Inspection on 11/07/06 for Lymehurst

This inspection was carried out on 11th July 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

Lymehurst 30/10/07

Lymehurst 21/11/06

Lymehurst 28/11/05

Lymehurst 24/08/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lymehurst 112 Ellesmere Road Shrewsbury Shropshire SY1 2QT Lead Inspector Joy Hoelzel Key Unannounced Inspection 11th July 2006 08:40 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 Lymehurst DS0000061052.V297442.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. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lymehurst Address 112 Ellesmere Road Shrewsbury Shropshire SY1 2QT 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) 01743 351615 01743 351416 lymehurst@aol.com Mrs Goulsen Ibrahim Mr Tay Sivri, Mr Seref Ibrahim, Ms Narin Ibrahim Care Home 32 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (24) of places Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 32 Elderly Persons of which a maximum of 8 persons may be suffering from Dementia. 28th November 2005 Date of last inspection Brief Description of the Service: Lymehurst is a private care home registered with the Commission for Social Care Inspection to provide a full residential service for up to thirty-two older people. The home is situated on Ellesmere Road close to the centre of Shrewsbury. The homes owners Mrs Ibrahim and her family operate the business with Tay Sivri having day-to-day management responsibilities. Weekly fees range from £400.00 - £460.00. The property has been converted from a large double fronted Victorian family style residence and extended at ground floor level to provide comprehensive and spacious accommodation. The Home stands in its own grounds entered from the road onto a large forecourt. There is an established staff group providing residents with consistency in a homely atmosphere. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over six and a half hours on Tuesday 11th July 2006. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty seven of the thirty eight National Minimum Standards for older people were inspected. Twenty three people are currently resident and were observed throughout the day to be accessing all areas of the home. Staffing levels appeared to be below the required numbers. One of the owners was in charge of the building and was supported by one senior staff and two care staff. The person in charge explained that a member of the care team had called in sick at short notice, a replacement could not be found. Domestic and catering staffs were additional to the care staff. Four case files were selected for case tracking, relevant documents were inspected, discussions were held with service users, visitors and members of staff. Observation was made of the various daily activities and a tour of the premises was conducted. What the service does well: What has improved since the last inspection? The shower room has recently been refurbished and is now in use. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lymehurst DS0000061052.V297442.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 Lymehurst DS0000061052.V297442.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): OP 1,2,3,6 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Prospective service users have a full assessment of their needs prior to moving into the home, however, the lack of information in the service brochure does not provide a full overview of life at the home. EVIDENCE: The home has produced a statement of purpose detailing the service and facilities it offers. It states on the document that it will be reviewed each six months to ensure that the information in the document is correct. It was not possible to establish when the last review took place. A copy of the statement of purpose was forwarded following this inspection and contained information relating to 2003. The person in charge could not find a copy of the service user guide. Without these two documents being readily available prospective service users cannot make an informed choice about life at the home. Four case files were selected for inspection, only two of the files contained a contract of terms and conditions between the individual person and the home. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 9 The statement of purpose states that prospective service users are invited to the home prior to making a decision to move in, discussions with two service users confirms this. They both paid a visit to the home with their families prior to moving in. One service user stated ‘ you cannot beat this place I have been here for some years and love it’. Copies of an assessment of a persons care needs conducted by the local authorities are included in the case file. The home completes an interim care plan at the point of admission. The home does not provide an intermediate care service. Lymehurst DS0000061052.V297442.