Inspection on 28/02/06 for Lyndon Croft Care Centre

This inspection was carried out on 28th February 2006.

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

Lyndon Croft Care Centre 21/01/08

Lyndon Croft Care Centre 11/07/06

Lyndon Croft Care Centre 26/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lyndon Croft Care Centre Ulleries Road Solihull West Midlands Lead Inspector Lisa Evitts Unannounced Inspection 28th February 2006 09:50 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 Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lyndon Croft Care Centre Address Ulleries Road Solihull West Midlands 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) 0121 742 3562 0121 742 3562 Prime Life Ltd Care Home 52 Category(ies) of Dementia - over 65 years of age (52) registration, with number of places Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Registered to provide care for up to 52 older people for reasons of dementia 52DE/E For full occupancy, 7 care workers are to be on duty throughout waking hours, including one of whom is designated as a senior member of staff. For full occupancy, 3 care workers are to be on waking duty throughout night time hours, including one of whom is designated as a senior member of staff That the home may accommodate 1 named service user who is in need of care for reasons of old age. Registration Category 1(OP). 26th July 2005 Date of last inspection Brief Description of the Service: Lyndon Croft first opened in January 2005 and is a custom built facility owned by Prime Life Ltd providing residential care for 52 older people over the age of 65 years with dementia care needs. All beds are contracted with Solihull Metropolitan Borough Council. The home is spacious and accommodation is provided over two floors. All bedrooms are for single occupancy with an en suite facility that includes a walk in shower. All rooms offer an excellent standard of accommodation and include all of the furnishings and fittings as required by the National Minimum Standards. The ground floor rooms have an adjoining patio and there is an attractive enclosed garden for all residents to enjoy. There are numerous lounge and dining areas in the home and these have all been furnished and equipped to a high standard. Meals are cooked on site and the home offers a full laundry service for people living there. The home has one passenger lift and one service lift. There is ample car parking space to the front and side of the building. The home is located in a residetial area of Solihull and is close to shops and public transport links. Residents are permitted to smoke at the home following individual assessments. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by two inspectors over one day and were assisted throughout by the Manager. There were 51 residents living at the home on the day of the inspection and one of these residents was currently in hospital. Information was gathered from speaking to residents, from observing care staff perform their duties, and examining care and health and safety records. A partial tour of the building was undertaken. This is the second statutory inspection for the 2005-2006 year and it is recommended that this report be read in conjunction with the previous inspection report for the year. Two immediate requirements were made on the day of the inspection. Staff were receiving fire and food hygiene training on the day of the inspection and a fire drill was carried out. What the service does well: What has improved since the last inspection? The home has started to implement a new care planning system in order to ensure that specific actions are documented for care staff to follow to ensure that care needs are met. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 6 The home has worked towards meeting a number of requirements made at the previous inspection. Some staff have received training in the Safe Handling of Medicines and some staff are in the process of completing a course specific to Dementia care. 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. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The assessment processes are comprehensive and ensure that the resident knows that their assessed needs can be met. EVIDENCE: Four residents files were sampled and they all included a comprehensive pre admission assessment. These ensured that the staff at the home knew and were able to meet the needs of the prospective residents. The home does not offer intermediate care services. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 Resident’s health and personal care needs were generally well met by the care staff. The new care planning system in the home was good and needed to be put in place for all residents detailing how their individual needs are to be met. Residents are cared for in a respectful manner however staff must ensure that privacy is maintained. EVIDENCE: The manager has introduced a new set of documentation for the care planning system and it is recognised that there will be some problems to work through in the initial stages and that the process of changing the care plans over will take some time. Four care files were reviewed, this included two files with the new documentation. All files had had pre admission assessments undertaken; care plans were then devised from this information and further information obtained at the admission assessment. A number of care plans had good details of the specific help that a resident needed or details of what the resident was able to do for themselves, but this was not consistent across all files. Some personal preferences were recorded. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 10 Continence care plans did not provide details of the type of aids required, if the resident knew they needed to go to the toilet or if they required prompting. Care plans for disorientation had been written and provided details of actions to follow to help to reduce this. Not all care plans had been evaluated monthly and one care plan had only been evaluated twice in nine months. This does not ensure that care plans are providing up to date information for care staff to follow. The new care plans that were reviewed were found to contain much more detail and were consistent. It appeared there were several pages in the care plans that were not required and it is recommended that these be filed separately, to ease with monitoring. Key workers were identified and one resident said, “I’ve got a key worker and I’ve seen my care plans” This shows this evidenced that residents who are able are involved in the planning of their care. Daily records were informative but contained information on some occasions that had not been transferred onto care plans. An example of this was a dressing, which was recorded as being changed, but there was no evidence of any sores previously. Another sore identified had no follow up action recorded so the outcome of this was not clear. Nutritional screening for one resident had not been completed. There was evidence that residents weight is monitored, but this was not always monitored monthly. Weights had been recorded more regularly in December and January. A falls risk assessment was not in place on one file and the resident had a history of falls within the home. Two files did not have manual handling risk assessments completed and this does not afford protection to the resident or staff. Tissue viability assessments did not include the action to be taken by staff when the residents were identified as being at risk and some were not fully completed or dated when the assessment took place. Assessments were not reviewed regularly as one assessment was undertaken in April 2005 but had not been reviewed since. There was evidence of visiting healthcare professionals such as GPs, opticians, chiropodists and support services. The medication management was not reviewed on this occasion. Residents were well supported to meet their hygiene needs and were dressed appropriately for the time of the year. Whilst the inspectors were talking to a resident in her room, a member of staff entered the room without knocking and this does not ensure that the privacy of residents is maintained. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion but were reviewed at the last inspection. EVIDENCE: Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16, 18 The home has a comprehensive complaints procedure in place but documentation of investigations undertaken and any outcomes and future action to improve the service is inadequate. To ensure the safety of the residents, the adult protection procedures needed to be further developed so that staff have guidelines to follow in the event of an allegation of abuse. EVIDENCE: The home had recorded five complaints since the last inspection. Documentation of the responses and outcomes was inadequate and some complaints had no responses on file, therefore the inspectors were unable to determine if the complaints had been resolved satisfactorily. Complaints must have an outcome recorded and any documentation of investigations undertaken should be kept alongside the complaint. The complaints recorded were of similar themes and it is recommended that an audit log is maintained which will identify trends or reoccurrences of complaints, in order for appropriate actions to be taken. Staff have received training in Protection Of Vulnerable Adults. The homes adult protection policy incorporated the Department of Health’s publication “No Secrets” and was easy to follow. The policy requires amending to include contact details of social services and CSCI. The home does not have a copy of the Solihull Multi Agency Guidelines and it is required that a copy of this document is obtained. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 13 The accident book identified two issues that potentially could have been deemed as adult protection, however the accidents were not fully explained and the accident book does not allow for full recording of explanations or actions taken. CSCI and appropriate authorities must be informed of any incident of a possible adult protection nature. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 26 Lyndon Croft provides a safe and comfortable environment in which to live. Improvements are required to the cleanliness of the home. EVIDENCE: Decorators were on site on the day of the inspection who were painting any areas as needed, due to the building being a year old. A partial tour of the building was undertaken. Toilet doors are painted blue and this aids residents to identify the facilities available. The home has five assisted bathing facilities and these were decorated in a homely style. There are lots of smaller seating areas throughout the home and this enables the residents to move freely about the home and to feel secure in their surroundings. Corridors are wide and spacious and allow residents to move throughout the home as they wish, in a safe environment. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 15 Some bedrooms had photographs of the occupants on the doors to assist residents to identify their own rooms and the home plans to introduce “memory boxes” in the future to further assist residents to identify their own rooms. Bedrooms seen were personalised to reflect individual tastes and ensure the residents were in as familiar environment as possible. Doorknockers were available for use on entering rooms. One resident said “Its a very nice place here” During the tour it was noted that some areas of the home were dusty and some of the furnishings were soiled, due to the nature of the material. Tables were noted to be sticky and skirting boards required cleaning. One bedroom reviewed was quite dusty and some complaints recorded by the home were regarding cleanliness. One resident stated, “They clean the toilet and vacuum everyday” As discussed under standard 27 the home manager is to review the amount of domestic hours. The home was odour free on the day of the inspection. The home has an attractive garden area, with gravel paths leading around to a water feature. Inspectors were concerned that the gravel paths may be unstable for residents and pose a potential trip hazard and it is required that this is included in the risk assessment as discussed under standard 38. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The home has adequate numbers of staff on duty to meet the assessed needs of residents. Improvements are required to the recruitment process to ensure that residents are protected. EVIDENCE: The home did not have any staff vacancies at the time of the inspection. Staffing levels identified that the home have adequate numbers of staff on duty. Sickness and absence was clearly recorded on the rotas. The staffing rotas did not identify the surnames of staff employed at the home and it was previously recommended that the rotas are changed and this is included. A condition of registration is that a member of staff is designated as a senior. This is identified on the daily staff rota but not on the night rota and it is required that the manager forwards confirmation to CSCI that a senior member of staff is on duty during the night. The home currently has 6 staff members who have completed NVQ Level 2 and a further 10 are currently working towards achieving the qualification. The home should work towards achieving the recommended 50 of care staff who hold this qualification. The homes secretary is working towards an NVQ in administration. Laundry, domestic and kitchen staff provide ancillary support to the home. Domestic staff work Monday to Friday. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 17 There is no domestic cover at the weekends. During the tour it was noted that some areas of the home were dusty and some of the furnishings were soiled. One bedroom reviewed was quite dusty and some complaints recorded by the home were regarding cleanliness. This was discussed with the manager on the day of the inspection and it is required that a review of the domestic staffing levels and weekend cover for domestics is reviewed. Some complaints recorded by the home were also regarding laundry not being available or missing items. One resident said, “I never get any ironing done”. There is currently one member of staff employed for the laundry and in her absence care staff are rotered on duty to undertake this task. It is required that the home manager reviews the amount of hours allocated for laundry to be undertaken and review the current system. Recruitment practice was poor and does not ensure that residents are safeguarded from harm. Two staff files were reviewed and both members of staff had commenced employment at the home prior to POVA first checks being received and this does not ensure that residents are protected. An immediate requirement was made that all new staff must have a POVA first check in place prior to commencing employment at the home. Both files reviewed had one reference from family members and this is not appropriate, an immediate requirement was made that the manager must review the appropriateness of where the references are obtained. One file had a reference from the last employer but the second file had not requested a reference from the college where the staff member was currently studying. No interview notes were recorded and it is recommended that notes are recorded at interview to evidence any questions asked and the answers received. Health declarations were available and Working Time Disclaimers had been signed for staff working in excess of their contracted hours. 16 staff are currently enrolled onto a distance learning dementia care course. A copy of the staff-training matrix was taken for review and identified that some members of staff required updates for moving and handling training. It is required that the manager ensures the training matrix has up to date information available and ensures that the identified staff have received an update. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The manager has previous experience of managing care homes. There is a robust system in place for the management of personal finances. Resident’s health and safety is at risk until some health and safety issues are addressed. EVIDENCE: The manager has been in post since November 2005 and was in the process of completing application forms for the registered managers position. The manager has previous experience of managing homes and has been the registered manager for other establishments. The manager has the Registered Managers Award and is currently working towards NVQ Level 4 in Care. She has also completed a dementia training course. Two senior carers and a secretary support the manager, and the manager receives visits from external managers every two weeks. The manager stated that she “likes to go and work alongside the staff on the floor”. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 19 The company send out questionnaires twice yearly and the response is collated by head office once a year. No audit has taken place at Lyndon croft, and this must now be addressed, as the home has been open for just over a year. Senior Managers undertake regulation 26 visits and copies of these reports were available for review. Senior care meetings are held on a monthly basis and the minutes of the February meeting were available for review. Staff meetings are held every eight weeks. Residents meetings are not held at the moment but the manager aims to do this in the future. The home currently manages the personal monies of eight residents. The system was found to be robust with two signatures for debits and credits and receipts available. Balances checked were correct. It was noted that the home had responsibility for the safe keeping of one residents cheque book and cash card, and it is recommended that a record of this is kept separately. Personal finances are audited regularly by head office. Fire records were reviewed and the fire risk assessment had been completed in August 2005. Fire alarms are tested on a weekly basis. The last recorded fire drill was March 2005, the manager stated that further fire drills have been undertaken but had not been documented. A fire drill took place during the inspection and it is required that the names of staff attending fire drills and the dates fire drills are undertaken are recorded to ensure that all staff receive training and have the knowledge and competence to act appropriately in the event of a fire occurring. The risk assessment in respect of the garden water feature had been undertaken but this requires further development to include other identified hazards throughout the garden area. Staff do not always record accidents, as two incidents were identified from the daily records that were not in the accident book and this does not ensure that residents are safeguarded. The accident book identified two issues that potentially could have been deemed as adult protection, however the accidents were not fully explained and the accident book does not allow for full recording of explanations or actions taken. CSCI and appropriate authorities must be informed of any incident of a possible adult protection nature. It is recommended that a alternative book for recording of accidents is sought. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 4 4 X 4 4 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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 OP7 Regulation 15 Requirement The care planning system must be further developed to include the following: Physical health care needs Activities Oral hygiene needs Evidence of monthly reviews Evidence of involvement of residents or their representatives in agreeing the care plans. Previous timescale of 01/10/05 partially met. Continence aids required. Falls risk assessments. Moving & Handling assessments. Tissue Viability assessments must be completed. Nutritional screening must be completed for all residents and must be reviewed periodically. Staff must ensure that any new identified problems are recorded on a plan of care to ensure that progress is monitored and an outcome recorded. The quantity of medicines received (or balance carried over DS0000063159.V284966.R01.S.doc Timescale for action 23/05/06 2. 3. OP8 OP8 12(1) 15(2)(b) 25/04/06 21/04/06 4. OP9 13(2) 24/04/06 Lyndon Croft Care Centre Version 5.1 Page 22 5. OP9 13(2) 6. 7. OP10 OP15 12(4)(a) 17(2) Sch 4 from previous cycles) must be recorded on the Medicine Administration Record (MAR) chart to enable accurate audits to be undertaken. All mediaction available for administration must be recorded on the MAR chart. Staff must refer to the MAR chart before administration and sign directly after the transaction or record the reasons for nonadministration at all times. Previous timescale of 28/07/05 not assessed on this occasion. Regular staff drug audits must 30/04/06 be undertaken before and after a medicine round to confirm staff competence in the administration and recording of medicines. Previous timescale of 02/08/05 not met. Staff must respect resident’s 03/03/06 privacy and knock on doors prior to entering the room. A daily record of food provided 15/09/06 for residents must be kept in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual residents. (Not assessed on this occasion) Complaint investigations must be 10/04/06 recorded along with the outcome. The adult protection policy must 31/03/06 include contact details of the local authorities and CSCI. Staff must inform relevant agencies of any incidents, which may be deemed as adult protection. The manager must obtain a copy 8. 9. OP16 OP18 22(3)(4) 13(6) 37 Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 23 10. OP27OP26 16(2)(e,j) 18(1)(a) of the multi agency guidelines for Solihull area. The manager must review the amount of domestic hours allocated and ensure that all areas of the home are clean and dust free. 17/04/06 11. OP27 18(1)(a) 12. OP29 13(6) 19(1) The manager must review the amount of hours allocated to the laundry and the review the current working system. The manager must forward 14/04/06 confirmation that a designated senior is on duty throughout the night. Staff must not commence 28/02/06 employment at the home without satisfactory POVA first checks being received. The Registered Manager received this in the form of an immediate requirement. 28/02/06 The Registered Person must obtain two appropriate satisfactory references for all staff prior to them commencing employment at the Home. The Registered Manager received this in the form of an immediate requirement Previous immediate requirement timescale of 26/07/05 not met. The manager must ensure that the training matrix is up to date and that staff have received mandatory training. A quality assurance audit must be undertaken and a report must be available. A written record of formal staff supervision must be kept. (Not assessed on this occasion) Fire drills and names of staff attending must be recorded to DS0000063159.V284966.R01.S.doc 13. OP29 19(1) 14. OP30 18(1)(c) (i) 24 18(2) 22(4)(e) 30/04/06 15. 16. 17. OP33 OP36 OP38 02/06/06 01/10/06 07/04/06 Page 24 Lyndon Croft Care Centre Version 5.1 18. 19. OP38 OP38 13(4) Sch 3(j) 13(4) ensure that all staff receive training twice a year. Staff must ensure that all accidents are recorded on an accident from. Risk assessments in respect of the garden area need to be further developed. 01/05/06 28/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP7 OP9 Good Practice Recommendations The location of where the pre admission assessment took place should be documented on the assessment record. Additional documentation in care files not in use should be filed separately for ease of monitoring the file in use. Staff should install a facing page for each service users Medicine Administration Record (MAR) chart and all page numbers must be written for each MAR chart. E.g. 1 of 2, 2 of 2 and the photocopied prescription kept alongside the MAR chart for future reference. Risk assessments in respect of bedroom door locks should be available on all residents’ files. An audit of complaints should be maintained to identify any trends or reoccurrences. It is recommended that the staffing rotas identify the surnames of staff employed at the home and the format of the rotas be revised for ease of calculating actual staff hours worked. Detail of the on call arrangements for the home should be identified on the staffing rotas. The home should work towards achieving 50 of care staff that have NVQ Level 2. It is recommended that interview notes are kept in order to evidence the information that is given and received in respect of prospective employees during their interviews. A residents meeting should be arranged. The Manager should audit all accidents involving residents living at the home and maintain a written record of any follow up action taken on the accident record for ease of auditing. DS0000063159.V284966.R01.S.doc Version 5.1 Page 25 4. 5. 6. OP10 OP16 OP27 7. 8. 9. 10. OP28 OP29 OP32 OP38 Lyndon Croft Care Centre It is recommended that an alternative accident book is sought to record any accidents. Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lyndon Croft Care Centre DS0000063159.V284966.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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