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Inspection on 22/08/07 for Lyndhurst Nursing Home

Also see our care home review for Lyndhurst Nursing Home for more information

This inspection was carried out on 22nd August 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff were approachable and friendly and 50% of care staff had attained a vocational qualification in care at level two or above. Residents and relatives expressed satisfaction with the standard of care provided. Relatives were satisfied with the visiting arrangements and said that they were kept informed about their resident. The home was well-maintained, clean, tidy and odour free. Safety systems and equipment was serviced at regular intervals and fire safety arrangements were satisfactory. Practice in the home did not generate complaints.

What has improved since the last inspection?

New residents received written confirmation that based on assessment the home was suited to meeting their needs. Risk assessments were completed prior to using bedrails. With the aid of the assessment the number of bedrails used in the home was reduced. Medicine management had improved, the provider purchased homely remedies and kept accurate records for these medicines. Management and staff are to be congratulated on the improvements to social and leisure activities provided. A new activity organiser was employed and activities were provided five days a week. Work was continuing on developing a suitable staff induction programme. A staff training programme was provided. Some advances had been made to the implementation of a quality assurance system. Fire drills were held at regular intervals and satisfactory records kept.

What the care home could do better:

Accurate records must be kept for medicines and any drug errors must be investigated and reported to the Commission under regulation 37. The medicine management policy must be amended to include the action to be taken if a resident goes on leave from the home. The Commission must be informed in writing of the action and timescale in place to use the triple bedroom as a double bedroom. A system must be in place to ensure staff that commence before a CRB check is received are supervised when on duty. Records must be kept to show who acted as supervision on every shift. Staff must have access to an induction programme that meets the National Training Organisation specification. Serious consideration must be given to finalise the planned quality assurance system. A copy of any review of the service sent to the Commission and made available to residents, relatives and others.

