Inspection on 20/05/05 for Lyndhurst Nursing Home

This inspection was carried out on 20th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Lyndhurst Nursing Home 22/08/07

Lyndhurst Nursing Home 16/08/06

Lyndhurst Nursing Home 16/12/05

Lyndhurst Nursing Home 30/12/04

Lyndhurst Nursing Home 15/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst Nursing Home 238 Upton Road South Bexley Kent DA5 1QS Lead Inspector Maria Kinson Unannounced 20 May 2005 09:40 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 Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lyndhurst Nursing Home Address 238 Upton Road South Bexley Kent DA5 1QS 01322 523 821 01322 523 821 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) Mr Richard Mahomed Mrs Rookaya Mahomed Mr Richard Mahomed Care Home with Nursing 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 16 beds Elderly and Infirm Date of last inspection 30.12.04 Brief Description of the Service: This home is located in a residential area of Bexley, within walking distance of local shops, a railway station and bus routes. There are five double, one triple and three single bedrooms in the home. Communal space consists of a lounge, which is also used as a dining area during mealtimes. At the rear of the property there is a spacious garden for residents use. Parking is restricted in the roads surrounding the home, limited off street parking is provided on the driveway. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 20th May 2005 between 09.40am and 17.40pm. The inspector undertook a full tour of the home and examined a sample of care, medication and recruitment records. Four members of staff, three residents and two relatives were spoken with during the inspection and comment cards were distributed to relatives and other health and social care professionals who had contact with the home. Three questionnaires were returned to the commission. One additional unannounced visit has been made to the home since the last statutory inspection. Further information about the inspector’s findings during this visit can be found on page 15 of this report. A copy of the letter sent to the provider following the visit can be obtained from Commission for Social Care Inspection office on request. What the service does well: The home has a comprehensive Statement of Purpose, which provides useful information for prospective residents. The building was maintained to a satisfactory standard and all areas were kept clean and tidy. The garden at the rear of the property provides a peaceful and relaxing area for residents to sit during the warmer weather. The home employs a designated Activities Coordinator who has developed a varied programme of activities to stimulate and entertain residents. The home has a stable team of staff that were caring in their approach and appeared committed to their work. Staff and management have established good working relationships with resident’s relatives and kept relatives advised of significant changes. This probably accounts in part for the low incidence of complaints received in the home and by the commission. Relatives were satisfied with the overall care provided in the home and indicated that staff were “always polite and helpful and seem to have the comfort of patients at heart”. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Several concerns were identified during this inspection, which must be addressed by the Registered Manager. The information provided for residents in the Service Users Guide about the facilities and care provided in the home was inadequate. This document must be updated to include information about the homes complaints procedure, access to inspection reports and contact details for the commission. Medical advice was not always obtained prior to administering medication and records were not maintained for all medication received in the home and administered to residents. Staff recruitment was poor. Staff were appointed without adequate documentation and information being obtained. There was no clear recruitment procedure in place to protect residents and staff received insufficient training and written information about their role, prior to commencing work in the home. There were no formal systems in place for monitoring work practices and supervising staff. Staff were motivated but did not always have adequate information to meet residents health and welfare needs. Policies and procedures were not accessible to staff. This could result in staff managing issues such as accidents in an inconsistent and potentially unsafe manner. Adequate procedures were not in place to protect vulnerable people. Equipment to prevent cross infection was not always available for residents or staff to use. Adequate action was not being taken to monitor and address health and safety issues promptly. This included leaving some radiators without covers and Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 7 using bedrails without fully considering and documenting the potential risks to residents. 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 Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 (standard 6 does not apply to this home) The information provided for residents in the Service Users Guide was inadequate. This document must be updated to ensure that residents have access to sufficient information about the care and facilities provided in the home. EVIDENCE: The home has a comprehensive Statement of Purpose, which was distributed to prospective residents and their representatives on request. The previous requirement to include additional information in the Service Users Guide about access to inspection reports, the homes complaints procedure and contact details for the Commission had not been addressed. See requirement 1 and recommendation 1. