Inspection on 17/10/07 for Lyngate Care Home

This inspection was carried out on 17th October 2007.

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

Lyngate Care Home 24/11/08

Lyngate Care Home 22/07/08

Lyngate Care Home 01/04/08

Lyngate Care Home 24/05/06

Lyngate Care Home 13/12/05

Lyngate Care Home 23/05/05

Lyngate Care Home 14/12/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyngate Care Home 236 Wigan Road Bolton Lancashire BL3 5QE Lead Inspector Judith Stanley Unannounced Inspection 09:15 17 October 2007 th 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 Lyngate Care Home DS0000059303.V337276.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. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyngate Care Home Address 236 Wigan Road Bolton Lancashire BL3 5QE 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) 01204 62150 Lyngate Health Care Limited Mrs Ann Marie Else Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is registered for a maximum of 41 service-users to include: Up to 41 service-users in the category of OP (Older People) The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 24th May 2006 Date of last inspection Brief Description of the Service: Lyngate care home provides care and accommodation for up to 41 older people. The home is situated approximately 1 mile from Bolton town centre. There are bus routes, shops, a bank, and other community facilities close by. The home is on three floors and it has 29 single bedrooms and 6 doubles. Twenty-four of the rooms are en-suite. There are four lounge/dining rooms and an activities lounge. Three of the lounges have kitchenettes where residents and visitors can make drinks. There is a garden at the front of the home and a car park at the back. The home is fitted with suitable adaptations and equipment such as a passenger lift, assisted baths and showers, portable hoists, and grab rails. In addition to care staff, the home employs an activities co-ordinator, cooks, kitchen assistants, domestic staff, and a maintenance worker. A brochure describing the home’s services is available and the provider gives other information about the home to new and prospective residents and their families verbally and they are also offered a copy of the home’s Service User Guide (Residents Information Guide). The current weekly charge for accommodation and services range from £309.00 to £358.00 with additional charges being made for hairdressing, chiropody, extra toiletries, newspapers, holidays and trips out. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspectio, which included a site visit that the home did not know was going to happen, was conducted over 6 ¼ hours on one day. Part of the time was spent in the office looking at information the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being properly run. The inspector spoke with the home’s manager, some of the staff and with residents. Prior the inspection the home was sent a Annual Quality Assurance Assessment form (AQAA). This is completed by the manager and informs the inspector how the home meets the National Minimum Standards, what they feel the home does well at and in what areas they need to improve. Comment cards were also sent to residents, relatives and to other people who visit the home such as doctors, district nurses and chiropodists etc. Three residents returned comment cards and although no added comments were made, residents indicated they were happy with the care provided. Of the three relatives returned comment cards, one said, “ The home is very efficient in all aspects and I cannot find any faults”. There were no returned cards from visiting professionals. There has been one complaint made to the manager of the home regarding a member of staff this was suitably recorded and dealt with by the manager and the owner of the home and the outcome documented. There have been no complaints made to the CSCI since the last inspection. What the service does well: The home is clean and the standard of accommodation is satisfactory. The home offers several communal areas to allow residents the choice of where they sit and with whom they wish to spend time with. The home’s hobby therapist provides residents with a wide range of fulfilling and stimulating activities to suit their needs and capabilities. The food served at the home offers residents with a nutritious diet and offers resident’s choice and variety. Staff have a good understanding of the residents needs and ensure those needs are met. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should continue with its refurbishment, as parts of the home are looking ‘tired and dated’. The lounge on the lower ground and ground floor carpets are stained and in need of replacing. Suitable lighting should be provided to a recognised standard (lux 150) in all areas used by residents. The staff administering medication must ensure that it is properly recorded. Staff training must be improved to ensure the health, welfare and safety of the residents. Two immediate requirements were made with regard to outstanding training in protection of vulnerable adults and mandatory training for all staff. The registered provider must ensure that he visits the home monthly and that a written report is available for inspection. To ensure the safety and welfare of the residents and staff, the registered person must ensure that the Fire Officers requirements from the last inspection are addressed. Fire doors must not be wedged open. Please contact the provider for advice of actions taken in response to this Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lyngate Care Home DS0000059303.V337276.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 Lyngate Care Home DS0000059303.V337276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 were assessed. Standard 6 does not apply at Lyngate as the home does not provide an intermediate care service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were pre admission assessments seen in the care plans, however these were basic and need more detail to ensure the needs of the residents can be fully met. EVIDENCE: On admission to the home all residents are provided with a written contract/terms and conditions regardless of how their care is purchased. Contracts files are kept in the manager’s office and were available for inspection. Three care plans were chosen for inspection. There were different types of pre admission assessments formats used. Some of the information in some of the Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 10 files was incomplete. To ensure that the home can fully meet the resident’s individual needs the manager must make sure that the assessment covers: • personal care and physical well-being • diet, weight, including dietary preferences • sight, hearing and communication • oral health • foot care • mobility and dexterity • history of falls • continence • medication (self medication) • mental state and cognition • social interests, hobbies, religious and cultural needs. From the inspector’s observations and through discussion with the home’s manager, it was apparent that a number of residents living at the home had a dementia related condition. The manager must ensure that all staff individually and collectively have the skills and experience to deliver the services and care which the home offers to provide. All staff must undertake training in caring for people with a dementia related illness. Lyngate Care Home DS0000059303.V337276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care is offered in such a way as to promote and protect resident’s privacy and dignity. Systems need to be properly monitored to ensure that residents receive their prescribed medication and that all medication can be accounted for. EVIDENCE: Three care plans were chosen for inspection. All three plans contained a different format for the pre admission assessment to ensure the home could meet the needs of the residents. Some of the information was incomplete and did not therefore provide staff with ‘on the spot’ information they would need to offer immediate care. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 12 Information completed after admission is clear and covers personal care needed, skin care, eating, bathing, vision, communication, mobility, history of falls etc. Other information contained in the care plan includes some risk assessments, records of weights and baths, records of visits from the doctor or district nurse and general observations. There were some forms in duplicate and the inspector recommended to the home’s manager if forms were not needed to remove them as it gives the impression that they are incomplete. The care plans had been updated monthly as required. Observation throughout the inspection showed that the personal care needs of residents were being met. Attention was given to all residents personal grooming. Resident’s were seen to be clean and clothes were nicely washed and ironed and were coordinated. On the day of the inspection the hairdresser was at the home and all residents, if they wished could have their hair done. Staff were seen knocking on bedroom, bathroom and toilet doors before entering. Staff were heard speaking with residents in a friendly and respectful manner. It was evident that the manager and her staff knew the residents well and good relationships had been formed between them. The deputy manager gave out the morning medication. On checking with the deputy manager it was noted that there was a discrepancy, one resident had not been given her antibiotic as required at 07.00 am. There was no recording to explain why this had occurred. The deputy manager was not able to confirm whether or not the antibiotic had being given or not. Another resident keeps an angina spray and angina tablets in her room, these were seen on the bedside cabinet. The inspector has concerns as to why there are both tablets and a spray when both offer the same pain relief. The home’s manager must ensure that it is recorded when a new spray is being used and how often they are ordered and that it is stored away. If the tablets are to be taken they must be securely stored in a place where the resident can access them easily, for example a bedside cabinet. If another resident went in to the residents room and took any of the tablets it could result in their health and safety being placed at risk. The home’s manager must have a system in place so that staff can account for the number of tablets taken and the frequency. A risk assessment must be in place for this resident to keep her tablets in her room and to self medicate. The resident, if able to do so may wish to keep her medication with her at all times. The home’s manager must ensure that staff who administer medication have received up to date training and that on each shift there is a trained person that can administer medication as required. The training matrix provided by the home shows that some medication training is overdue. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 13 The length of time the morning medication round took needs to be given some consideration as this started at approximately 09.30 am and tablets were still be given at 11.50 am. This length of time could have a ‘knock on’ effect on the time of the next medication round. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a wide and varied range of activities to meet their expectations and capabilities. EVIDENCE: The home has a hobby therapist who with the help of the resident’s plans a wide range of indoor and outdoor activities. The activities file was available for inspection. Activities include the celebration of different festivals, birthdays, bingo, picture bingo, quizzes, arts and crafts, canal trips, visits to local garden centre, raffles, entertainers, clothes parties, visit to Blackpool and overnight stay at a hotel. One resident spoken with said,” there is always something going on, we have a good time”. The hobby therapist completed a report on each resident in June 2007 about what activities they like to take part in and if they wish to join in or not as is their choice. The home benefits from the use of its own mini bus for trips out. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 15 There are no restrictions on visiting times and the home welcomes visitors. There are areas where visitors can make themselves a drink on arrival if they wish. Residents can meet with their visitors in one of the lounges or in the privacy of there own rooms. Although there were no visitors available to speak with the inspector, the returned comment cards expressed satisfaction of the standard of the home and of the care provided. The menus were available for inspection and show that a good choice of meals was offered. The menus are nicely printed and in large letters making them easy to read. It may benefit residents and relatives if these were displayed for people to look at. Residents confirmed that for breakfast there was a choice of cereals, toast or a cooked breakfast if required and tea or coffee. Lunch is the main meal of the day and on the day of the inspection, residents were asked if they would like roast pork and gravy or sweet and sour pork accompanied by creamed potatoes and green beans, followed by a dessert. Although the meal was well cooked, nicely presented and with good portions offered, both options were pork, however when residents were asked what would happen if they did not want the main meal, they confirmed that the cook would make something else. One resident said, “The food is very good, there is plenty of it and it’s very tasty”. The cook serves the residents on all floors so that she is certain everybody has had a meal of their choice. Staff were seen sitting and offering assistance to those residents who needed help in a discreet and sensitive manner. One resident had asked the manager if he could have black pudding and on the day of the inspection the manager arrived at the home with black puddings for him. A lighter afternoon tea is served, again with a good variety of alternatives available. Suppers are available before residents retire. Hot and cold drinks and snacks are available throughout the day. There are lounge/dining areas on each floor and residents mainly stay in one area. The tables were nicely set with tablecloths, appropriate cutlery and condiments. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 16 Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Due to the lack of staff training in the protection of vulnerable adults, residents cannot be assured that they will be protected from abuse in any of its forms. EVIDENCE: A complaints procedure exists and records of complaints are kept. The complaints book and file was available for inspection. One complaint regarding a member of staff had been made. The registered provider and the home’s manager dealt with this complaint in a prompt manner and all the information and outcome was recorded. There have been no complaints made to the CSCI since the last inspection. The home has a copy of the local authority adult protection procedures available to staff. Information provided on the training matrix indicates that only four staff have completed training in the protection of vulnerable adults and three of those are now overdue a refresher course. Residents living at the home and their relatives cannot therefore be assured that staff are familiar with abuse in any of its forms and would not know what they were looking for and what to do of they had any concerns. This is placing residents at risk of potential harm. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 18 It was a requirement at the last inspection for staff to attend training in this area. An immediate requirement was made regarding this outstanding issue (an immediate requirement means the registered provider must inform the CSCI with in 48 hours of how this is to be addressed). Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lyngate provides a clean and comfortable environment for people living at the home. EVIDENCE: From a tour of the premises it was evident that some refurbishment has taken place. One lounge/dining room on the ground floor has been decorated and is waiting for new blinds to be fitted. Some of the light bulbs in the chandeliers were in need of replacing. The carpets in the other lounge/dining area are in need of replacing as these were stained and looked unsightly. From discussion with the owner this is on the ‘to do list’. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 20 Parts of the home, although clean are looking ‘tired and dated’. The lounge/dining room on the lower ground floor is dark and would benefit from a lighter standard of décor. Several resident’s bedrooms were looked at, these were seen to be clean and tidy and residents had personalised their rooms with some of their own belongings brought with them from home. One resident spoken with said, “The room is a little small but it is comfortable, warm and clean”. Bathrooms and toilets were clean and had paper towels and liquid soap. There was no evidence of communal toiletries. The outside of the home was clean and tidy and appeared well maintained. There are tables and chairs outside and a gazebo for residents who wish to sit outside. The lighting throughout the home needs to be reviewed. Several areas appeared to be dark and gave an overall dismal appearance. Lighting in resident’s accommodation and communal areas must meet the recognised standard (150 lux) and must be domestic in character, and could include tablelevel lamp lighting. Systems are in place to control the risk of cross infection. Staff were seen wearing different protective clothing when carrying out tasks. The laundry is sited on the lower ground floor away from food preparation and food storage areas and does not intrude on the residents. The home has a CCTV system covering the outer doors only for added security for residents and staff. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff at the home have not yet received the necessary training they require to enable them to carry out their job in safe and competent manner, therefore putting resident safety and welfare at risk. EVIDENCE: Staff rotas were forwarded to the CSCI prior to the inspection. As recommended at the last inspection staffing levels have been increased to five care staff during the morning. The home’s manager told the inspector that she was trying to recruit staff to enable five care staff to cover the afternoon shift. This would be beneficial given the layout and size of the home. There is three staff on waking duty throughout the night. Domestic and kitchen staff are employed in sufficient numbers to cater for the needs of the residents and to support care staff. Of the staff group 12 staff have now completed NVQ Level 2 or above. The home has therefore achieved the target of 50 of care staff being trained to NVQ Level 2. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 22 Several of the staff had worked at the home for several years. This helps provide reliable and consistent care to residents by staff they are familiar with. Staff morale appeared to be good and there was a willingness from staff to help one another. A full copy of each members of staff’s employment file is kept at the home in a secure location. Three staff files were inspected and contained a written application form, copies of CRB disclosure numbers, references and other forms of identification. All new staff now complete a full induction programme, there was evidence of this in one staff file inspected. Staff training is an area that is poor and must be addressed. An immediate requirement was made that staff must be trained appropriately in the work they are to perform. A training matrix was shown to the inspector that indicated that some staff have not had moving and handling training since March 2004. For some staff health and safety has not been covered since December 1998, fire training since July 2005, medication awareness for one member of staff was completed in October 2002. Three staff undertook protection of vulnerable adults training in May and October 2004 and one member of staff completed training in October 2006. No other staff have training in this area. Four members of staff have completed training in caring for residents with dementia despite the home clearly having residents with a dementia related condition. Nine members of staff hold a current first aid certificate. The home’s manager is reminded that on all shifts there must be a trained person that can administer medication and a trained first aider. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents and their supporters cannot be assured that the health and safety of the residents is promoted and protected. EVIDENCE: The home’s manager has a number of years experience in working with and caring for the elderly. The manager is currently working towards the NVQ Level 4 Registered Managers Award. It was evident from the inspector’s observations and through discussions with the staff and residents that the manager knows her residents well and strives continually to meet their needs. Her manner in dealing with the residents appeared to be very kind, with Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 24 patience and understanding. One resident said the manager was, “Very kind, a lovely person and always willing to help you “. The manager operates an ‘open door’ policy so that she can be approached at any time by staff or residents or their families, this was observed during the inspection, when residents came to speak with the manager. From the inspectors observations the manager is a ‘hands on’ manager and is very comfortable in that role. Although the paperwork and records required by regulation were available, the inspector feels the manager would benefit from some administration support which would free the managers time more, to ensure that issues such as training and development are completed and updated as required. Systems are in place for self-monitoring within the home. The inspector was shown examples of resident’s satisfaction questionnaires, which had been returned. Feedback from residents was positive about the care provided. The registered provider has completed some monthly visits as required, however the last two monthly reports were unavailable for inspection. Some of the residents living at Lyngate have handed over the responsibility for their financial affairs to their families but keep a small amount of money with manager for safekeeping. A sample of residents’ monies was checked and found to be in order and matching the written record of transactions. Equipment and systems used in the home are serviced and maintained, and records were kept. The following checks have taken place and certificates were available to verify that: Hoists – serviced May 2007 Gas – December 2006 Electrics – September 2005 Water testing – December 2006 Bath hoist – April 2007 Alarm system – February 2007 Lift – October 2007 The fire officer’s report was not available for inspection, however the registered provider confirmed that the requirements had not been completed. The home’s accident book was available for inspection and incidents, accidents and injuries had been documented. The CSCI had not been made aware of some injuries or accidents to residents. The CSCI must be informed using the Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 25 appropriate forms, as soon as possible. Some significant incidents had not be reported. The home’s manager must ensure that risk assessments are completed and updated and that safe working practices such as moving and handling training is completed and that the fire officer’s requirements from 13 December 2005 are addressed. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 26 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 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14 (1) (a) Requirement Residents must only be admitted in to the home following a detailed pre admission assessment by a suitably qualified or trained person, to ensure that their needs can be met. All staff must be appropriately trained in caring for people with a dementia related illness to ensure their needs can be met. Timescale for action 16/11/07 2. OP4 18 (1) (c) (i) 16/11/07 3. OP9 13 4 OP9 13 5. OP18 13 (6) Arrangements must be made for 16/11/07 the recording, handling, and safe keeping of medicines received in the care home, so as to ensure residents receive the appropriate medication. Unnecessary risks to the health 16/11/07 and safety of the residents must be identified and so far as possible eliminated and make suitable arrangements for the training of staff in medication awareness. You must ensure that all of the 17/10/07 staff are provided with training in adult protection issues, so as to DS0000059303.V337276.R01.S.doc Version 5.2 Page 28 Lyngate Care Home be able to protect residents from abuse (outstanding from the last inspection, with a timescale given of 31/07/07. Immediate requirement was made given at the inspection of 17/10/07) 6 OP19 23 (d) That there is a rolling programme of maintenance to keep all parts of the home clean (carpets) and reasonably decorated. That the requirements made by the fire officer are complied with, so as to protect the residents and staffs safety. That there is suitable lighting for residents in all parts of the home that is used by them All staff must be suitably trained and competent to carry out the work they are to perform, so as protect the residents safety and welfare. You are required to forward to the CSCI in a training matrix names of staff and dates of the training courses planned. The registered person or an appointee must visit the home on a monthly basis and provide a written report of the findings. The reports must be available for inspection. Serious accidents, injuries and incidents must be reported to the CSCI. 16/11/07 7 OP19 Part V 23 (4 b) Part V 23 (2 p) 18 (1) (a) (c) (1) 16/11/07 8 9 OP25 OP30 16/11/07 16/11/07 10 OP33 26 16/11/07 11 OP38 Sch 3 (3) (j) 16/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 29 No. 1. 2. Refer to Standard OP31 OP27 Good Practice Recommendations The manager is part way through the NVQ level 4 course and she needs to continue to progress with this until completed. The inspector strongly recommends that the proposed staffing increase to five care assistants throughout the day be implemented so taking into account the changing numbers and needs of the residents, and the layout of the building. The inspector recommends that the home’s manager would benefit from the support of administrator to assist with office duties. 3. OP31 Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyngate Care Home DS0000059303.V337276.R01.S.doc Version 5.2 Page 31 - 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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