Inspection on 05/06/08 for Lyncroft

This inspection was carried out on 5th June 2008.

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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyncroft 17/04/09

Lyncroft 02/08/06

Lyncroft 06/10/05

Lyncroft 03/05/05

Lyncroft 07/10/04

Lyncroft 13/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Lyncroft 237 Banstead Road Banstead Surrey SM7 1RB Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 5th June 2008 09:30 Lyncroft DS0000007137.V364758.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 Lyncroft DS0000007137.V364758.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. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyncroft Address 237 Banstead Road Banstead Surrey SM7 1RB 020 8786 8381 020 8786 8381 bansteadrd@walsingham.com www.walsingham.com Walsingham 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) Manager post vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 5 2nd August 2006 Date of last inspection Brief Description of the Service: Lyncroft is a residential care home that was first registered in January 1997 to provide care for people with learning disabilities. Over recent years there has been a period of uncertainty as the future of the home was unclear. The home has a clearer direction and focus now; it will be providing an interim home to people who have recently been discharged from Orchard Hill Hospital (a long stay hospital for people with learning difficulties in the London Borough of Sutton) and preparing them for supported living accommodation in the community. The home is registered for five people with learning difficulties. At the time of writing this report there are two people with learning difficulties living in the home, with another person coming in the near future. In addition, there is an individual who has an acquired brain injury; this person is not appropriately placed within the home, however, the individuals’ needs are being met and there are plans to move them on. This home’s ethos is based on Christian philosophies. The home is one of four homes in the Croydon and Sutton area that are owned by ‘Walsingham’, which is a registered charity. Lyncroft is a two storey detached property in keeping with the other houses in Banstead Road. The property lies between Banstead and Ewell; it cannot be Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 5 accessed easily by public transport, with a train station ten minutes walk away and no bus links. The current costings for the year 2008/09 ranges from £1,728 to £2,960 per week. The costings reflect the level of needs of the individuals placed into the home; placing authorities are advised to contact the home directly to get a full menu of costs. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use the service experience adequate quality outcomes. This was the home’s first inspection for the year 2007/08 it was an unannounced inspection, which started at 9.30 am. The inspection took approximately six hours during which time the inspector had a tour of the building; discussions with staff and the manager; looked through documentation relating to people who use the service and to the running of the home. There was limited opportunity to share views with the people who use the service. This is because the three people currently living in the home do not have verbal communication. Of the three, two have moved into the home relatively recently, they do not have any family or friends who have contact with them. Instead, we looked at interactions between staff and people who use the service; we also examined the questionnaires completed by people who use the service. These questionnaires were positive. The inspector also viewed all documentation relating to the service, which had been received by the Commission in the preceding year. This included a document called an Annual Quality Assurance Assessment, which is a selfassessment of the service completed by the manager. In July 2007, during a routine test, traces of Legionella were found in the water supply, this issue has been resolved. The home has been in a period of flux of some considerable time. Meetings over a number of years between the managers of Walsingham and representatives of the Local Authority have considered the future of the home and the people placed there. It appears that decisions have been arrived at; Lyncroft will provide an interim home for people with learning difficulties being discharged from Orchard Hill Hospital, before moving people into supported living accommodation. The home is currently registered for five people with a learning difficulty. This period of uncertainty has had an impact upon the staffing within the home, with the home having to carry a number of vacancies for some considerable time. Now decisions have been made about the home, it is envisaged that there will be a period of stability. The inspector would like to thank the service users, staff and manager who made them available during the inspection, and wishes them well for the future. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? All requirements made at the previous inspection in August 2006 have been actioned. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 8 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. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 9 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 Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 10 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 and 4 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service The home gathers a lot of information about any potential new person coming into the home. Therefore the home has a full picture of the individual and their needs, and is only providing a service to those whose needs it can meet. EVIDENCE: The home has been in a period of flux of some considerable time. Meetings over a number of years between the managers of Walsingham and representatives of the Local Authority have considered the future of the home and the people placed there. It appears that decisions have been arrived at; Lyncroft will provide an interim home for people with learning difficulties being discharged from Orchard Hill Hospital, before moving people into supported living accommodation. The home is currently registered for five people with a learning difficulty. There is a person living in the home who has an acquired brain injury, this person is not appropriately placed, however, the their needs are being met by the home staff. There are plans to move them into their own accommodation in the near future. