Inspection on 05/06/07 for Lyndel Homes

This inspection was carried out on 5th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lyndel Homes 06/06/06

Lyndel Homes 21/02/06

Lyndel Homes 17/05/05

Lyndel Homes 23/11/04

Lyndel Homes 14/06/04

Lyndel Homes 13/01/04

Lyndel Homes 21/07/03

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

CARE HOMES FOR OLDER PEOPLE Lyndel Homes 9 Radnor Road Handsworth Birmingham West Midlands B20 3SP Lead Inspector Sean Devine Key Unannounced Inspection 5th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndel Homes Address 9 Radnor Road Handsworth Birmingham West Midlands B20 3SP 0121 507 0708 0121 515 2544 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) Mrs Delores Matadeen Mrs Delores Matadeen Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 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. The home has 15 bedrooms located on the ground, first and second floors. These are both single and shared rooms. No rooms are en-suite. The home has a passenger lift which enables access to all floors. On the ground floor is a quiet lounge/ office. This has some seating and access to a TV. There is another smaller lounge also with 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 residents to sit and chat outside of meal times. Bathrooms, showers and toilets are 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 garden. The home provides a service to persons of old age with a mental disorder. The manager informed us that the fees for the home range from between £325.00 and £405.00 each week and hairdressing, some chiropody, toiletries, clothing, items specifically requested by residents such as daily papers, magazines, make up etc are additional cost paid for by each individual resident. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was visited unannounced by a regulation inspector and it lasted for one day. Prior to the inspection visit the home had been sent an Annual Quality Assurance Assessment referred to in the report as AQAA, which was returned, and 10 surveys sent to residents called have your say about were returned, other residents were able to complete surveys that the inspector had brought to the inspection. In total fourteen were returned explaining their experiences of living at the home. The inspector was able to meet with and talk with seven residents, who shared some of their opinions of what it is like to live in the home. A tour of communal and service areas was completed and records about safety of equipment and the building were checked. Records about how staff are recruited, trained and supported were seen to help determine whether the staff have the skills to meet the needs of the residents. During the inspection the inspector followed the experiences of living at the home for two of the residents, including looking at their health and care records, discussions with the two residents and their key workers, this is referred to within the report as case tracking. In the past twelve months the home has received four formal complaints about care in the home, which have not been upheld and the home has not made any referrals to safeguard residents under the local authority adult protection procedures. An additional inspection of the home to determine progress on requirements issued at the last key inspection was conducted on the 5th December 2006 and the findings from this short but focussed visit are recorded in the main body of the report. What the service does well: The home ensures that people who wish to use the service have information about what it provides, how much it costs and whether the service can meet their assessed needs. This will help people to make a choice on whether it is the right service for them. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 6 The people who use the service are supported to access community healthcare services such as their GP and optician and the home closely monitors their health and well being reporting when needed to healthcare professionals. This ensures changing health needs are quickly reported. The people who use this service have varied lifestyles and the home is able to meet these requirements. The people who use this service and their representatives are able to make complaints and the home will take it seriously and where required make changes in their best interests. The people who use the service are safeguarded from abuse by good recruitment, good staff training and good policies. The people who use this service will have support from staff who are available in good numbers in varying roles such as care, catering, administration and management, which will provide support to them in all areas of their lives. The people who use this service benefit from a home that is well run, safe and which asks about their views. What has improved since the last inspection? The people who use this service have experienced improvements in the following areas; Their care plans have been revised to ensure they provide staff with the information they need to meet their choices and preferences, about their chosen lifestyles, health needs and aspirations. Further arrangements have been made to ensure the staff can accurately monitor their health, including seated weighing scales and ensure the physical support they give is safe by providing new equipment. The environment they live is undergoing redecoration and refurbishment and their choices have been included, for example new beds and colour schemes for painting. They have a fully refurbished shower room with adaptations to support their mobility needs. Staff abilities and competencies, due to them receiving further training in mental health and safe working practices, such as first aid and moving and handling. Health and safety of the premises and the equipment used such as water temperature records and electrical equipment records, these are now fully completed and report on findings. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 7 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. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people who potentially may wish to use the service with current information about the services and facilities and ensure that they can provide the service needed before offering accommodation. EVIDENCE: There was a good range of evidence available to confirm that potential new residents can make a choice on whether the home is suitable to meet their needs, this included residents surveys stating that they were provided with lots of information and confirming they were involved in deciding whether to live at the home or not. A detailed Service Users Guide and a Statement of Purpose are available for prospective residents. The residents who were case tracked had pre-admission assessments conducted by the home and also care plans and reports from Social Workers and Community Mental Health teams. These assessments recorded the needs and aspirations of residents, considering their Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 10 physical, mental, social and psychological health and helped the home advise on whether they could meet the needs of the potential new resident. To improve this process the home should write to the potential new resident and referring body advising whether following assessment the home is suitable to meet this persons needs. Each resident case tracked had a contract on a file detailing the terms and conditions of residency, so they are aware of their rights, responsibilities, insurance cover, how to complaint and payment of their fees. The home does not provide an intermediate care service. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents are being met by the home, the practices and knowledge of the staff ensure the needs of residents are closely monitored and any changes reported quickly to the appropriate healthcare professionals. EVIDENCE: An additional visit was undertaken on the 5th December 2006 at this visit it was evident that all care plans were being revised to ensure they provide staff with clear and concise information about how to support the residents. One sampled included an update of the assessments about activities of daily living, they included information about the service to be provided and also stated the objective and how the residents were to be involved. There is also a care plan action sheet, these are written in addition to the care plan where further needs are identified. The manager advised that approximately 30 of Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 12 residents have had their care plans revised and this will be completed by the end of the year. Risk assessments were also seen to be available including the risk of falls for one resident who had fallen on more than one occasion and a care plan had also been written. At this visit there was good evidence that the home has now completed a full revision of all the care plans to ensure they where possible involve residents and provide staff with clear instructions about how the needs of residents will be met. This had also been completed for risk assessments. The home does need to write care plans or a protocol for the administration of medication that have been prescribed as when required. The survey completed by the residents, fourteen in total all advised that they do receive the care and support that they need. The health of residents is closely monitored by the staff, and such actions as regularly checking on body weight, recording of the food and drink consumed and recording all health appointments are clearly written into care plans. There was recorded evidence that the home acts in the best interests of residents as they when needed they have appointments with the GP, hospital, chiropodist, dentist and optician. There were some residents who are unable to use the normal stand on weighing scales and the manager since inspection has confirmed that some new scales where residents can sit on them have been ordered, so their weights can be accurately monitored. The manager also advised that new equipment had been ordered to help residents with their mobility, including a hoist, sling, slide sheets and handling belts. All personal care was given with a great deal of respect from the staff as required by residents and in privacy. Two residents discussed what the staff were like, they said they were never rude, they were always polite and that they could depend on them. The management of medicine for the two residents who were case tracked was assessed and found to be given as prescribed by their GP and safely stored. The home have recently acted quickly and written to the GP about residents who were having difficulties swallowing tablets so that the GP was aware and could make changes. Medication administration records were available for each resident; these are completed when medicines are received into the home, when administered to the resident and when any excess is returned to the supplying chemist. Improvements are needed when the staff carry forward liquid medication onto the next medication administration record, which should state how many millilitres approximately are being carried forward, instead of how many bottles. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated they have the capacity to meet the daily life and social activity needs of residents. Residents have opportunities to choose how they live and staff will support the residents take part in their chosen way of life. EVIDENCE: At the additional visit on the 5th December 2006 residents told the inspector that they can be very active and are supported by the staff to go out, take part within in-house activities, enjoy their meals, choose their dress, listen to their choice of music and buy things they wish. They had a weekly activity programme; records of who attended, what happened and how the residents felt about the activity are made. Activities included sing along, board games, church service, relaxation and beauty sessions and watching videos with “munchies”. Residents who could talk with the inspector said they enjoyed most of these activities. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 14 At this visit it was evident that the staff have continued to provide a varied activity programme to residents, based upon the residents choices and now each member of staff takes responsibility for leading this, residents were seen joining in with the planned board games as per the programme and the staff keep records of how well it went and whether residents enjoyed it. The programme has been improved and the residents said they enjoy it. It now includes a weekly church service, temple visits, exercise and relaxation and bingo. Observations of daily life activity involving residents was very positive; residents take some responsibility for tidying the dining room after meals and a resident was peeling potatoes and preparing vegetables. There are some residents who enjoy sitting on benches in the garden talking and petting the dog called “Max”. No visitors came to the home during the visit. Discussions with residents and staff confirmed that there are no restrictions on visitors and it was seen in care plans that important people in the lives of residents are involved and regular contact is maintained. The majority of questionnaires completed by residents stated that they enjoyed the food. There is a cyclical menu and it is prepared to meet the needs of the residents including softer option and for diabetics. Residents seen at the dining room table were assisted where needed by the staff and the residents ate meals at their own pace, staff described what was on the plate and politely had a discussion about food. The menu is healthy, nutritional and varied to appeal to all the tastes and preferences of the residents. All residents have a care plan for mealtimes, there intake is closely monitored and recorded and reported to the GP when needed. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to ensure that when there are concerns about the service received by residents or about the protection of residents that it has the skills and processes to effectively and quickly take appropriate action. EVIDENCE: The AQAA completed by the manager described what they do well, examples of this included; all complaints are recorded and responded to, where possible they have meetings with the person to ensure we have dealt with their concerns and complaints, fully. The home has a published complaints procedure which sets out a clear pathway for making a complaint it gives a commitment on the part of the home that all complaints will be taken seriously, if a complaint is valid the home will take action to prevent reoccurrence. Evidence that the home does follow their procedure was available, as a record of complaints was upto date, it recording the nature of the complaint and the actions they have taken where needed to make improvements. Improvements are needed, as the home must follow its policy and write to acknowledge and write with the findings after investigating the complaint to the complainant. This will commit the home to making changes in the best interests pf residents where this is required. The home advised on the AQAA that this was an area they needed to improve. The surveys Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 16 completed by the residents recorded that they are aware of how to make complaints. The policy was seen upon the lounge wall in the home and also in the dining room. The AQAA advised that all staff have received training in adult protection, and that they have a good knowledge of best practice in safeguarding vulnerable adults; the training matrix received after the inspection visit confirmed this. The manager has not needed to raise a referral under POVA. The home does have an Adult Protection policy that meets with the DoH paper “No Secrets” and the staff have a Whistleblwqoing Policy to follow. The manager ensures that all new employees are checked against the POVA register before making a decision on whether to confirm employment. These are all good practices and help safeguard residents. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 22 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not been able to fully demonstrate that it can safely meet the environmental needs of the residents and this may affect their welfare and their comfort. EVIDENCE: At the additional visit on the 5th December 2006 there were areas of the environment that needed improvement to make it safe and comfortable for residents, for example the door to the second floor by the lift had a handle that required repair, seating in lounge areas needed to be improved as some were seen with the springs pushing through the material and others had arms with the inners (stuffing) coming out. Downstairs the shower room had some tiles missing and some were damaged, the handle on the door did not work properly it showed the “engaged” sign when the door was open. Outside in the Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 18 garden area the dog has been jumping up at windows ledges and had left paw marks, which needed to be kept clean. The AQAA completed by the manager advised that there has been considerable improvement, that those required previously had been completed except replacing armchairs. The manager advised on a programme of refurbishment and redecoration and during the visit it was evident that it had started and the home was beginning to be more comfortable and safer for the residents. The downstairs shower room has been fully refurbished to a good standard and is a safer and nicer environment for residents to have their needs met. During a tour of the premises there was further evidence that the programme was well under way including; portable call system in all rooms and additional furniture in shared rooms, some residents had new divan beds and decorators were painting corridors. There is a large amount of communal space available for the current 13 residents, including two large lounges, a large dining area and the rearenclosed garden. There are some improvements needed including providing new arm chairs in the lounges, replacing a work surface in the kitchen, removing plant life from the footpath in the rear garden, providing more garden facilities such as chairs and tables and cleaning the filters above the cooker in the kitchen. The manager advised that these improvements would be included within the programme of redecoration and refurbishment. The have your say survey completed by the residents all recorded that the home was always kept fresh and clean. The kitchen was found to be clean except the extraction fan filters. An Environmental Health Officer visited on the 21st December 2006 and provided a report that was positive with no major concerns. The home maintains a risk assessment known as HACCP and keeps records to evidence the hygiene and cleanliness in the kitchen and other food areas. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that the staff are available in good numbers, well trained and recruited to effectively meet the varying and individual needs of the residents. EVIDENCE: At the additional visit on the 5th December 2006 there was some evidence that staff are undertaking training to ensure they are safe and capable to do their work, examples of this included; an additional 4 staff had completed their NVQ level 2 in Care during 2006, 6 staff had completed their Health and Safety training and 14 had completed Infection Control training. However there were gaps in safe working practices including first aid and moving and handling. At this inspection the manager advised that this had been improved and provided a training matrix after the inspection of training completed in the 12 months. This recorded that all staff had completed required mandatory health and safety training including first aid and moving and handling. The have your say about surveys completed by the residents recorded that most of the time staff were available when they were needed and that staff always listen and act upon what they say. Several staff were engaged in Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 20 discussion with the inspector about the care of residents, they had a good knowledge of mental health, the ageing process and some had a good knowledge of how dementia has an impact on peoples lives. They were observed to be considerate people, they spent time with resident talking, singing, playing board games and discreetly assisting with personal care. The more senior staff at the home have certain roles, such as managing residents medication and overseeing activities for residents. The assistant manager discussed how they could further develop care planning and risk assessing and was keen to ensure they do it right where possible involving residents and their representatives. At the time of the visit there were 7 staff on duty providing care and support for the 13 residents, including catering and administration. The current staff rota was seen which indicates that although this number reduces during the evening and at weekends there are good numbers on duty in various roles to meet the residents needs. Staff files were seen for the two most recent employees. They had been safely recruited to help protect and ensure they are suitable people to care for the residents. The process included completing an application form, POVA register checks and a CRB disclosure and two references including one from the most recent employer. These employees had letters detailing their terms and conditions of employment. One new employee has no experience in the caring profession and although an induction to the home had been completed there was no evidence of an induction based upon the Skills for Care standards, which will not help this employee develop the skills needed to effectively care and support residents. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that the conduct and management of the home is effectively meeting the needs of the residents in a well lead, inclusive and safe manner. EVIDENCE: At the additional visit on the 5th December 2006 the manager advised that she is now waiting for her portfolio, which is complete to be verified in relation to the Registered Managers Award. After the inspection the manager advised that it has been completed and she is now awaiting the certificate. The manager has appointed an assistant manager who met with the inspector, she had a good knowledge of the residents, care planning and the importance of Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 22 activity and residents being occupied, she was also seen to be “hands on” and helped lead and direct other staff to care for the residents. She has commenced NVQ level 4 Registered Managers Award. Records seen about fire drills indicated they are conducted regularly that all staff are attending them and outcomes are recorded. Staff are receiving fire extinguisher training annually and also watch a fire video, following watching the video staff complete a questionnaire about fire safety. This is good practice and will help staff and residents respond effectively in an emergency situation. Maintenance records were sampled including checking water temperatures and electrical tests, these had been completed and were seen to be safe for use by residents and staff. At this visit maintenance of equipment and the premises, was checked and found to in good order. This included good records of fire safety such as tests of equipment and staff attending fire drills; there were also records that the staff are receiving fire training. Other records available included servicing of the passenger lift and hoists and water bacteriological and temperature tests. The AQAA completed by the manager advised that there were regular reviews of policies and procedures; and that the last review of all policies was in January 2007. This ensures staff are provided with latest information to support and care for the residents. At the additional visit on the 5th December 2006 the supervision records of staff were seen and a planner was available, it was evident that the schedule is not met and that staff only receive sporadic supervision and are not adequately supported to do their jobs. At this inspection two staff files regarding supervision were seen; it was evident there had been some improvement as one member of staff receives frequent supervision yet the other had no recent records of supervision available, the manager did advise that supervision with this employee had been completed. There is a quality assurance system in place, the most recent questionnaires completed by four residents and seven relatives were seen. They had been asked to comment upon nutrition, communication and two sections called “Your home” and “Your care”. Comments were positive and often complemented the manager and the staff for excellent care to residents. There was also a questionnaire completed by a visiting professional who was also pleased with the professionalism of the home and the commitment and knowledge of the staff. The manager advised that the findings of this audit would be recorded within a quality report. The home does provide a safekeeping service for residents to place their money and valuables. How this was managed for two residents was assessed. Accounts were seen to be well maintained and reflected their current balance, Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 23 where money had been spent on behalf of the resident by the home receipts were all available. There are regular internal audits of the residents account to ensure it is safely maintained. One of the residents signs the record when he deposits or withdraws money from the account otherwise two staff sign the record to ensure it is safely managed. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 3 Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23(2)(c) (g) Requirement You must ensure the programme of refurbishment including providing comfortable communal seating “arm chairs” is completed. You must ensure that all care staff are adequately supported through receiving supervision on a regular basis. Previous timescale 31/8/06 not met, this requirement is carried forward. Timescale for action 31/07/07 2. OP36 18(2) 31/07/07 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. Refer to Standard OP1 Good Practice Recommendations You should further develop the statement of purpose to describe the types of formats or forums the home uses to consult the residents about standards and the quality of service at the home. Not assessed and is carried forward. DS0000016844.V342255.R01.S.doc Version 5.2 Page 26 Lyndel Homes 2. 3. 4. 5. OP3 OP9 OP9 OP16 6. 7. OP26 OP30 8. OP33 You should ensure that you write to the potential resident following assessment advising whether or not you are able to meet their needs in the home. You should ensure that medication administration records are accurately completed when medication in liquids is carried forward from one cycle to the next. You should ensure that a care plan or a protocol is written to guide staff in the administration of all as required medicines to residents. You should ensure that you fully apply your complaints policy and that when you receive and respond to complaints that this completed in writing to the complainant. You should ensure that you maintain good hygiene standards in the kitchen and that the extraction hood filters above the cooker are kept clean. You should ensure that employees new to social care receive an induction based upon the skills for care standards, which will help them, provide appropriate care and support to the residents. You should ensure that after completing your audits on quality you prepare and share a report on your findings to enable current and potential residents to have information about what you do well, not so well and how you intend to improve. Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lyndel Homes DS0000016844.V342255.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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