Inspection on 11/09/06 for Lindum Park House

This inspection was carried out on 11th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lindum Park House 12/02/07

Lindum Park House 30/11/05

Lindum Park House 11/07/05

Lindum Park House 28/02/05

Lindum Park House 13/09/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Lindum Park House 1-2 Lindum Road Lincoln Lincs LN2 1NN Lead Inspector Mr Doug Tunmore Key Unannounced Inspection 11th September 2006 09:15 11/09/06 09:15 Lindum Park House DS0000002377.V310768.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 Lindum Park House DS0000002377.V310768.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 and 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. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindum Park House Address 1-2 Lindum Road Lincoln Lincs LN2 1NN 01522 545099 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) United Health Limited Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Lindum Park House is a large three storey, semi-detached, Georgian, grade 2 listed building, which has been adapted to provide accommodation and services for seventeen residents with mental health needs. The home has single bedrooms and a self-contained flat on the top floor, two lounges and a large dining room. United Healthcare Ltd owns the home and provides support through the companies Operations Manager. The home is situated in the centre of the city of Lincoln with all the local facilities available to the residents. The local bus and railway stations are close by and the home is within easy reach of all the citys main shopping areas. Although the home is close to the city centre, it has a small garden and yard, which is used by the residents. The home has a flat rate of current charges, which is £348.00. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by the Commission for Social Care Inspection (commission) including the homes previous inspection reports, their service history, the homes pre-inspection questionnaire and residents questionnaires sent to the home by the commission prior to this inspection. The site inspection consisted of case tracking a sample of two resident’s records and assessing their care. The inspector spoke with two of the residents who was being case tracked and joined three other residents for lunch. The inspector also spent time with the acting manager and a carer. One community psychiatric nurse was spoken to and an approved mental health social worker was also contacted, who had clients placed at this home. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? What they could do better: The owners of this home have not been proactive in ensuring that past requirements have been met. There appears to be ‘a hands off’ approach to the running of this home which has lent to a drift in action required to be taken for the benefit of prospective residents and those living in the home. Due to Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 6 this an additional inspection is to take place to ensure that all requirements are met. The providers have not addressed a requirement from 2004 relating to amending the homes policies to reflect the carrying out of pre-admission assessments. The home does not have a dedicated care needs pre-assessment form for prospective residents, which is fundamental to assessing whether the home can meet a residents needs and how they may or may not be suitable for this home. This inspection found that residents did not have contracts on file, which would give details of the conditions and fees for individual placements. Staff at this home have not had training specific for this client group. This requirement was made in November 2005 and was to have been addressed by 20/02/06. No action has been taken. The providers have not established a system for ensuring that there is a quality assurance process in which residents are informed of the outcomes. This requirement was made in November 2005 and was to have been addressed by 20/02/06. No action has been taken. The home does not have a complaints procedure, which empowers residents. This requirement was made in November 2005 and was to have been addressed by 20/02/06. No action has been taken. The providers must fit radiator guards and thermostatic controls to ensure the safety of residents. This requirement was made on the 15/12/04 and has not been met. Those residents who are now elderly need to be assessed as soon as possible to ensure that their care needs can be met at this home. Residents files did not evidence that risk assessments are drawn up with residents, detailing any risk of them travelling on their own or going into town and how this might impinge on their freedoms. There was no evidence that residents are actively engaged about decision making in their own lives. Medication had been signed for in the morning by care staff for the rest of the day, for a resident who would not be seen to have taken this medication. The resident must sign for the medication or the medication code ‘D’ signifying resident out all day. There was no risk assessment carried out for residents who self medicate or partially self medicate. Lindum Park House DS0000002377.V310768.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. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) 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 5 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a comprehensive care needs admission assessment, which helps to ensure that a residents needs would be met. EVIDENCE: A previous inspection carried out on the 30/11/05 evidenced that the home had a prospective residents care needs admission form. However, this inspection found that no such document was in use. A risk assessment form was in use for admission purposes with little written evidences to support the number system used for assessing a residents care needs. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 10 The acting manager stated that he visits all prospective residents prior to admission. He also said that there have been two admissions since the last inspection to this home and both were unsuccessful. Two residents files seen did not contain their written contract, giving their terms of conditions of occupancy with the provider. The commission sent residents questionnaire forms to the home prior to this inspection and one was returned. The questionnaire showed that this resident wanted to move to this home and had enough information about the home before moving in. The residents written comments were; ‘I was told to look around two homes to see if I would like to visit and stay in one. This house was shown and I saw a lot of the rooms. I thought the other home would be too much’. Another comment was, ‘it seemed well situated and the garden was nice’. One resident confirmed that she had visited this home prior to admission and it was her choice to live in this home. The homes policies and procedures do not reflect the current practice of the acting manager or other staff undertaking assessments of care needs, prior to the admission of residents. Intermediate care is not provided in this home. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to be proactive and encourage residents to take a full and meaningful part in all aspects of the delivery of care. EVIDENCE: A review of all information available prior to this inspection and a previous key inspection carried out in November 05 at this home evidenced that residents had an individual detailed care plan. This inspection found that those care plans of two residents who were being case tracked had been reviewed on a regular basis and reflected the changing needs of the resident. Neither of the Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 12 two care plans seen had been signed by the residents. Neither of the residents spoken to was aware that they had a care plan. Residents reviews were available, with a number of residents, who are under sixty five years of age, having been reviewed recently by an approved social worker from the mental health team. It is now relevant that all those residents who are over sixty-five years of age are also reviewed, so as to ensure that their care needs are being met. Risk assessments seen in residents files did not identify those risks to residents who travel alone or go into town or how this might effect their daily living. Residents commented that ‘ I like it here, its handy for town and shopping’. It was noted during this inspection that a number of residents came and went as they wished. It was also seen that there was friendly banter between residents and care staff throughout the day. Previous inspections have found that regular house meetings are held in which residents are empowered to raise any issues and discuss the running of the home. This inspection showed that the last house meeting was undertaken on the 28/07/06 and issues discussed related to outings and holidays. The minutes also showed that the acting manager had ‘abolished’ the past practice of having a timed tea break system at this home and residents are now encouraged to make their own drinks as they so wish. All residents felt that this was better as they could get a drink when they wanted. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 & 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 14 Service users had busy and varied lifestyles, with opportunities to engage in a range of leisure activities. EVIDENCE: A previous inspection of this home has shown that outings and various activities take place. Numerous residents confirmed that they go into town shopping and this activity was seen on the day of this inspection. One resident who has an interest in trains stated that he caught a train to Market Rasen last week, had a walk around the town and then returned home. Another resident collects football programmes and visits specialist shops to buy programmes. Two residents joined up with another home to go on holiday to Bridlington. A senior carer confirmed that residents go for trips out in the mini-bus to the east coast and local outings to garden centres, Whisby wild life centre and local public houses. Two residents stated that, we go out for day outings in the mini-bus. We also go out to the pub, have a couple of pints and come back. One also confirmed that ‘girls from the local college came for a number of weeks to do dancing and singing, it was very good’. Two residents confirmed that they keep in contact with their families. A senior carer stated that one resident visits his mother and does some shopping for her. The acting manager confirmed that one resident has a full time job. A social worker was contacted who made positive comments regarding the acting manager who was trying to encourage residents to be more independent. One residents questionnaire returned to the commission showed that she usually made decisions about what she did every day. Her written comments reflected ,‘ I clean my bedroom, I do my own washing and want to do a little helping at dinner time’. The regulator joined five residents for lunch and engaged a number of others who said that the meals are good at this home and they have their main meal at lunchtime. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health care needs are met and personal support is only given to residents with their consent. Risk assessments are not available for residents who self-administer medication and appropriate records of medication are not kept. EVIDENCE: Previous inspections have shown that all rooms have lockable doors and residents have a key to their rooms to ensure privacy. A senior carer commented that ‘we knock and wait for permission to enter a residents bedroom’. Care plans seen highlighted that residents have a ‘key worker’ to Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 16 help with the personal care of residents. This is based on friendships and gender as well as the expressed wishes of a resident. One resident stated that ‘staff keep and eye on me when I shower and they wash my back’. Observations made by the inspector was that residents are able to express their needs and during this inspection appeared happy and free to do so. At the last visit on 29/03/06 the pharmacist report showed that administration records were good and storage, stock control and administration of records was good. However, an examination of resident’s medication sheets showed that medication had been signed for from morning to evening. No member of staff would have seen medication being taken by the resident, so are not in a position to sign for it as taken. The carers should use the legend at the bottom of the medication sheet, which has a ‘D’ for out all day. There was no evidence in resident’s files that there were risk assessments for those residents who self-medicate. The homes training profile showed that the majority of staff had undertaken medication training on the 02/05/06. A staff member confirmed that she had undertaken medication training. One resident stated that she does not administer her own medication. Those residents files seen, evidence that residents health care needs are met. The homes daily records show that a chiropodist visits the home and residents visit their G.P when required. Two residents confirmed that they see their GP, or in one instance the psychiatrist, with appointments made six months in advance. A visiting community psychiatric nurse (CPN) confirmed that she visits her client and holds reviews, which are not attended by carers from this home, at the request of her client. She confirmed that her client has lived in this home for many years. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not empowered by the complaints process. Only one member of staff has undertaken adult protection training. EVIDENCE: A previous inspection carried on the 30/11/05 found that residents are not empowered by the homes complaints format, as it does not have a space for the signature of a resident/complainant to signify whether they are happy with the way the complaint process has been undertaken or the outcome. The providers have not addressed this issue and this requirement is not met. The homes pre-inspection questionnaire shows that no complaints have been made since the last inspection. Two residents stated that they had no complaints and that staff are kind to us and we feel safe. There were appropriate policies and procedures in place regarding the protection of vulnerable adults. The staff training profile evidence that only one carer had undertaken adult protection training. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 & 30 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and clean environment. EVIDENCE: A previous inspection undertaken in July 05 found the home to be clean with no unpleasant odours detected. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 19 A resident showed the inspector around the home, taking in a bedroom, toilets, bathrooms, showers and communal areas. Not all of the bedrooms were seen as some service users were out and others did not want them to be seen. One bedroom seen was large and had been personalised by the occupant. The resident expressed satisfaction with his room explaining that he had been moved from a smaller room to his present accommodation where he can keep all his belongings. A residents questionnaire stated that ‘the home is usually quite clean and tidy’. Two other residents confirmed that a lot of decorating has been done and that the dining room carpet has been replaced. The home currently employs an agency cleaner who works twenty hours a week. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment practices. Staff do not receive training specific to the needs of this client group. EVIDENCE: A previous inspection carried out in November 06 found that the homes requirement practices were in place and contained all of the documentation required by law. A cursory inspection of one carers personnel file was undertaken and it was found that appropriate checks are undertaken to ensure the safety of residents. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 21 One senior carer stated that she had undertaken the homes recruitment process and confirmed that references and criminal record bureau checks were acquired prior to starting work at this home. Each worker in the home has been given the General Social Care councils pack relating to the registration of care workers and the philosophy of the Care Council for all social care homes. The homes training plan was received by the commission and found to be up to date. The training record identified those care workers who had undertaken statutory training in 2006 and those carers who required a training input. The homes pre-inspection questionnaire evidenced that none of the care staff had acquired National Vocation Qualifications (NVQ) training in care at level 2 or 3. This home does not meet the 50 required for staff to be trained to NVQ level 2. The acting manager confirmed that none of the staff hold an NVQ qualification. One senior carer commented that she had applied to undertake NVQ training level 3. She was also able to demonstrate a clear understanding of her role and responsibilities. Previous inspections have shown that the providers have not promoted training for staff specific for this client groups needs, this requirement is still outstanding. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 & 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate checks are carried out to ensure the safety of residents. The home is not pro-active in undertaking quality monitoring checks. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 23 EVIDENCE: The acting manager has experience in working with clients who have had a wide range of social care needs. This includes people with a physical, mental health need or who are elderly mentally infirm. He has NVQ level 3 in mental health care and is currently undertaking the registered managers award. He has also undertaken statutory training as required. The score of two will be given for this standard due to the manager not being registered but no requirement will be made. One resident informed the inspector that that he hoped ‘John’ the acting manager stays at the home because he is friendly and is doing things for the residents. Two other residents made similar positive comments during this inspection. A previous inspection of this home found that the home does not conduct an in-house quality assurance check or report based on the views of residents as to how this home is managed. The acting manager confirmed that in house surveys are not undertaken and posted on a notice board for the information of residents /relatives or visiting professionals. The providers have not addressed this issue and this requirement is not met. Previous inspections have found that there are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. Risk assessments are also available for the risk posed by radiators, which do not have thermostatic controls or radiator guards. This inspection has shown that the providers have not fitted radiator guards or thermostatic valves, this requirement is still outstanding. The homes pre-inspection questionnaire evidence that fire alarm, fire drill and emergency lighting checks are carried out. Staff also receive fire training as part of the homes initial training and as a regular training event. Certificates were available showing that gas safety inspections have been carried out, electrical wiring checks, and portable electrical equipment checks. Window restrictors are fitted to all first floor and second floor windows and some of the ground floor windows. Lindum Park House DS0000002377.V310768.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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 x 3 2 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT Standard No Score 37 2 38 x 39 2 40 x 41 x 42 3 43 x 3 3 X 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lindum Park House Score 3 3 2 x DS0000002377.V310768.R01.S.doc Version 5.2 Page 25 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 Requirement The home must amend its policies/procedures to reflect that the home must carryout a pre-admission assessment with or with out other agencies (The timescale of 01/09/04 and 15/06/06 not met) The provider must ensure that pre-admission care needs assessments are carried out using a format suitable for this purpose. The provider must ensure that contracts/terms and conditions are available in residents files. The registered person must ensure that risk assessments are available and regularly assessed for residents who self medicate. The registered person must make arrangements for the accurate recording of medication that is given to residents who partially self medicate. The home must have a complaints procedure, which empowers residents. (The timescale of 20/02/06 has DS0000002377.V310768.R01.S.doc Timescale for action 16/11/06 2 YA3 14 16/11/06 3 4 YA5 YA9 5(1)(b) 13(4) 16/11/06 16/11/06 5 YA20 13 16/11/06 6. YA22 22(2) 16/11/06 Lindum Park House Version 5.2 Page 26 7 8. YA23 YA35 18(c)(i) 18 (c ) (i) 9. YA39 24 (a)(b) 10. YA42 13(4) not been met) All staff must receive safe guarding vulnerable adults training. The registered person must ensure that persons employed to work at the care home receive training appropriate (specific to this client group) to the work they are to perform.(The timescale of 20/02/04 has not been met) The registered person must establish and maintain a system for reviewing at appropriate intervals the quality of care provided at the care home and inform residents of the outcomes of any survey undertaken. .(The timescale of 20/02/04 has not been met) The home must fit radiator guards and thermostatic controls to ensure the safety of residents (Timescale of 15/12/04 and 20/02/06 not met) 26/11/06 16/11/06 16/11/06 16/11/06 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 YA32 Good Practice Recommendations A minimum ratio of 50 trained staff members to NVQ level two excluding the registered manager should be available in the home by 2005.(This recommendation has not been met) Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. Lindum Park House DS0000002377.V310768.R01.S.doc Version 5.2 Page 28 - 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. 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