Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 17/05/05 for Lyndel Homes

Also see our care home review for Lyndel Homes for more information

This inspection was carried out on 17th 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has in place a good system to plan the care and identify risks of residents, this describes to staff how residents needs are to be achieved. Staff were seen to be skilful and respectful when supporting the residents and residents commented that staff were helpful. The home has developed a system to keep in contact with residents` families and encourages family involvement and has in place a complaints procedure that enables residents and their representatives to raise concerns. Meals are well balanced in respect of nutritional value and two residents confirmed that they enjoyed meals at the home.

What has improved since the last inspection?

Staff training has improved, all care staff have achieved national qualifications in Care, they also receive training in safe working practices such as first aid and manual handling, this is now fully recorded. Repairs and improvements have been undertaken in relation to water temperatures, lighting in shower areas and toilets. The residents care plans have been improved, they provide clear information to staff, they are changed where needed and are subject to a full six monthly review. The recording of medicine received into the home has improved. The recording of complaints has been updated and now details outcomes. The manager has ensured that the emergency call system used by residents and staff is serviced and that the commercial cooker in the kitchen is maintained in a hygienic condition.

What the care home could do better:

The home must ensure that the comprehensive risk assessments of hazards in the home are shared with staff and that staff have an understanding of how risks are managed and reduced. The weights of residents need to be recorded on a monthly basis or other methods introduced to monitor this. Staff who handle and administer medicine should attend a course that will develop their competencies. The assessment of residents abilities and preferences in respect of activities in the home must be reviewed and a programme developed and implemented that reflects this. The food preferences of residents must be reviewed and incorporated within the cyclical set menu. Staff need to receive ongoing training in fire safety and regularly attend drills, it must be clear that fire doors must never be wedged open. Staff must also receive training in how to protect residents from abuse. The home needs to develop a system after consultation with residents and their representatives to monitor and improve the quality of the service. Infection control measures in toilets must be improved to ensure that infections do not spread through the home.

