Inspection on 29/11/05 for Lyndon Hall Nursing Home

This inspection was carried out on 29th November 2005.

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

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

Other inspections for this house

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 11/09/06

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 Mrs Amanda Hennessy Unannounced Inspection 29th November 2005 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.V263111.R01.S.doc Version 5.0 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.V263111.R01.S.doc Version 5.0 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 Southern Cross Healthcare Services Limited Janet Ann Lewis 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.V263111.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Service users category of OP must not exceed 40. Poppy Unit accommodates 20 DE(E). Sunflower Unit accommodates 20 DE(E). Rose Unit accommodates 20 OP. A senior care assistant is defined as a person who holds NVQ III and has completed all mandatory training. Bluebell accommodates 20 OP. Staffing levels do not fall below the following minimum numbers: Poppy and Sunflower Unit Two registered nurses (07:30 - 14:30 hrs) and eight care assistants (08:00 - 14:00hrs) Two registered nurses (14:15 -21:15 hrs) and eight assistants (14:00 - 20:00 hrs) One registered nurse (21:00 - 07:45 hrs), one senior care assistant and three care assistants (20:00 - 08:00 hrs) One registered nurse - mental health(RMN) will be on duty on at least one shift during a twenty four hour period. Rose and Bluebell Unit Two registered nurses (07:30 - 14:30 hrs) and eight carers (08:00 14:00 hrs). Two registered nurses (14:15 - 21:15hrs) and six carers (14:00 20:00hrs) One registered nurse (21:00 - 07:45hrs), one senior care assistant and three carers (20:00 - 08:00hrs) Service users category of DE(E) must not exceed 40. 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. DS0000004800.V263111.R01.S.doc Version 5.0 Page 5 8. 9. 10. Lyndon Hall Nursing Home 11. 12. 13. 14. 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. One service user identified in the variation approval dated 8.11.04 may be accommodated on Rose Unit in the category SI(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 report dated 21.1.05 who is 64 years of age may be accommodated at the home in the category of OP. 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. 5th May 2005 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 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.V263111.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken between 10.15 and 16.15 on the 29 November and 12.30-19.30 on the 30 November 2005 by one Inspector. The inspection included a tour of the building, case tracking newly admitted service users to the home, talking to visitors service users and staff, a review of medication, a check of maintenance records and attendance at a relatives meeting. Lyndon Hall is owned by Southern Cross Healthcare. Mr Tim Hodgetts was appointed as the Home Manager in July 2005. Nine of the previous fourteen requirements have been fully addressed. Fifteen new requirements were made as a result of this inspection. One immediate requirement was made requiring that proposals were forwarded to the Commission for Social Care Inspection to repair and address the problems with the central heating system. What the service does well: What has improved since the last inspection? The home experienced some problems during the six weeks whilst the home was without a Manager. It is pleasing to report that since the appointment of the new manager and the re-organisation of the home’s management structure the home is again going forward. A total refurbishment of the entire home will Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 7 commence shortly, despite this two units have had new lounge chairs, dining furniture has been replaced and more specialist equipment is available for dependent service users. Care staff now have a considerable increase in training opportunities available to them. 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.V263111.R01.S.doc Version 5.0 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.V263111.R01.S.doc Version 5.0 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): 4 Facilities available for people with dementia need to be developed to give assurances that the home is meeting all service users needs. EVIDENCE: The home has two units- Sunflower and Poppy that care for service users with dementia. The dementia care units have limited evidence in relation to the environment, social stimulation and equipment that demonstrate how the specialist needs of people with dementia are considered and met. The Manager has received some advice and will be adapted as part of the refurbishment. Some bedrooms in the dementia care unit are sparse due to the challenging needs of some service users. Staff need to look creatively at solutions around the destruction and removal of items, such as laminating pictures and photographs and securing other items when appropriate, providing sensory boards or reminisce aids. There is a need for a specialist in dementia care to give advice on how the environment, equipment and activities can be developed for people with dementia. A programme of dementia training has commenced, although not all staff spoken to during the inspection had received any training in caring for people with dementia care needs. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10. Care plans are generally comprehensive giving assurance that service users needs are identified and met. Medicine policies and procedures are generally satisfactory and safeguard service users. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Care records of recently admitted service users were generally complete and accurately reflected their needs. One service user accommodated on Bluebell did not have completed care risk assessments despite being a resident in the home for almost two weeks. Some of this service users needs had not been evident until her admission and specialist equipment to enhance her life in the home have been identified and ordered. Care reports of another service user (Sunflower) identified that this service user consistently refused diet and fluids. The service users weight had been recorded but, as a newly admitted service it was unclear whether they had lost weight as no record was available of their previous intake of diet and fluids. Care records for the same service user on Sunflower identified that they required hoisting within a large sling, although the weight of this service user would suggest a need for a small or medium sling (dependent on the manufacturers instructions). Care records seen did not Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 11 contain evidence that relatives or service users are involved in care planning. The implementation of care reviews and their importance was explained and discussed by the Home’s Management during the relatives meeting. The homes policies and procedures for the safekeeping and safe administration of medicines were reviewed which were generally satisfactory. No gaps were seen on the medication administration record. It was a concern that insulin for one service user (Bluebell) had been omitted as her blood sugar at that time was low. No medical opinion had been sought or further action undertaken despite this insulin only being given once daily. Staff now record the administration of creams or lotions which was a requirement at a previous inspection. 