Inspection on 08/01/08 for Lyndale

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Adequate service.

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 15/01/09

Lyndale 13/08/07

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

CARE HOME ADULTS 18-65 Lyndale 2 Alumdale Road Westbourne Bournemouth Dorset BH4 8HX Lead Inspector Jo Pasker Key Unannounced Inspection 8th January 2008 10:20 Lyndale DS0000069815.V357553.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 Lyndale DS0000069815.V357553.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. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndale Address 2 Alumdale Road Westbourne Bournemouth Dorset BH4 8HX 01202 764425 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) Purple Care Ltd ****Post Vacant**** Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary needs on admission to the home are within the following category: Mental Disorder, excluding learning disabilities and dementia (Code MD) The Maximum number of service users who may be accommodated is 9. 13th August 2007 2. Date of last inspection Brief Description of the Service: Lyndale is registered as a care home providing residential care for up to 9 people under the age of 65 years old, who are experiencing mental health problems. The home is located in a residential area of Westbourne within a short walk to the beach and close to the community facilities of Westbourne. Local bus services are good and link to both Poole and Bournemouth town centres. Lyndale is an older style, detached house with a large garden for residents’ use to the rear. Accommodation is provided over two floors with 4 single rooms (3 with en-suite) and a shower room on the ground floor and 5 single rooms all with en-suite and a bathroom, on the first floor. Communal areas on the ground floor consist of a large open lounge and dining area and a shared kitchen. Car parking is available directly outside the home or in the surrounding roads. Purple Care Ltd owns the home and the Registered Provider is Mrs Miljana Kiss. The home is currently without a Registered Manager but does have a manager in place that oversees the day-to-day running of the home. The fee prices in January 2008 range from £430 to £900 per week for residential care. See the following website for further guidance on fees and contracts: www.oft.gov.uk (Value for Money and Fair Terms in Contracts). Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The unannounced key inspection was undertaken in line with the Care Standards Act 2000 and following the Commission’s Inspecting for Better Lives guidance. Since the last key inspection a random unannounced specialist pharmacy inspection has also taken place on the 3 October 2007 and this report can also be viewed on our website. The purpose of the inspection was to review the requirements and recommendations made at these last inspections. As part of the inspection process an expert by experience was involved and spent time looking round the home, talking with residents and the staff. The expert talked to residents to find out what activities they do, what choices and support are available for them and what day-to-day life is like in the home for them. The expert also considered the general environment of the home and the standard of facilities provided. Comments and information from the expert’s report are reflected throughout this report. The registered provider, Mrs Miljana Kiss was on hand throughout to aid the inspection process. Information for this report was obtained from discussion with the Registered Provider, discussions with 4 residents, 1 member of staff on duty and other external professionals, a review of a variety of documentation including records provided to the Commission, care records, staff records, maintenance records, policies and procedures and a tour of the home. What the service does well: The home’s pre admission procedure is good and prospective residents are provided with information about Lyndale and are encouraged to visit, in advance of admission, to establish their impressions of life at the home and the standard of available accommodation. Individual plans and risk assessments are detailed, person-centred and informative ensuring residents and staff are fully aware of how needs and goals are to be met. People are able to make a range of choices about their daily lives. Residents are supported and encouraged to participate in activities, which interest them, to be part of their local community and to maintain links with family and friends so that they have networks of support outside of their home. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 6 Daily routines in the home promote residents’ independence and there is a flexible approach to mealtimes, which promotes residents’ well-being and enjoyment of their meals. Access to generic and specialist health care services ensure that residents’ physical and mental health care needs are well met. What has improved since the last inspection? Following the last key inspection and random unannounced specialist pharmacy inspection, improvements have been made in many areas within the home. Assessments and records of care now are documented to accurately reflect what happens in practice. Goal plans and risk assessments are signed by residents to confirm that they have discussed and agreed with them. Photographs of each resident are kept on their file and a resident’s refusal documented if necessary. Staff are being provided with adequate training to ensure that their skills meet minimum health and safety requirements and equip them to adequately meet the specific needs of residents. Risk assessments are now carried out for all residents who are self-medicating to ensure their safety is maintained and independence promoted. The policy and systems for the administering and handling of medication have been reviewed to ensure that residents remain safely cared for. Staffing levels have been increased if needed to provide additional support to residents. Recruitment procedures have improved to prevent residents being put at risk of unsuitable carers being employed by the home. Consideration has been given to how the staff team could reflect the gender mix of residents and this will continue. A suitable candidate’s application for the registered managers post has been put forward to the Commission within the previous timescale, of 6 months, that was made. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 7 The home has provided a copy of the registered provider’s annual development plans to the Commission to help evidence the home’s quality assurance procedure. Copies of the report by the Registered Provider as specified in Regulation 26 of the Care Homes Regulations 2001 are being supplied to the Commission on a monthly basis. 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. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 8 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 Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information about Lyndale and are encouraged to visit, in advance of admission, to establish their impressions of life at the home and the standard of available accommodation. EVIDENCE: There have been no new admissions to Lyndale since the last inspection, therefore this standard has not been able to be fully assessed. However, the registered provider had recently assessed a potential new resident, with the manager and was knowledgeable about what pre admission practices were necessary to ensure that individual’s needs were accurately assessed and whether the home could meet these needs. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans and risk assessments are detailed, person-centred and informative ensuring residents and staff are fully aware of how needs and goals are to be met. People are able to make a range of choices about their daily lives and are involved in decision making within the home. EVIDENCE: The individual plans of 3 residents were seen. All contained detailed information on aspects of personal and social support, healthcare needs, leisure activities and independent living skills. These goal plans were dated and signed by the resident or staff to evidence that they had discussed and agreed them and there was written evidence of recent reviews taking place in 2 of the 3 files. There was documented evidence in the daily entry notes of staff addressing individuals’ goals and staff spoken with, confirmed that they were aware of individual’s needs and any interventions preferred. These files also contained photographs of the residents. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 11 The plans clearly included resident’s own personal goals, such as attending the gym or playing the guitar and the daily entries made in each residents’ file by staff also evidenced that people were regularly attending various centres, going to the shops or out with friends and family. The expert observed in her report that residents were seen being supported to make their own decisions. These included making their own drinks when they liked, choosing to eat when it suited them and going out at different times of the day. A sample of risk assessments were seen and covered areas such as social activities, the misuse of alcohol and illicit substances, personal care, self harm and vulnerability. At the last inspection, a requirement was made, that all residents who are self medicating must have a risk assessment in place. The registered provider has now introduced forms to address this and residents also sign them. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to participate in activities, which interest them, to be part of their local community and to maintain links with family and friends so that they have networks of support outside of their home. However, further development of activities within the home could be explored. Daily routines in the home promote their independence and there is a flexible approach to mealtimes. EVIDENCE: The people living at Lyndale attend different day services in the community, which enable them to be with their peer group and take part in a range of activities. A programme of activities is kept in the office but not on display on the communal notice board in the hallway of the home. The expert by experience commented that “Notice board [had] minimal information for residents” and queried why there was not more information about community options and activities displayed there. The registered provider stated that Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 13 information had been put up previously but generally then gets taken as needed by individuals and has to be replaced several times. The expert commented that although some residents attended mental health resource centres and projects outside of Lyndale, there appeared few activities offered to occupy them within the home. The expert’s report observed that “Residents are left to their own devices mostly” and that “Those motivated therefore are up and out utilising community mental health facilities and visiting nearby shops”, however “There is nothing therapeutic happening in the home, no activities on offer at all, so those not well enough or who suffer from a lack of motivation are not engaged it seems”. The registered provider stated that activities, trips out to the pub or different places of interest have been arranged and discussed amongst the residents, but that lack of interest had prevented many of them from taking place. The annual development submitted to the Commission states that there will be a strong focus on Lyndale providing a diverse range of activities, in the coming year and working closely with relevant organisations, such as the local adult learning colleges and Re-Think group. This will be looked at during the next inspection. The home does not currently have a dedicated vehicle but most residents attend appointments and activities themselves by getting public transport or going with their care manager. Residents spoken with confirmed that they were able to see their family and friends as they liked and the visitors’ book demonstrated this. The communal telephone in the hallway continues to be out of use (as it was at the last inspection, due to a problem with the billing) and it was discussed that if the situation remains the same then it should be removed. Residents are able to use the portable office phone to make and receive calls in private when needed. The expert commented that the “atmosphere between residents was chatty and friendly” and those residents could help themselves to breakfast and lunch with staff help as needed. The rota for everyone’s meals and chores was on the kitchen wall and the expert said in her report, that this was “good-encourages ownership and involvement of running of home”. The registered provider has also implemented a suggestion board, so people can write down what meals they would like to see on the menu rota. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of staff have a good understanding of residents’ care needs and support is offered in a way that promotes independence and respects personal preferences. However staff language differences may, at times, have a negative impact on the support offered to residents. Access to generic and specialist health care services though, ensures that residents’ physical and mental health care needs are well met. Improvements to the home’s medication handling and procedure mean people are better protected. EVIDENCE: Individual plans seen provided staff with enough detail about the care needs and routines of people living in the home, for example, how often they need chiropody and the help they need with their personal care. Risk assessments seen also showed evidence that risks around personal care and self-neglect had been considered. Some residents expressed on going concerns that some staff do not always understand their needs due to language difficulties and this had caused problems within the home. However, staff spoken with showed a clear understanding of residents needs and the registered provider confirmed Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 15 that the staff also hold a professional nursing qualification in mental health from their country of origin. The home continue to ensure that individuals’ health care needs, both mental and physical, are properly monitored and appointments made as appropriate. Residents’ records showed evidence of liaison with generic and specialist health care services, for example general medical practitioners, care managers, chiropody and psychiatrists. Following the last key inspection and random unannounced specialist pharmacy inspection, improvements have been made in the administration and handling of medicines within the home. Most medicines in the home are administered from Monitored Dosage System (MDS) blister packs and the sample checked during the inspection agreed with the Medication Administration Record (MAR) charts. 3 residents self medicate and have a recent appropriate risk assessment in place for this. All handwritten entries seen were counter signed, there were no gaps in recording, allergies were documented and all disposals were signed by 2 staff. The policy seen reflected this practice and is read and signed by all staff. The potential reasons for administering a medication ‘as required’ are now also recorded on the back of the MAR sheet. As a good practice measure, the home have introduced medication front sheets, which are signed by the individual residents and address any relevant equality and diversity issues. All staff responsible for the administration and handling of medication held valid certificates of training in their staff files. A controlled drugs cupboard is now held by the home but this is not yet secured to the wall, therefore does not meet the previous requirement made legally. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are procedures in place to ensure that complaints are fully investigated and residents are given an opportunity to raise any concerns, however, some residents do not feel confident that they will be listened to. Policies, procedures and training are in place to protect residents from abuse but staff do not always demonstrate a clear understanding of local procedure. EVIDENCE: The home has a clear complaints policy and procedure available to everyone. The Commission for Social Care Inspection have received some complaints and have referred them back to the home to investigate. Residents spoken with during the inspection said that if they had any concerns they could raise them in residents’ meetings held but also said that often, “staff are busy” when asked about something. Some residents also appeared anxious to raise any concerns with the home that may be perceived to be negative. The home has an adequate policy and procedure to respond to suspicion or evidence of abuse or neglect. The registered provider and manager are booked to attend a safeguarding for managers’ session and all staff have received some adult protection training, with certificates seen. In discussion, staff are able to identify different types of abuse but appeared unfamiliar with local safeguarding procedures. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lyndale provides residents with an attractive, homely and safe place to live however some areas require further improvement and these are being addressed by the provider. EVIDENCE: A tour of the premises found the home remained generally clean and well maintained with the new kitchen units now fully fitted, the front outside area of the home tidy and the front wall repainted. The improvement plan completed by the provider states that the shower room ceiling has also been repainted and a new extractor fan fitted. However, when turned on it is very noisy and does not appear to be situated correctly to be effective. Some other areas within the home also appeared to be in need of maintenance work/replacement, including: • Upstairs bathroom- window seen to be mouldy, with a dirty net and no blind in place to maintain residents’ dignity and privacy. DS0000069815.V357553.R01.S.doc Version 5.2 Page 18 Lyndale • • • Kitchen- ceiling tile needs replacing due to water damage, cracked window pane and scorch mark on wooden fitting behind gas hob which is also a fire hazard. Laundry room- hole seen in roof only covered with loose tile, mould on large down pipe and lack of storage, especially for mops. Bedrooms- lack of towel rails/facilities to hang up damp towels and some soft furnishings, such as bedding, looks worn and needs replacing. All of these issues were discussed with the provider who stated that they will be immediately addressed and also that all new residents will have a choice in how their rooms are decorated and that new furniture will be bought as needed. The expert noted in her report that all bedrooms had a lock, the kitchen appeared clean and tidy, there was a rota for using the laundry equipment that worked well and the home had a big television and Skybox which offered plenty of viewing options for residents. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in staffing levels and training have been made to ensure that the needs of the people living in the home are better met. However, recording needs to improve to evidence this. Recruitment practice has improved and ensures that residents living in the home are better protected. EVIDENCE: There are now only 4 members of staff on the rota, in addition to the manager and provider and these are all female staff. The provider stated that it had been difficult to ensure that the staff mix reflected the gender mix of residents, as no male applicants had applied when jobs were advertised by the home. However there is a possibility that a male carer will be joining the team. The provider stated that staffing levels are now generally 2 staff in the morning, 2-3 for the afternoon until 6pm, with 1 staff member there from 6pm-10pm and the manager (who lives in), on call overnight. However the rota seen did not accurately reflect this, with gaps seen for the previous day and only 1 member of staff on duty when the inspection started. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 20 Discussion with the member of staff on duty demonstrated that she was very aware of all the residents’ needs and appeared to have a caring and appropriate manner with them. The expert commented that the staff member present “appeared very efficient, helpful and friendly with residents”. No completed new staff files were available to view, however appropriate checks and information were being sought for 2 potential members of staff. All files seen of current staff, contained evidence of training certificates and recent sessions attended included the Mental Capacity Act, borderline personality disorder, challenging behaviour, medication handling, food hygiene and safeguarding training. 2 staff members are also undertaking their NVQ 3 award in care and further training is planned to cover infection control, personal safety awareness, advanced medication handling and equality and diversity issues. The provider is also actively contacting resources, such as the local Learning Hub, Skills for Care and the local community mental health team, to access more training opportunities. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a manager who undertakes the day-to-day running of Lyndale and is currently applying to be registered with the Commission. Some improvements have been made in providing an adequate quality assurance system, which is based on the views of residents. Practices in the home ensure that the health, safety and welfare of all are promoted and protected. EVIDENCE: The acting manager who was in place at the time of the last inspection is now the appointed manager and has submitted her application to register with the Commission for Social Care Inspection. Standard 31 cannot be fully assessed though until her application has been processed and approved. However staff and residents spoken with, confirmed that there was a good working Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 22 atmosphere under her management and the Registered Provider, Mrs Kiss, supports her. She is also completing an NVQ level 4 award in management. Copies of monthly visits by the Registered Provider are now provided to the Commission and an annual development plan is available detailing plans for training, social activities and environmental changes for the next year. The home’s quality assurance record showed that the registered provider sends out questionnaires to residents, with the most recent being in November 2007. Records showed evidence that issues raised in surveys had been followed up by the provider. Residents also hold regular meetings and several issues raised have been addressed following these. Work has started on audits being carried out and this needs to continue. Records showed that staff had all received fire safety training and substances hazardous to health were seen to be stored securely. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 30/04/08 2. YA23 3. YA24 The home must have a Controlled Drugs (CD) cupboard that meets legal requirements in the Misuse of Drugs (Safe Custody) Regulations. 13(6) All staff must receive appropriate training in Safe Guarding adults and demonstrate a good understanding of the home’s Safe Guarding procedure and policy. 23(2)(d)&(o) The registered person must ensure that all internal and external areas of the home are kept clean and well maintained. The previous timescale for action was 31/12/07. 30/04/08 31/08/08 Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 5. 9. Refer to Standard YA12 YA12 YA22 YA33 YA39 Good Practice Recommendations Consideration should be given to how the residents could take more ownership/responsibility of their activity/information board. An increased choice of activities should be available within the home to ensure that residents are actively engaged more often. It should be considered how further improvements could be made to ensure that residents feel that their views are listened to openly. Actual staffing levels should be accurately recorded on the staff rota to reflect what is happening in practice. It is recommended that the home’s quality assurance system continues to expand on the audits it carries out. Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Lyndale DS0000069815.V357553.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!