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): OP 7,8,9,10 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The care plans do not provide sufficient information on the assessed care needs and without this there is no guarantee that care needs are being fully met. The homes systems for medication administration are currently unsafe amendments are required to ensure that a safe system of medication administration is adopted. EVIDENCE: All service users have a plan of care based on the activities of daily living; information is recorded using a tick list of yes or no answers to particular activities. There are no specific instructions for staff to follow when a care need has been identified. For instance where a person has an identified need for assistance with personal care the plan does not include instructions for oral hygiene, nail care, personal hygiene or the persons preferred way of bathing. One care plan inspected identified a potential problem with maintaining good skin integrity; the district nurse had carried out the assessment and identified that this person is at potential risk of developing pressure ulcers. To reduce Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 11 the risk, pressure relieving cushions were identified as required. Observation confirmed that cushions are in use but a care plan had not been developed for further action needed for pressure relief during the day or night. Another service user was having difficulties with continence and required the interventions from the district nurse. There was no plan of care, specific instructions or procedures for staff to follow on catheter care and how to reduce the risk of infection and potential contamination or what to do in the case of an emergency. Falls risk assessments, nutritional screening, tissue viability or psychological screening are not carried out. The plans are not being reviewed on a regular basis and there is no evidence to suggest that service users and/or their representatives are involved in the process. The statement of purpose states that the service users plan will be reviewed monthly and updated, with the involvement of the service user. All visits from the GP and other professionals are recorded in the case file, daily reports of one service user identifies a health problem where a visit is needed from the GP. The GP visited very shortly after contact with the surgery had been made. The person in charge demonstrated a good knowledge in the needs of all service users at the home and commented that he felt the care plans could be more comprehensive but felt it was more important to deliver the care directly to the people, less time is then available for report writing and recording the information. The home operates a twenty eight day regime for medication administration using blister type packaging with additional boxes and bottles. The morning medication round was observed being carried out by the person in charge. He was observed to be assisting service users to take their prescribed medication in a discreet manner. He demonstrated a satisfactory method of recording the medication at the time of the administration using the Medication Administration Record (MAR). Plastic dividers are needed in between each person’s individual MAR, to reduce the risk of administration errors and photographs of service users are needed for ease of identification. Some hand written instructions had been made on the MAR, Latin abbreviations for the frequency of the medication are used. All amendments must be written out in full, the use of abbreviations must not be used e.g. the instruction BD must be written as twice daily. Any amendments must be checked, signed and dated by another member of staff. A tube of daktacort and a pot of liquid medication were observed to be stored in the fridge in the main kitchen. A dedicated medication fridge must be available for the storage of medications where cold storage is required. Correctional fluid (Tippex) is being used on the MAR charts and documents in the case files. This practice must cease any mistakes made to any document must be crossed through and initialled. Staff were observed to be assisting with the personal care of service users in a discreet and dignified manner any interventions were carried out in private. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 12 Staff and service users appear to have developed good relationships with each other there was much chatter, conversations and discussions happening throughout the day. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 13 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): OP 12,13,14,15 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Limited social activities are being arranged by the care staff but are very much determined by the constraints of time and workload. EVIDENCE: A programme of activities is displayed on the notice board in the main lounge detailing the times and frequency of each session. The programme for the day should have been knitting during the morning, painting by numbers in the afternoon with bingo in the evening. For most of the day the majority of the people were sat in the main lounge, no activities took place at the time of the inspection. The statement of purpose states ‘ the home offers a wide range of activities designed to encourage the client to keep mobile, and most importantly take an interest in life’. It is acknowledged that some service users would not wish to partake in any arranged activity nevertheless a more proactive approach is required. One service user commented that he did not wish to join in any arranged activities but preferred his own company and liked to watch the television in his own room. Another service user spoke of the very varied activities that happen outside of the home. She is involved at the local church and likes to attend the weekly Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 14 services. At the time of the inspection she was waiting for her relative to take her out for the afternoon. Two service users felt that more activities would be beneficial and would improve their lives. Visitors are welcomed at the home and can visit in private in they so wish. One service user stated that he looked forward to visits from the family and that ‘ the best thing about living at Lymehurst is the close locality of the relatives’. Staff were observed to be offering choices through out the day mainly with drinks and snacks. The person in