Inspection on 20/04/05 for Lyndhurst

This inspection was carried out on 20th April 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lyndhurst 27/06/06

Lyndhurst 26/10/05

Lyndhurst 22/09/04

Lyndhurst 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst Care Home College Street, Leigh, Wigan, WN7 5QH. Lead Inspector Lindsey Withers Unannounced 20th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address College Street, Leigh, Wigan, WN7 5QH. 01942 606319 01942 671246 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CLS Care Services LTD Ms Janice Pickup Care Home 48 Category(ies) of Older People 40 & Physical Disability (Elderly) 8 registration, with number of places Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the maximum registered number (40), there can be up to:40 OP and up to 8 PD (E). 2. The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission For Social Care Inspection. Date of last inspection 22nd September 2004 Brief Description of the Service: Lyndhurst - part of the CLS group of Homes - is situated close to the centre of Leigh, near to shops and other essential services. A large three storey building, residents are accommodated on each floor. Throughout the building there are a number of lounges and seating areas, and there is a separate visitors lounge. The main dining room is located on the ground floor. Each of the 40 bedrooms is for single occupancy. There is limited outside space. However, the courtyard garden is secure, well-maintained and attractive. There is limited car parking for visitors to the Home; however, a pay and display car park is located within a few minutes walk. Lyndhurst offers accommodation to people aged 65 and over, who require assistance with personal care. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over a period of 7.5 hours on one day. The first part of the day was spent in the office talking to the Manager and looking at care plans. The remainder of the day was spent speaking at length to eight residents, four visitors, and three members of staff, as well as making a tour of the premises. Other staff and residents were spoken to over the course of the day. CLS had applied to the CSCI to change the registration of Lyndhurst to include three places for people with dementia. The decision on this was not known at the time of writing this report. In the weeks leading up to this inspection, a number of residents had moved from another CLS home that had closed (Manor Fold), and staff had moved with them. The Manager had been making sure that new residents were comfortable and cared for properly, as well making sure that new staff were properly watched over and helped in their new roles. What the service does well: The care at Lyndhurst is based on looking at what each individual person needs to live as independently as possible. Care plans state what each resident is able to do for themselves, as well as what they cannot do. Residents are encouraged to choose how they spend their lives, and help is given where it is needed or asked for. Meals are very much enjoyed by residents, and care is given to those who need special diets. Staff interact well with residents and each other. Staff have a good approach to their work, are provided with the right training, and have clear guidance from the Manager. Residents, relatives and staff had no hesitation in speaking well about the care at Lyndhurst. Residents and staff from Manor Fold have been accepted. Residents had been given time to settle in and care plans had been reviewed. Staff had been properly introduced to how the Home runs and said they were settled and happy in their work. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 and 5. Standard 6 is not applicable as rehabilitation services are not provided at Lyndhurst Pre-admission assessments were good and formed the basis of the residents plan of care, ensuring needs were identified and met. There had been opportunities for prospective residents and their supporters to visit the Home, and for the resident to move in on a trial basis so that the suitability of the Home can be assessed. Staff were aware of the needs and expectations of residents, ensuring they provided a needs-led service. EVIDENCE: Four care plans were looked at. It was clear from the written records that a full assessment had been undertaken prior to anyone moving into Lyndhurst. There was evidence to confirm that social workers and other supporters had been involved in the assessment and admission process. A relative of one newly-admitted resident said that the assessment had been thorough and that they had had the opportunity to ask questions about the care that would be provided. She said that any questions had been answered fully, with honesty, and with consideration of the benefits that could be Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 9 provided to the prospective resident. Two out of eight residents spoken to said it was they who had made the decision to move into Lyndhurst. One resident had moved in following a period of respite care at the Home. One resident spoke about his trial period. He accepted he could not manage if he were to live alone, that he appreciated the concern of staff regarding his physical condition, and that, when the review meeting took place, he would be saying he wanted to live at Lyndhurst permanently and would be happy to sign the contract. The three members of staff spoken to on this occasion were aware of the different needs that residents had, as well as their personal preferences. The members of staff all spoke about the residents as being individuals. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 The standard of care planning and review was good, providing staff with the information they needed to meet the residents needs. The health needs of residents were met, with evidence of inter-agency working, as needed. Staff were working hard to ensure that residents were treated with dignity and that their privacy was maintained. EVIDENCE: Four care plans were looked at including two people who had transferred from another CLS Home, one person accessing respite care, and one person who had lived at Lyndhurst for some time. Each record set out in detail the aspects of health, personal and social care needs of the resident, and showed that amendments had been made when necessary, but at least once per month. The content had been based on the initial assessment. Risk assessments had been written for each person. Some risk assessments applied to all residents, for example, in relation to the prevention of falls, while others were specific to the individual, for example, in relation to smoking, or for safely getting in and out of a car. All risk assessments had been reviewed at least once per month and had been adjusted, where appropriate. Entries were clearly written, and all those care plans seen at this inspection had been signed by the resident or their representative. One relative said he was very satisfied with the plan of care, and that he had been consulted with about the content. He said he kept Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 11 a copy of his mothers care plan - at her request. Another relative said she had been involved in the development of her aunts care plan, and that she felt sufficient time had been spent making sure that the care plan was correct. Both said that staff ring them if there were any problems. One resident said he knew he had a care plan and that he had a minder (personal carer), who he liked. He said she sorted out any problems for him, and went to the shop for him. From the records and from conversations with staff, it was clear that, where a residents needs could no longer be met, arrangements were put in place to move the resident to an alternative care setting. This was done with the full co-operation of the resident and/or relative or other advocate. Care plans showed the different techniques that had been employed to encourage a resident to maintain independence, and that help was provided if needed. Residents spoke about the support they had to assist them with personal care, and the Manager reported that a small number of residents were, to a greater degree, self-caring. One resident said he was left to his own devices but that staff were on hand if he needed some help. The records showed that residents had been assessed by an appropriate health professional where there were concerns regarding pressure areas, continence, diet and nutrition, and psychological health. There was evidence in the records of staff chasing up results, for example, of blood tests, or outstanding consultancy appointments. Residents spoke about having seen the dietician, the District Nurse, and the GP. In general, those residents spoken to appeared to have a good insight into their physical condition and any treatment that they were receiving. Records emphasised the need for a residents privacy and dignity to be maintained at all times. Residents said that they were not made to feel embarrassed about personal care; they said that staff were friendly and chatty so you dont feel uncomfortable. Residents were observed to go to their own rooms to meet with the GP or district nurse. A visitor said that people are treated as people - not old people who dont matter, and that her relative had got some quality of life back. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 12, 13,14 and The Home provides an excellent range of activities that takes account of individual expectations and preferences, and provides good opportunities for social inclusion. Residents maintain good links with family, friends and the local community, as they choose. Staff have a good idea of the level of support each resident needs. Support is offered in a way that promotes and protects residents privacy, dignity and independence. The meals in this Home are good, offering choice and variety, and catering for special dietary needs. EVIDENCE: The records showed that activities offered by the Home are extensive. There are regular trips out on an organised basis (using the community bus or Ring and Ride), and residents will go out with staff to the shop, to the market, or just for a walk out. The Home tries to offer some spontaneity and will make changes to the activities programme depending on the weather or at the request of residents. There is an active Residents Committee who suggest and vote on social events. Every opportunity is taken to join in events that are being held local to Leigh, and residents are invited to join in events at other CLS homes. Residents make a small contribution to the cost of excursions but, in the main, the Homes budget and fund-raising cover the cost. Residents said that there was always something going on, but that you were not forced Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 13 to join in if you did not wish to. Relatives said that they knew that residents had lots of opportunities. The opening of a Prayer Room on the third floor appears to have been very successful. Residents (and staff to a lesser degree) had been involved in the design and decoration of the room (with reference being made to Western and Eastern faiths). For two residents, this included surfing the internet for suitable pictures and symbols. A local craftsman had made a cross, which had been blessed. A good number of residents, relatives and staff made use of the room. Services are held on a regular basis. At other times, the room is used for quiet contemplation. During the course of conversations, residents spoke frequently about making choices, for example, in relation to what they do during the day, what time they got up or went to bed, and whether they spent time with others or alone. Staff referred to residents as individuals and spoke about people not all liking the same thing. One resident said that he went to the visitors lounge when friends and relatives called, and that they could have a cup of tea together. Others took their visitors to one of the main lounges or to their private bedroom. Visitors