Inspection on 11/09/06 for Lyndon Hall Nursing Home

This inspection was carried out on 11th September 2006.

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.

Other inspections for this house

Lyndon Hall Nursing Home 14/10/09

Lyndon Hall Nursing Home 23/06/09

Lyndon Hall Nursing Home 29/01/08

Lyndon Hall Nursing Home 29/11/05

Lyndon Hall Nursing Home 05/05/05

Lyndon Hall Nursing Home 11/10/04

Lyndon Hall Nursing Home 27/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Lyndon Hall Nursing Home Malvern Close West Bromwich West Midlands B71 1PP Lead Inspector Mr Richard Eaves Key Unannounced Inspection 11th September 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 Lyndon Hall Nursing Home DS0000004800.V309869.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. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndon Hall Nursing Home Address Malvern Close West Bromwich West Midlands B71 1PP 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 500 5777 0121 500 5551 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Care Home 80 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40) of places Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Poppy Unit accommodates 20 DE(E). Sunflower Unit accommodates 20 DE(E). Rose Unit accommodates 20 OP. Bluebell accommodates 20 OP. One service user in the category of OP may be 60 years and over. This will remain until such time that the current service users placement is terminated. One service user identified in the variation report of 25.8.04 may be accommodated at the home in the category of MD(E) on Sunflower Unit. This will remain until such time that the identified service users placement is terminated. One service user identified in the variation approval dated 8.11.04 may be accommodated on Rose Unit in the category of MD(E). This will remain until such time that the service users placement is terminated and whilst the home is able to meet the service users needs. One service user identified in the variation approval dated 8.11.04 may be accommodated in the category MD(E) on Rose Unit for respite. This will remain until such time that the service users placement is terminated and whilst the home is able to meet the service users needs. 29th November 2005 7. 8. Date of last inspection Brief Description of the Service: Lyndon Hall Nursing Home is a purpose built three storey building, which was constructed approximately eight years ago. The Home is set in attractive grounds surrounded by mature trees. There are ample car parking facilities available. Entrance to the home is through a secure door that leads into a small reception area. Accommodation is provided on the ground and first floor with staff room and meeting room on the second floor. The home is divided into four 20 bedded units, namely Poppy, Rose, Sunflower and Bluebell. Poppy unit and Sunflower are registered for the care of service users with Dementia and are situated on the first floor. Rose and Bluebell are situated on the ground floor and are registered to accommodate residents who are elderly and frail. Each unit has a large lounge and separate dining room for communal use. There is Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 5 also a quiet lounge situated on Bluebell. There are seventy-eight bedrooms in total, sixty-six single rooms with en-suite facilities and two double bedrooms both also having en-suite facilities available on Sunflower and Rose units, and ten single rooms without en-suite facilities, five on Poppy and five on Bluebell. Assisted baths are available on each unit. A shaft lift is available to provide access to all floors. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by a single Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection during November 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home. The inspection involved a full tour of the home including, bedrooms, communal rooms, service areas and provided an opportunity to speak with many service users, visitors and staff. What the service does well: What has improved since the last inspection? The home has made excellent progress in training staff both in all aspects of mandatory topics but specifically in preparing staff in working with service users with dementia. Since the previous inspection the programme of redecoration and refurbishment of each of the units is nearing completion which has made a big impact on the homeliness of the units and also improved the working environment providing a boost to staff morale. The home has made good progress addressing the requirements of previous inspections. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home this is confirmed by contract. The most experienced staff undertake pre-admission assessments and confirmation is given to the service users that their needs can be met by the home. EVIDENCE: The statement of purpose and service users guide are currently the subject of review to include details of the new in post manager and are an excellent source of information for current and prospective service users. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 10 In addition to providing confirmation that the home can fulfil the agreed needs prior to admission a contract of terms and conditions is provided and a copy retained on file. The pre and post admission assessment processes are thorough, including all activities of daily living and an extensive range of risk assessments, all subject to regular review, these include maintaining safety and preventing falls and use of bedrails, nutrition, manual handling and pressure risks. The file documents information of the service user or representatives involvement in the assessment process. A sample of 2 case files were randomly selected for case tracking from each of the 4 units and show that the assessment process is thorough. Sunflower Unit. Assessments of activities of daily living seen to be extensive, completed thoroughly and subject to regular evaluations and review. A range of risk assessments undertaken were also subject to regular reviews. Poppy. Assessments of activities of daily living seen to be extensive, completed thoroughly and subject to regular evaluations and review. A range of risk assessments undertaken were also subject to regular reviews. Bluebell. Assessments of activities of daily living seen to be extensive, completed thoroughly and subject to regular evaluations and review. A range of risk assessments undertaken were also subject to regular reviews. Documented evidence of relatives involvement in reviews was seen and quotes of personal satisfaction with how their relative is cared for. E.g. “Very happy with care, no worries”. Rose. Assessments of activities of daily living seen to be extensive, completed thoroughly and subject to regular evaluations and review. A range of risk assessments undertaken were also subject to regular reviews. Involvement of relatives documented. An audit has been undertaken by a specialist in dementia care and an action plan developed this is currently being implemented. Staff training in dementia is progressing well with half of carers having commenced or completed it. Prospective service users are invited to make trial visits prior to accepting a place at the home. The home does not provide an intermediate care service. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 11 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 – 10 The overall quality in this outcome area is good. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Health care needs of service users are fully met. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. EVIDENCE: A sample of two case files were selected on each of the four units for inspection and case tracking. It was observed that the care plans were derived from the assessment process, were relevant and maintained to a good standard. Each file is set out in a consistent way with the assessments including social, risk assessments, care plans, evaluations and monitoring records. One example of no social assessment or care plan was found. The care plans reflect actual care requirements and the service users preferences of how it should be delivered. The care plans are subject to at least monthly Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 12 reviews, these reviews were generally adequate but there is scope to make them more relevant and descriptive of progress towards addressing problems. In addition there requires to be a fully descriptive/directive contingency plan for conditions such as diabetes giving directions for potential risks such as hypo and hyperglycaemia and for epilepsy the risk of status. Risk assessments addressing falls, nutrition and pressure care have derived care plans. It is recommended that these care plans would be better described as risk management plans. The case files show that service users all are allocated to a GP and receive other allied healthcare inputs on a regular basis. The home provides a plentiful supply of equipment for the promotion of tissue viability and the prevention and treatment of pressure sores. The medication arrangements on each unit were inspected. The policies and procedures for the safekeeping and safe administration of medicines and records were reviewed and were generally satisfactory. No gaps were seen on the medication administration record. Records were seen of the administration of creams or lotions, which was a requirement previously. Controlled drugs are safely and appropriately administered throughout the home. A drugs fridge is available on each unit with temperatures checked daily to ensure that they are at a safe temperature for the medicines that require refrigeration; the rooms’ ambient temperature is also recorded and maintained at a safe level. There was no date of opening of medicines that have a limited life such as eye drops. Evidence of re-sheathing of used hypodermics was observed on one unit. Arrangements for the disposal of pharmaceutical waste are satisfactory. During visits to each of the units staff were observed to interact well with service users showing respect and using the preferred terms of address, they were seen to be sensitive to protecting the service users dignity in dress, toileting and cleanliness. The topics of respect and dignity are given prominence in the induction programme for new staff. A public phone is provided and located in the homes foyer; staff advise that the office telephones are cordless and used to allow service users to take incoming calls. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 13 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): 12 – 15 The overall quality in this outcome area is good. The home provides a limited but appropriate and varied social and recreational activity programme that provides interest and pleasure for the service users. An open visiting policy assists service users to maintain contact with their family and friends. Service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: Activities at the home are provided by a co-ordinator these regularly include, Bingo, sing-a-longs, exercises, hand massage and nail care, games, a programme is provided of the regular events. Progress has been made in developing dementia appropriate activity since the audit by the dementia specialist. Visiting clergy provide regular church services for a number of service users. Visiting arrangements remain unchanged and service users continue to receive visitors at any reasonable time in the day and a number were observed to arrive and leave during the course of the day. Most service users receive their visitors in the lounges and there appears to be a good relationship between visitors and other service users. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 14 The case files include a section that identifies personal likes and wishes such as rising and settling time and their ability to make their own choices of clothes to wear. In conversation with service users they were content that these wishes are taken into account by care staff in the assistance they provide and routines are applied flexibly to accommodate personal wishes of the moment. Individual rooms were seen to include personal possessions and reflect the personality of the individual. Notices are available that provide information about advocacy. The home has a four-week menu, which offers choice at each meal, tasty and nutritious food. The head cook has also produced a pictorial menu. The daily menu shows the main items for each of the three main meals and identifies one option, additional choices menu being available on a separate menu, this includes lamb and pork chops, meat pies, omelettes and a variety of salads. It is necessary to demonstrate that the additional choice menu is promoted. The home offers three main meals each with a cooked option and with hot and cold drinks and snacks available throughout the day, Supper is also shown on the daily menu. Special diets such as diabetic, soft and pureed are available. In conversation with many service users they were happy to confirm that the meals are very good and all enjoyed the lunch taken during the day. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 15 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 overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected. EVIDENCE: The home has a detailed complaints procedure, which is displayed in the reception area of the home and is also in the service user guide. A record of complaints show that the Manager undertakes appropriate investigation and comprehensive feedback to the complainant. One record of concern was seen that had no outcome and checks show this was not included in the reports to senior management, it is thought that the previous manager may have made a note expecting a complaint but none received. The new Manager demonstrates a positive attitude to complaints and how they assist in improving service. The home provides leaflets promoting advocacy services for service users. The electoral roll was completed for this year and a number of service users took advantage of postal voting arrangements. The home has robust procedures for responding to any suggestion of abuse and in-house training is given in adult protection procedures. 35 staff have attended adult protection training during the last twelve months. Lyndon Hall Nursing Home DS0000004800.V309869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The overall quality in this outcome area is good. The home provides a good standard of décor, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The bedrooms have bathrooms in close proximity for the convenience of service users. The home is clean, free from odours and hygienic. EVIDENCE: A full tour of the building found the home to be clean, hygienic and free from offensive odours. There are extensive grounds that service users and their relatives said that they enjoy, currently the grounds appear generally unkempt and the waste storage areas are unsightly and not used appropriately, the area is also untidy and appears not to have a cleaning regime. One tree in the area looks to be dead and requires the attention of a tree surgeon, other trees may also require attention. The loose surface driveway to the parking areas require to be maintained. Although extensive the grounds offer little facility for service users and their visitors to sit in the main grounds or to take out. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 17 The refurbishment of the dining rooms and lounges are near completion and greatly enhance the environment. A number of profiling beds have been provided since the previous inspection and a further supply are planned. The dementia specialist identified a number of environmental improvements such as letterboxes different coloured doors and other door furniture to be fitted to bedroom doors has commenced on the EMI units. Sunflower unit refurbishment is as yet incomplete with corridor lounge and a proportion of bedrooms to have replacement carpets fitted, this was planned to commence on the first day of inspection but was postponed by the fitters to later in the week. A shower room on Sunflower unit was utilised as a pad store, this practice is to be discontinued and the shower facility re-instated. The home has appropriate infection control practices, additional development is required to further safeguard service users, such as the control of hot water at staff hand wash outlets with a view to promoting good hand washing. The laundry is fitted with equipment that meets required standards and has appropriate policies and procedures for the management of dirty laundry. Sluicing disinfectors are provided on Rose and Poppy units and machines have been delivered to the other units but have not yet been plumbed in. The kitchenettes serving the units require a cleaning schedule and allocation of responsibilities for monitoring the refrigerators and defrosting. The home has a range of aids and adaptations for people who are dependent such as grab rails, handrails, hoists and specialist baths, beds and pressure relieving mattresses. There is a passenger shaft lift available to access the first floor. Lyndon Hall Nursing Home DS0000004800.V309869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: The rotas confirm that numbers across the 24hour period and skill mix of qualified and unqualified staff are appropriate to the needs of service users. The ancillary services provide a full 7-day service. Currently each unit staff allocation provides for a ratio of 1 – 4 am, 1 – 5 pm and 1 – 8 over night. Staff met and spoken with were enthusiastic and those who were recently employed received formal induction that meets Skills for Care standards. The standard of 50 of care staff being trained to NVQ level 2 achieved at the last inspection has fallen back to 38 . It is anticipated that the 10 currently enrolled will bring the numbers qualified to 60 . Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 19 Individual staff files and training matrix show that mandatory training is kept up to date and other professional updating is provided for. There was no information available showing the level of certificated first-aiders on the staff. It is further recommended that all staff receive emergency first aid training. A random selection of staff files were inspected with the addition of the most recent starter and recruitment and selection procedures were seen to be completed to a very good standard including all required checks including application, references, CRB and POVA declaration. The company procedures are based on good practice and equal opportunities. It was noted that some files included a checklist at the front of the file, it is recommended that this be included in all files. Some files were seen not to include a photograph of the member of staff. Staff showed a selection of photographs indicating that the process to provide was underway. Lyndon Hall Nursing Home DS0000004800.V309869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The overall quality in this outcome area is good. Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities. The home regularly reviews its performance which includes consultation and seeking the views of service users and their families and evidenced that it is acted upon. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager who took up post on the day of inspection is well qualified and experienced. The home has a comprehensive quality assurance programme which is overviewed the home’s owners Southern Cross. A random selection if residents, relatives and professional visitors are surveyed to ascertain their views on all aspects of life within the home. Staff and resident/ relative meetings have been held regularly with notes displayed on notice boards, the manager indicated that this practice will continue. Monthly audits are undertaken of pressure sores, accidents, complaints, residents weights, records of checks on equipment such as wheelchairs, fire equipment, pressure relieving equipment and a review of their settings. The area manager also undertakes monthly regulation 26 inspections. The majority of service users money is managed by their families, although service users can manage their own finances if they wish to. Secure facilities are available for the safe keeping of service users personal money and valuables. Records are available for all transactions which detail the reason for the withdrawal, receipts are available as proof of purchases. Inspection of the health and safety monitoring records show these to be up to date and that very good standards are being maintained consistently. Hot water was noted to frequently be at the lower end of the range of HSE recommended levels at 41°c, it is required that water should be provided as close to the standard 43°c and a record maintained of each adjustment. Certification of services and equipment are all in date. Staff training in health and safety, fire safety training is satisfactory. Lyndon Hall Nursing Home DS0000004800.V309869.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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 17 3 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 4 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 23 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 OP31 Regulation 9 Requirement An application for the Home Manager to register must be forwarded to the Commission for Social Care Inspection. Timescale for action 15/12/06 2. OP36 18(2), 21 To produce and implement a 31/03/07 staff supervision policy, which ensures staff receive regular supervision, in addition to day to day contact at least 6 times per year and records are maintained. Not inspected on this occasion Timescale 31/3/05 not met. The registered person must ensure that care plans for medical conditions include contingency plans for potential side effects. The registered person must stop the practice of storing incontinence pads in the shower must stop and the shower reinstated. The registered person must make arrangements for the grounds to be properly maintained and the Waste storage area kept clean and tidy. DS0000004800.V309869.R01.S.doc 3. OP7 15(1) 31/10/06 4. OP19 23 (4) 30/09/06 5. OP19 23 (2) 31/10/06 Lyndon Hall Nursing Home Version 5.2 Page 24 6. OP26 23(2)(d) 7. OP28 18(1)(c) The registered person must provide a cleaning schedule for the kitchenette and allocate responsibilities. The registered person must ensure that at least 50 of care staff hold a NVQ qualification at level 2 in care consistently. 31/10/06 31/12/06 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. 4. Refer to Standard OP29 OP7 OP9 OP38 Good Practice Recommendations A photograph of each member of staff is retained within their staff file within the home. Continues to be progressed. It is recommended that care plans derived from risk assessments include the title risk management plan. The manager should direct staff to date short life medication on opening and advise staff of the dangers of re-sheathing used hypodermic needles. The manager must ensure that any adjustments to hot water mixing valves are documented. Lyndon Hall Nursing Home DS0000004800.V309869.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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