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Inspection on 18/12/06 for Lyndhurst Park Nursing & Residential Care Home

Also see our care home review for Lyndhurst Park Nursing & Residential Care Home for more information

This inspection was carried out on 18th December 2006.

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

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

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

The staff work well as a team and ensure the well-being and comfort of the residents` and treat them with great respect and kindness. For example 4 residents spoken with said, "the home is lovely, the staff are kind and caring, and the food is good." There is a good rapport between staff and residents and occupancy level are consistently high. Meals are varied, healthy and nicely presented offering choice and variety. Residents` health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One relative said `the home is excellent.`

What has improved since the last inspection?

A new system for the safe storage, handling and administration of medicines has been implemented for the safety of patients. Staff say it is working well, and makes administration safer. The information contained in the complaints procedure has been updated and residents and relatives are aware of its contents.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Lyndhurst Park Nursing & Residential Care Home 33-35 Severn Road Weston Super Mare North Somerset BS23 1DW Lead Inspector Patricia Hellier Unannounced Inspection 18th December 2006 09:30 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 Park Nursing & Residential Care Home DS0000020359.V316254.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 Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Park Nursing & Residential Care Home Address 33-35 Severn Road Weston Super Mare North Somerset BS23 1DW 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) 01934 627471 01934 627518 Mrs Margaret Ann Butcher Mr Gordon Butcher Mrs Margaret Ann Butcher Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (1) of places Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 27 persons aged 65 years and over, who require nursing care Manager must be a RN on part 1 or 12 of the NMC register May accommodate one person between 50 - 64 years of age, with Physical disabilities who may require nursing care. 13th February 2006 Date of last inspection Brief Description of the Service: Lyndhurst Park Nursing and Residential Care Home is situated in a quiet residential area of Weston-Super-Mare to the south of the town. The sea front is only a short walking distance away and is within close to proximity to some local shops and amenities. The proprietors of this family run home and are very involved in the day-to-day running. The building and décor is of a high standard providing a comfortable and homely environment. Accommodation is provided over two floors with a passenger lift giving easy access to all floors. There are twenty-six single rooms, and one that may be shared. Some of these have en-suite facilities and all have a call bell system. Communal space is provided in 2 lounges and a dining room in the main building, and a recently built conservatory. This includes a water feature and pond and is much appreciated by the residents. Provision is made within the home for a variety of activities and outings, which also enable close links with the local community to be maintained. All local facilities are within easy walking distance but some are closed in winter. The provider makes information available through a booklet about the home on request. CSCI reports are displayed in the entrance to the home and available for all to read. The fess range from £494.25 - £560 per week with additional charges being made for hairdressing, chiropody, newspapers, outings, aromatherapy, optician. This information was provided in November 2006. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over 5 hours. The Registered Provider and Manager, Mr and Mrs Butcher, were present throughout. Before the inspection the information about the home was received from the pre inspection questionnaire and comment cards received from 3 residents and 1 Health Care Professional. The last inspection report was reviewed and all correspondence since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 7 residents, 3 relatives, and 5 staff; observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. Of the 6 resident surveys sent 3 were returned and all were satisfied with the care they received. All said the home is clean and fresh, and that they would know who to speak to if they were unhappy. Comments from residents were “this is a happy home”, “the staff are very thoughtful”, “many word of mouth recommendations about the home locally.” All relatives spoken with felt welcomed at the home and that they were consulted regarding their relatives care and needs. Comments included “the staff are very friendly and welcoming”, “the staff’s kindness and care help my relative to settle in”. Surveys were sent to 5 Health Care Professionals that visit the home and 1 was returned. They felt that the care given is good and that the home works in close partnership with them incorporating specialist advice into the care given to enhance the health and well being of residents. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “I would recommend it to anyone”, “my relatives care needs are well met”. What the service does well: The staff work well as a team and ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. For example 4 residents spoken with said, “the home is lovely, the staff are kind and caring, and the food is good.” There is a good rapport between staff and residents and occupancy level are consistently high. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 6 Meals are varied, healthy and nicely presented offering choice and variety. Residents’ health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One relative said ‘the home is excellent.’ What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The 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 Park Nursing & Residential Care Home DS0000020359.V316254.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 Park Nursing & Residential Care Home DS0000020359.V316254.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): 1,2,3,4,5 (6) does not apply Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they or their relatives have access to the relevant information at all times. All residents who returned surveys stated they had received contracts, or Terms and Conditions of Residency documents. Contracts inspected showed clear identification of fees to be charged and how the Registered Nursing Care contribution is used. