Inspection on 02/10/06 for Lyndhurst

This inspection was carried out on 2nd October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyndhurst 16/11/07

Lyndhurst 12/08/05

Lyndhurst 09/02/05

Lyndhurst 08/02/05

Lyndhurst 22/09/04

Lyndhurst 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Lyndhurst Hea Road Heamoor Penzance Cornwall TR18 3HB Lead Inspector Ian Wright Key Unannounced Inspection 2nd and 4th October 2006 16:30 Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address Hea Road Heamoor Penzance Cornwall TR18 3HB 01736 331008 F/P 01736 331008 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) www.mencap.org.uk Royal Mencap Society Mr David James Flecknor Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration of Mr David James Flecknor as Manager for a maximum of 18 months pending Ms Rachael Lee`s return as Manager 12th August 2005 Date of last inspection Brief Description of the Service: Lyndhurst provides care for up to 5 adults with learning disabilities. The home is situated in the village of Heamoor, which is a few miles from the town of Penzance. The registered provider is Mencap, which operates several care homes and domiciliary care agencies in Cornwall. The current registered manager is on maternity leave, and Mr David Flecknor has been registered as manager for a period of up to 18 months. All service users have their own bedrooms. There is a dining room and a lounge for service users use. The home is not suitable for wheelchair users without further adaptation. The home has a pleasant front garden, which service users can use. There is parking for two cars at the front of the property. A copy of the inspection report is available in the dining room, and it is suggested a copy is requested from management or CSCI if required. The range of fees at the time of the inspection is £370.78 to £806.73 per week. There are additional charges e.g. for hairdressing, newspapers etc. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over twelve and half hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track three service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other service users and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? The registered persons approach to handling service user monies has improved, and there are clearer guidelines within this home regarding what service users have to pay for and what Mencap will pay for. Care plans have been rewritten and these offer better information. However one service user’s needs have changed significantly recently and this person’s care plan will need to be rewritten. The staff team however have provided the person with good care. Checks to prevent Legionella are now regularly carried out in line with Mencap policy. There have been some positive developments to assist service users to be more independent such as enabling them to go out on their own or stay in the house on their own. However these matters must be risk assessed and appropriate consultation must take place with relevant parties. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 6 The registered manager has arranged for the communal areas of the house to be redecorated, and this was being completed at the time of the inspection. New lounge furniture and carpets are also to be purchased. 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. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this area is generally good. The judgement has been made using available evidence including a visit to the service. Service users receive a copy of the terms and conditions of residency at the time of admission. This enables service users to be aware of their rights and responsibilities. Arrangements regarding tenancy agreements need to be clarified. The pre admission assessment procedure is good. If implemented in full, this will enable the registered persons to ascertain they can meet the needs of new service users, before admission is arranged. EVIDENCE: A copy of terms and conditions of residency were on each service users’ files. The house has recently been transferred to a new housing association. Service users have only been issued with assured short hold tenancy agreements (renewable agreements allowing service users rights of tenancy for 6 months at a time) whereas previously they had assured agreements (allowing service users indefinite tenure). The inspector understands to offer service users less right of tenure does not adhere to legal requirements and housing corporation guidelines. Mencap needs to clarify this arrangement with the housing association. Copies of social services contracts of care were also available for inspection. The registered provider has developed a suitable assessment policy and procedure. This includes the opportunity for potential service users to visit the home before admission is arranged. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. All service users have a care plan and these are regularly reviewed. Most care plans ensure staff have suitable information to provide care. However one service user’s needs have significantly changed and subsequently their care plan needs to be rewritten. Service users are encouraged to make decisions about their lives with suitable assistance as required. However suitable risk assessment procedures must be put in place to document steps taken to help improve service users’ independence, where there may be some level of risk. The registered persons approach to handling service users moneys is satisfactory. Service users are encouraged to make choices and decisions about their lives with appropriate support e.g. from staff and advocacy services. EVIDENCE: There is a copy of a care plan in each service user file. Staff said care plans were accessible to them. Some service users said they were aware of their care plans and are involved in drawing them up. The care plan format is comprehensive and gives clear guidance to staff regarding service user needs. One service user’s needs have changed significantly in recent months and Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 10 subsequently the care plan needs to be rewritten to reflect the person’s current needs. Service users and staff said service users are encouraged to make decisions regarding their lives. There has been