charge appeared very aware of each person’s capacity to exercise personal autonomy and choice and was guiding the care staff in an efficient way. The risk assessments have been completed for the safe use of the stair lift and for accessing the stairs; these must be reviewed at regular intervals. A rotational menu is operational, alternatives are provided from the menu when required. One service user stated that the ‘meals are ok, much improved’, and went on to explain his preferences for the supper menu and how he is offered a supper of his choice. The inspection began at breakfast time, many service users were sitting at the dining table having breakfast, which consisted of a variety of foods including fresh fruit. The cook was the only kitchen personnel on duty and was extremely busy with the preparation of lunch, serving morning coffee and attending to the preparation of sandwiches for the staff. The dining room was prepared for the lunchtime meal, the meal when served looked appetising and nutritious. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 15 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): OP 16,18 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has procedures in place for dealing with concerns and complaints. Systems in place are not sufficiently robust to protect people from potential financial abuse. EVIDENCE: The homes complaint procedure is included in the statement of purpose and a copy is displayed on the notice board. One complaint raised in February 2006 was sent directly to Commission for Social Care Inspection. The home was requested to investigate fully the concerns using their own procedures. The complainant was not fully satisfied with the explanation and outcome of the response. During this inspection the case file of the service user involved, observation of staff working practice and discussions with staff were held to look further at the concerns, and issues are reported on in the appropriate sections of this report. One other complaint was forwarded to Shropshire County Council, in February 2006, where a joint planning meeting looked into the concerns raised. The home was asked to review their current practice of recording contact and interventions with individuals on a daily basis. The four case files inspected on this occasion did not contain a regular daily report and when a recording was made the comments of ‘ medication given’ is not sufficient to evidence that the care that the home proffers to offer is fully met. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 16 Concerns, complaints and compliments are logged at the home. There are many letters from relatives and service users complimenting the owners and staff of the care that is given. Two service users stated that if they had any concerns or worries about any aspect of life at the home then they would ask to see one of the owners. One service user wrote many letters to the owner, explaining the difficulties with certain medications and diet, in a very positive way and stating that she was very happy and contented with living at the home. The home has produced a policy and procedure for dealing with vulnerable adult and abuse awareness; it is due for revision in May 2007. One of the three staff personnel files contained an attendance certificate for training in the protection of vulnerable adults in December 2005. The procedure for the care and storage of client’s money is not included in the statement of purpose. The homes policy and procedure did not reflect the actual practice of safeguarding service users personal monies. Observation of the procedure is reported on in the management and administration section of this report. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 17 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): OP 19,21,22,25,26 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable place for people to live however; the environment and equipment within the home are not being maintained safely EVIDENCE: The person in charge commented on the further development of the home and described the demolition of the older wing and rebuilding it to a higher standard. This will include a further eleven bedrooms all with ensuite facilities and additional communal areas. During the tour of the premises, wooden door wedges and pieces of furniture were in use to prop open communal and bedroom doors. Where there is a need or personal preference for a door to be kept open then an appropriate door closure must be fitted that is linked into the fire alarm to close efficiently when the alarm is activated. The fire risk assessment for the premises is out of date, (April 2005), and includes an assessment of two areas only, laundry and kitchen, very little information has been recorded. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 18 It was recommended to the person in charge that contact is made with the local fire officer for advice in this area. The CCTV cameras are sited at the entrance of the building, car park and kitchen area. The walk in shower facility in the main building is now in use and is offering service users an alternative bathing facility. Observations of the bed rails on some beds were incorrectly fitted with some being very loose. One bed had a pressure-relieving air mattress placed over the original mattress; the bedrail is use was ineffective for the height of the mattresses. As overlay mattresses increase the total mattress height, extra height bedrails must be used to ensure that a person does not topple or fall over the rail. The hot water temperatures were randomly tested both in the communal and private areas. The temperature of the water in bathroom no.5 had a reading of 50 degrees Celsius. This bathroom was immediately taken out of use and the person in charge called the contractor to remedy this. All other outlets were at the required temperature of close to 43 degrees Celsius. The person in charge confirmed that in some private areas staff assist with personal care interventions. Hand wash facilities for staff use for the effective control of infection have not been provided at the point of the delivery of care. All communal toilets and bathrooms have paper towels and liquid soap. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 19 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): OP 27,28,29,30 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The home is failing to maintain an adequate number of staff at all times, consequently not all care needs of people living at the home are being met. Processes which promote the well being of service users and staff competence (such as care planning, reviews, staff supervision and appraisals) are also not being undertaken, leading to shortfalls in the safety and standard of care provided at the home. EVIDENCE: The person in charge stated that the usual staffing levels are maintained at four care staff during the day with two waking night staff. Ancillary staff are additional to this. Staffing levels at the time of the inspection were low with one care staff calling in sick at short notice. The person in charge was unable to find a replacement consequently staff on duty were extremely busy and pressurised to complete the care tasks. One member of the care team appeared to be very stressed. The statement of purpose states that all care staff are trained to a minimum level of National Vocational Qualification level 2 in care. Two of the staff personnel files contained information of the induction training. The personnel file of the most recent employee contained all of the required information including a recent criminal record bureau disclosure. The person in charge stated that staff receive training in the core topic areas. The staff files contained certificates for basic food hygiene, first aid, protection Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 20 of vulnerable adults and moving and handling. The person in charge agreed that training in fire safety is urgently required; records were produced for the last training dated 2004. Two staff members were observed to be transferring a service user from wheelchair to comfortable chair using the condemned underarm lift. The National Vocational Qualification assessor was on the premises and confirmed that the staff members have had recent training in moving and handling. This was discussed with the person in charge and further training and any specialist equipment that is needed will be organised. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 21 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): OP 31,33,35,36,37,38 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The results of working practices do not promote and safeguard the health, safety and welfare of service users or staff. EVIDENCE: The person in charge has the day-to-day management responsibilities together with the other owners of the home. He has gained the National Vocational Qualification Level 4 in management since the inspection in November 2005. The person in charge demonstrated a good knowledge of the current service users group and the conditions and diseases associated with ageing. Service users made positive comments regarding all of the owners, one person stated ‘The owners are really nice…. I like it here’. Satisfaction surveys and questionnaires were sent out in January 2006, the person in charged stated that the responses were at another establishment Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 22 and had not yet been audited. He confirmed that the results would be fed back through the various arranged monthly staff and service users meetings. A suggestion box is available in the hall where service users, visitors or staff can put any comments. The home safekeeps personal monies for two people selected for case tracking. The money is kept in the locked filing cabinet in the office. Individual recording sheets are maintained. The balance recorded on one sheet stated that there was a credit amount of £14.41. There was no cash in the wallet. Another sheet indicated that a balance of £26.76 was available, on checking there was only £20.00 cash. The person in charge could not account for these discrepancies. The policy and procedure for the safekeeping of someone’s personal money must be reviewed and revised with clear instructions on the safe handling. The person in charge accepted that formal supervision at least six times a year together with an annual appraisal of work performance is outstanding for all levels of staff. A requirement was made following the inspection in November 2005 regarding this has not been complied with. A record is not maintained of the diet offered to service users on a daily basis, ensuring there is sufficient evidence of maintenance of good nutrition. All records are stored in one of the two offices. The care plans do not contain a full assessment of moving and handling and of the safe techniques or any specialist equipment to be used. The person in charge stated that at times a handling strap is used for transferring people from one area to another, the care plans did not contain this information. The weekly fire and emergency lighting test had not been carried out since 07/06/06. During the tour of the kitchen the care and domestic staff were entering the kitchen with out putting on any protective/alternative clothing. As they had been carrying out cleaning and personal care prior to entering the kitchen there was a great risk of the spread of infections and toxic conditions. The kitchen door was wedged open allowing ease of access for staff. Jars and bottles of foodstuff stored in the fridge after opening had not had the opening date placed on the label. Only semi skimmed milk is being used. Some risk assessments had been carried out for the safe working practice topics but had not been reviewed since March, April and June 2003. The assessments for the safe use of chemicals (COSHH) had been last reviewed in April 2005. Lymehurst DS0000061052.V297442.