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 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, 9 and 10 Staff were not given adequate information to meet resident’s needs. The management of some health issues and medicines was poor. These practices could compromise resident’s health and safety. EVIDENCE: All of the residents had been assessed using a recognised assessment tool for older people. Staff had developed a care plan for each of the residents and reviewed the care plan regularly. New issues were not added to care plans when they occurred or when staff formally reviewed the plan. For instance there were no instructions for staff in the care plans about the action they should take to manage a wound, treat a skin disorder, prevent further weight loss or to reduce the anxiety that one of the residents was experiencing. As a result of this residents were receiving different treatment from different staff members. Some parts of the documentation such as the social history and profile sheets were blank. Action had been taken to ensure that relatives were familiar with care plans. See requirement 2. A General Practitioner visits the home regularly and other specialists visit when required. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 11 Records of receipt, administration and disposal of prescribed medication were good. One bottle of liquid medication, which was purchased over the counter, was found on a resident’s locker. It was not clear whom the medication belonged to, as there was no label on the bottle. Staff confirmed that they had been asked by the manager to apply the lotion to a residents skin, but were not clear why the resident required it. There was no reference to the treatment or the underlying medical condition in the residents care plan. The medication was not included on the medication administration record and there was no record of receipt. The medication had been administered more frequently than recommended and on at least one occasion by care staff. The medication was not included on the homely remedies list. (See standard 26) See requirement 3 and 4. All of the staff observed during this inspection were responsive to residents needs, courteous and polite. Staff treated residents with respect. Action was taken to maintain resident’s privacy and dignity. One of the visitors commented that “It cannot be easy nursing elderly patients, but I have never seen them treated with anything but respect”. One resident was disappointed that she had not been able to see a hairdresser regularly. The Registered Manager was attempting to address this issue. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 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) 12, 13 and 15 The provision of activities in the home ensured that residents’ social needs were met. A balanced selection of food was provided at each meal but an increased range of fresh vegetables is required to meet resident’s tastes. EVIDENCE: The home employs a part time activities coordinator who facilitates the activities programme in the home. The activities programme was displayed in the lounge. Residents spoken with during this visit were pleased with the activities that the newly appointed coordinator had arranged. The activities coordinator also visits residents who prefer to spend the majority of their time in their room or who are too unwell to take part in group activities. Comments from residents included “The activities are good I have made some cards, which I really enjoyed and played dominoes” “ I spend my time watching TV and doing word puzzles, the activities lady is always coming up to have a chat with me”. During the inspection a talk about evacuation during the war was taking place followed by refreshments. Relatives were satisfied with the visiting arrangements and indicated that they were made welcome by staff. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 13 Since the last inspection a new menu had been developed and introduced. The choice and variety of food provided at suppertime had been increased to include cooked food such as homemade quiche and fish fingers. Residents were mostly satisfied with the food provided but stated that the choice of fresh vegetables was limited with carrots and white cabbage served regularly. See recommendation 2. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 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 and 18 The home had adequate systems in place to manage complaints and concerns promptly. Further work must be undertaken to ensure that the homes adult protection procedure provides adequate protection for residents and complies with Department of Health guidance. EVIDENCE: The complaints procedure was displayed on a notice board outside the office. Of the three relatives that responded to the comment cards sent out by the commission, two were not aware of the homes complaints procedure and did not know where the inspection report was kept in the home. The Registered Manager should consider repositioning the complaints procedure to ensure that it is displayed in a prominent position. See recommendation 3. None of the people surveyed had made a complaint before but one relative said, “If I ever did have any complaints, I am certain the manager would deal with it sympathetically”. Details of complaints received in the home were recorded in a book. There had been no complaints received in the home since the last statutory inspection but one anonymous complaint was forwarded to the commission. An additional unannounced visit was undertaken on 22.02.05 to investigate the concerns. The complainant alleged that no action had been taken to treat service users and staff with “bites”. The outcome of the investigation was that the complaint could not be upheld. It was noted however that the poor management of medicines could lead to residents receiving incorrect treatment. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 15 A requirement was made that the Registered Person must ensure that all medicines, including external preparations such as creams and lotions are recorded on the MAR sheet and a record must be maintained of all medicines administered to service users, including external preparations such as creams and lotions. The Registered Person was asked to take action to address the requirement by 07.03.05. This requirement was outstanding at the time of this visit. See standard 9 and requirement 4. The home had an Adult Protection procedure but this document was not signed or dated and did not indicate that allegations would be referred to Social Services. See standard 29 and requirement 5. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 16 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, 20, 23, 25 and 26 This home provides a clean and comfortable environment for residents but some poor practice in relation to the prevention of infection was identified. Failure to rectify these issues promptly could put staff and residents health at risk. EVIDENCE: The building was maintained to a satisfactory standard and work to improve the facilities and space for residents was in progress. Since the last inspection a new boiler and heating system had been installed. This will supply a more efficient supply of hot water and will enable staff to regulate the temperature to meet residents’ needs. The temperature of the hot water in the ground floor bathroom was satisfactory. Work to build a conservatory at the rear of the property had been suspended but was due to restart soon. The garden was maintained to a high standard but access was restricted due to building work. Bedrooms were clean, comfortable and decorated to a satisfactory standard. Screening was provided in all of the shared rooms. Three residents occupied Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 17 one of the bedrooms on the first floor. The Registered Person has advised the commission that this room will be converted into a double room by December 2005. All parts of the home were clean and tidy but measures to prevent cross infection were poor. Some of the soap dispensers in toilets were broken or empty, the toilet seat in the ground floor toilet was worn and scratched and clean bed linen had been placed on wooden pallets on the floor. The Registered Manager told the inspector that arrangements were being made to fit shelves in the cupboard. Staff on duty did not have access to a suitable supply of gloves to use when undertaking invasive procedures or activities that may carry a risk of exposure to blood or body fluids. The polythene gloves that were available for staff to use did not conform to European Community (CE) standards. The afternoon staff were able to locate a supply of vinyl gloves when they came on duty. One of the residents had a rash (see standard 7 and 8). Staff had not been told what the cause of the rash was and did not know whether they were supposed to be taking any additional precautions to protect themselves or other residents. There was no written information in the residents care plan about the care that staff should provide. Some of the care staff that were responsible for preparing and serving supper had not undertaken food hygiene training. One of the bedrooms in the home was malodorous. See requirement 6. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 18 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, 29 and 30 This home has a stable team of staff. This provides good continuity of care for residents. The homes recruitment practices were unsafe and could place vulnerable residents at risk of harm. EVIDENCE: The mix and numbers of staff on duty on the day of the inspection were satisfactory. The home has a fairly stable team of staff, some of whom have worked in the home for several years. Temporary staff were used infrequently. Two staff recruitment files were examined. Some of the documentation and information that must be obtained from employees such as two written references, a recent photograph, evidence of relevant training and qualifications and evidence of registration with the Nursing and Midwifery Council could not be located. There was no information on the files to suggest that employees had been interviewed or had received a job description and terms and conditions of employment. Criminal Record Bureau disclosures had been obtained but the certificates were from previous employers and did not include a current POVA check. It was unclear whether any action had been taken to assess possible risks to residents, which were identified when recruiting staff. See requirement 7 and 8 and recommendation 4. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 19 The support systems for new and existing staff were poor with no record of induction training or formal supervision. Staff reported that senior staff were approachable and helpful but some concerns were raised about the lack of notice that staff were given about the duties they were asked to work. This inspection took place on a Friday, the off duty roster for the week beginning 23.05.05 was not available in the home. See requirement 9 and recommendation 5. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 20 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, 37 and 38 The management arrangements in this home were stable but adequate action was not taken to monitor and address some basic health and safety issues. Further work is required to provide adequate support and information for staff. Failure to address these issues could place residents at risk of harm. EVIDENCE: The previous requirement to fix the radiator cover in room two and at the top of the staircase to the wall and to undertake a risk assessment prior to using bed sides had not been addressed. The records indicated that one resident had caught her head in the bedrails on one occasion causing an injury. This accident was not recorded in the accident book. The Registered Person must ensure that a full risk assessment is undertaken prior to using bedsides and use bedside covers if appropriate. One additional radiator at the foot of the rear staircase was uncovered and the window restrictor in room 6 was broken. See requirement 11, 12 and 13. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 21 Staff did not have access to relevant policies and procedures. See requirement 10. Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 3 x 2 x 3 2 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x x x x x 2 2 Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 23 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 1 Regulation 5 Requirement The Registered Person must amend the Service Users Guide to include information about: access to inspection reports, a summary of the homes complaints procedure and the address and telephone number for the Commission. A copy of the amended Service Users Guide must be forwarded to the Commission. (Previous timescale of 01.12.04 not met) The Registered Person must ensure that care plans identify how service users needs are to be met. (Previous timescale of 01.11.04 not met) The Registered Person must ensure that all medicines are stored securely, are prescribed or are included on a locally agreed homely remedy list. A record must be made when delegating the task of administering medication. The Registered Person must ensure that all medicines, including external preparations such as creams and lotions are recorded on the MAR sheet. A record must be maintained of all Timescale for action 01 September 2005 2. 7 15 21 August 2005 3. 9 13 01 August 2005 4. 9 13(2) 01 August 2005 Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 24 5. 18 13 6. 26 13 & 16 7. 29 19 8. 29 19 9. 30 17 10. 11. 37 38 17 13(4) medicines administered to service users, including external preparations such as creams and lotions. (Previous timescale of 07.03.05 not met) The Registered Person must ensure that a robust procedure for responding to allegations of abuse is developed and available to staff in the home. The Registered Person must replace the toilet seat in the ground floor toilet, ensure that staff have access to suitable gloves, ensure that soap dispensers are in working order and refilled as necessary, ensure that clean linen is stored appropriately and ensure that action is taken to eliminate the offensive odour in room 3. The Registered Person must not allow a person to work in the care home unless he has obtained a recent photograph of the employee. (Previous timescale of 01.04.05 not met) The Registered Person must not allow a person to work in the care home unless he has obtained two written references, a enhanced CRB disclosure or POVA first check, documentary evidence of relevant qualifications and training and evidence of registration with a professional body. The Registered Person must ensure that a record of induction training is maintained and kept in the care home. The Registered Person must ensure that staff have access to relevant policies and procedures. The Registered Person must fix the radiator cover in room two and at the top of the staircase securely to the wall and 01 September 2005 01 September 2005 21 August 2005 21 August 2005 01 September 2005 01 August 2005 21 August 2005 Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 25 12. 37 & 38 17 13. 38 13 undertake a risk assessment prior to using bed sides. (Previous timescale of 01.04.05 not met) The Registered Person must ensure that adequate records are maintained about all accidents that occur in the care home. The Registered Person must repair the broken window restrictor in room 6 and replace the radiator cover at the bottom of the rear staircase. 21 August 2005 21 August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations The Registered Person should amend the Service Users Guide to include the following information: The qualifications and experience of the Registered Manager and staff, details of any special needs or interests catered for and information about how the home meets the following standards 20.4, 21.4, 22.2, 22.5, 23.3 and 23.10. The Registered Person should review and update the homes menu to include a greater variety of fresh vegetables. The Registered Person should display the complaints procedure and inspection report in a more visable position in the home. The Registered Person should provide all staff with a written job description and contract / terms and conditions of employment, maintain an accurate record of staff interviews and keep a copy of the homes recruitment procedure in the home. The Registered Person should ensure that care staff receive formal supervision six times a year. 2. 3. 4. 15 16 29 5. 36 Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup Kent, DA14 5RH 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. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst Nursing Home G51 G01 S6765 Lyndhurst V211936 200505 Stage 4.doc Version 1.30 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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