some improvement to assist service users to become more independent e.g. allowing service users to stay in the house without a staff member present and allowing them to go out on their own. However regarding these issues, there does not appear to be any risk assessments. For example these should be in place to outline what steps are taken to assess the risks involved, and document any skills assessment. If service users are left in the house without staff support this must be negotiated with the Commission for Social Care Inspection. Copies of risk assessments must be sent to the commission when they are completed. Care staff look after some service users’ monies. Suitable records (including a risk assessment) are maintained regarding this practice. Advocates are involved with assisting some service users to make decisions. Service users are encouraged to make decisions and choices regarding how they spend their time and any major life changes. The registered provider has satisfactory policies regarding diversity and equality. There are currently no service users from ethnic minorities, although the registered provider has stated they would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, and disability seem to be suitably addressed. A female service user requested that more female staff be employed. This is detailed elsewhere in the report and Mencap should address this issue. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Service users can participate in a suitable range of activities, and are able to mix with the wider community. Service users are encouraged to maintain relationships with friends and relatives. Service users rights are respected, and service users are enabled to take a suitable amount of responsibility in their daily lives. Suitable arrangements are in place so service users can enjoy a healthy and varied diet. EVIDENCE: Service users said they attend a range of day activities including attending day centres and colleges. Some service users also have voluntary jobs and sheltered work placements. Service users and staff said other activities are also arranged sometimes in the evenings and at weekends. Service users can have an annual holiday, which they have to pay for. Service users said they visit friends and relatives regularly, and they are encouraged to maintain contact via the telephone or post. Visiting arrangements are flexible. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 12 Service users said they could get up and go to bed when they wish. Service users said staff work with them in a way, which respects their privacy and dignity. Staff knock on bedroom doors, and mail is not opened without service users’ agreement. Locks are fitted to bedroom doors although one service user said they were not provided with a key. The registered manager said he would arrange this and had not been aware of the problem previously. Service users and staff said service users are involved in household tasks for example doing laundry, cleaning tasks, shopping and cooking. Interaction between other staff and service users was observed to be positive. Service users either prepare their own meals or eat together. Staff involve service users in the preparation of food. Service users said they are involved in choosing the menu and preparing the meals each day. Suitable records are maintained regarding food provided. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Personal care is delivered to a satisfactory standard, however the availability of more female staff for one service user should be addressed. There appears to be suitable links with medical professionals. Staff have dealt very well with a particular difficult situation regarding the care of one service user. The management of service users medicines needs improvement so service users can be assured their medication is suitably looked after. EVIDENCE: Most service users said they received suitable care and support from staff. However one female service user said she was concerned about the lack of women staff employed at the home, particularly as she needed support with personal care. The registered manager said a second female member of staff would be employed shortly, and effort was made to get staff from a sister home nearby to come around to provide assistance. Using a member of staff from another home is an adequate step- in the short term- but staffing levels at the sister home must not fall below the levels agreed with the Commission for Social Care Inspection. The registered provider should take further steps to try to rectify the gender imbalance in the staff team where possible. However, staff the inspector spoke to seem clear regarding what assistance service users need, and how to deliver care in a manner sensitive to individual needs. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 14 One service user has had failing health in recent months. The staff team have managed this situation very well and have involved relevant professionals appropriately. Medical interventions are appropriately recorded. There seems suitable links with GP’s, dental services, chiropodists and other professionals. The registered manager and other staff reported no problems with links with medical professionals. Medication is stored securely, and dispensed via a ‘monitored dosage system’. However some improvements to the system are required: • There were some gaps in medication records being signed; for example on 29/9/06 and 2/10/06. • One Lorazepam tablet was missing and staff could not account for its absence. • There is some excess medication stored in the medication cabinet. This includes some oversupply of medication. The registered persons were notified at the last inspection on 8th February 2006 of the need to improve medication. Failure to comply with the requirement within the timescale set may result in the Commission for Social Care Inspection (CSCI) taking legal action. Most staff now have medication training from the pharmacist as well as completing Mencap’s internal course. Two new staff have recently been employed who require training. The registered manager must arrange this training for the staff concerned, and copies to verify this training has been completed must be sent to the commission within the timescale. As this issue has been notified on three previous occasions, the commission may take legal action if the registered persons fail to comply with the requirement. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Complaints are dealt with appropriately although the registered provider’s Complaints Procedure does not meet the national minimum standard. Mencap has a satisfactory adult protection policy, however improvement is required in recruitment practices so all staff have a Protection of Vulnerable Adults (First) check before they commence employment. This will give service users more assurance they are in safe hands. EVIDENCE: The registered provider has developed a complaints procedure. The registered manager has included a summary of this in the service user guide. The registered manager has provided information to service users’ next of kin how to make a complaint. The inspector read the organisation’s complaints policy in the ‘Operations Manual.’ This requires updating, for example the organisational policy refers to the National Care Standards Commission, which has now been superseded by the Commission for Social Care Inspection. The policy also regards the complainant’s right to contact the Commission as the last stage of the procedure, rather than stating complainants can contact the Commission at any time as outlined in NMS 22.3. The registered provider has been notified regarding this in several CSCI reports for Mencap care homes in Cornwall and now needs to ensure the policy is amended. However, service users said they would have confidence in staff / management if they had a concern or a complaint, and they felt the matter would be dealt with appropriately. One service user was also aware of the role of CSCI and said he knew he could complaint to the commission if he had a concern. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 16 Mencap has an appropriate adult protection policy. New staff attend the Mencap training regarding abuse (Protect Me) as part of the organisation’s foundation training. All established staff have a Criminal Records Bureau (CRB) check. Two staff have recently started and their checks have been applied for. However both staff had not had a Protection of Vulnerable Adults (POVA) First check. The registered provider needs to ensure managers are aware of this legal requirement, and all staff need to have this check before they commence employment. Staff and service users said they believed there to be no abusive practices in the home, and were aware who they would approach if they were concerned about abuse. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Richmond provides a pleasant, homely and clean environment for service users. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. Bedrooms and communal areas are of suitable size to meet the needs of service users. The home was clean and hygienic on the day of the inspection. Suitable cleaning routines are in place. The inspector raised a concern there was no soap in some of the toilets / bathrooms. The registered manager said he would address the matter. It may be necessary to purchase wall-mounted dispensers, as this seems an ongoing problem. Service user bedrooms are pleasantly decorated according to individual tastes. Furnishings in bedrooms are appropriate. A decorator was at the home on the days of the inspection. The registered manager said the interior of the home would be completely redecorated. The manager also said some of the carpets, and the lounge three-piece suite, are also to be replaced shortly. There is a plan to move some of the files into the dining room due to lack of space. Care must be taken to ensure this remains the service users spacerather than an extension of the office. The commission cannot agree to any Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 18 reduction in communal space for service users use. Any files stored in the dining room must be locked away and any storage units should be domestic in appearance. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Staffing levels are satisfactory so service users cannot be assured they will get suitable levels of staff support. Recruitment records are generally good although staff must receive a POVA First check as detailed in the previous section. This will assure service users recruitment procedures are rigorous. Staff training needs some improvement so staff receive appropriate training as required by regulation and to meet the needs of service users. This will assure service users that staff have suitable skills and knowledge to cater for their needs. Equal opportunities issues regarding recruitment and work practices seem appropriate. EVIDENCE: Lyndhurst is linked to another Mencap home-Richmond- nearby. Lyndhurst however has a dedicated staff team, and the deputy works exclusively within this home. The manager works at across both homes. Currently there is a minimum of one member of staff on duty. One person ‘sleeps in,’ but is ‘on call’ between 22:30 and 0700. During the week, there is sometimes an additional member of staff on duty either during the day or in the afternoon/ evening. At the weekend there is an additional member of staff, to the sleep in person, between e.g. between 11:00 –19:00. The inspector observed information kept on staff files. Information regarding the recruitment of staff is generally satisfactory. This includes an application Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 20 form, two references and information confirming the person’s identity. However two recent employees did not have a POVA First check as outlined in the previous section. There is suitable evidence that staff have a satisfactory induction. This includes Mencap’s staff induction package, and an in house induction to make staff aware of Lyndhurst’s routines and procedures. Mencap has a suitable training programme. There is however some gaps in training received as required by regulation. This includes infection control (for at least one member of staff), manual handling (for at least one member of staff), medication (for at least one member of staff) and fire training (for at least one member of staff). New staff also need to attend training required by regulation. Failure to provide this training within the timescale set could result in the commission taking legal action. Copies to verify this training has been completed must be sent to the commission within the timescale set. There is evidence that some staff have attended training regarding epilepsy. However all staff need to receive this training due to the needs of the service users accommodated. The registered persons have been notified on three previous occasions regarding the need to provide epilepsy training. Failure to provide this training within the timescale set could result in the commission taking legal action. Copies to verify this training has been completed must be sent to the commission within the timescale set. Mencap has a suitable approach to ensuring staff have the opportunity to obtain a National Vocational Qualification in care. Currently 50 of staff have either a NVQ 2 or 3. The inspector read a suitable equal opportunities policy regarding staff recruitment and selection. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered manager has been assessed as having suitable experience and skills to manage the home. However additional care needs to be taken by management to check regulatory requirements are being met, for example, as outlined elsewhere in this report. There is a suitable quality assurance system in place to enable service users and other stakeholders to be consulted about their views. The management of health and safety issues is good so service users can be generally assured they live in a safe environment. However some concerns have been expressed elsewhere in the report particularly regarding staff training and medication, which could put service users and staff at risk. EVIDENCE: Mr David Flecknor is a registered nurse to work with people with learning disabilities. He is currently completing the Registered Manager’s Award, which he has stated he will complete shortly. Mr Flecknor is the registered manager for both Lyndhurst, and its sister home Richmond, which is in walking distance of this home. Staff were very positive about Mr Flecknor’s management approach. They said he assisted them to be involved in the running of the Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 22 home, and consulted them about decisions that needed to be made. They were also very positive regarding what was seen as an increasing emphasis on encouraging service users to be more independent; for example enabling service users to go out on their own. Service users said they were also happy with Mr Flecknor’s management style and found him approachable. The Commission for Social Care Inspection is encouraged by these developments. However the inspector is concerned regarding the number of repeated requirements in this report, and that enforcement action could follow if action is not taken within the timescales set. Additional care must be taken to ensure such issues are addressed. It is suggested that Mencap provide the registered manager with appropriate support and guidance to address these issues of concern. Mencap has a suitable approach to quality assurance. A survey of service user views was recently completed, and the results of the survey were positive. A summary report of the findings, and a development plan was subsequently produced. A representative from the registered provider visits the home on a monthly basis. The registered provider has a suitable health and safety policy. Regular health and safety checks are completed. Other records kept of checks required by regulation are satisfactory. For example there are suitable records of the testing of fire equipment, the central heating system, portable electrical appliances and the electrical hardwire circuit. Accident records are suitably kept. Health and safety risk assessments are satisfactory. There is a suitable fire risk assessment. Suitable insurance cover appears to be in place. The report has raised concerns regarding medication and training, which could negatively impact on the health and safety of staff and service users. Suitable requirements have been made regarding these issues. Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 1 3 X 3 X X 3 X Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 24 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 YA5 Regulation 5, 7 Requirement The registered provider must ensure service users are issued with a suitable tenancy agreement. Provide an up to date care plan for one service user. Suitable risk assessment procedures must be in place to document steps taken to assist service users to increase their independence. Consultation and negotiation with relevant parties needs to take place where appropriate. The registered provider must provide staff with appropriate training regarding the handling, administration and recording of medication (Previous deadline of 01/11/05 not met. 3rd Notification.) Copies of certificates verifying staff have received this training must be sent to the commission within the timescale set. Timescale for action 01/12/06 2 3 YA6 YA7 YA9 15 12, 13 01/12/06 01/12/06 4. YA20 12, 13, 19 01/02/07 Lyndhurst DS0000008911.V311900.R02.S.doc Version 5.2 Page 25 5. YA20 7, 13 The registered provider must operate within the home a satisfactory system for the receipt, administration, recording and disposal medication. New staff must have a POVA First check before they commence employment The registered provider must ensure staff receive training required by regulation. This must include fire training, manual handling and infection control. Copies to verify this training has been completed must be sent to the commission within the timescale set. (Previous deadline of 01/06/06 not met. 4th Notification.) 01/11/06 6. 7. YA23 OP34 YA42 10, 12, 13, 19, 37 12, 13, 18 01/11/06 01/02/07 8. YA42 12, 13, 18 The registered provider must provide all staff with training in epilepsy. Copies to verify this training has been completed must be sent to the commission within the timescale set. (Previous deadline of 01/14/06 not met. 4th Notification.) 01/02/07 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 Lyndhurst Refer to Standard OP20 Good Practice Recommendations The number of female staff employed should increase. DS0000008911.V311900.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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