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 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 2 2 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 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 2 2 X 3 2 X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 1 1 2 2 Lymehurst DS0000061052.V297442.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 OP1 Regulation 4(1) 5(1) Requirement The statement of purpose and service user guide must be reviewed to contain all relevant information, be readily available and in the appropriate format. The home is required to ensure that all residents have a formal agreement setting out the terms and conditions of residence Previous timescale 02/01/06 not fully met. All care plans must set out in detail the action required to be taken by staff to ensure that the health, personal and social care needs of a person are fully met The care plans must be drawn up with the full involvement of the service users and/or representative whenever possible. All care plans must be reviewed at least monthly or when a change in need has been identified. Nutritional and psychological screening, tissue viability and falls risk assessments must be DS0000061052.V297442.R01.S.doc Timescale for action 31/10/06 2. OP2 5(b) 31/10/06 3 OP7 15(1) 31/10/06 4 OP7 !5(1) 31/10/06 5 OP7 15(2) 31/10/06 6 OP8 12(1)(a) (b) 31/10/06 Lymehurst Version 5.2 Page 25 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 11 OP9 OP12 13(2) 16(2)(m) (n) 12 OP18 19(5)(b) 13 14 OP18 OP19 Data Protection Act 23(4)(a) 15 16 OP19 OP22 23(4)(v) 13(4)(c) 17 OP25 13(4)(a) (c) undertaken and reviewed at regular intervals. To reduce the risk of medication errors plastic dividers are needed in between the individual Medication Administration Record charts. For ease of identification a photograph of each service user must be placed on the Medication Administration Record charts. All amendments and additions to the Medication Administration Record charts must be written in full and signed as correct by a second person. A dedicated fridge is needed for the cold storage of medications and external preparations. The registered person must ensure that the social and recreational activities arranged for all service users are further developed and sustained The home is required to ensure that all staff and managers receive appropriate Protection of Vulnerable Adults training. Previous timescale 06/02/06 not fully met. A revision is required to the procedure for dealing with service users personal monies. Wooden wedges or pieces of furniture must not be used to prop open doors in the communal or private areas of the home. The fire risk assessment for the premises must be reviewed. A full assessment is required to ensure that all bedrails in use are safe and fully suitable for the purpose. All hot water outlets accessible to service users must be tested DS0000061052.V297442.R01.S.doc 31/08/06 31/08/06 31/08/06 31/10/06 31/10/06 31/10/06 31/08/06 31/07/06 31/07/06 31/07/06 31/07/06 Lymehurst Version 5.2 Page 26 18 OP26 13(3) 19 20 21 OP27 OP30 OP35 18(1)(a) 18(1) 17(2) Schedule 4 (9) 22. OP36 18(1)(c) (i) at regular intervals to ensure that a temperature of close to 43 degrees Celsius is maintained. For effective control of infection suitable hand wash facilities must be provided at the point of the delivery of care. Adequate staffing levels must be maintained at all times. All staff must receive training in the core topics and any specialist areas relating to the client group The registered person must ensure that a safe system is adopted for the safekeeping of service users personal monies. Accurate records must be maintained. The home is required to provide formal and recorded staff supervision at least six times a year and in an appropriate format. Previous timescale 02/01/06 not met A records of food provided for service users must be in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory The registered person must ensure that safe working practices are adopted, in particular moving and handling, fire safety, food hygiene and infection control Fire and emergency lighting tests must be maintained at regular intervals. The date of opening must be placed on all bottles and jars of foodstuffs that are stored in the fridge. 31/08/06 31/07/06 31/10/06 31/08/06 31/10/06 23 OP37 17(2) Schedule 4 (13) 31/10/06 24 OP38 13(4) 13(3) 16(2) 31/10/06 25 26 OP38 OP38 13(4) 13(3) 31/07/06 31/07/06 Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 27 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 2 3 Refer to Standard OP9 OP35 OP15 Good Practice Recommendations Correctional fluid (Tippex) should not be used for crossing out mistakes on any document It is recommended that a monthly audit be carried out to ensure that the records and actual amount of cash held by the home on a service users behalf are accurate. Unless there are dietary requirements or persons personal preference full fat milk should be offered. Lymehurst DS0000061052.V297442.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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