Inspection on 13/05/05 for Lyndale

This inspection was carried out on 13th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyndale 23/08/06

Lyndale 21/11/05

Lyndale 26/11/04

Lyndale 23/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Lyndale 24 Southbank Close Hereford Herefordshire HR1 2TQ Lead Inspector Christina Lavelle Unannounced Inspection 13th May 2005:11.45am - 3.45pm 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 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 Stationary 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. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lyndale Address 24 Southbank Close Hereford Herefordshire HR1 2TQ 01432 378118 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Lyndale (Hereford) Limited Mrs Julie Mogg Care home only 8 Category(ies) of Learning disability (8) registration, with number of places Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The following conditions of registration apply in addition to the category of registration detailed on the previous page: 1. Residents may also have a physical disablility or a mental disorder in addition to a learning disability. 2. The registered manager must undertake training and achieve a qualification in management and care at NVQ Level 4 by 31st December 2005. 3. The registered manager must undertake training in fire safety and in relation to general health and safety matters (including risk assessments) to a management level by 31st December 2005. In respect of the above conditions that relate to the managers training an extension to these timescales indicated has been agreed with the Commission. Progress to comply with these conditions is discussed in this report and requirements are made with the extended timescales for compliance indicated. Date of last inspection 26th of November 2004 Brief Description of the Service: Lyndale is registered to provide accommodation and personal care for eight adults aged from eighteen up to sixty-five. Service users must require care due primarily to learning disabilities and may also have an associated physical disability or mental health disorder. This may include conditions such as epilepsy and behaviour that could be considered challenging to a care service. The home comprises of a large detached Victorian property that is located in a quiet residential cul-de-sac within a short walking distance of Hereford centre. The cities services and facilities are therefore easily accessible. Bedrooms are single and all but one are situated on the first floor and two of them have en-suite facilities. There are two lounges and a separate dining room available to service users as communal space and bathrooms and toilets located on each floor. The garden is to the rear of the property and is large and secure. There is also a small enclosed courtard area that is accessed from the kitchen and has patio tables and chairs so that residents are able to sit outside and have their meals it they wish. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection was carried out over four hours on a Friday afternoon. As it was not pre-arranged residents’ families and other relevant people were not consulted about the home before the inspection. Time was spent with residents at home and the service discussed with two who are able to communicate verbally. The deputy manager and two care staff were spoken with individually about the residents; the care provided and the running of the home. A sample of residents’ care records and some health and safety related records were checked and parts of the building looked at. A Commission pharmacist inspector will visit the home soon to inspect the handling of medicines by staff. The outcome of this medicines inspection will be detailed in a separate letter and sent to the home’s manager. It will be available to the public on request from the Hereford CSCI office in due course. The deputy manager and other staff on duty today were open and co-operative and readily made themselves available to assist with the inspection. This last year the Commission has dealt with one complaint about the home and the provider was asked to investigate the concerns raised. A satisfactory response was received that indicated appropriate action had been taken and the manager and staff had been made aware of the issues. It was confirmed by management that any action advised and/or recommendations made by the Fire Authority would be actioned. Consulting with a Fire safety Officer about an aspect of fire safety of the premises was part of the complaint investigation. What the service does well: Lyndale has an open, relaxed and welcoming atmosphere and the physical environment is homely, comfortable, secure and well maintained. The location is very convenient for this group of physically able and active younger adults as they can walk easily to most of the cities facilities and services. The focus is on staff time allocated so residents can get out as much as possible to pursue their interests and mix with other people in the local community. The home provides a suitable vehicle for outings and activities further away. Staff provide a personalised service to residents and help them to develop their life skills and independence. Residents say they are happy living at Lyndale and like the manager and staff. Interactions between residents and staff were all seen to be supportive and friendly. Those residents able to understand are clear about the role and responsibilities of manager and their keyworkers. They make choices and decisions in their daily lives and routines The staff team appear to have good morale and to be well motivated and the management approach is open and positive. Staff work together for the wider Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 6 benefit of the home and the residents and there is good communication and clear lines of accountability between staff, the manager and provider. Care planning for residents is comprehensive so that staff know each person’s needs, preferences and goals and any action needed from staff to meet them. This helps to ensure that quality care is provided in a consistent way. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 & 4 Information is provided about the home to help prospective residents decide whether they might like to live at Lyndale and if the home could meet their needs. These documents would be improved if provided in a format suitable for people with a learning disability and include current residents’ views of the home. There are thorough procedures in place when possible new residents are referred for a placement to ensure their needs can be met properly. EVIDENCE: There is a Statement of Purpose, Service users’ Guide and a Terms and Conditions of Residence for the home. Each resident also has a contract agreed between the provider and their purchasing local authority. These documents are all written and do not contain any pictures, photographs or symbols which could help prospective residents understand them more easily. Although there have not been any recent admissions it was previously confirmed that home management always visit prospective residents at their current residence to assess their care needs and determine if the home could meet them. They are also invited to visit Lyndale as part of their introduction before a trial stay is arranged. A decision is made about whether they will remain at the home in a review meeting held following the trial stay. The residents and relevant others, such as their families and social workers, are appropriately involved in the assessment, admission and review process. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 & 9 Assessment and care planning has been developed so that all aspects of the residents’ care needs are identified and staff know how to meet them. If the care plans drawn up are now reviewed and updated at least six monthly, and as any changes in residents’ needs occur, it would ensure they always reflect residents’ current needs and the action staff need to take. Care planning is person centred, and so appropriately takes into account residents’ choices and wishes. Keyworkers are closely involved in care planning with and/or on behalf of their allocated residents which makes care more personal. Residents’ and others safety is safeguarded by the carrying out of risk assessments, which also indicate risks that can be taken to promote independence and life skills. EVIDENCE: A sample of two residents’ care records were looked at in detail. A recently introduced care planning format covers all relevant areas of their personal, behavioural, emotional/psychological and social needs and includes action plans and risk assessments. One resident said he has agreed and signed his own Plan and described his goals in life and how his keyworkers had discussed and drawn up his Plan with him. The Plan format includes residents’ families and/or representatives, social workers etc. agreeing to the Plans and the home intends to include this as part of the care planning and review process. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 10 Plans had recently been reviewed and updated, although it had been eight months since the previous review of one Plan. It is intended in future that staff review all Plans monthly and a formal review be carried out six monthly. This should be implemented and will be checked in future inspections. Staff said they have access to all the information available about residents. They take an active role in drawing up, reviewing and updating Plans and carrying out risk assessments for residents they “keywork”. They clearly know the residents and their needs and preferences well as confirmed through discussion, the Plans and other records. Staff complete daily reports on each resident and significant event sheets, providing useful information about their progress, events in their lives etc. and to inform the care planning process. Risk assessments are comprehensive, covering residents’ personal safety; environmental and other possible risks to staff and other people. Staff also complete detailed accident records and incident sheets following any incidence of challenging behaviour. Individual physical intervention policies are in place that appropriately state restraint must only ever be used as a last resort. These incident records are analysed regularly by an external specialist to check action taken was appropriate and to make recommendations if necessary. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12, 14, & 16 Residents are given choice and flexibility in their daily lives and routines to encourage their independence and self-determination. They are supported by staff to take part in some planned activities; to go out on leisure outings and to have holidays. Efforts by staff to seek more opportunities to develop their life skills and participate in activities that provide more constructive stimulation should continue. Residents are helped by staff to maintain their family links. EVIDENCE: Residents made choices today, such as where to go out and where in the home and what to eat for lunch. One resident said he is really looking forward to living in the separate flat as a means to greater independence. He currently helps with the home’s shopping, household and DIY as well as taking responsibility for personal tasks. All residents are encouraged to keep their rooms tidy, do their own laundry and help around the home as far as they can. Each resident has a social needs assessment and a weekly activity programme. Various activities take place in-house, including an art group and music session which involves making instruments as well as playing them. The local college provide tutors to take these sessions and residents also attend some classes at the college. The home had information available about activity sessions that Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 12 will take place over this summer for people with learning disabilities and are encouraging residents to enrol on them. There was an information leaflet in the home about another project, and the home plans to attend an open day to check it out. As many current activities are based around shopping in town and meals out more work related and constructive activities would be beneficial. Today two residents had gone out for the day shopping to Birmingham and two had gone out locally with staff. One resident came back from clothes shopping with her keyworker and was proud to show the inspector and deputy manager what she had chosen. Residents said they go out on leisure trips with staff individually most days, either locally or in the home’s vehicle. Staff are allocated at the start of each working shift to escort them. Two residents were going to Spain for a week’s holiday soon and another has chosen to go to Scotland. Care records detail residents’ visits to their families with staff support, and two residents say they regularly telephone and keep in contact with their families. Standard 17 was not fully assessed but some aspects of food provision were checked. Residents and staff confirmed meals and mealtimes in the home are flexible and residents help with shopping and choosing menus. Staff encourage healthy options e.g fresh fruit, salads and cereals. The Lunch today was jacket potatoes with cheese and/or baked beans and fruit or yoghurts. Residents also enjoy having meals and snacks out of the home and clearly often do. Staff are aware that one resident would choose to take a very limited diet which would not be healthy or nutritious. They describe how they encourage him to eat a variety of more wholesome food. A GP had been made aware of the issues and prescribed vitamin supplements and a Dietician been consulted for advice. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 There are suitable arrangements in place to ensure the personal and health care needs of residents are met. Staff provide support residents need whilst encouraging independence of those more able. Input is appropriately obtained from relevant health care specialists and links with them maintained. Routine check ups are arranged at accepted intervals so that good health is promoted. EVIDENCE: Residents’ Plans detail their personal care needs and preferred routines and the action staff need to take to meet them. Care records show their health is monitored and describe any issues as they are identified, with the action taken by staff to deal with them. Relevant physical health checks, such as weight and incidence of seizures, are maintained and there are individual protocols in respect of specific conditions or risk areas e.g. the management of epilepsy, bathing and positive interventions for challenging behaviour. A Psychiatrist visits the home monthly to review residents’ mental health and medication and is available to provide input and advice whenever necessary. For one person with dietary issues a Dietician had been consulted and given advice and a record is now kept of their daily food intake. Records are kept of visits to GPs and regular check ups to dentists, opticians etc. which are arranged by keyworkers who also support residents to attend appointments. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 An effective complaints procedure is operated and so residents’ views and concerns are heeded by staff, taken seriously and action taken to resolve any issues. Suitable arrangements are in place overall to safeguard residents. The protection of these vulnerable adults would be improved if the home can always show an effort has been made to identify the cause of all injuries to residents and that relevant people have been informed. EVIDENCE: The home provides a written complaints procedure in a suitable format for the residents. Residents say they feel able to discuss their views and concerns with the manager and their keyworkers and are confident action will be taken. Keyworkers understand part of their role is to advocate for residents and to ensure their views, needs and preferences are known and taken into account. Referrals have been appropriately made by the home through the local multiagency procedures for Protection of Vulnerable Adults. An ongoing record also has to be signed by staff after every shift to confirm they have not witnessed any abusive incidents or behaviour. Incident, accident and body charts are completed by staff when residents’ behaviour is challenging or they have any injuries. However one resident’s records state that on return to the home from relatives they had a large bruise on their leg. Whilst staff explained that this person’s hyperactivity often resulted in bruising it is considered that more effort should have be made to find an explanation for the injury and relevant other people, such as the purchasing authority and social worker, informed. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27&28 The home is suitable for it’s purpose and offers residents a secure, stable and comfortable environment in a convenient location to local services and facilities. Arrangements to maintain and upgrade the accommodation are in place and appear to be working effectively. EVIDENCE: Those areas of the premises viewed were bright, clean, tidy and the home fresh and airy. Residents all have single bedrooms that are appropriately furnished, well personalised and some people choose to spend a lot of time in them when at home The communal rooms are comfortable and well furnished and provide adequate space for shared activities, although the dining room is rather small. The garden and patio areas are enclosed, pleasant and well kept. The patio has a table and chairs so that residents can eat meals outside if they wish. There are sufficient toilets and bathrooms on each floor and the kitchen and laundry are domestic in size and scale and are suitably equipped. One of the lounges is being redecorated and refurbished. An area on the ground floor is to be converted into a self contained flat and also shows the needs of residents who could manage more independently are considered. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 16 There were no aspects of the premises seen that required immediate repair or that appeared to pose a safety hazard to residents and /or other people. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33 & 35 Staffing levels and deployment are being maintained at an adequate minimum level (including staffing agreed with some contracting authorities) to meet residents’ needs. The staff team is more stable and with increased opportunities for staff training this should benefit residents by greater consistency of care, provided by a competent staff team. Clear direction and support from home management and the provider reflects positively on the effectiveness of the staff team and so on residents’ care. The staff approach to residents and general atmosphere indicates a caring and supportive attitude and commitment to the home’s aims and purpose. EVIDENCE: There is a sufficient number of care staff on duty today including the deputy manager and a team leader on each shift. Rotas indicate which of the staff are allocated to particular residents on each shift who have an agreed staffing ratio e.g. 1 to 1 in the home and 2 to 1 when out in the community. The deputy manager confirms staff arrangements are still in place to ensure the safety of one service user during the night, as was agreed by a Protection of Vulnerable Adults multi-agency strategy group (which included the service provider). Agency staff are not deployed as much as previously and this comprises of a few individuals who are used regularly and know the home and residents well. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 18 Most staff had completed all the mandatory health and safety topics and there are trainers within the providers small group of care homes who can now provide regular updates and train new staff in areas such as basic first aid, epilepsy and moving and handling. All the staff spoken with had completed NVQ and one person is now doing the NVQ assessor’s course. The home has recently adopted an induction and foundation programme for new staff that is in line with relevant specifications (Learning Disability Accredited Framework i.e. LDAF) and staff have started to attend training sessions covering relevant topics, such as epilepsy and positive approaches to challenging behaviour. This should improve the knowledge and skills of the staff team and provide a basis for staff to go on to obtain an NVQ qualification. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,42 & 43 The home has a positive and open management approach. This ensures staff have good leadership and direction and there are clear lines of accountability and so promotes good quality and consistent care. When the manager achieves an NVQ qualification this should also benefit the home. Overall working practices appear to safeguard residents’ and staff health, safety and welfare. This should improve when the manager has completed a health and safety training course. Also when there is always staff on duty who are qualified first aiders (unless a risk assessment shows that other adequate arrangements for first aid emergencies are already in place). For the protection of residents against unsuitable staff working at the home records, e.g. CRB checks and references, must be available for inspection. EVIDENCE: Staff and residents spoken with understand the role and responsibilities of the provider, manager and their keyworkers. They confirm they feel able to Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 20 approach them freely and they are supportive and respond positively. They can also air their views and know they will be listened to and actioned. In respect of the manager’s training to achieve an NVQ level 4 in care and fire/health and safety to a management level, (which was a condition of her registration) extended timescales have been agreed with the Commission. The deputy manager does not have a first aid qualification although other staff on duty had completed first aid training to Appointed Person level. However the National Minimum Standards states that a qualified first aider should be on duty at all times which is the First Aid at Work course. The deputy said it is already planned that she, the manager and all team leaders (including night staff) will attend this first aid training course and in the meantime a risk assessment must be completed to assess what arrangements are sufficient to safeguard residents. Any additional training needs identified through this process should be put in place within the next six months. There are no issues of concern identified during this inspection in respect of the environment that pose a risk to the safety of residents and staff. The fire log was also checked and showed that all required tests and checks on the fire safety system and equipment had been recorded as carried out at the specified intervals. Fire drills had been arranged regularly and staff spoken with confirm they participated in such a drill within the last six months. There is a written fire risk assessment for the home that had last been updated in July 2004. The deputy was unable to access staff records which are needed to check that references and CRB/POVA checks are obtained for staff. Consideration should be given as to how this could be addressed. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x x Standard No 11 12 13 14 15 16 17 3 3 x 3 x 3 x Standard No 31 32 33 34 35 36 Score x 2 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lyndale Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 2 2 E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 23 Regulation 13(6) Requirement The home must always make efforts to find an explanation for any injuries to residents. Also relevant other people (e.g social workers) must be informed when such injuries occur. Staff must undertake training that is relevant to the particular disabilities and specialist needs of service users. (Some progress has been made and so the previous timescale of the 31/3/05 is brought forward; not fully actioned) A risk assessment in respect of the need to provide a qualified First Aider at all times must be completed. Any additional staff training identified from the risk assessment must be completed. The manager must achieve an NVQ level 4 qualification in management and care. (This was a condition of registration and had a previous timescale of August 31st 2004. It was agreed to extend the timescale as the manager was unable to enrol on a course.) Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 23 Timescale for action Immediate & Ongoing 2. YA32 & 35 13(4) & 18(1) By September 30th 2005 3. YA 42 & 18(1) By December 30th 2005 4. YA37 9 By August 31st 2005 5. YA37 & 42 9 By The manager must undertake training in fire safety and general September health and safety (including risk 30th 2005 assessments) to a management level. (This was a condition of registration with a previous timescale of March 31st 2005. It was agreed to extend the timescale) 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. Refer to Standard YA1 YA41 Good Practice Recommendations The service users guide should also be produced in a format more suitable for people with learning disabilities and include current residents views of the home. Consideration should be given to how required records can be available for inspection whilst maintaining confidentiality and other statutory requirements, e.g Data Protection. Lyndale E52 E02 S55244 Lyndale V227283 130505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 178 Widemarsh Street Hereford Herefordshire HR4 9HN 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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