CARE HOMES FOR OLDER PEOPLE Lyndhurst Nursing Home 238 Upton Road South Bexley Kent DA5 1QS Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 22nd August 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Nursing Home Address 238 Upton Road South Bexley Kent DA5 1QS 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) 01322 523821 F/P 01322 523821 Mr Richard Mahomed Mrs Rookaya Mahomed Mr Richard Mahomed Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 16 beds Elderly and infirm Date of last inspection 16th August 2006 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/ dining room. This room has been extended to provide a large sunny space for residents to enjoy and participate in activities. At the rear of the property there is a spacious garden for residents use. Parking is restricted in the roads surrounding the home and limited off street parking is provided on the driveway. The current fees ranged from £557 - £630 per week. Residents paid privately for hairdressing, chiropody and personal items. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced key inspection was completed on 22nd August 2007. The manager and staff assisted with the inspection. Sixteen residents were in the home. The last key inspection was carried out on 16th August 2006 and a random unannounced inspection on 14th February 2007. The inspection included a review of information held on the service file, a tour of the premises, and inspection of records, talking to residents, staff and the registered person and reviewing compliance with previous requirements. Prior to the inspection the Commission sent satisfaction surveys to relatives and residents. The Commission received eleven completed survey forms from residents and relatives and one from a visiting health professional. Feedback on the service was generally positive and indicated an overall satisfaction with the quality of care provided. Comments included “meals are very good”, “I am always made feel welcome” and “staff do everything well”. What the service does well: What has improved since the last inspection? New residents received written confirmation that based on assessment the home was suited to meeting their needs. Risk assessments were completed prior to using bedrails. With the aid of the assessment the number of bedrails used in the home was reduced. Medicine management had improved, the provider purchased homely remedies and kept accurate records for these medicines. Management and staff are to be congratulated on the improvements to social and leisure activities provided. A new activity organiser was employed and activities were provided five days a week. Work was continuing on developing a suitable staff induction programme. A staff training programme was provided. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 6 Some advances had been made to the implementation of a quality assurance system. Fire drills were held at regular intervals and satisfactory records kept. 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 Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4. Standard 6 does not apply to the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information was provided for residents. Residents were admitted based a pre-admission assessment of need and received confirmation in writing that the home could meet their assessed care needs. EVIDENCE: Adequate information was available in the statement of purpose and service user guide for residents on the property and the service provided. Residents were admitted to the home based a pre-admission of assessment. The pre-admission assessments seen were very detailed and provided satisfactory information about the person’s needs. There was evidence to show that residents admitted to the home had received written confirmation that the home could meet their assessed care needs. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans seen were well written and provided adequate guidance on how to meet assessed needs. Bed rail risk assessments were completed. Medicine management was satisfactory and attention was given to ensuring residents had access to health care. From observation and comments received staff respected residents dignity and privacy. EVIDENCE: Two care plans were viewed; one for resident admitted since the last inspection and one for a long stay resident. These included pre-admission assessments, social histories and relevant risk assessments with care plans prepared to show how needs were to be met. There was some evidence to show that residents or relatives had been consulted about care plans. Risk assessments were in place for residents using bedrails. Care plans seen reflected the resident’s needs, were reviewed and were up to date. Personal hygiene care plans were quite detailed and showed how staff should encourage residents to remain independent, address communication and mouth and hair Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 10 care. Neither of the files seen included a night care plan. Residents and relatives seen were satisfied with the quality of care provided. Recommendation 1. Residents were registered with a GP and staff ensured residents had access to the services of a dentist, optician and tissue viability nurse. Other medical advice was obtained through GP referral. A record was kept of professional visits to each resident. Accident records were kept and if required medical attention obtained following an accident involving a resident. Policies and procedures were provided in relation to medicine management and were reviewed in May 2007. This address all areas of medicine management except for medicines when a resident is on leave from the home. Medicines were stored in the staff office on the ground floor. The temperature of this room was monitored and showed storage medicines were stored at a safe temperature. Adequate storage space was provided. Receipts were kept for medicines received, administered and returned to the pharmacy. The home did not have a medicine fridge and stored medicines in a locked box in the kitchen fridge when needed. Staff had access to up to date information on medicines. Medicine records for two residents were checked and an inaccuracy noted for one medicine. On checking stock it was noted that there were 2 extra tablets in stock for one medicine compared with the numbers supplied and administered. Administration charts were well maintained. No controlled drugs were in use but systems were in place to safely store and manage these. Homely remedies were provided and agreed with the GP. The homely remedy list was last reviewed on 16/3/07. Records for homely remedies were well maintained and medicines checked were found to be correct. The manager said he completed a medicine audit every three months. All the nurses employed had received medicine management training at Bromley College in November 2006. A discussion took place with the manager in relation to maintaining a medicine profile for residents, evidence that staff had annual competency assessments and that a protocol was provided to administer ‘as required’ medicines to residents with poor communication. Requirement 1 and recommendation 2. Staff were observed interacting appropriately with residents. Many of the residents were unable to voice their views of the service. Residents who were spoken with said staff treated them with respect. Feedback received from relatives on the day and in survey forms indicated an overall satisfaction with the service and with the way residents were respected. Comments made were “the resident is fully prepared to receive Holy Communion”, “staff are professional and committed to caring for residents” and “staff provide a homely atmosphere for residents”. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 - 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Great improvements had been made to the provision of social activities and stimulation. Residents were supported to maintain contact with family and friends. Efforts were made to involve residents and relatives in making decisions relevant to the resident’s lifestyle. Residents were provided with a varied and nutritious diet and systems in place to monitor resident’s weight. EVIDENCE: The ability of residents to participate in organised activities varied. Residents who could participate said they enjoyed these and during the inspection were seen enjoying a ‘memory game’, ball exercises in the morning and a game of bingo in the afternoon. During the activity suitable background music was played. Residents who could or did not want to participate were encouraged to watch and enjoy the music. Since the last inspection a second activity organiser had been employed and a lot of work done to improve social and leisure activities. Activity staff were therefore on duty five days a week. Social histories and care plans were prepared for most residents. The new activity organiser was updating and preparing individual social care plans for all residents. Records were kept of the activities provided and showed a variety of activities were provided such as bingo, memory games, quizzes, Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 12 music sessions and exercises. Residents were also support to go out to the park, shopping and to use the lovely back garden. All residents were registered with ‘dial-a-ride’ to enable them to enjoy outings. Bexley Social Services completed a social stimulation monitoring visit to the home on 14th June 2007. The report of the visit showed satisfaction with the activities provided and included comments such as “the activities file was impressively organised”, “the care plans are the most detailed and person centred I have seen” and there was “a clear commitment to improving and developing the activities in the home”. No concerns were noted in relation to residents maintaining contact with family and friends. Verbal and written feedback received from relatives indicated they were made feel welcome when visiting the home and kept informed of issues relating to their resident. A number of relatives commented on the ‘homely’ atmosphere in the home. From records seen, talking to residents and observation residents who could make decisions were encouraged to do so. It was not possible to access how this standard was met from the perspective of the less able residents. Feedback received from relatives indicated staff involved them in making decisions on behalf of residents and discussed how resident’s care needs were to be met. Relatives said they were made feel welcome when visiting and were offered refreshments. A menu seen indicated residents were provided with a varied diet and a choice of meal. No concerns were raised about the food provided by residents or relatives. Lunch was observed and residents had a choice of meal, were satisfied with the portion offered, said or indicated they enjoyed the meal and staff assisted residents where needed. Residents were weighed monthly and a system in place to refer residents for professional advice if this was indicated. A number of residents had been prescribed food supplements to help maintain body weight. The weighing scales had been serviced on 28th September 2006 to ensure accuracy. Since the last inspection the kitchen had been repainted, all equipment was in good working order and the kitchen was clean and tidy. The cleaning schedule and temperature checks of food storage and cooked foods were up to date. Plans were in place to replace the kitchen floor. Adequate food stocks were seen. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems were in place to manage complaints and allegations or suspicions of abuse. EVIDENCE: Policies and procedures were provided in relation to management of complaints and safeguarding adults. Since the last inspection records seen showed that two complaints had been made about the service and these had been managed appropriately. Residents spoken with and feedback received from relatives indicated they were aware of the home’s complaint procedure and how to make a complaint. Relatives said they would always speak to the staff on duty or see the manager if they had a concern. No allegations or suspicions of abuse had been reported to the home or the Commission since the last inspection. Staff spoken with displayed an awareness of adult protection. Staff had received training on safeguarding adults since the last inspection. Some staff seen had difficulty with the English language and it was not possible to assess their understanding of safeguarding adults. Other staff spoken with displayed a good understanding of the subject. (Please see comments under standard 29). Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 23, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy, well maintained and satisfactorily decorated. Bedrooms, bathing and toilet facilities seen were satisfactory. The home still has one triple bedroom in use. Adequate systems were in place to enable staff to practice infection control. EVIDENCE: The home was clean, tidy and free of offensive odours. The home was decorated, furnished and fitted to a satisfactory standard. Since the last inspection some redecoration had been carried out and a new carpet laid in the lounge. Residents had begun to sit in and enjoy the conservatory. A maintenance book was kept where staff recorded issues requiring attention. A maintenance technician visited on request to carry out repairs. The records seen showed that repairs were addressed within acceptable time limits. The property had a well maintained rear garden with a patio, water feature and seating provided for resident comfort and enjoyment. Recommendation 3. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 15 Adequate bathing and toilet facilities were provided for residents. Bathrooms and toilets seen were clean and tidy and no maintenance issues noted. A number of bedrooms were viewed. These were clean, tidy, satisfactorily decorated and included resident’s personal items. Screening was provided in shared rooms. No maintenance issues were noted in the bedrooms seen. Residents and relatives were satisfied with the environment and those in shared rooms did not find this a problem. The registered person had agreed with the Commission to use the triple bedroom as a double from December 2006 but this had not happened. The registered person said that he had agreed with the relatives of the current occupants of the triple room that the residents would continue to occupy the room for the remainder of their lives. When a vacancy arises the registered person said the room would be used as a double. The registered person must keep the Commission informed of any changes to this situation or to the number of beds registered. Requirement 2. As mentioned the home was clean, tidy and odour free. Hand washing facilities were provided where waste was handled. Staff said they had access to adequate supplies of protective clothing. A housekeeper was employed and said a schedule for general cleaning and ‘spring cleaning’ regularly was in place. The person said they had received some training such as moving & handling, fire safety, dementia and safeguarding adults. Relatives said the home was kept clean, tidy and odour free. A relative commented on how nicely and naturally the housekeeper interacted with residents. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were some occasions when staffing levels on the morning shift were inadequate. 50 of care staff had NVQ 2 qualification or above. Recruitment procedures were satisfactory and an induction programme was being developed. Staff received training relevant to the work they perform. EVIDENCE: The staff team comprised of a manager, trained nurses, care assistants and ancillary staff. Staff rotas were viewed for a two-week period and showed adequate staffing levels were maintained. Residents and relatives gave positive feedback on staff and comments made by relatives included “staff always considered residents needs”, “everyone is very friendly” and “it’s a very well run home with caring staff. Staff rosters for a two-week period were viewed. These showed that on some morning shifts staffing levels were inadequate. The manager said that the staff rosters seen were not accurate, as they did not include some staff hours including some hours he spent in the home. The need to maintain adequate staffing levels on all shifts and accurate rosters was discussed with the manager. Requirement 3. From the information provided by the registered person ten care assistants were employed and six of these had achieved NVQ 2 qualification or above. The home had therefore met the standard to have 50 of care staff with this level of qualification. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 17 Three employee files were viewed. All but one file included the information required by regulation. This file was for a care assistant who had not actually commenced work required a second reference. One file for one of the kitchen staff did not include a CRB check and it was unclear what level of supervision this employee had when on duty while waiting the outcome of the CRB check. One of the files seen contained some evidence of induction. The registered person said that he was working on a new induction programme with the training consultant. One relative said that ‘staff turnover was high’ and some relatives commented on difficulty communicating with staff when English was not their first language. The inspector also found it difficult to communicate with some staff for this reason. The registered person said that currently one care assistant was attending college to improve their English and another was due to start in September 2007. Requirement 4 and recommendation 4. The training consultant had worked with the registered person to develop a staff training plan based on training needs identified through supervision. Individual training records were maintained for staff and five seen showed that all staff had received three days training in the last year. Training provided included moving & handling, safeguarding adults, infection control, dementia care, food hygiene and fire safety. Staff spoken with said they had the opportunity to attend training relevant to their work. Work to provide a staff induction programme was slow to progress. Requirement 5. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was managed satisfactorily and attention was given to providing a safe environment. The registered person did not manage personal finances for residents. Plans were in place to develop a quality assurance system but this has been slow to develop and will require further review. EVIDENCE: The registered manager was also the registered provider. He is registered with the Commission and divides his time between working shifts and management days. A part-time person was employed to assist the manager with administration work. The home was well managed and residents and relatives agreed with this view. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 19 The registered provider was also the manager therefore he did not have to comply with regulation 26. Being a small home the manager met regularly with relatives and held relative meetings as part of a social event such as a cheese and wine evening. The manager had introduced a ‘Newsletter’ for the service and when this was written a copy was sent to all relatives and a copy made available to residents. Staff meetings were held and minutes were seen for the last meeting held. Formal resident meetings were not held as the registered person was in regular contact with them and many residents could not participate. The registered person was developing a satisfaction questionnaire to send to residents, relatives and others but there was currently no quality assurance system in place. The manager had introduced specific audits for example on the environment, the kitchen and medicine management. He planned to include in the quality review information obtained from relatives through general and one to one meetings, use of an annual satisfaction questionnaire and the introduction of a ‘suggestion box’. This system was in the development stages and was slow to progress. Advances made with and implementation of the quality assurance system will be reviewed at future inspections. Requirement 5. The registered person did not manage personal allowances for residents. Residents requiring money could access this from petty cash and the registered person invoiced the resident or relative. Receipts were obtained for resident personal expenditure such as hairdressing, chiropody and personal shopping and the resident or relatives invoiced for the money. A system was in place to provide staff supervision and the registered person worked with staff on the floor and had the opportunity to observe practice. Supervision records were seen for four care and two domestic staff. Staff confirmed they received regular supervision and found this beneficial to their work in the home. A maintenance book was kept and staff recorded repairs needed. A handyman visited and completed repairs identified. On the day of the inspection a repair and maintenance issues were being addressed. A number of safety records were viewed including service for the lift, moving & handling equipment, fire alarm, electricity supply, portable appliance testing, gas safety certificate and hot water temperature monitoring. All records seen were up to date. The fire alarm was tested weekly and fire drills held at regular intervals and at times to include both day and night staff. A fire risk assessment for the premises was completed in 2006 and an evacuation policy and procedure was provided. Accident records were seen and were well completed. Two accidents involving residents had been recorded since the last inspection and neither resident required medical attention. A risk assessment had been introduced in relation to the use of bedrails. The manager was pleased to report that based on completion of this assessment the use of bedrails had reduced in the home. Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered person must ensure accurate records are kept for medicines and any drug errors are investigated and reported to the Commission. The medicine management policy must include the action to be taken if a resident goes on leave from the home. The registered person must inform the Commission in writing of the action and timescale in place to use the triple bedroom as a double bedroom. The registered person must ensure adequate staffing levels are maintained on all shifts and accurate records are kept to show who was on duty in the home at all times. The registered person must ensure that staff commencing work before a CRB check is received are supervised when on duty. Records must be kept to show who acted as supervision on every shift. The registered person must ensure staff have access a DS0000006765.V342985.R01.S.doc Timescale for action 19/10/07 2 OP23 23 19/10/07 3 OP27 18 12/10/07 4 OP29 18 19/10/07 5 OP30 18 19/10/07 Lyndhurst Nursing Home Version 5.2 Page 22 5 OP33 24 structured induction programme that meets the National Training Organisation specification. (Timescale of 9/4/07 was not met). The registered person must ensure the planned quality assurance system is developed and implemented. 19/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations The registered person should ensure that a night care plan is prepared for each resident. The registered person should ensure a medicine profile is kept for each resident, that staff competency in relation to medicine management is assessed annually and that a protocol is provided for the administration of ‘as required’ medicines to residents with poor communication. The registered person should ensure that more suitable armchairs are provided for residents who need them in the lounge. The registered person should ensure that staff recruited have enough understanding of the English language to enable the current residents to communicate with them. 3 4 OP19 OP29 Lyndhurst Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Nursing Home DS0000006765.V342985.R01.S.doc Version 5.2 Page 24 - 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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