CARE HOMES FOR OLDER PEOPLE Lyndel Homes 9 Radnor Road Handsworth Birmingham B2 4UZ Lead Inspector Sean Devine Unannounced 17 May 2005 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lyndel Homes Address 9 Radnor Road Handsworth Birmingham B20 3SP 0121 507 0708 0121 515 2544 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) Delores Matadeen Delores Matadeen Care Home 15 Category(ies) of Mental Disorder (15) registration, with number of places Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no current conditions on the registration of this service. Date of last inspection 23 November 2004 Brief Description of the Service: 9 Radnor Road is located in a residential street of North Birmingham. It is close to local shops, health services, public transport and places of worship. The building has been sensitively restored into an attractive and useable property. It is interesting to see the history of the building on display in the entrance area. The home has 15 bedrooms located on the ground, first and second floors. These are both single and shared rooms. No rooms are ensuite. The home has a passenger lift which enables access to all floors. On the ground floor is a quiet lounge/ office. This has some comfortable seating and access to a TV. There is another smaller lounge also with comfortable lounge chairs and access to a TV. The home has a large, bright dining room, which doubles as the smoking area. This was seen to be a popular place for some service users to sit, chat and listen to music outside of meal times. Bathrooms, showers and toilets were located on all floors. The home has a laundry in which staff can undertake the routine laundry of most clothing. The home has a large kitchen and all meals are cooked on site. At the rear of the property is a pleasant garden. The home provides a service to persons of old age and with a mental discorder, for this reason the home is assessed against the National Minimum Standards for Older Persons. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a period of one day by one regulation inspector on an unannounced basis. The inspector was able to meet with residents and staff, observe care provided, view records pertaining to care and health and safety practices and undertake a tour of communal facilities. The home had addressed the majority of improvements that were needed following the last inspection, however some improvements remain outstanding. It is evident the home assesses and plans the care of residents to a good standard and the new care plans are very informative. What the service does well: What has improved since the last inspection? Staff training has improved, all care staff have achieved national qualifications in Care, they also receive training in safe working practices such as first aid and manual handling, this is now fully recorded. Repairs and improvements have been undertaken in relation to water temperatures, lighting in shower areas and toilets. The residents care plans have been improved, they provide clear information to staff, they are changed where needed and are subject to a full six monthly review. The recording of medicine received into the home has improved. The recording of complaints has been updated and now details outcomes. The manager has ensured that the emergency call system used by residents and staff is serviced and that the commercial cooker in the kitchen is maintained in a hygienic condition. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,6 The home provides appropriate information and undertakes the assessment of prospective residents, this enables prospective residents to make a fully informed choice and for the home to assure the prospective resident that their needs can be met. EVIDENCE: The home has an informative statement of purpose and residents guide, these documents detail the service and facilities available at the home and enable the prospective resident and their representatives to make an informed choice. The documents do reflect the service and available facilities. Sampled residents files included assessment documents completed prior to admission to the home. The assessments were comprehensive and included for example, personal and physical care needs, cultural and religious observation, mental health needs, social activity and contact with family and friends. The home manager has visited and assessed the needs of prospective residents prior to admission to the home. The home does not provide an intermediate care service. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The home adequately meets the health and personal care needs of the residents, however improvements to ensure that risks are reviewed and medication systems meet the health and safety needs for residents is needed. EVIDENCE: Residents have written plans completed from the assessment of need, these also identify risks. The plans have recently been revised, they were seen to be informative to staff and also included how residents can be involved in their own care. The risk assessments completed varied in standard, those completed on the more recent documents were clear and concise and a management care plan was available, those on the older format were less informative. Risk assessments for manual handling, falls, fire and nutrition are available, specific risks are also assessed including going out and selfadministration of medicines. Some risk assessments are routinely evaluated, however others are not, some risk assessments were not dated. Care plans for oral health care are completed. Reviews of care plans are planned on a monthly basis, the home needs to ensure that this is maintained. Records that reflect the healthcare provision are well maintained, these include dates and outcomes of visits by GP, District Nurses, Optician, Dentist, Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 10 Chiropodists and Hospitals. The home must ensure that either the weight or where needed the body mass index of residents is recorded on a monthly basis. The home promotes that a monthly report by key-workers is completed, this was found to vary, although reports were informative. Six monthly reviews are completed and if identified changes are made to care plans and risk assessments. Two residents confirmed that they have recently had appointments, one with the GP and the other with the Chiropodist. A local chemist supplies medicines for residents at the home, using a system called Nomad; medicines are dispensed weekly, mainly in the form of cassettes. The medication administration records (MAR) completed by the home record when medicines are received into the home and administered to the resident, however they do not record when medicines are carried forward from one to another, thus some stocks, especially boxed medicines were found to be inaccurate. The staff at the home have not as yet received accredited training in the safe handling of medicines, this has been a requirement of previous inspections. Staff were observed sensitively supporting residents, this included assistance with using the toilet, ensuring doors were knocked and or locked when in use, that residents were addressed by their preferred name and also residents were observed to dress in accordance with their choice and culture. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The daily life and social activity needs of residents are not entirely met at the home, preferences in relation to social and recreational activity and preferred foods need to be improved to enable the home to fully meet these needs. Mealtimes in the home are relaxed sociable occasions. EVIDENCE: A social activity programme has been developed and is on display in the dining area, a member of staff informed the inspector that this had been developed after consultation with residents. During the inspection residents were not involved in the days programme of activity. One resident commented on enjoying going for a walk and another commented on enjoying time in the garden. The programme of activity was not fully reflective of residents’ choices and abilities. The likes and preferences in respect of social and recreational activity, contact with family and friends and meals and mealtimes are assessed. The home has developed a contact sheet in the residents’ files, to allow contact between the resident, staff and the family. Visiting hours are flexible, however busy periods such as meal times are not included. One resident confirmed that a friend visits weekly and they go out, this was seen in the care plan and assessment documentation. Residents commented on how enjoyable the meals are, a new cook has recently been employed, it is not clear that the likes and dislikes of residents Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 12 have been included within the set menu. The meal-time was relaxed, it was a sociable occasion, staff assisted residents who needed support in a dignified and respectful manner. The meal served included pasta, vegetables and meats, residents were offered a choice for example, pasta with tomatoes or rice and meatballs or tuna. Residents who required a soft diet had this provided. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has not fully made arrangements to adequately protect residents in respect of the risk of abuse, measures to include appropriate staff training are needed to fully afford this. Residents’ complaints are recorded together with outcomes of investigation demonstrating that the home are responsive. EVIDENCE: The home has updated its log of complaints to truly reflect outcomes from a recent complaint. The procedure to make complaints is displayed upon the notice board and included with the residents guide and the homes’ statement of purpose. The home has a policy in respect of Protecting Adults; this has been seen at previous inspections and has not altered. Training to educate staff in the procedures and how to identify abuse has not been fully completed, a more informal training session has been introduced during supervision to explore the knowledge of staff in relation the homes’ adult protection policy. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,26 The environment is generally well maintained and risk assessed to promote the health, safety and well being of residents. However improvements to further address infection control measures are needed to consolidate good practice. EVIDENCE: The manager has ensured that relevant health and safety tests and servicing is undertaken, for example the electric supply. The internal and external premises are well maintained and risk assessments in respect of the premises have been completed to identify possible hazards. CCTV is in place, however this only covers entrance areas. Furniture and fittings in communal areas are domestic in style and although older in design, they are well maintained. One armchair in the lounge (by front door) needs replacing or repair as the arm is torn. Garden furniture including tables and chairs are heavily stained and some of the plastic has split which presents a hazard. Communal toilets and the shower room on the ground floor were inspected, they were found to have the necessary equipment to meet the needs of residents, including grab rails. The toilet, and the toilet in the shower room did not have any toilet roll or paper towels available, material hand towels were being used and soap tablets Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 15 had not been returned to residents’ rooms. A sanitary disposal system and a clinical waste contract is in place to dispose of and remove such materials. As identified at the last inspection the home must address the practice of staff having to empty soiled laundry into the machine from plastic disposable bags, the manager confirmed that this had not been fully addressed. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,30 The home has a team of staff that is trained to a nationally recognised level and have also developed competencies in safe working practices and the specific needs of residents. It is clear that residents are in the care of well trained staff at all times. EVIDENCE: The majority of staff, including night and day care assistants have achieved the National Vocational Qualification at level Two in Care. The awards for nine staff were confirmed. Staff training in respect of safe working practices has been improved, training records and certification confirmed that most training is current, including, Manual Handling, Emergency First Aid, Health and Safety and Food Hygiene. Training in respect of twice yearly Fire Safety training had lapsed for some staff. Staff are also receiving training in relation to the specific needs of the current residents, this includes Dementia, Care Planning and Residents Meals. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,38 In the main the health and safety practice at the home is adequate to protect the health and safety of residents and staff. Improvements to the fire safety at the home are needed to fully inform staff of their roles and responsibilities in such an emergency. EVIDENCE: The home has previously had links with an external body to assist in developing a verifiable quality assurance system, this has not been progressed. However the home does at intervals produce staff and resident questionnaires. This needs to be further developed to include residents’ representatives and also stakeholders such as Social Care and Health. Findings from the questionnaires need to be used to develop an annual improvement plan. The home ensures that tests, servicing and maintenance of for example fire systems, gas and electrical supply and appliances, lift, waste and water are maintained. Detailed risk assessments have been developed to identify risks Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 18 pertaining to fire, premises, staff and food hazards. The fire risk assessment needs to detail findings of audits. Fire drills are conducted, however this is not frequent enough to afford adequate safety. The last drill was recorded as August 2004. Staff training in fire safety has not been fully completed twice yearly, the system of the manager providing this training should only be implemented if the manager has completed the approved trainers course. The recent service of emergency lights recommended that three fittings be replaced as the life of the back-up battery was now limited. Records in relation to accidents and incidents are generally well maintained, however two accident forms were seen to be incomplete, the inspector had previously been notified of the accidents. The fire door to the large main lounge was found to be held open by a footstall and presented an unnecessary risk to residents and staff. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 2 3 x x x x 2 STAFFING Standard No Score 27 x 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x x x 2 Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 20 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 OP7 Regulation 12(1)(a) 13(4)(c ) Requirement Risk assessments must be further developed, the tick list risk assessment must be replaced with a more comprehensive assessment, this must detail how the risk is to be managed or reduced. Risk assessments must be routinely evaluated, they must be dated and signed. All written care plans must be reviewed on a monthly basis. The weights of residents must be regularly taken and recorded, where this is difficult for the resident a body mass index must be completed. All staff who handle medicines must complete an accredited course in the safe handling of medicines. Previous timescale 30/11/04 not met, this requirement is carried forward. The manager must ensure that stock levels of medicines are correct, any discrpancies must be investigated and corrective Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Timescale for action 31/7/05 2. 3. OP7 OP8 15(2)(b) 12(1) 31/7/05 31/7/05 4. OP9 18(1)(c )(i) 13(2) 31/10/05 15/7/05 Page 21 Version 1.30 actions taken. 5. OP12 16(2)(n) A programme of activity based 31/8/05 upon residents individual preference and ability must be developed, this must be advertised, implemented and fully recorded. The manager must ensure that 31/7/05 the food likes and dislikes of residents is included within the current menu, this must be subject to frequent review. The home must ensure that all 31/8/05 staff are appropriatley trained in protecting vulnerable adults from abuse. Previous timescale of 30/11/04 not met, this requirement is carried forward. The arm chair in the front lounge must be replaced or repaired. Garden furniture that is heavily stained must be cleaned or replaced. Garden furniture that is damaged must be repaired or replaced. The manager must ensure that toilet roll and appropriate hand washing facilities, e.g. liquid soap and paper towels are available in all communal toilets. The home must use a system that adequately protects staff from the risks of infection is introduced in the laundry, e.g. alginate bags for soiled items of laundry that can be put into the washing machine. The home must have in place a system for reviewing and improving the Quality of Care. The home must elicit the views of family and friends and also other professionals / stakeholders in the service. The 6. OP15 16(2)(i) 7. OP18 13(6) 8. OP20 23(2)(c ) 31/8/05 9. OP26 13(3) 31/7/05 10. OP26 13(3) 31/5/05 11. OP33 24 30/9/05 Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 22 findings should be used to implement a plan of continuous improvement. Previous timescale 31/5/05 not met, this requirement is carried forward. The frequency of fire drills must be increased, all staff must attend at least two fire drills annually. All accident forms must be fully completed. Records confirming staff have received and understand the homes risk assessments must be available. Previous timescale 31/5/05 not met, this requirement is carried forward. Fire doors must never be wedged or held open. All staff must attend fire safety training at least two times a year. 12. OP38 23(4)(e) 18/5/05 13. 14. OP38 OP38 17(1) Schedule 3 (3)(j) 13(4)(c ) 30/6/05 31/8/05 15. 16. OP38 OP38 23(4)(c )(i) 23(4)(d) 17/5/05 31/07/05 17. OP38 23(4)(c )(iii) The training must be provided by a person or body that has been approved or judged to be competent.i The three emergency light 30/6/05 fittings as identified at the recent service should be replaced. 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 OP7 OP38 Good Practice Recommendations Key worker reports should be completed in line with the providers expectations, this being on a monthly basis. The fire risk assessment must be further developed to E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 23 Lyndel Homes 3. OP1 meet with guidance from the West Midlands Fire Service. The home should further develop the statement of purpose to describe the types of formats or forums the home uses to consult the service users. Not assessed and is carried forward. The manager should complete NVQ 4 in Care & Management or the Registered Managers Award by 2005. Not assessed and is carried forward. 4. OP31 5. 6. Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Lyndel Homes E54 S16844 Lyndel Homes V228054 170505 Stage 4.doc Version 1.30 Page 25 - 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!