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 a safe temperature for the medicines that require refrigeration. It was noted that the drugs fridge minimum temperature on Poppy was 9oC which is above the safe temperature of 8oC and which may compromise the effectiveness of medicine. There was no opening date for medicines that have a limited life when opening, particularly liquid antibiotics (Bluebell) and calogen (all units). Homely remedies are being used on Poppy and Bluebell units but the GP agreements seen were incomplete and did not include essential information. Service users spoken to said that they are generally treated with respect. One service user said that staff always seemed to be in a hurry and felt that they were sometimes treated with impatience. All relatives at the relatives meeting agreed that staff could not do enough for their relative and were “fantastic”. Staff were seen to knock on bedroom and bathroom doors before entering. Privacy curtains are provided in double bedrooms. It was noted that although a small number of residents on Bluebell were wearing socks, several had bare legs despite the unit being cold in places. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 Social opportunities are limited and do not meet service users needs, expectations and preferences. Services users are not consistently able to exercise choice and control over their lives. EVIDENCE: The home has regular bingo and singalong sessions, the mobile library visits monthly and service users enjoyed the recent bonfire and firework display. All service users have a record of their life history and a social plan of care. It is disappointing that despite every attempt to gain insight into service users social interests, needs and expectations social opportunities are their needs. No activities were seen being undertaken during either day of the inspection with the identified activities programme not followed. There was no evidence that service users are taken out other than by their families, little evidence of one to one activities and a general lack of suitable activities for service users with dementia. The valuable resource of a full time activities organiser is not being appropriately and effectively utilised. Service users and visitors spoken to during the inspection said that visitors are also made welcome by staff. Visitors are able to visit at any time that is convenient to the service user. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 13 Service users spoken to said that they can get up and go to bed when they wish and can choose whether they remain in their rooms or spend the day in the lounge and have their meals in the dining room. A menu is available that service users can choose from, although one service user said that staff did not give her the menu. The same service user at 16.00 said that she hadn’t had a hot drink since 11.30, although she would have liked one earlier and went on to say that staff had forgotten to give her drinks previously. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has appropriate policies and procedures to highlight concerns and complaints and act appropriately to address any concerns. 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. Relatives at the relatives meeting said that if they had any concerns they would not hesitate to contact the Home Manager and that they valued the relatives meeting. The Manager demonstrates a positive attitude to complaints with appropriate actions identified to address complaints identified. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 15 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): 19,22,26 The home is clean, homely, hygienic and a pleasant place for service users to live. EVIDENCE: The home is clean, homely, welcoming and generally free from offensive odours. There are extensive grounds that service users and their relatives said that they enjoy. Relatives said that they would like somewhere to sit in the main grounds when they take their relative out. New dining furniture and lounge chairs and specialist beds have been provided since the previous inspection. A total refurbishment of the home starting with Bluebell is commencing shortly. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 16 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 Poppy and Sunflower which are on the first floor of the home. A check of lifting slings on each unit identified that are insufficient to meet service users needs, keep them safe and have sufficient to wash and use. The home has appropriate infection control practices, additional development is required to further safeguard service users (see requirements section for detail). The laundry meets required standards and has appropriate policies and procedures for the management of dirty laundry. A mechanical sluice is available on Rose and Poppy but consideration should be given to a mechanical sluice being available for each unit. A mechanical sluice on each unit would effectively clean commode pots and minimise the risk of cross infection. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 17 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): 28,29 The skill mix of staff meet service users needs. Recruitment and selection procedures are robust and protect service users. EVIDENCE: The home has twenty-three of its forty-five care staff with at least National Vocational level two qualification (NVQ) meeting the requirement of at least 50 qualified care staff. An additional six care staff are also undertaking their NVQ level 2. Staff files contained all required information with the exception of their photograph which are sent to Southern Cross Head office. Robust recruitment and selection procedures helps to protect service users. The Manager was advised to ensure that whenever possible an employment history of at least ten years is available and that a photograph of the staff member is retained on their staff file. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 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): 31,35,36,38 The home is well managed with ongoing developments and appropriate systems in place to ensure the home is run in the best interests of the service users and that they are protected. EVIDENCE: Tim Hodgetts commenced as Home Manager of Lyndon Hall in July 2005. Mr Hodgetts has been a qualified nurse for seven years, he has also completed a qualification in caring for older people who have dementia. He has worked both within the National Health Service and Nursing Homes where he had a post managing a unit for older people with dementia. Mr Hodgetts is supported by three unit managers and a Deputy Manager who manages the fourth unit. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 19 Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Money that was randomly checked in the safe was found to be correct and equal the balance identified. Regular external audits of service users personal money is undertaken. The majority of services users have their finances managed by their families or by the Court of Protection. The home has good employment policies in relation to induction of new staff. The Deputy Manager is currently introducing formal supervision for all care staff, but to date staff have not received formal supervision as frequently as required. Procedures to protect service users include regular and required checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, health and safety, infection control and protection of vulnerable adults. There is a need for staff to also attend training in first aid. There is also a need for all staff to have a fire drill at least twice a year- it was noted that records identified there had only been one fire drill for night staff. A recent visit by the Fire Officer identified that fire arrangements were satisfactory. Maintenance records and contracts were reviewed and were found to be up to date. Problems continue with the central heating system with “cold spots” particularly in the on Bluebell and Rose units. To supplement the heating portable heaters are being used although corridors and some bedrooms were found to be chilly as some windows were left open. An immediate requirement was issued at the time of the inspection in relation to risk assessments for the use of portable heaters and proposals to address the long standing problems with the central heating system. Hazard data on substances that are hazardous to health are available in all areas that the chemicals are being stored or used. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 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 x 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x x 2 x x x 2 STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 2 x 2 Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 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 OP4 Regulation 23 Requirement An assessment of the dementia care units must be undertaken by a dementia care specialist. The report of the assessment with action plan to address the recommendations of the report must be forwarded to the Commission for Social Care Inspection. Evidence must be available of the involvement or wish not to be involved in planning service users care. A record must be available of the diet and fluid intake of those service users who are identified at risk of compromised nutrition. A protocol/ record of care instructions must be available for all service users with diabetes. This must include frequency of blood glucose monitoring, optimum blood glucose levels and actions to be undertaken if the service users blood glucose is outside required levels. Drugs fridges must be maintained between 2 and 8oC. Timescale for action 28/02/06 2 OP7 15 31/12/05 3 OP8 15 01/12/05 4 OP9OP8 13(2) 31/12/05 5 OP9 13(2) 01/12/05 Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 22 6 7 OP9 OP9 13(2) 13(2) 8 OP10 12 9 10 OP12 OP12 16(2)(m) 16(2)(n) 11 OP14 15 A date of opening must be recorded for short life items. A record of agreement by the service users Doctor for the use of homely remedies for individual service users is available and which identifies their medical history and, all medicines that they require. Service users must be appropriately dressed both to climate and their choice. An effective system must be operation enabling care staff service users requirements. A review must be undertaken of activities to ensure that activities meet the needs of service users. Consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. Discussions with residents are undertaken, in such areas as getting up and going to bed, food and drink preferences, key holding decisions made are entered into the service user plan, and where appropriate a risk assessment is completed. Partially met- records were partially completed. This requirement was made following the inspection undertaken in July 2002 Service users must be given a choice of meals and when appropriate be given the menu to review. Staff must ensure that service users are offered three meals and regular snacks and drinks. DS0000004800.V263111.R01.S.doc 01/12/05 31/12/05 15/12/05 31/01/06 31/01/06 31/12/05 12 OP14 15 01/12/05 13 OP15 16(2)(i) 01/12/05 Lyndon Hall Nursing Home Version 5.0 Page 23 14 OP22 23(2)(n) 15 16 OP26 OP30 13(3) 18 17 OP30 18(1)(a) 18 OP31 9 19 OP36 18(2), 21 Lifting slings must be available in all required sizes, with sufficient to provide a wash and use for each required size for each unit. Appropriate arrangements must be available for the disposal of hazardous clinical waste. Staff induction/foundation training needs to meet National Training Organisation Specifications. Each member of staff must have an individual training plan in place. Partially met. Comprehensive induction training is undertaken by new staff but this is not completed within six weeks. Foundation training is not available. Training plans are not available for individual staff. This requirement is outstanding since the inspection undertaken in July 2002 A training programme for Dementia care training must be implemented for all staff. This requirement should have been addressed by 1/9/04. Partially met – but not all staff caring for service users with dementia have received training in the care for people with dementia. An application for the Home Manager to register must be forwarded to the Commission for Social Care Inspection. To produce and implement a 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. Partially met. This requirement was made 31/01/06 15/12/05 31/03/06 31/03/06 15/12/05 31/03/05 Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 24 20 OP38 18 following the inspection undertaken in July 2002. All staff receive statutory training and regular in: Fire safety and fire drills Moving and lifting First aid Health and safety Infection control Protection of vulnerable adults Food hygiene Partially met – Training has been arranged in all of the above, although not all staff have received all required training. This requirement is outstanding since the inspection undertaken in July 2002. 31/03/06 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 5 Refer to Standard OP12 OP19 OP26 OP29 OP29 Good Practice Recommendations The roles and responsibilities of the Activities Organiser are reviewed. Benches are also available in the main grounds as well as the small patio area off Bluebell. A mechanical sluice is available on each unit. An employment history of at least ten years is identified whenever possible. A photograph of each member of staff is retained within their staff file within the home. Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 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. Extracts may not be used or reproduced without the express permission of CSCI Lyndon Hall Nursing Home DS0000004800.V263111.R01.S.doc Version 5.0 Page 26 - 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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