were seen to be made welcome and were given a drink which staff appeared happy to have arranged. Those visitors spoken to said they could visit whenever they wanted to; no restrictions were imposed. Two residents spoke about relatives looking after financial matters on their behalf. The residents knew that they had some money that was kept at Lyndhurst for their day-to-day use, and knew how to access it. Residents are encouraged to bring in personal possessions that will help them to feel more at home, and a list is maintained in the residents records. The relative of one service user spoke about the extent of personal possessions that had been brought in when his mother had made the decision to come to live at Lyndhurst. Seven out of eight residents said they were very satisfied with the quality, quantity and choice that was available. While breakfast is flexible, lunch and tea are served at set times. A choice of hot and cold drinks are available throughout the day, and through the night if you want one. One resident said that, The meat is beautiful. It falls off the bone. One resident said, Seconds were always available. One resident said that there were choices but, You dont need to make a choice. Its all good. Residents were seen to linger over their meals, no-one was rushed, and a small number remained after the meal was over, chatting with each other over a cup of tea. Staff were observed to provide assistance and reassurance when it was needed, but independence was encouraged. Special diets were catered for, and crossmatched to the care plan. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16. The Home has a satisfactory complaints system that residents and relatives were familiar with. Residents views are listened to and acted upon. EVIDENCE: The Home has a complaints procedure that is widely advertised throughout the premises. The main policy and procedure is a document that is devised by CLS but which can be amended so that it is appropriate to Lyndhurst. Residents knew that they could raise concerns with a member of staff or with the Manager, and that things would be sorted out. One such incident was observed: The Manager said that, occasionally, an item of clothing could go missing, either because it had not been marked or the label had come off. One resident came to see the Manager about a missing top, which was immediately found for him. One resident said her daughter would sort out any problems for her, but that there havent been any. One resident said they had no cause to grumble, and this was the general view of those residents spoken to. Relatives spoken to were familiar with the complaints procedure but said they had had no cause to make a complaint. No complaints had been received at Lyndhurst since the last inspection. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26. The standard of the environment within Lyndhurst is good, providing residents with a comfortable and homely place to live. Residents can personalise their bedrooms to make them suit their needs, if they choose to. Infection control procedures are good, making this a clean environment for residents. EVIDENCE: From a tour of the building, it was seen that the premises were being maintained to a good standard, both inside and out. There was evidence of redecoration and some renewal of fabric and furnishings. Management had identified that a new floor covering was needed for the dining room and upstairs corridor. The premises were clean and free from offensive odours throughout, and residents and relatives spoken to complimented the domestic staff on the level of cleanliness that was maintained. One resident said there was enough space to move around, so she did not have to sit in one place all day. Residents said their bedrooms were comfortable and that they had everything that they needed, including some personal items that they had brought from Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 16 their own home. Those residents spoken to chose not to spend time in their rooms in the day, preferring to sit in one of the lounges, the conservatory, or to join in with activities. However, they said they could if they wanted to. Those bedrooms seen were clean and tidy - according to the wish of the resident - with furniture and fittings that were maintained to a good standard. Systems were in place to control the spread of infection. In conversations with residents, it was clear they were aware about the need for good hygiene. Staff were knowledgeable about infection control procedures, and were seen to be using hand gel inbetween hand-washing. One member of staff said that the hand gel was very good when you cant wash your hands, but emphasised that it was not used instead of hand-washing. The laundry was not inspected on this occasion but the Manager advised that all equipment was in good working order. Residents and relatives said that clothing was always nicely washed and ironed, and that it was returned quickly. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30. Staff morale is good, with low levels of sickness and turnover. This ensures residents are provided with care by people they know and are familiar with. Staff are properly trained to deliver the care that residents need. The practice of retaining two staff on duty overnight needs constant review to ensure residents needs are met. EVIDENCE: Shifts during the day comprise of one Care Team Leader and three Care Assistants. This reduces to one Care Team Leader and one Care Assistant over night for a maximum number of 40 residents, located on three floors. This may not always be sufficient if the dependency levels of the residents living at Lyndhurst changes. Additional staff are included in the rota, for example, if a resident requires additional support because of illness or incapacity. With the lighter mornings, residents are choosing to get up earlier and, at the time of this inspection, the Manager was reviewing the start times for care staff to ensure sufficient assistance was available for