Inspection on 18/06/08 for Lychgate House

This inspection was carried out on 18th June 2008.

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

Other inspections for this house

Lychgate House 20/07/07

Lychgate House 13/10/06

Lychgate House 11/01/06

Lychgate House 14/09/05

Lychgate House 05/01/05

Lychgate House 01/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Lychgate House 145 Shrub End Road Colchester Essex CO3 4RE Lead Inspector Jane Offord Unannounced Inspection 18th June 2008 09:45 Lychgate House DS0000017874.V366667.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 Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lychgate House Address 145 Shrub End Road Colchester Essex CO3 4RE 01206 500074 01206 510916 mar.doobay@ntlworld.com 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) Doobay Care (Lychgate) Limited Mrs Natascha Hill Care Home 12 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number disorder, excluding learning disability or of places dementia (12) Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a mental disorder (not to exceed 12 persons) Two named people, over the age of 65 years, who require care by reason of dementia The total number of service users accommodated in the home must not exceed 12 persons Date of last inspection 20th July 2007 Brief Description of the Service: Lychgate House is a detached property, situated in a residential area, close to a range of community facilities and Colchester town centre. This home provides care in a homely and comfortable environment for twelve adults, of varying ages, with mental health problems. Accommodation is provided on two floors. The first floor can be accessed by stairs or a passenger lift. There are eight single rooms and two shared rooms, all the rooms have a vanity unit and one has an en suite shower. There are two lounges and a dining room on the ground floor and a conservatory that can be used as a further lounge or small dining area. There is a pleasant, private garden to the rear of the property with a patio and mature trees. There is off road car parking to the front of the building. The weekly charge for a room ranges from £650.00 to £700.00 per week. Items not covered by the fees include newspapers, hairdressing, chiropody, holidays, toiletries and clothing. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is two star. This means that people who use this service experience good quality outcomes. This key unannounced inspection looking at the core standards of care of adults took place on a weekday between 9.45 and 16.00. The registered manager was present throughout the day and assisted with the inspection process by providing documents and information. This report has been compiled using information available prior to the inspection such as the annual quality assurance assessment (AQAA), which is a self-assessment document completed by the service, as well as evidence found on the day. During the day a tour of the property was made with the manager and various documents and policies were inspected. Three residents’ files and two staff files were looked at as well as the medication administration records (MAR sheets), some service certificates, the duty rotas, the menus and quality assurance results. The lunch serving was observed and a number of residents, visitors and staff were spoken with. There was a welcoming atmosphere in the home and residents looked happy and relaxed. Everywhere was clean and tidy and there were no unpleasant odours noted. People were using all areas of the home and a number of residents went out to local shops or with a relative during the day. The meal at lunch was well presented and looked appetising. Residents spoken with said they had enjoyed the lunch. Interactions between residents and staff were friendly and appropriate. Staff were observed spending time sitting and chatting with residents. What the service does well: What has improved since the last inspection? Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 6 The care plans and risk assessments of each resident are detailed and individualised reflecting the special needs and aspirations of the person. A regular system of staff supervision has been established and records of supervision sessions are kept in staff files. The redecoration of the environment has continued and new carpets have been laid in the lounges, dining room and corridors. To comply with legislation a new patio with a gazebo has been made for residents who wish to smoke. The kitchen has been completely refurbished and redesigned to give more space to work in. 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. The summary of this inspection report can be made available in other formats on request. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 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 Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4. Quality in this outcome area is good. The home has a robust assessment process in place so that people wanting to use the service know that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive statement of purpose and service users’ guide that are available to anyone on request. All prospective residents are given copies of these documents to enable them to make a fully informed choice about whether they wish to live in the home. Questionnaires completed by residents, for the service, about the admission process confirm that they received sufficient information. The admission policy offers twenty-four hour introductory visits to potential residents so they can meet the other residents and staff. There is a three-month ‘settling-in’ period for both parties and a review after that date. The files for three residents were seen, two were recent emergency admissions and the third was a person who had been in the home a little longer. All the files had a pre-admission assessment document completed. The manager said that the documents for the people admitted as an emergency had been completed the day of their admission, as it had not been possible to visit. