Inspection on 14/01/08 for Lyndhurst

This inspection was carried out on 14th January 2008.

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

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

Lyndhurst 07/07/08

Lyndhurst 07/02/07

Lyndhurst 12/07/06

Lyndhurst 07/10/05

Lyndhurst 05/05/05

Lyndhurst 27/10/04

Lyndhurst 27/04/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst 20 Oxford Road Dewsbury West Yorkshire WF13 4JT Lead Inspector Lynda Jones Key Unannounced Inspection 14th January 2008 10:15 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 Lyndhurst DS0000026278.V358125.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. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address 20 Oxford Road Dewsbury West Yorkshire WF13 4JT 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) 01924 459666 01924 455223 Mr Annamalai Subramanian Mrs Meena Subramanian, Dr Mohammed Ismail Kardasha Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2007 Brief Description of the Service: Lyndhurst is a care home registered to provide care and accommodation for up to fifteen older people. It is situated in a residential area of Dewsbury, set in extensive grounds. The home was formerly a private house that has been adapted for its current use. The accommodation is on two floors, with the majority of bedrooms being on the first floor. People who live at the home need to be reasonably mobile. The first floor can be accessed by stair lift but people need to cross the landing to access a second staircase leading to additional bedrooms. The provider informed us that the fees range from £344.56 to £368.12 per week. There are additional charges for chiropody, optician, dentist, hairdressing and newspapers. Lyndhurst DS0000026278.V358125.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 *zero star. This means the people who use this service experience poor quality outcomes. The last key inspection took place on 7 February 2007. We also did a random inspection on 3 January 2008 because of some concerns passed to us about medication administration. We found the way night time medication was being administered to be unsafe. In the report we sent to the homeowner after the inspection, we said that there must be a suitably trained member of staff on duty at all times to administer medication. This is to make sure that medication is safely managed and that people have access to pain relieving medication when they need it. We were also concerned to find that not all of the staff working at the home were included on the duty rota. We said the duty rota must show which staff are on duty at all times of the day and night. This is to make sure that people are safe and cared for by suitably qualified staff. The provider has taken the appropriate action to address both of these issues. The process for this inspection included looking at the information we have received about the home since the last key inspection. We also visited the home over one day between 10.15 am and 3.15 pm. During the visit, we spoke to people living in the home and to the staff on duty. We looked at various records relating to care, staff and maintenance. We also looked around the home. Before the visit, we asked the home to complete a self-assessment form. This was returned before the visit and we have used the information in this report. We also sent surveys to a sample of people who live at the home and their relatives. We received replies from six people. The surveys provide an opportunity for people to share their views on the service with us. Information provided in this way is shared with the home without identifying who has provided it. The comments we received have been used in this report What the service does well: People are always assessed before they move into the home to make sure that all of their needs can be met and it is the right place for them. The care plans contain valuable information about people’s daily routines and about what they like and dislike. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 6 The staff know people well, they respect people’s preferred routines. One person said in a survey “Individual needs are catered for. Staff are always caring, friendly and helpful”’ Health care needs are generally met. Everyone told us that they always receive the medical support they need. What has improved since the last inspection? What they could do better: Better information that tells people about the home and the service needs to be available so that it can be given out to people when they call to look round. Everyone must be given a terms and conditions of residence document which tells them about their rights and responsibilities. Information about people’s interests and the sort of activities they enjoy should be documented in the care plans so that activities can be organised to meet individual needs. Individual risk assessments must be in place to make sure health needs are carefully monitored and to make sure people are safe. Some of the fixtures and fittings need replacing and the décor requires upgrading. This was a requirement at the last inspection key inspection and has not been addressed. There must be a plan for upgrading the facilities. The designated smoking area needs to be better ventilated. The recruitment procedure is poor and must be improved. Staff are not properly checked to make sure they are suitable to work with older people, this places people at risk. The documentation of complaints must be improved. Records must show details of the complaint, any investigation that takes place and whether the complainant is satisfied with the outcome. Allegations of abuse must be fully documented. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 7 An application must be made to register a manager for the home so that there is someone legally responsible for the management of the home. People who live at the home, and their relatives, should be consulted about the way the home is run. They should be given the opportunity to say if they are satisfied or if it could be improved in any way. The registered provider must provide regular monthly reports on the conduct of the home and the care provided. 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. Lyndhurst DS0000026278.V358125.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 Lyndhurst DS0000026278.V358125.