residents. This process had been followed last summer, to good effect. The Manager has some autonomy to increase staffing numbers on the rota, so long as it can be justified. Residents said that staff are always around and are happy to help. One relative described staff at Lyndhurst as helpful, caring and kind and that they were considerate. Two members of staff said that because there is good team-working, jobs can be organised so nothing gets missed. Staff were observed to be working effectively, but made time to speak to residents and Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 18 relatives. One member of staff remarked that, ... like all jobs, sometimes there just arent enough hours in the day. The care staff team is complemented by the domestic team, which comprises a domestic supervisor, domestic assistants, cooks, kitchen assistants, an activities organiser, and a handyman. Appropriate arrangements are in place to cover holidays and sickness. Reliance on bank/agency staff is low. A temporary arrangement will need to be made to cover the impending sickness absence of the activities organiser. Those staff who have transferred from Manor Fold appear to have integrated well into the staff team at Lyndhurst. One transferee said that she thought the best thing about Lyndhurst was the Care Team Leaders, whom she had found to be a good support - firm but not strict. She had undergone an induction on transfer and had attended a meeting with the Manager at the end of the induction period. The member of staff was observed to have a good rapport with residents at Lyndhurst, and residents responded positively to her. The Manager was concerned that she was not going to achieve the minimum 50 target of care staff with NVQ level II award in care by the end of 2005. Reviewing this, however, the indications were that the target would be met The Manager was aware of the changes to the national occupational standards for care staff. Induction of new staff lasts for a minimum of six weeks. All staff have a training and development plan. Recent training opportunities have included fire safety and first aid. Planned training includes care of people with dementia. Residents can be assured, therefore, that staff delivering their care are properly trained, assessed, and monitored. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 33. The Manager is properly qualified and experienced, and manages the home well. The Manager and staff work hard to maintain an open culture, where everyone is included and valued. There are systems in place to audit the service provision, so that improvements are made, and poor practice eradicated, in keeping with residents best interests. Continued support for staff to gain their NVQ awards is vital if the Home is to employ a competent workforce. EVIDENCE: The Manager has now achieved the NVQ level IV in Care and the Registered Managers Award. She has a certificate that allows her to assess staff undertaking the National Vocational Qualifications in Care, is a Moving and Handling Instructor, and is qualified to deliver First Aid. She has extensive experience in the care of the elderly, including people with challenging behaviours and cognitive impairment. It was clear that her Manager Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 20 colleagues held her in high regard and felt able to approach her for support and advice. A number of residents had moved into Lyndhurst from Manor Fold (a CLS Home that had closed) and a number of staff had transferred. This could have posed problems for those residents who had lost their home, and for staff who were forced to move jobs. However, the process appears to have run smoothly. Residents appeared content, although staff reported that there had been some initial disorientation. One transferee said she liked working at Lyndhurst and that the Manager had helped her to take up a working pattern that met her needs as well as those of the residents. A long-standing resident at Lyndhurst said she had made efforts to talk to the new people. After all, she said, I know what its like being new. This comment was indicative of the positive attitude of residents and staff alike. The Manager had been in post for just a year. One member of staff said she thought that the overall feel of the Home was probably better than it had been a year ago. Relatives said they felt they could approach the Manager at any time. A small number of residents attended a staff meeting. Two residents were actively involved in the recruitment of a carer. These comments and actions indicate that there is an open, inclusive, and positive atmosphere at Lyndhurst from which residents gain benefit. The Home employs a system for auditing and monitoring the quality of the service. The records showed that there are regular audits of documentation, as well as audits of systems and procedures by a representative of CLS from outside of the Home. Residents, relatives and other stakeholders are encouraged to meet with the Manager and staff to discuss issues, and to make suggestions about improving the service. This was an unannounced inspection yet residents, relatives and staff felt empowered to approach the Inspector to talk about life at Lyndhurst, and felt free to speak their mind. Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x x x x Lyndhurst Care Home F56 F06 S5747 Lyndhurst V221728 200405 Stage 4.doc Version 1.20 Page 22 NO 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 Regulation None. Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 27 27 30 Good Practice Recommendations Arrangements should be put in place to provide cover for the planned sickness absence of the Activities Organiser. Additional staff should continue to be provided if the dependency levels of residents changes, for example, overnight or at peak periods during the day. Support should continue to be provided for care staff so that the minimum target of 50 NVQ level II is achieved by the end of 2005. 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