Inspection on 09/01/07 for Lyndhurst Grove (1)

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyndhurst Grove (1) 04/02/09

Lyndhurst Grove (1) 20/12/05

Lyndhurst Grove (1) 30/03/05

Lyndhurst Grove (1) 20/07/04

Lyndhurst Grove (1) 03/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Lyndhurst Grove (1) Low Fell Gateshead Tyne & Wear NE9 6AU Lead Inspector Mr Lee Bennett Key Unannounced Inspection 9 and 18th January 2007 12:00 th Lyndhurst Grove (1) DS0000007374.V320779.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 Grove (1) DS0000007374.V320779.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 Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Grove (1) Address Low Fell Gateshead Tyne & Wear NE9 6AU 0191 482 3104 0191 482 3104 ntawnt.lyndhurst@nhs.net 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) Northumberland, Tyne & Wear NHS Trust Kim Christine Lang Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Lyndhurst Grove is care home, providing personal care for up to six people with a learning disability related need. Nursing care is not provided, but District, Learning Disability and Psychiatric Nursing services can be arranged where necessary. It is an adapted, detached house with accommodation provided over two floors. There is a bedroom on the ground floor, with en-suite bathroom that allows level access. Five other bedrooms and a bathroom and separate WC are situated on the first floor. Access is by stairs only, so accommodation on the first floor is unsuitable for people with a physical disability, or who cannot use the stairs for reasons of safety. There are enclosed garden areas to the rear of the home. The home is situated near to a range of local services, including local public transport links and a wide range of local facilities, including a doctors surgery, shops, pubs, a library and places of worship. The fees for the home are range between £548.57 and £647.78 per person per week for the financial year April 2006 to March 2007. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in January 2007 and was a scheduled unannounced inspection. The inspection included a separate look at a pre inspection questionnaire and comment cards received from service users and their relatives. The care experienced by a sample of service users was ‘case tracked’ (this is where the inspector focuses on the service provided for individual service users) and time was spent chatting with service users and observing life in the home. The inspector was shown around the home by service users, and a sample of staffing and service users’ records was inspected. Service users, a visitor, the registered manager and other staff were spoken with. The judgements made are based on the evidence available to the inspector during the inspection and from the information received before and during the site visit. What the service does well: There is a lively and friendly atmosphere in the home, and service users and staff get on very well. Staff in the home are experienced, knowledgeable and work well to help and encourage service users to access community services and facilities. There is a shared vehicle available to help service users to get out and about. Staff will also assist service users to speak up for themselves and have an excellent rapport with them. Relatives and visitors are made welcome in the home, are able to visit in private, kept up to date about service users progress, and are satisfied with the overall care provided. Service users needs are clearly detailed, and their records kept up to date. Staff have a good understanding of service users needs. Comments received from service users included: • • • “Yes, I’m happy here and I want to stay here with my friends.” “We all try to get on as friends.” “I’ve been drawing today and I’m going to the disco tonight.” Several relatives made comments as well. These included: Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 6 • • • “My relative is very happy at Lyndhurst. I have no problems at all.” “(Name)’s appearance has improved since she went to Lyndhurst. She is also joining in a lot more activities.” “I am very happy with the care my sister receives at Lyndhurst Grove.” The care provider (Northumberland, Tyne & Wear NHS Trust) make sure the accommodation is kept at a high standard through regular cleaning, decoration and maintenance. Staff recruitment checks include references and Criminal Records checks. These help to ensure safe recruitment practices are in place. Staff also receive regular, structured supervisions (meetings with their manager), which allow them to discuss issues relevant to service users and themselves. It also means that the staff team is well managed, and that their work meets service users’ requirements first and is focused on their needs. The care provider has a clear policy on equal opportunities. This relates to both care practice and staffing issues. For example, staff recruitment is in part governed by equal opportunities principles, and the staff team vary in age, cultural and gender background. Service users cultural and spiritual needs are identified, acknowledged and supported. Service users are encouraged to be involved in day to day choices and in discussing plans and making decisions at meetings, which also helps them to be involved in the running of the home. The home is well managed and there are clear lines of accountability within and outside of the home. What has improved since the last inspection? The last inspection of the home pointed out the need to provide more detailed and easily understood information to service users in respect of the terms and conditions of their residency in the home. This has been attended to. Medication arrangements are handled with care and safely managed. The home’s manager also periodically reviews the quality of the service provided through regular maintenance checks and detailed monthly management inspections. Regular meetings with service users and staff are held, so that their views can be sought and acted upon. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 8 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 Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed before their admission to the home and are also periodically re-assessed to an excellent standard thereafter. This can help ensure that the service can be planned in a way that meets service users needs and wishes. The home is able to meet the range of service users’ diverse needs to a good standard. Each service user has an individual, written contract that has been written in an excellent manner to aid clarity of understanding for service users. This can help ensure that service users have clear information about the terms and conditions of their residency and about their rights and obligations. EVIDENCE: No new service users have moved to the home since the last inspection. However, the care of some service users was ‘case tracked’. Of the case files examined it was evident that their needs are subject to periodic review and reassessment. Following such an assessment plans of care and risk assessments Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 10 are developed by ‘key workers’. These mirror the needs observed by the inspector. The needs of each service user are detailed within their personal case files, and they also detail the action taken to meet these needs and progress made. Staff received training and guidance relevant to the majority of service users specific, diverse and specialist needs, such as those relating to epilepsy, and medication. Further advice is available from specialists within Social Services and from the Community Learning Disability Team. Those people who commented are satisfied with the overall care provide at Lyndhurst Avenue. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ care plans are in place, and reflect their observed needs (including their cultural needs and personal preference) to an excellent level. Effective care planning can offer guidance to care staff regarding care practice and ensure consistency where necessary. Service users are, as far as is practicable, consulted on and participate in the life of the home to an excellent level. This can help in the development of an inclusive service for those living there. Service users are supported to take risks within a planned framework, irrespective of their age, gender or level of ability. This can help ensure their independence is promoted, balanced against a judgement about any risks involved. This can also help promote an awareness of safety to a good level and ensure equality of access to community facilities and activities. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 12 EVIDENCE: Each service user has a personalised care plan file. These follow a standardised format. These care include picture prompts to aid discussion and understanding. One section summarises areas of need, likes, dislikes and so on. Another section outlines more detailed plans of care to help describe and guide staffs care practices. These plans are developed by key workers (staff who work specifically with an individual service user) in consultation with them, and cover a broad range of need areas. These are linked to regular monitoring of some areas such as personal care, behavioural needs, diet, weight and activities, and are then periodically reviewed and subsequently updated. Each service users needs are reviewed annually, where their progress and wishes can be discussed. This documentation highlights each service users’ abilities, strengths, and preferences, as well as areas of need. Staff are also able to comment on and describe service users’ strengths, abilities and needs. For those service users case tracked, these plans of care accurately mirrored the needs observed by the inspector. Those service users asked were able to give examples of how they make decisions affecting day to day choices and decisions, about their lives, and the way the home is run. This was observed during discussions about activities and plans for the day, mealtime choices and so on. Service users and staff will discuss routines in the home, and service users have been able to make choices about décor schemes, trips out and personal purchases. There are weekly house meetings where service users can voice their opinions on plans for the week ahead, menus and activities. Areas of risk are also documented within each service users’ care file, including assessments relating to activities out of the home, behaviours that may challenge the service, and the use of equipment. This can contribute to staff having guidance to enable service users to access community facilities without being placed at undue risk of harm. A model is used, whereby each risk area is identified, who or what may be harmed is noted, current and additional control measures are documented, and this is then reviewed. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assisted, to a good degree, to lead active and fulfilling lifestyles by having a regular community presence, and by accessing a range of community facilities. This will assist in them leading a full and enjoyable life. Service users are supported to maintain their personal relationships and friendships, to a good level, which helps them to keep in touch, and be involved in their family life. Service users rights are respected and routines in the home are flexible to a good level. This can help to promote a flexible service that encourages and promotes service users’ choices and preferences. Service users are offered and receive a varied, wholesome, nutritious and wellpresented menu. This can contribute to their general health and wellbeing. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 14 EVIDENCE: Service users explained to the inspector some of the activities they take part in and that are planned for the future, which include attending formal day services, college courses, going shopping and having various trips out. One service user receives extra support from another care provider during some days. Other activities participated in include gardening, discos and trips to the shops and to the pub. Service users can also spend time in their own rooms or in the various communal areas as they wish. A variety of relationships exist within and beyond the home. These are outlined within care plans, and should there be any concerns or needs in this area, plans of care have been developed to guide staffs’ practice. Relatives and friends are able to visit the home flexibly and a vehicle is available to service users to help them get out and about and to visit friends and relations. Staff have received training in respect of equal opportunities, and human rights awareness forms part of staffs’ NVQ work. The rights and obligations of service users are, in part, expressed and outlined within their residency agreement. Service users responsibilities towards one another, and in their conduct towards staff members are also outlined in their care plans. Most service users are able to clearly voice their opinions and views formally through care planning reviews and the house meetings, and can exercise independence and control in the planning and evaluation of activities. Service users have a range of dietary needs, which are outlined within their care plans. They are also involved in menu planning, shopping and meal preparation. These skills are promoted and supported. Staffs’ practice reflects the guidance and risk assessments provided. There is a record kept of the meals planned and provided. Meals are normally taken within the dining room, although service users can eat elsewhere if they wish. Staff share meals with service users and can provide support and prompting in a discreet way that promotes service users independence and personal dignity. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive personal support appropriate to their needs and preferences, to an excellent standard, which can help to ensure their privacy and dignity is respected. Service users health care needs are identified and arrangements are made to help ensure they are promoted and met to an excellent degree. Medication arrangements are appropriate for the needs of service users, and are managed in a good and safe manner. EVIDENCE: The service users living at Lyndhurst Grove have their personal care needs outlined within their case files. Their needs are supported and met, where appropriate, in private, and they are encouraged to be independent where Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 16 possible. Care staff are able to demonstrate, through discussion and observed practice, a good understanding of service users’ needs. Regular access to primary and secondary health care services, such as GP, occupational therapy and the dentist, is supported. Contact with health care professionals is documented within the service users care records, and regular healthcare updates are entered into service users care plans. All service users have an ‘okay health check’ which is an assessment of their health needs. Staff also monitor service users health and wellbeing closely and work with a range of professionals to promote service user’s needs. Service users are kept well informed of their healthcare by staff, and they can therefore demonstrate a good awareness of their own health needs, which some explained to the inspector. Locked storage has been installed for service users’ medications, with internal and external medicines stored separately from one another. Printed administration records are kept, and a sample signature list is maintained to identify what staff were responsible for each medication administration. Due to their levels of need, service users are not able to administer their own medicines, and designated staff therefore assist in this area. Staff at the home have undergone training in relation to medication administration. A stock check was undertaken for a sample of medications held in the home. This was concluded successfully, with stocks held corresponding to those recorded. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ views are listened to and acted upon to a good level. This can help contribute to a service user centred service. Steps are taken to help ensure that service users are protected from abuse, neglect and self-harm in a good manner. EVIDENCE: A complaints procedure is available within the home, and informs service users that they can contact the Commission if they wish regarding complaints. A record of complaints and suggestions is maintained, and none have been documented over that past year. None have been referred to the Commission. Service users are aware of who to speak to within the home should they be unhappy about the service they receive. Staff have, in the past, received training on the local Adult Protection arrangements, which will help to explain the role of adult protection, and to offer guidance to staff. Training in this area is seen by the care provider as mandatory for all staff, and staff receive annual refresher sessions. Written material is available in the home regarding these procedures should staff need guidance in this area, and individualised guidance is developed where necessary. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from good, well maintained, homely, safe and clean accommodation. This can help promote a positive image for service users, and ensure they remain comfortable and safe. Service users bedrooms are furnished to a good standard. This can contribute to their comfort during their stay at the home. EVIDENCE: Lyndhurst Grove is an adapted, detached house, with accommodation provided over two floors. There is one en-suite bedroom on the ground floor, that would be suitable for people who have a physical frailty or disability that meant they could not easily walk up stairs. All other private accommodation is provided on the first floor. There are two W.C.’s and a shared bathroom on the first floor and a communal shower and W.C. on the ground floor. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 19 Communal areas consist of a lounge area, and a separate dining room, as well as a kitchen diner and conservatory. Domestic style furnishings and fittings are provided, and decoration schemes have been developed in consultation with service users. Bedrooms have been decorated and furnished in a domestic manner and a regular, planned cycle of cleaning is implemented. Domestic type laundry facilities are provided, which all service users are encouraged to use. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported, to an excellent level, by an effective staff team, deployed in good numbers. This can help ensure their needs are safety met. An excellent number of staff have obtained qualifications in care. Service users are supported by competent staff who have received a good range of training, relevant to their roles, the purpose of the home and the majority of service users’ needs. This can ensure that service users are supported in a safe manner by staff who have an understanding of these needs. Service users are protected by the home’s recruitment policy and practices, which can help ensure unsuitable candidates do not gain employment in the home. These are implemented to a good standard. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 21 EVIDENCE: Some service users at Lyndhurst Grove are able to meet many of their needs independently, with staff support needed when accessing community facilities, with catering, medication and some aspects of personal care. There is always at least two members of staff on duty, with additional staff present to assist with various activities and appointments, both during the day and evening. Staffing levels are detailed within a staffing rota, which is available for inspection. Staff are supported by an ‘on-call’ arrangement, whereby they can contact a designated experienced staff member for advice and additional support if necessary. There have been no new staff recruited to the home, but previous inspections have noted that staff are only employed in the home after sufficient background checks have been carried out, which help determine their suitability to carry out their role. These checks include the receipt of a Criminal Records Bureau ‘disclosure’, two written references, and confirmation of physical fitness. Staff receive a range of training, relevant to the needs of service users, health and safety, and to care in general. Specialist support to help a service user with specific dietary needs has been provided, with ongoing support available as necessary. The manager keeps clear records of the training staff have received, which can assist in the planning of future training for the staff team. 80 of the staff team are qualified to NVQ level 2 or higher. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. Quality assurance systems seek the views of service users and their representatives to a good degree, which can help ensure the service remains focused on their needs and aspirations. Those records required by regulation are well maintained and available for inspection, to a good standard. This can help staff demonstrate how service users rights and best interests are safeguarded. The home is, to an adequate standard, free from hazards to service users and staff. This can contribute to the health, welfare and security of service users and staff. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has undertaken assessment by the Commission for Social Care Inspection, and adjudged fit to manage a care home. She is experienced in working with this client group and has previously been employed as a deputy manager. She undertakes regular training to keep her skills and knowledge up to date. The home operates a robust self- monitoring system using the Regulation 26 visits carried out by their external managers. These look at a range of aspects of the home, and make sure the residents are cared for properly. Due to the nature and size of the home the staff talk to the residents and visitors at all times and there is an open atmosphere that encourages them to let their views be known. The residents hold regular meetings so that they can tell the staff how they feel and talk about concerns and about the way the house is run as a group. The views of families are also sought. Staff hold separate meetings to share issues and talk about how they can improve the care they give to the residents. These meetings are recorded clearly and used to help develop plans for the future of the home and development for the residents. At the time of the inspection there were no observed hazards to safety. There is a health and safety policy available to guide staff, and various risk assessments have been developed, both to enable service users to be independent, but also to ensure care and working practices are undertaken in a safe manner. Health and safety checks are also undertaken regularly, including an audit of the building, fire safety checks and instruction, and regular water temperature tests. Some cleaning and chemical products did not have an associated COSHH data sheet available and must do. An immediate requirement form was issued to highlight this and is also a requirement of this report. Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 4 3 3 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 4 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 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 4 4 3 X 3 X 3 X X 2 x Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 25 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 YA42 Regulation 13 (4) C Requirement The registered person must arrange for COSHH data sheets to be available for all hazardous chemical products stored and used in the home. Timescale for action 29/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lyndhurst Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Grove (1) DS0000007374.V320779.R02.S.doc Version 5.2 Page 27 - 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. 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