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 9 The assessment covered all areas of health and mental health needs from mobility, continence, diet and medication to challenging behaviour and what to do if the person became mentally unwell. Two of the three documents were not dated so it was unclear when the assessments had taken place. This was discussed with the manager who agreed with the need to date assessments. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. People who use this service are able to participate in their care planning and know they will be supported to take risks as part of their chosen lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three residents were seen and were clearly developed from the assessments completed before or on admission. They reflected the areas that the person needed support to manage and covered actions required for identified risks. There was evidence that the care plans were regularly reviewed with the resident and key worker and if a new area of care or support was demonstrated the care plan was updated. Risk assessments were also reviewed and evaluated monthly to ensure that they respected residents’ rights and did not infringe the rights of other people in the home. One resident spoken with talked about the time they spent with their key worker discussing their care plan and what it should contain. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 11 The care plans had interventions for areas of support such as personal hygiene, mobility, continence and any skin condition that required monitoring. Mental health needs such as a fluctuating mood, aggression and depression were also addressed together with the support needed to manage daily activities or personal finances. Risk assessments were relevant to each person with some relating to personal care needs and others to safety while using public transport or making a hot drink. Some were related to personal habits like smoking or the potential to overeat without guidance or restriction. Support to manage these personal habits was detailed and agreed with the resident. One resident spoke of managing to lose weight after being helped with a diet. Each file had an evaluation sheet to look at the continued relevance of care plan interventions and risk assessments for the resident. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. People who use this service will be able to choose how they spend their time and with whom and know that the meals they are offered are based on their choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three residents’ files seen all had details of their interests and preferred pastimes. Some were sedentary such as bird watching in the garden and knitting or listening to music, others were more active like shopping, going to charity shops and car boot sales. The daily records of residents, which were informative about their lifestyle, detailed the kind of activity undertaken by residents on a day-to-day basis, this could include a game of Scrabble, keep fit exercises or watching television, or more actively a visit to the town, a church service or the day centre. A number of residents went to a local coffee shop for the morning on the day of inspection and returned in time for lunch. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 13 Contact details of the resident’s next of kin and their relationship with the person were kept in each file. A life history and family tree were noted in some files to help identify relatives and their place in the resident’s life. Daily records noted that some residents had frequent contact with their families and some had opposite sex relationships with people outside the home. One resident was taken to the town by their sibling on the day of inspection. The visitor said they were always made welcome by staff when they came and staff helped to get their relative ready for the trip out. An assessment of residents’ skills is recorded in their files so whether they can manage their own shopping, cooking and laundry is noted. Some residents are more able to participate in domestic tasks than others and it was observed that residents were laying the table for lunch and clearing plates later on the day of inspection. There was evidence in one file that an assessment under the Mental Capacity Act had been undertaken with one resident in relation to their understanding of finances and the management of money. The kitchen was visited and the layout and new units looked very smart and user-friendly. Food was stored appropriately and there was a wide selection of ingredients and fresh fruit and vegetables. Some plated food in the refrigerator was not labelled with content or date. The refrigerators and freezers all have temperature checks to ensure they are functioning at a level suitable for safe food storage. The cook of the day said that there was one resident who needed a diabetic diet and a couple who were on weight reducing diets. In the files seen there was evidence that a dietician had been consulted for advice about the weight reduction diets. One resident said how pleased they were that their diet was working although they still, ‘like a bit of chocolate’. The lunchtime meal on the day of inspection was corned beef hash with tomatoes, mashed swede, peas and broccoli followed by peaches and ice cream. For residents who did not want corned beef the cook had prepared fish fingers. The meal was freshly plated in the kitchen and served in the dining room. It looked hot and appetising. Residents spoken with later said they had enjoyed their lunch. The menus were seen and showed that a cooked breakfast was available at weekends and full roast on Sundays. Other meals included shepherds’ pie, fish ‘n chips and sausages. Teatime offered a hot snack such as spaghetti, soup or sandwiches. There was also a vegetarian menu available as an alternative for anyone who chose that included bean hotpot, jacket potatoes and fillings or an omelette. Minutes seen from residents’ meetings showed that meal choices were discussed and changes made to meals as a result. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. People who use this service will have their health needs met as they would choose and be protected by the medication practice in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the files seen contained contact details of the health professionals involved in the care of the resident these included the GP, psychiatrist, community psychiatric nurse (CPN), chiropodist, dentist, dietician and optician. There was a record of all professional appointments and the instructions given for treatment or change of medication. Records showed that some residents had influenza injections (flu jabs) each year to protect them during poor weather. Each file had a record of the residents’ weight taken monthly. One resident who had been a wheelchair user had lost some weight since admission to the home and was now able to walk short distances using a frame. Another who was a heavy smoker had expressed the wish to cut down on the number they smoked a day. A plan had been devised with their key worker so that the number of cigarettes offered each day was greatly reduced and the resident said, ‘my chest is much better now’. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 15 The home uses a monitored dose system (MDS) for the management of medication. The local pharmacy dispenses medicines following prescriptions into prepared blister packs for the carers to administer. All medicines are stored safely in a locked cupboard in the office and the senior on shift carries the keys. At the time of inspection none of the residents was self-medicating or receiving any controlled drugs (CDs). The medication administration records (MAR sheets) were inspected and showed that a specimen signature of all staff trained to administer medicines was kept in the file for reference. One record for diazepam to be given at night had some signatures both night and morning. The ones for the morning were scribbled out. It was unclear whether the tablets had been administered in the morning in error or that the boxes had been signed in error. The manager said that it had been a signing error but agreed that crossing out was not the way to manage a mistake. The staff would be spoken with and a different way of clarifying the situation would be devised. All other MAR sheets were correctly completed using codes if the medication was not given for any reason. Carry forward figures were used allowing an audit trail. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. People who use this service can be confident that their concerns will be taken seriously and investigated and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that is printed in the statement of purpose and the service users’ guide. Potential residents are given copies of these two documents and this was confirmed by the responses to a postadmission questionnaire. The complaints policy was also displayed strategically throughout the home. Residents and visitors spoken with were all clear about how to raise any concerns if they needed to. The complaints log was seen and had no entries but the manager showed a selection of letters from people who visit the home from a local church that were all very complimentary about the service being offered. Staff spoken with said they had received protection of vulnerable people (POVA) training and that it was also covered in NVQ training that they were undertaking. Staff were clear about their duty of care and able to identify different forms of abuse. Training certificates were seen in staff files to confirm that recent training had been done. The home has a POVA policy that is not up to date with the most recent Safeguarding Adults guidelines but the manager intends to access the web site to ensure staff have the correct guidance and policy. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. People who use this service will live in a comfortable home with their own choice of décor and furnishings around them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the day a tour of the house and garden was undertaken with the manager. Residents’ bedrooms were seen and were individually decorated with evidence of the resident’s particular interests on display such as soft toys, books or a favourite football team. The two shared rooms were a reasonable size but the manager said there were plans to build a further two bedrooms so the shared rooms would become single rooms. They would then be very large single rooms both with attractive bay windows. The communal lounges and dining room were pleasantly furnished and looked comfortable. Residents were using all areas of the home during the day and moved from one lounge to the other as they chose. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 18 To the rear of the property is a mature garden with secluded areas and some patio space. The manager said there is a gardener who attends to the grass and flowerbeds maintaining an attractive facility for residents to use. A patio area with a gazebo has been constructed for the use of residents who wish to smoke. There is a washing line for drying laundry outside during good weather. The garden can be accessed from a number of doors with level access for wheelchair users available from one of the lounges. The laundry was seen and although compact contained adequate equipment to safely manage the laundry requirements of the home. Hand washing facilities were equipped with liquid soap and paper towels and there was protective clothing available for ‘dirty’ tasks. Records showed that staff had received instruction in infection control. A discussion was held with the manager about upgrading the management of soiled linen, using alginate bags, to further protect staff and residents. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. People who use this service will benefit from the support of adequate numbers of trained, skilled staff available at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the morning and evening there are three carers on duty. In the afternoon there are two carers. One waking and one sleeping member of staff cover night duty. In addition the home has a cook and domestic on duty daily. A gardener and maintenance person are called in when required. Staff spoken with said that the staff team was stable and supportive of each other and at present sufficient to meet the needs of the present resident group. The service supports and encourages staff to undertake training relevant to their roles. At present fifty percent of staff have achieved an NVQ level 2 and others are working towards the qualification. One staff member has an NVQ at level 3 and there are plans to support further staff to achieve that in the next year. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 20 All staff have a structured induction programme that includes the principles of care, safe working practices, managing risks and the particular needs of the client group they are to work with. Evidence seen in staff files shows that the induction training also covers basic areas of care such as fire awareness, food hygiene and moving and handling. Certificates in both files seen showed that training had been done in the management of medication, infection control, health and safety and POVA. The two staff files seen contained evidence that recruitment checks had been made prior to offering people employment. There were criminal records bureau (CRB) checks, a copy of passports, birth certificates and for a carer from overseas a valid work permit. Each file had two references but not from the person’s last employer. Both contained a copy of the contract of terms and conditions for the post offered. There was evidence of supervision records with meetings recorded every eight weeks. Staff spoken with said they could raise any issues during their supervision sessions and records kept showed that discussions covered residents’ issues, staffing, training needs and personal progress. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. People who use this service can be confident that their views underpin the development of the home and that practice will protect their health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager demonstrated a clear understanding of the regulations and processes required to mange a care home. They have achieved a master’s degree in business management and completed NVQ level 4 registered managers award. Interactions observed during the day between the manager and residents, and the manager and staff were all supportive, friendly and appropriate. Staff spoken with said the manager gave clear leadership guidance and had an ‘open door’ policy to raise any issues. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 22 The home has developed a quality assurance system to allow the residents to express their views of the service and suggest changes they wish to have made. One questionnaire is completed soon after admission to find out if the admission process met the expectations of the resident and covers areas such as the level of information provided about the service, whether the terms and conditions of residency were explained and if people were welcoming. A further questionnaire that is offered to residents on a annual basis asks for comments on personal care, the premises, the daily routine, staffing and the food provided. The results are evaluated and changes made to the service in response to the findings. Residents’ meetings are held monthly and minutes are taken and put on the notice board for information. Recent minutes showed a wide range of subjects were discussed from new kitchen equipment, new carpets in the lounges and the importance of plenty of fluids during the recent heat wave. Documentary evidence was seen to show that equipment is maintained and serviced regularly. The lift was serviced every six months and done most recently in June 2008. There was a gas safety certificate valid for a year that had been issued in January 2008. External consultants had completed a fire risk assessment and the fire log showed that fire drills, talks and checks of equipment were undertaken on a weekly or monthly basis. The home has a comprehensive control of substances hazardous to health (COSHH) folder for staff information and it was noted that all COSHH products were kept locked away when not in use. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 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 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 Score 3 3 3 X 3 X 3 X X 3 X Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 (2) Requirement MAR sheets must be completed unambiguously to show that medication has been administered and a system devised to record when medicines are not given to ensure that residents receive their prescribed medicines correctly. The POVA policy must be written to give the most recent guidance on management and referral of concerns from the safeguarding adults initiative to ensure that staff have the information available to act promptly and protect residents if concerns are raised. Documentary evidence that a thorough recruitment process has been followed according to regulation must be retained in staff files to ensure residents are protected from unsuitable staff. Plated food that is stored in the refrigerator must be labelled with content and date of storage to ensure it is fresh and suitable for residents to use. Timescale for action 18/06/08 2. YA23 13 (6) 14/07/08 3. YA34 19 (1) (b) Sch 2 18/06/08 4. YA42 13 (4) (c) 18/06/08 Lychgate House DS0000017874.V366667.R01.S.doc 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. 1. Refer to Standard YA2 Good Practice Recommendations All assessment documents should be signed and dated to ensure that they are completed in a timely manner and by a competent person so residents’ needs are correctly identified. Lychgate House DS0000017874.V366667.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lychgate House DS0000017874.V366667.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. 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