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 9 Care needs are well met through a full assessment process and the completion of a care plan from this information. The assessment includes all the elements listed in the standard. A comprehensive assessment was seen for a newly admitted resident. The resident when spoken to said ‘they are very kind, know what I need and look after me well’. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. . Risks to residents are fully assessed and actions to minimise these planned, for the safeguarding of residents. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Three care plans were inspected and all clearly reflected current identified health and social care needs. Good practice was seen in two care plans that all care needs were referenced to psychological needs. Clear actions to meet identified needs were recorded and regular evaluation noted. All care plans showed resident or relative involvement. All care plans contained Manual Handling, nutrition, falls and pressure sore risk assessments, with the outcomes being used to inform the provision of care. Other personal and Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 11 environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. Daily records were up to date and written in a respectful manner. All residents were neatly dressed, and attention had been paid to hair and nail care. Detailed conversations with six of the residents confirmed a good standard of nursing and personal care. Comments made were – “the staff are very nice”, “staff are always kind and approachable – nothing is too much bother”; “I’m very happy here”. One relative praised the home for the way in which their mother is cared for, “it’s like the best of hotels, and they have all the specialist equipment needed to help mum”. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. One resident said ‘they always do things the way I like, and if I want to get up later they let me’. The newly implemented systems in place for the management of medicines are good, and staff felt that it provided better and safer practice. Hand transcribed prescriptions were seen on the Medication Administration Records and these had not been signed by two members of staff when written; thus not providing the recommended safeguard for residents. The area where medication is stored, in the centre of the building can get hot and the temperature may rise above 25°C, which is too high for the safe storage of medicines. Checks to the temperature of the storage area are recommended. All residents spoken with felt that kind and caring staff respected their dignity and privacy. One resident stating “they always knock on the door”; and another said, “they are always polite and ask what I would like”. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. In discussion with the manager and staff these issues have not yet arisen within the service provision. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents right to choice and control over their lives is well respected, and encouraged. Autonomy and personal choice is promoted, helping residents to maintain independence. Friendly staff always welcomes relatives and visitors. EVIDENCE: An excellent range of activities is provided with posters displaying information of forthcoming events throughout the home. Residents spoken with said, “we have plenty of choice and variety”. One resident said, “the activities are marvellous”. The activities organiser works hard to provide a varied programme with activities that will appeal to all. Resident survey responses showed that most people feel that there are usually, or always, activities arranged that they could take part in. Spiritual needs are catered for and local clergy visit as requested. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 13 Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt that their relatives were well looked after by friendly staff. One relative said, “the staff are so patient and residents never look untidy or uncomfortable”. Choice and preference is well respected. There was evidence of a good rapport between residents and staff, with lots of laughter and encouragement. Care records contained clear information about their likes and dislikes and residents’ preferred daily routine. The kitchen is clean, tidy and well organised. The lunch served during the inspection looked appetising and well presented. Good practice was seen in the dining room with the use of plate guards to assist residents in getting their food onto the fork/spoon. Good practice was also seen in the manner in which care staff were helping residents with their meal. One incident of poor practice was observed, but was quickly rectified by the manager when she observed this. All residents spoken with about the food said ‘it is good’. Many said they “ like the meals, and the choices offered”. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. All relatives and residents spoken with were aware of the complaints policy. There has been one complaint since the last inspection, which has been fully resolved. All residents stated that if they were not happy about anything they would speak to the manager. Staff and residents spoken to, say the manager is very approachable and understanding. One service user said ‘I’ve nothing to complain about, it’s a lovely home”. A record of complaints received, with actions taken and outcomes is kept to show residents are responded to, and the information used to inform the running of the home for the residents’ benefit. A comprehensive policy and procedure for responding to allegations of abuse is available, together with the Local Adult Protection guidelines. The home also has a Whislteblowing policy and staff said they would report any concerns to the manager. . Staff said they had never seen any signs of abuse in the home and demonstrated a good understanding of what abuse is. Staff have received Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 15 training in the recognition and handling of abusive situations for the safeguarding of residents. Care plans inspected showed that consent for the use of bedrails and recliner chairs had been obtained from residents or relatives thus safeguarding choice. All residents spoken with said ‘the staff are very kind’; ‘they take time to help me’; ‘I can’t fault them’. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with homely, safe and comfortable surroundings. . The home has suitable equipment to maximise resident independence. Robust Infection Control practices are followed. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. The living accommodation is well decorated and homely. Residents’ rooms are personalised and comfortable. All rooms are provided with ensuite facilities. The décor, fixtures and fittings are in excellent order. Maintenance and refurbishment plans and records are kept, to ensure the homes’ environment is maintained at a high standard. Since the last inspection the home has had a fire in the dining room and courtyard area of the home. Since then this area has been reconstructed and Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 17 decorated, providing a more spacious dining area, together with a pleasant atmosphere. Many areas of the home have also been redecorated and new carpet has been fitted throughout, providing a tasteful décor. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility, and aid independence within the home. All resident rooms are provided with a lockable space for securing personal possessions, if desired, and door locks that are accessible to staff in an emergency. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. The washing machines seen were covered with soggy soap powder and areas of the floor were unclean with spilt soapy water and powder. This is a potential source of infection spread, and should be kept clean to safeguard residents. When pointed out the provider the area was cleaned immediately. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. The home has good facilities for ensuring that staff can maintain good hand washing practices, between caring for residents. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are sufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide the safeguards required for residents’ protection. Staff access external training to ensure training is matched to the residents needs. EVIDENCE: Staff went about their duties in an unhurried manner and were observed spending time talking with residents. Residents reported, “staff make time for a chat when they can.” Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “ the staff are very good”. Copies of two weeks staffing rosters were supplied to the inspector. Staffing levels rostered are in accordance with CSCI requirements. A sufficient team of ancillary workers supports care and nursing staff to ensure the smooth running of the service. Residents spoken with told the inspector “staff are always there when you need them”; “ you only have to ring the bell and they come”. Staff interviewed said that they were kept busy, but still had time to chat with the residents. Call bells were answered promptly during the inspection. The home has a Key Worker system in place for all residents. Relatives were aware of the role and said, “it worked well”. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 19 A few of the staff team employed at the home are from overseas. Residents and staff said, “they fit into the team well”. Recruitment procedures are robust and all four files inspected contained the required documentation. All staff interviewed stated they had contracts of employment and job descriptions. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen in personnel files. The home provides all induction and in house training. Evidence of specialist training accessed through the Primary Care Trust and other sources was seen e.g. stroke awareness. . Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Quality assurance processes in the home are formal demonstrating that the home consults with residents, families and visiting professionals. The management of resident’s monies in the home are well managed. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. Staff interviewed stated that they felt well supported by an approachable manager. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 21 A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents, and that comments from them are acted upon. Feedback to residents and relatives is provided through the displaying of results, and discussion of these at residents / relatives meetings. The results are also discussed at staff meetings to inform practice and implement changes for the benefit of residents’ health and well-being. Residents and relatives told the inspector that they were always encouraged to express their view and “to air the grumbles”. One resident said, “the manager is very proactive and helpful in many ways”. The provider has recently taken on an administrator to assist with the administration of the home and to develop and implement a new quality assurance process. He and the manager are aware of the new developments within care regulation and are developing their Quality Assurance with the forthcoming changes required. This is to be commended. The management of resident monies by the home were inspected. Small amounts of cash are held for some residents for the purchase of toiletries and the hairdresser. Monies inspected tallied but and receipts were present. Supervision for staff takes place on an informal basis during the year culminating in an appraisal. Staff interviewed said ‘supervision does take place sometimes’, but were not aware of formal records. Records inspected for supervision were minimal. A more formal system of documented supervision, six times a year, should be implemented to ensure staff have received the knowledge and skills to meet residents’ needs. Staff interviewed confirmed that informal supervision takes place every 3-4 months when they are working with a senior member of staff. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. A number of staff have received First Aid training. Records indicating regular maintenance to gas and water systems were seen, together with servicing records for all equipment. Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 4 3 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 2 3 3 Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP9 OP26 OP36 Good Practice Recommendations To ensure two members of staff sign hand written entries on Medication Administration Records. Monitor the temperatures of the area in which medicines are kept to ensure it is below 25°C, for safekeeping. Maintain clean surfaces and floors within the laundry to prevent the spread of infection. To ensure that supervision is formally provided six times a year and clearly documented Lyndhurst Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Park Nursing & Residential Care Home DS0000020359.V316254.R01.S.doc Version 5.2 Page 25 - 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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