had caused problems. Emergency work had been carried out but further work had been planned for “when the weather gets warmer” because the whole system needed to be shut down. The area manager was asked about this. No action had been taken, but the area manager said that she would contact the contractors and plan a date for the work to be carried out. The pane of glass in the kitchen skylight had been replaced but an extra bin for kitchen waste had not been provided. The cook confirmed that an extra bin was needed. Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12,15 Timescale for action Care staff in consultation with 07/08/06 the service user must review service users’ care plans at least once a month. (Timescale of 1st September 2004 not met) Daily Care Records must be 07/08/06 more detailed to reflect the care needs of service users. (Timescale of 1st September 2005 not met) Inventories of residents clothing 07/08/06 and personal possessions must provide specific details. Where residents sustain falls or 10/07/06 accidents, the recording and the monitoring of the care, must be kept up to date to enable a judgement to be made and ensure that residents’ health and welfare are promoted (i.e. 72 hour plans). Health needs including mobility 10/07/06 problems must be met by referral to the relevant health professional Staff who deal with medication 10/07/06 must adhere to the procedures for the receipt, recording, storage, handling and DS0000018262.V298921.R01.S.doc Version 5.2 Page 24 Requirement 2 OP7 12,13 3 4 OP7 OP8 12 13 5 OP8 13 6 OP9 13 Lindhurst Lodge 7 OP12 16 8 OP19 23 9 OP29 19 10 11 OP31 8, 9 24 OP33 12 OP38 13 and 23 13 OP38 23 14 OP38 16,23 administration of medicines. A programme of activities, suited to the needs of service users, must be provided. (Timescale of 1st September 2005 not met.) An audit of all bedrooms must be carried out and a rolling programme of redecoration must give high priority to those bedrooms that are drab and damaged. All staff must be deemed fit to work at the home, by the provision of CRB enhanced disclosures, authenticated references, proof of identity, full employment history and evidence that discrepancies have been discussed. A manager must be appointed and apply for registration with the Commission. Evidence that quality assurance procedures are in operation must be demonstrated including audits of the home environment, systems used within the home, e.g. medication checks, and the views of residents, relatives and stakeholders in the community sought and acted upon. All care staff must have up to date mandatory health and safety training including first aid, basic food hygiene, infection control, fire awareness, adult protection and moving and handling. Servicing and maintenance work must be carried out on the boiler system to ensure it works at full capacity to protect the health and safety of service users. An extra bin for kitchen waste must be provided to ensure health and safety. (Timescale of 31 August 2005 not met.) DS0000018262.V298921.R01.S.doc 10/07/06 10/07/06 10/07/06 04/09/06 07/08/06 04/09/06 04/09/06 10/07/06 Lindhurst Lodge Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Lindhurst Lodge DS0000018262.V298921.R01.S.doc Version 5.2 Page 27 - 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!