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): 1,2,3 & 5 (standard 6 does not apply) People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are not being given sufficient information about the home to help them make a decision about moving in. Contracts and terms and conditions of residence that tell people about their rights are not always given to people. People are assessed before they move in to make sure that all their needs can be met. EVIDENCE: There is a Statement of Purpose and Service User Guide but both are out of date. These documents should provide people with information about the fees and what the fee covers, the facilities at the home and about the service they Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 10 can expect. The staff said they tell people about the home when they call to have a look round but there is no written information that can be given to people to take away with them. This means that people are not being given the information they need to help them make an informed choice about where they want to live. These documents need to be reviewed and updated. We looked at some of the care plans and saw that people are assessed before they move into the home. This is done to make sure that the home is the right place for them and that all of their needs can be met. The manager needs to make sure that all of these assessments are signed and dated. Not everyone has a contract or terms and conditions of residence on their personal file. These documents are important because they tell people about their rights and responsibilities and those of the homeowners. This needs to be addressed. The home does not provide intermediate care. Lyndhurst DS0000026278.V358125.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): 7,8,9,10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Health care is monitored regularly and people’s needs are generally being met. People receive their prescribed medication but safe practice guidelines are not always followed which may leave people at risk. EVIDENCE: We looked at the care plans for four people. The plans are important because they provide staff with information about people’s needs and tell them what they must do to meet their needs. The care plans contain some useful information about the sort of daily routines that people prefer. Personal support is tailored to meet individual needs and there is evidence that people are being consulted about how they want their Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 12 care and support to be delivered. We observed staff treating people with dignity and providing personal care in private. When we talked to staff, they demonstrated a good understanding of people’s needs. They know what people like and dislike and they know how people prefer to spend their time. The plans varied in the amount of information recorded about social care needs; some contained quite detailed information yet on others there was no mention of people’s interests and the sort of activities they like to take part in. People are supported to be as independent as possible; we saw evidence of this in the care plans and from observing the staff at work. People said they liked the staff and they found them really helpful. They told us they received the care and support that they felt they needed. One person told us in a survey that the laundry tends to get mixed up and sometimes clothing is given out randomly. This needs to be investigated by the manager. People have access to a range of health care services in the community. From the records, we could tell when people had contact with various health care practitioners such as the Doctor, Dentist, Optician and District Nurse. On the records we looked at we could not find any evidence of moving and handling plans, nutritional assessments and Waterlow pressure sore risk assessments. This means that there is a risk that some health care needs could be overlooked and that people are at risk of not being moved safely. We have already mentioned in the summary of this report that we made an unannounced visit to the home because we were concerned about medication administration. We found staff giving out some night time medication without having had any training about handling medication. After the visit we wrote to the homeowner to say that this is unsafe practice and it must not continue. The manager then made arrangements to ensure that there was always a suitably trained member of staff on duty at night. We have been informed that arrangements are in place for all of the night staff to receive the training they require. On this inspection, the medication records that we looked at were up to date. The records show when medicines are received, administered and disposed of. We talked to staff about the need for two staff to check prescribing instructions and sign the medication record sheets whenever they book in any medication. This is to make sure that the information is double checked and entered correctly. Lyndhurst DS0000026278.V358125.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): 12,13,14,15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staff have plenty of contact with people and they respect their preferred routines. People are treated with respect and dignity. EVIDENCE: In the surveys we asked if any activities are arranged for people to take part in. Four people said “usually”. During the morning when we were there, people sat in the two lounges with the TV on. In one lounge, half of the people were asleep and only woke up when tea and biscuits were served. One person told us it was “boring”, she said the TV is always on but no one watches it. One person sat reading for most of the morning, occasionally people talked to each other. The staff called into the lounge frequently to make sure everyone was comfortable and to Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 14 assist people to the toilet. As staff got on with their tasks, they chatted to people. We were told this was a typical morning. Four people choose to spend all their time in their rooms. The staff respect their preferred routines and call on them regularly throughout the day and take them their meals and drinks. In the afternoon, some people joined in a game of cards in the dining room. Other people sat talking to staff after lunch. The atmosphere was relaxed and friendly. There is a varied weekly menu. In addition, the cook asks everyone each day if they would like the meal of the day or if they would like an alternative. There is plenty of choice at teatime and suppertime. People told us they enjoyed the food. Lyndhurst DS0000026278.V358125.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): 16,18. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are not routinely given information about the complaints procedure. Some people do not know how to make a complaint or who to complain to. People are not fully protected from abuse as there is no information recorded about allegations made or how they have been dealt with. EVIDENCE: In the surveys, two relatives told us they didn’t know about the complaints procedure and they didn’t know how to make a complaint. The complaints procedure that is on display needs to be updated. Information must be available for people so that they know who to contact if they want to make a complaint. In the information provided before the inspection, we were told that there have been no complaints. We were unable to check this because the complaints log could not be found. People living at the home told us in their surveys that they know who to speak to if they are unhappy, they did not say who this would be. Two people we talked to said they would tell a member of their family. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 16 We could not find any records showing that staff have had adult protection training, although staff on duty said they had received some training. We have been notified of one incident where a person living at the home raised concerns about the way a member of staff had treated her. We have been given a verbal account of how this was managed; we have not received any written details about the outcome of the investigation carried out by the manager. We could not find any records of the incident in staff records or in the care records. Lyndhurst DS0000026278.V358125.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): 19,21,24,25,26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a comfortable home but many areas require refurbishment and redecoration to improve the facilities. EVIDENCE: Anyone visiting the home for the first time would call at the front door and ring the doorbell. However, this area is not used for access, it is the staff smoking area. When we called, the doorbell was not working so we walked to the back of the house to find staff. There should be a notice to tell callers that the main entrance is at the rear of the building. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 18 The communal areas of the home are comfortable. Bedrooms are personalised, most people have lots of ornaments and photographs around them. Some of the bedrooms need to be redecorated. Paintwork is chipped and wallpaper is torn in some of the rooms. In some rooms there are no lampshades and not everyone has a bedside light. Some of the bedroom carpets are stained and worn and need to be replaced. Not all of the bedroom doors close properly. When we talked to staff, no one could remember when bedrooms were last decorated and no one had knowledge of any plans for refurbishment. An audit of the environment needs to be carried out to establish what work needs to be done. Shelving is needed in the toilets so that pads and gloves can be stored hygienically. At the moment, they are stored on the floor. Privacy cannot be guaranteed in all of the toilets because some of the locks do not work. The home is superficially clean. Routine domestic chores are dealt with but there is little evidence of any deep cleaning to take place. One person who returned a survey said, “cleanliness is low priority and the décor is poor”. One of the ground floor lounges is used as a designated smoking area. Checks need to be carried out to make sure the ventilation in this room is adequate. We found the room full of smoke and smelling strongly of stale tobacco. The door to this room does not close properly and poses a health and safety hazard. The laundry room was very hot when the door was opened. A check needs to be carried out to make sure the tumble driers are adequately vented. Lyndhurst DS0000026278.V358125.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): 27,28,29,30. People who use the service experience poor quality outcomes in this area.. We have made this judgement using a range of evidence, including a visit to the service. Staff are employed in sufficient numbers to meet the needs of the people who live there. Recruitment practice is poor which puts people at risk of being cared for by staff who are unsuitable to care for older people. EVIDENCE: The home is adequately staffed at all times. During the day there is one senior member of the team on duty with two care staff. Throughout the night, there are two care staff on duty. There is domestic cover every day for five hours and a cook is available every day between 7.30 am and 2.45 pm. In the surveys people told us the staff are always available when they are needed. To account for everyone working in the home, all staff must be included on the duty rota. When we visited on 3 January 2008 the manager’s hours were not on the rota, so we wrote the homeowner about this. On this visit all staff were included on the duty rota. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 20 We talked to staff about the training that they have undertaken. Most people have received basic training; the majority have achieved NVQ (National Vocational Qualification) level 2. There is no evidence of staff supervision and no evidence of a training plan or any training records. This is important because it enables the manager to make sure that staff are competent and have the skills to carry out their work. The information provided before the visit says that these areas will be improved over the next twelve months. The recruitment procedure is unsafe. Staff have been recruited without first being checked to make sure they are suitable to work with older people. This means that people are at risk of being cared for by unsuitable staff. In the information provided before the inspection, we were told that all staff have had satisfactory pre-employment checks but we did not find this to be the case. We looked at a sample of staff files. We found that four staff have been recruited without first completing an application form; this means that: 1.There are no details about their employment histories 2.They have not been asked to provide the names of referees who can comment on their suitability for the post. There are no references for three of these staff. We found CRB (Criminal Records Bureau) checks for three out of four staff but, as there are no start dates on the files, we could not tell whether the checks were carried out before they started work. Lyndhurst DS0000026278.V358125.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): 31,33,35,36,38. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is not being managed properly. There is no registered manager. The registered person (the owner) is not making sure that the home is being run in the best interests of the people living there. EVIDENCE: There is no registered manager at the home. This means that there is no one legally responsible for the day-to-day management of the home. The acting manager has been in post since August 2007 and has not yet applied to be registered with us. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 22 There is no evidence that people are being consulted about the way the home is run. There is no quality assurance system in place. The registered provider calls at the home each week but does not complete monthly reports about the conduct of the home. These reports must include evidence of consultation with people living there, their representatives and staff about the standard of care provided. The last available report was completed in February 2007. People living at the home are being put at risk by allowing staff to work there before they have been fully checked to see if they are suitable. The registered provider is failing to ensure that we are being provided with written notification of any incidents that occur in the home that affect the wellbeing of the people living there. For example, we have not yet been notified about the concern we referred to in the complaints and protection section of this report. We have not been provided with any information about how this was investigated nor about the outcome of the investigation. We looked at records of money held on behalf of people living there. Individual money records should be kept on separate finance sheets, not in one bound book. The finance sheets need to be stored separate from the money so that, if the money goes missing, there will be a record of all transactions and balance of all money held. We found receipts for all purchases made and the money held could be reconciled with the balance on the records. Each receipt should be numbered; this would make it easier to cross reference receipts with the details on the finance sheets. When cash cards are held for people, details of the account and the start and expiry dates need to be recorded. This information would be important if the card goes missing or is mislaid. We found records showing that staff have attended a fire drill and fire lecture. We also found evidence that the boiler at the home had been serviced in January 2008. In the information provided before the visit, we were informed that electrical circuits, portable appliances, passenger lift and emergency call equipment had been tested but we were unable to find the service records. We were provided with a list of policies and procedures that are in place. We have no information about whether they are up to date or when they were last reviewed. Lyndhurst DS0000026278.V358125.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 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 1 2 3 X 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X 2 X X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 2 Lyndhurst DS0000026278.V358125.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 OP2 Standard Regulation Requirement 5 People must be issued with a contract/terms and conditions of residence document before or on the day of admission. This will provide them with information about their rights and responsibilities and those of the provider. Copies of the service user guide/statement of purpose must be updated and made available. This will provide people with information about the home and help them make a choice about where they want to live. Individual risk assessments must be in place to make sure individual health needs are carefully monitored and to make sure people are safe. A record must be kept of all complaints made which includes details of investigation and any action taken. This is so that people can know their complaints will be taken seriously and acted upon. DS0000026278.V358125.R01.S.doc Timescale for action 12/05/08 2 OP1 5 14/04/08 3 OP8 13 10/03/08 4 OP16 Schedule 4 18/02/08 Lyndhurst Version 5.2 Page 25 5 OP18 13 6. OP19 23 All allegations of abuse must be promptly followed up and fully documented. This is to make sure that people are protected and safe from harm. A programme of maintenance, decoration and refurbishment for the interior and exterior of the home must be continued so that people can live in a pleasant, well maintained environment (this requirement was first made on7/2/07) The door to the designated smoking room must adjusted so that it closes properly for fire safety purposes and to prevent cigarette smoke drifting out of the room. The tumble driers must be checked to make sure they are properly vented and do not pose a fire safety hazard. All the required checks must be carried out before new staff start work in the home. This is to make sure that staff are suitable and people are safe. There must be a staff training and development plan so that staff can improve their skills and keep up with good care practice. An application must be made to register a manager so that there is someone legally responsible for the day-to-day management of the home. Arrangements must be made by the registered provider for monthly visits to the home to take place to report on conduct of the home. This is to make sure that the home is effectively managed and people are well cared for. Arrangements must be in place to notify us about any incidents DS0000026278.V358125.R01.S.doc 18/02/08 18/02/08 7. OP19 23 29/02/08 8. OP19 23 29/02/08 9. OP29 19 18/02/08 10. OP30 18 31/05/08 11. OP31 9 31/03/08 12. OP33 26 18/02/08 13. Lyndhurst OP38 37 18/02/08 Page 26 Version 5.2 that affect the well being of people living at the home. This is so that we can monitor the welfare of people living at the home. 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 OP35 Good Practice Recommendations Records of money held for people should be held on separate finance sheets rather than a bound book. The records should be stored separately from the money. Receipts should be numbered so that they can be easily cross referenced with the finance sheets. Full details need to be recorded about any cash cards that are held for people. Lyndhurst DS0000026278.V358125.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Lyndhurst DS0000026278.V358125.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. 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!