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 11 Two new people have moved into the home since Autumn 2007, and there is a further planned admission next week. We examined the documents relating to the new people coming into the service. The process by which this happens, is that an assessment is received from the placing borough; the manager then meets the prospective new person two or three times in their existing home, during which time the manager would complete Walsingham’s own assessment. There are then a minimum of three transitions meetings held with the placing authority, these have input from other professionals such as occupational therapists and psychologists. Once these meetings have taken place, introductions to the home begin. We noted that for the individual coming into the home in the forthcoming week, has had various visits to the home including two overnights, and on every occasion they have bought a few of their belongings to assist them in settling into the home. The visits had peaked to once every other day. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 12 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 and 9 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service People who use the service have care plans drawn up from comprehensive assessments. In general, these care plans are detailed and well written, people who use the service are involved, as are their representatives so as to ensure that they reflect the needs of the people who use the service. EVIDENCE: We case-tracked two people who use the service; there were full assessments in both cases, however, with one person, their Walsingham care plan was not complete, although in the process of being written. The manager stated that this had been because the one resident had been in a long-term residential hospital for a number of years and it had been difficult to accurately assess their needs. The home had instead been using the care plans that had been devised in their last placement. We consider that care plans should have meaning and be realistic therefore we will not penalising the home for incomplete care plans, but urge that they are completed as soon as possible. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 13 The other person who uses the service had a very thorough care plan, which, had been developed from the comprehensive assessment. In one example of taking a bath there were eight different points that needed to be considered, in addition there was a risk assessment. The care plan had been written in April 2008 and was due to be reviewed six months later. In addition to reviewing the documentation, there was evidence that the home had had regular review meetings with Social Services to monitor the placement; people who use the service are invited to these meeting, as well as their representatives. It was noted that whilst the documentation was thorough, comprehensive and generally reviewed regularly, some of the risk assessments were due to be reviewed in May 2008 and had not been. A requirement has been made that risk assessments must be reviewed on a regular basis, particular given the nature of the people who use the service. All of the people who use the service have an independent advocate that visits on a regular basis and attends various meetings Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14,15,16 and 17 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service People who use the service are offered the opportunity to participate in a range of activities, dependent upon preferences Dietary needs are catered for with meals based on people’s choice, providing them with daily variation and healthy eating options. The daily routines and house rules promote rights and encourage independence. The home has an open visitors policy to ensure friendships and family links are maintained. EVIDENCE: People who use the service each have their own activities timetable; these have been developed by the staff, and are based on each person’s preferences Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 15 and wishes. We viewed all the timetables, and observed that one person had social activities which included going to the pub and out for coffee; their spiritual needs were being met by attending the church; and recreational activities included going for a walk. For two people who use the service there was a bias towards activities that were specifically for people with learning difficulties, such as a MENCAP club. The manager explained that the care managers had promoted this. However, there was still a balance between attending specific groups for people with a learning difficulty and being engaged in the community. Two people who use the service were booked on a caravan holiday to Clactonon-Sea. The manager stated that the two people who use the service had not been involved in this decision. The reason given for this was that both had been in institutional care for a great many years and had only experienced one holiday in their lives. It was therefore difficult at this stage for them to express choice in any meaningful way. The staff team will be working towards enabling people who use the service to be more involved in the future. The third person within the service went on a long weekend break to Prague. With regard to meals, people who use the service choose a week’s menu in advance; this is done with pictorial images of food and each individual has the choice of two evening meals per week. One person within the home has not made any active choices. However, the staff team through a process of trial and error have established some of their likes and dislikes. People who use the service are encouraged to participate in the shopping and preparation of the meals. Snacks and drinks were readily available. There is an open visitors policy. This was evident as one of the people who use the service has family who live nearby, they often pop in. The home has also been in recent contact with another person’s family. All people who use the service have their own independent advocate who visits regularly and attends meetings People who use the service are given a choice of having keys to their bedrooms and the front door of the home. There is also a lockable space provided in their bedrooms. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 16 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 and 20 People using the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service Personal care is carried out in a way that people who use the service have their dignity and choice maintained. The recording and administration of medication needs to be improved so that it does not compromise the safety and welfare of people who use the service. EVIDENCE: The way in which people who use the service prefer to receive their personal care is recorded on their files. The designation of a key worker also allows for consistency and continuity of care. One member of staff was asked about issues of privacy and dignity and their responses indicated that they had an appropriate awareness and understanding of the issues. With regard to health records, information is recorded for every visit detailing the outcomes. These records appeared up to date and accurate. However, it was noted that two separate records were being maintained in one file. This Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 17 could lead to confusion and follow up appointments being missed. A requirement has therefore been made that health appointments must be recorded in systematic way. The home stores all medication in a locked metal cabinet in the office. The home receives much of its medication from the pharmacist in ‘dossette’ packs on a monthly basis. The home receives a pharmacist audit on a regular basis, the last being on the 13.2.08. Medication Administration Records (MAR) were checked and found to contain information about people who use the service, including a photograph of them, and information about the medication and any reactions that they may have. We were concerned however, that on the previous day one person had not been given a dose of their prescribed medication. This oversight had occurred because of the person using the service had gone out at lunchtime. Two requirements have been made regarding medication; firstly, that all people who use the service must receive prescribed medication at the required time. Secondly, that the home’s manager must review the administration of medication policy with her staff team to ensure that such an error does not occur again. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 18 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 and 23 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service There is complaints policy and procedure, which facilitates good access to the complaints system for people who use the service, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable adults. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The complaints procedure is also in picture format. The home has a complaints log, the last recorded complaint was made in July 2007. It was resolved slightly over the 28-day time scale, but refers to repairs. The home has a copy of Sutton’s local authority Adult Protection Policy on site. The manager completed two one-day courses relating to vulnerable adults in the last year. We had a discussion with one member of staff regarding adult protection and the whistle blowing policy. From the response it was possible to ascertain that Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 19 there was an understanding and awareness of the procedures and action that maybe required. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 20 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): 24,27,28 and 30 People using the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service In general the décor of the home is good providing a comfortable environment for people who use the service to live in. there are a number of cleanliness and safety issues that the home need to address so that people who use the service are assured of a secure and homely place to live. Bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: The home is a detached house on a residential road. It is close to Banstead train station, but local amenities can only be accessed via car. The home’s premises are in keeping with the local community and are suitable for their purpose. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 21 On the ground floor there is a large communal lounge with access to an integral garage. There is also a dining room, kitchen, laundry room, two bedrooms and one bathroom. The arrangement of having a lounge with access to an integral garage raises some concern. We found that the door to the garage had been left unlocked; there were steep concrete steps into the garage; there were substances hazards to health being stored there; and finally the garage doors allowed for possible access for intruders. A requirement has therefore been made that the home must secure the access from the lounge into the garage. On the first floor there are a further three bedrooms, two bathrooms, a sleeping in room and an office. One of the rooms on the first floor has been recently redecorated and made into a further lounge. It was noted that although secondary glazing had been fitted to all the windows, there was an absence of window restrictors. This was of particular concern given that one of the windows was full length and opened onto a rooftop. A requirement has therefore been made that the home must fit window restrictors to all the first floor windows. To the rear of the property, there is a mature garden, which can be accessed via French doors from the lounge. The home has purchased new garden furniture, which is being used in a recently developed seating area. There is a garden pond, which has been fenced off. The premises were generally clean, bright and airy. However, it was observed that the ground floor bathroom was dirty with mildew and soap scum. A requirement has been made that the bathroom must be deep cleaned. A bathroom on the second floor had no taps at the sink, and therefore no water. The manager explained that the taps had been removed, following a flood in the home and they were awaiting a replacement. A requirement has been made that the taps must be replaced with some urgency as it contravenes health and safety. Each person using the home has a single room, which has been decorated to reflect their individual taste. The furniture is domestic in style and of good quality. It was noted that the carpet in the hallway and stairs was stained, and therefore a further requirement has been made that the condition of the carpet must be reviewed and made good. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 22 Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 23 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): 32,33,35 and 36 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service The staff team at the home have a range of skills and abilities, which enable them to meet the needs of people who use the service. Staff receive levels of training and support through supervision so that the calibre of staff remains high so that they continue to understand the needs of the people who use the service. EVIDENCE: The current arrangements for staffing at the home are three staff on an early shift, and three on a late. There is one waking night staff and one sleeping in. Staff rotas were checked at random to ascertain the staffing levels at any given time; the rota’s confirmed the level of staffing. As previously mentioned the home has had a period of transition, this is reflected in the number of vacancies that it currently has. There are the Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 24 equivalent of nine full time vacancies and only six full and part time permanent staff. The manager stated that of the nine vacancies, seven are in the process of being recruited; three temporary staff would be starting work for a minimum of sixteen weeks from next week. These temporary staff were being recruited via an agency that were present on the day of inspection. The manager acknowledged that the home was only able to keep running, because of the commitment of the existing permanent staff and because it was not up to full capacity. A recommendation has been made that once the home is heading towards being fully staffed, that the staff team are given the opportunity to work towards shared goals and objectives during a team day. The staff team are all female; once the current recruitment has taken place there will be five people from black minority groups within the staff team. Walsingham offers ample training opportunities to staff at all levels. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to people who use the service. The induction programmes are signed, dated and kept on staff files. Records of training are kept both within the home and centrally. Records were checked for three individual members of staff and showed that they had completed the requisite number of days training. Information from the Annual Quality Assurance Assessment showed that of the six permanent members of staff, five had either achieved or were working towards their National Vocational Qualification Level 2 or 3 Recruitment records are all held centrally by Walsingham and were therefore not checked during this inspection. Supervision records were examined for three individual members of staff. The records indicated that generally staff receive supervision once every six to eight weeks. The meetings are recorded and signed by both parties. There was also evidence of annual appraisal. Staff meetings take place monthly. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 25 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 and 40 People using the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to this service In general, the home has adequate arrangements for ensuring the health and safety of people who use the service, although there are areas of improvement, which need to be made to ensure that risks are minimised. EVIDENCE: The manager Ms. Williams has been in post since April 2007; prior to then Ms Williams was the manager for a supported living scheme run by the Walsingham group in Croydon. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 26 Ms Williams has not registered with the CSCI as the manager for Lyncroft, nor has she enrolled for the National Vocational Qualification Level 4. Ms. Williams stated that she would initiate both within the next six months. People who use the service had completed Walsingham’s own questionnaires; the questionnaires had been written specifically for people with learning difficulties and compromised of pictures and tick boxes. The results of the surveys were all positive. The Walsingham group have a legal responsibility to complete Regulation 26 visits every month and have copies available for inspection purposes. The regulation 26 visits are an internal audit by a person not directly responsible for running the home, as a way of ensuring quality. Copies of regulation visits were only available for December 2007 and May 2008. There is a legal responsibility to complete these and therefore a requirement has been made regarding this. Documentation relating to health and safety were checked. Portable Appliance Testing was completed on the 16.11.07; gas certificate was obtained on the 8.907; Legionella bacteria was detected in the home in July 2007, however, recent testing was undertaken and the home was given the all clear. Fire servicing was completed on the 1.2.07 and there was recording of weekly fire checks. Fire drills were undertaken on a regular basis. A first aid box and a fire blanket are situated in the kitchen. The first aid box was examined and a number of expired items were found, for example a mouth-to-mouth resuscitation item expired in August 2006. A requirement has been made that all out of date items from first aid boxes must be removed and that there must boxes must be regularly checked. Fridge and freezer checks were examined, they showed that checks were undertaken on a daily basis. An out of date food item was found, this was disposed of at the time of inspection. However, a requirement has been made that the home must ensure that out of date food items are withdrawn so that they do not affect the health of people who use the service. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 27 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 28 No 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 YA9 Regulation 14(2) Requirement Risk assessments must be reviewed in a timely fashion to ensure the welfare of people who use the service. Health appointments must be recorded accurately for each person using the service. People who use the service must receive their prescribed medication at the stated time. Timescale for action 05/08/08 2 YA19 13(1)(b) 05/07/08 3 YA20 13(2) 05/06/08 4 YA20 18(1)(c)(i) Staff need to be aware of the 05/06/08 policies and procedures for the administration of medication when people who use the service are out of the building. This is to ensure the well-being of the people within the service. 23(1)(a) Within the environment of the home i) The condition of the carpet must be reviewed in the hallway and stairs The lounge doors to the garage must be secured Version 5.2 Page 29 5 YA23 05/09/08 ii) Lyncroft DS0000007137.V364758.R01.S.doc iii) Window restrictors must be fitted throughout the first floor These requirements are to ensure the welfare of people who use the service and to provide them with a homely environment. 6 YA27 23(2)(j) Taps must be fitted to the first floor bathroom so that there is a water supply; this is to ensure that hygiene is maintained. The ground floor bathroom must be thoroughly cleaned so that standards of hygiene are maintained. The manager must be registered with the CSCI, and enrol and complete her NVQ Level 4. Regulation 26 visits must be completed on a monthly basis to ensure consist quality of service. Out of date food must be disposed when it expires. Out of date items in the first aid boxes must be removed and a system initiated to monitor and check items. 05/07/08 7 YA30 23(2)(d) 05/06/08 8 YA37 9(1) 05/06/08 9 YA39 26 05/07/08 10 11 YA42 YA42 12(1)(a) 12(1)(a) 05/06/08 05/07/08 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 Lyncroft Refer to Standard YA33 Good Practice Recommendations When fully staffed, Walsingham should give consideration DS0000007137.V364758.R01.S.doc Version 5.2 Page 30 to holding a team day. Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Lyncroft DS0000007137.V364758.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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