Inspection on 13/10/05 for Lynton Terrace, 1-3

This inspection was carried out on 13th October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lynton Terrace, 1-3 09/05/07

Lynton Terrace, 1-3 04/12/06

Lynton Terrace, 1-3 23/05/06

Lynton Terrace, 1-3 29/04/05

Lynton Terrace, 1-3 20/09/04

Lynton Terrace, 1-3 01/06/04

Lynton Terrace, 1-3 23/06/03

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

CARE HOME ADULTS 18-65 Lynton Terrace, 1-3 Lynton Road Acton London W3 9DU Lead Inspector Ms Jane Collisson Unannounced Inspection 13th October 2005 9.30 Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 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 Lynton Terrace, 1-3 DS0000027756.V257353.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 Adults 18-65. 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. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lynton Terrace, 1-3 Address Lynton Road Acton London W3 9DU 0208 992 3343 0208 992 1154 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) Hestia Housing & Support Oladipo Babatunde Fagunwa Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29/04/05 Brief Description of the Service: 1/3 Lynton Terrace is a detached property, situated in a residential area of Acton and close to Acton Main Line Station and bus routes. Acton town centre is within a mile and there are local shops nearby. The home is a mental health facility for ten service users, providing medium to long-term accommodation. Hestia Housing and Support own and manage the home. The communal areas consist of two lounges, a dining room, kitchen, and games room on the ground floor, and a small kitchenette on the first floor. There are ten single bedrooms, four of which are on the ground floor. A total of three bathrooms, one with a separate shower, are available for ten service users. All of the bathrooms have toilets and there is one separate toilet close to the commuanl facilities. The sleeping-in room, which has its own bathing facilities, is on the first floor. There is a small garden to the rear, with a separate building which houses the laundry room. The staff team consists of a Project Manager, two Deputy Managers, and a team of five Project Workers who support service users with personal care, practical tasks and leisure activities. There are no waking night staff and one member of staff sleeps in at night. The domestic work is contracted to an agency. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 13th October 2005, between 9.30am and 2.35pm. The Registered Manager was present for part of the inspection. Three staff were present and all of the nine service users were met. Two of the service users had been invited to the House of Lords for an anniversary celebration for the provider organisation, Hestia. There is one service user vacancy, due to the death of a service user which had occurred since the last inspection. An additional visit was made on the 28th October 2005 to discuss further the outstanding requirements and give feedback to the Registered Manager. Three staff were met on this occasion and five service users. The inspection took a total of seven hours. One staff post was vacant at the time of the inspection, and one of the Deputy Managers had been seconded to another establishment. There were sixteen requirements at the inspection in April 2005 and eleven of these have been met. Five were not met or fully met. These are restated and a further eight requirements have been made. For an assessment of all of the key standards, this inspection report should be read in conjunction with the unannounced inspection of the 29th April 2005. What the service does well: What has improved since the last inspection? What they could do better: It is not demonstrated that, following an assessment and admission to the home, all of the needs and aspirations of the service users are fully taken into account and work is carried out with them to achieve their aims. Better programmes to participate both in the running of the home, and developing skills, should be in place to ensure that the full potential of each service users is reached. With staff encouragement and support, service users should be able to access a wider range of activities, on a regular basis, to assist them to progress with their lives. Service users who spend little time in the home need to be Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 6 encouraged to participate in activities which will benefit them particularly if they wish to move to less supported accommodation. Not all of the service users participate in the communal meal or have other meals in the home. Wherever possible, the recording of meals, to ensure that service users are offered and receive an adequate diet, needs to take place and with more accuracy. Not all of the service users have sufficient storage in their bedrooms. It needs to be shown that they have been offered the furniture they required to support them to keep their rooms in a reasonable order and for their individual needs. The kitchen was found to be in need of more thorough cleaning. While this work was commenced during the inspection, better monitoring is required to ensure a good standard is maintained at all times. While records had been maintained of the refrigerator temperatures, the equipment being used was found to be faulty and needing replacement. The record keeping for staff files and training information needs improvement. It has been previously required that the information is available to be inspected. The training and development records for staff need to be kept upto-dare and evidence that staff have the training they require and that their development needs are being met. In order for it to be demonstrated that there is progress being made, both for the service users and staff, quality assurance and quality monitoring systems need to be in place which result in a regular review of the quality of care. Consultation with the service users to ensure that the home is meeting their needs must be included and the report needs to be provided to the service users and the Commission for Social Care Inspection. 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. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Service users’ needs and aspirations need to be clearly defined so that the most appropriate support can be offered, and agreed with the service users prior to admission. Information is available about the home to assist new service users to make a decision about living moving into the house. EVIDENCE: At the last inspection, risk assessments and care plans had not been completed for the newest service user admitted to the home. Although several had been completed, the service user’s key worker had only recently been looking at activities the service user would like to do, and their likes and dislikes. This work is being carried out some months after the service user’s admission and should be completed at an earlier stage. Preliminary care plans and risk assessments should be drawn up from the needs-led assessment and the home’s initial assessment, in conjunction with the service user, so that it can be shown that the home can meet their needs. These can then be reviewed and amended as required. The last service user to be admitted was able to visit before the decision was taken to move to the home. There is service user one vacancy and staff said that referrals have been made although there were no plans for anyone to move in at the present time. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 All of the service users demonstrate that they are able to make decisions about their daily lives. However, they need support to participate further in the life of the home in ways which enhance their personal development and wellbeing. EVIDENCE: Care plans are in place for all of the service users, which have space for recording when goals have been completed. There is, however, little evidence to show the progress of long-term goals. This is an area where work could be undertaken to make the care plans more meaningful, and beneficial, to the service users. It is recommended that care planning is more closely linked to key working to demonstrate that service users are being supported to achieve their personal goals. This is particularly important for any service user who may wish to less supported accommodation. Although there are opportunities for the service users to assist in the running of the home, not all choose to do so. Previous inspections of the home have resulted in requirements that further opportunities to participate are made available in order to maintain and to develop the service users’ social Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 10 and independent living skills. Although two of the service users cook for themselves for part of the week, few service users assist with the cooking of the main meals or are supported to do so to improve their skills. It was discussed with the Registered Manager that one of the aims of the home is for service users to move on, wherever possible, and there are plans for one service users to do so. It needs to be shown, therefore, that the home has programmes to support this. It is recommended that more work is carried out with the service users as to how they can be encouraged to participate. There is a small financial incentive scheme in place for the service users who assist with chores and it is recommended that this is reviewed to see if it can be made more effective. Service users confirmed that they are able to choose how they spend their time. Although the majority prefer not to join in organised activities, these are available to them and two service users spend time at local mental health drop-in services. Other service users spend time outside of the home, sometimes for most of the day. It was discussed with the Registered Manager whether the home was continuing to meet the needs of the service users who do so. Restrictions placed on the service users, including those for returning to the home at night, were seen to be agreed. Service users have information given to them on the “house rules” and a copy of these was seen in the file for a recently admitted service user. Within the home, service users chose to spend their time in their own rooms, or in the lounges. A number of service users use the larger lounge, which is designated as the room for smoking. Since the last inspection, it has been agreed that the dining room is no longer used by service users for smoking. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 17 Opportunities for personal development are not seen to be encouraged sufficiently for the service users who wish to move on, or to improve the quality of their lives, to do so. Facilities are available outside of the home for participation, but service users need to be supported to try new activities. For those who prefer not to attend organised activities, participation in activities in the home should be encouraged. EVIDENCE: It has been a concern at previous inspections that programmes to promote and maintain the welfare and wellbeing of the service users are not in evidence. The files examined did not show that that service users are encouraged, with staff support, to undertake new activities or that there any strategies to work towards achieving this. Two service users attend the mental health drop-in centre where one enjoys both cooking and gardening. This service user is also able to travel independently and enjoys trips to the coast, and locally, to shops and markets. While other service users spend time outside of the home by choice, it must be demonstrated that the opportunities for educational and day activities are actively offered and encouraged. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 12 A book of activities offered, such as outings, has been collated but this did not provide details of who had attended. The Registered Manager was asked to ensure that this is done to make the record more useful and to ask the service users for their views on the event. Four service users had enjoyed a day trip to the coast, using community transport. Although the home has its own games room, this seems to be underused and consultation should take place with the service users to see if this can be utilised better for their benefit. Involvement in the local community is limited by the location of the home, which is close to a busy main road. Service users do use the local shops, however, and there are shopping facilities in Acton High Street, which is within walking distance. Although a weekly menu is prepared, which has a vegetarian and diabetic alternative, there was no information to show if service users were participating in the meal times and receiving a wholesome, nutritious and varied diet. The staff generally prepares meals although two service users are choose to self-cater for part of the week. A food diary is being kept, but this was incomplete and does not demonstrate that all of the service users are having a balanced diet or having meals in the home at all. Staff need to encourage service users to maintain a healthy diet and to support them with shopping and cooking where this may assist them to move on. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Service users have appropriate input from health professionals, including specialist mental health staff, when required. EVIDENCE: No service users require full assistance with their personal care but some prompting is required. Each room has a wash hand basin and there are three bathrooms, one on the ground floor, for the use of ten service users. Plans to upgrade the ground floor bathroom are not going ahead, but the bathroom would benefit from some refurbishment, in due course, to make it a more pleasant facility for the service users to use. Community Psychiatric Nurses continue to support the service users with injections either in the home or at the clinic. Compliance with medication remains a problem with some service users and details are recorded in care plans where this is a known area of risk. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users show confidence is being able to make complaints and action has been taken when these have been made. EVIDENCE: Service users who were spoken to during this inspection aid that they felt confident about making complaints to the management staff and a number had done so. It was seen from the service users’ meeting minutes that the complaints procedure had been discussed in June 2005. Six complaints had been recorded since the last inspection in April 2005. Complaints usually relate to complaints about other service users although one concerned staff not reminding a service user of an appointment The outcomes of the complaints were recorded and all had responses within a few days. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 The environment is maintained in a reasonable condition and there are sufficient communal spaces for service users to enjoy separate activities, such as listening to music or watching television. The cleanliness of the kitchen was found to be poor and monitoring needs to be carried out by all staff to ensure that hygienic conditions are maintained. EVIDENCE: No major changes have taken place to the environment since the last inspection. The home had received a visit from a London Fire and Emergency Planning Authority officer who was advising on precautions in homes where a high percentage of service user smoke and a second visit was planned. The garden of the home is small and was reasonably tidy. However, the garden is without additional interest, such as shrubs and flowers, which would help to create a pleasant environment for the service users to enjoy. A budget to provide for a more relaxing area should be considered for next summer, to ensure that service users have the opportunity to enjoy outside activities. It has been noted at previous inspections that insufficient furnishings were available in some of the bedrooms for service users to store all of their belongings. Service users are offered basic items for their bedrooms and, to assist with their privacy, keys to their bedroom and to the front door are Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 16 offered. The Registered Manager said that an audit of the bedrooms has been undertaken and new beds and other items were to be provided. It was discussed with the Registered Manager that where additional storage is required this should be provided by Hestia. One bedroom needs to have the floor covering replaced. The Registered Manager said this work would commence when the handyperson returned from sick leave. Although an agency cleaner is employed five days a week, there were areas of the kitchen that had greasy surfaces and a thorough clean was required. The cleaner commenced this work before the end of the inspection visit. It is recommended that a professional “deep clean” is undertaken for the tiled areas to bring the kitchen up to a good standard of cleanliness. The work surface needs to be replaced around the cooker as it been burned in some areas, which makes hygiene more difficult to maintain. Monitoring by management staff needs to take place to ensure a better standard of hygiene. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 34, 35 There needs to be progress in providing a consistent staff team, who have the training and experience to develop their skills to meet the service users’ changing needs. EVIDENCE: Although there has been a more stable staff team for some time, changes are still taking place which do not assist the staff to provide consistency. The permanent staff team consists of the Registered Manager, two Deputy Managers and three project workers. One member of staff, on a short-term contract to cover for the seconded Deputy Manager, is providing additional female cover as there is only one female member of staff in the permanent team. One Project Worker had just left the home’s employment. The home has been without a full, permanent management team during several periods in the last three years which has impacted on the development of the staff team. Although the records for one staff member indicated that training had been undertaken in most of the core subjects, and mental health awareness, the remaining records provided were insufficient to show that staff had attended all of the core and specialised training required. The requirement, which was made at the April 2005 and November 2004 inspections, to provide the staff with training appropriate to the duties they have to perform, including Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 18 specialist mental health training, could not be fully assessed. The Registered Manager has been required to provide a record of these to show when the staff had undertaking their training. One member of staff is undertaking NVQ Level 3. Not all of the staff records examined were being maintained in an orderly manner and this needs to be addressed by the Registered Manager. Some of the records required were not located. The information required under Schedule 4 of the Care Homes Regulations 2001 needed to be available for all staff working in the home, including agency and bank staff. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. 43 There needs to be further work carried out in monitoring by the Registered Manager to ensure that all of the records of maintained in good order, that the work with the service users is seen to make progress and that good team working ensures a better outcome for the service users. EVIDENCE: As mentioned elsewhere in this report, the changes that have occurred in the staff team do not help to provide continuity for the service users or the opportunity to develop and build the team. Whilst systems are in place to provide for the work in the home to assessed and recorded, there appeared to be insufficient monitoring of records to ensure that they are kept up-to-date and that the service users’ needs and aspirations are being addressed. The management staff need to look at better methods of recording and monitoring. Some consultation takes place regarding the day-to-day running of the home and activities but this is an area where all of the service users in the home need to be better engaged. Although there was evidence from the minutes that Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 20 some of the service users’ meetings are reasonably well attended, only two service users attended the last meeting. This was of concern to one of the service users who does attend regularly. A game of bingo is offered as an incentive for the service users to attend. No review of the quality of care has taken place although a Project Review took place earlier in the year. Monthly visits are made to the scheme by the Registered Providers’ representatives and submitted to the Commission for Social Care Inspection as required. Hestia continues to have tenants’ forum for those service users who are interested in attending and there is a Tenants’ Participation officer. The fire records checked were in order. The London Fire and Emergency Planning Authority last visited the home in May 2004 and found the procedures satisfactory. The staff panic alarm is checked monthly and this was carried out in September 2005. Hot water checks indicated that the temperatures were within the safe levels. Small electrical appliances were tested in May 2005 and the Landlord’s Gas check was carried out in June 2005. The work on the remaining radiator, which was required to be covered to minimise the risk to the service user, has now been completed. Although the refrigerator temperatures were recorded as being satisfactory, when the refrigerator was checked the thermometer was recording at 13°C. This appeared to be due to the faulty thermometer. Monitoring needs to take place to ensure that the equipment is working satisfactorily and that staff report any failures. Following a requirement at the last inspection regarding financial viability in relation to the home’s Statement of Purpose, a copy of the current budget was seen and showed that the there were sufficient budgets for the service users’ food and for the welfare budget, which is used for items within the home and for trips out. However, the service user vacancy since June 2005, together with staff sickness, will have an impact on the budget. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X X X X 2 LIFESTYLES Standard No Score 11 2 12 2 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 2 2 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lynton Terrace, 1-3 Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 2 3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 22 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 YA2 Regulation 15 (1)(2) Requirement Following assessment, care plans must be produced, in consultation with the service user to ascertain how their needs, in respect of health, welfare and activities, will be met. The service users must be offered further opportunities to participate in the day-to-day running of the home and to maintain and to develop social and independent living skills. (Previous timescale of 31/8/05 not met) Programmes to promote and maintain the welfare and wellbeing of the service users must be in evidence.(Previous timescale of 30/11/04 not met) It must be demonstrated that the opportunities for educational and day activities are actively offered and encouraged. A record of the meals taken by service users is required to be maintained to demonstrate that a wholesome, nutritious and varied diet is available. DS0000027756.V257353.R01.S.doc Timescale for action 31/01/06 2 YA7 YA8 12(1)b 16(2)m & n 31/12/05 3 YA11 12 (1)(a) 31/01/06 4 YA12 12 (1) (b) 31/01/06 5 YA17 17(2)Sch.4 (13) 31/12/05 Lynton Terrace, 1-3 Version 5.0 Page 23 6 YA25 16 (2)(c) 7 YA30 13 (3) 23 (2)(d) 17(2)Sch.4 6(g) 19 Sch.4 (6) 8 YA33 9 YA34 10 YA35 18 (1)(c)(i) 11 12 YA37 YA39 17 (3) a & b 24 (1) (2) (3) 13 YA42 13 (4) (c) Previous timescale of 31/5/05 not fully met). Adequate and suitable furniture and fittings must be provided in bedrooms to meet the needs of the service users. (Previous timescale 31/7/05 not fully met) Better monitoring of the cleaning of the home must take place to maintain good hygienic standards. Records must be maintained to demonstrate that staff have the required induction and training. The information required under Schedule 4 of the Care Homes Regulations 2001 must be available for all staff working in the home. (Previous timescale of 31/7/05 not met). It must be demonstrated that staff have training appropriate to the duties they perform, and to support their staff development. Further monitoring of the records is required to ensure that they remain up-to-date. A quality assurance and quality monitoring system must be in place and the outcomes used as part of the review of the quality of care. Systems must be in place to monitor the accuracy of record keeping, and the equipment being used for this purpose, to maintain food safety. 31/01/06 30/11/05 31/12/05 31/01/05 28/02/06 31/12/05 31/01/06 30/11/05 Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 24 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 YA6 YA7 YA7 YA30 Good Practice Recommendations That care planning is more closely linked to key working to demonstrate that service users are being supported to achieve their personal goals. That more work is carried out with the service users as to how they can be encouraged to participate more in the running of the home. That the financial incentive scheme for the service users who assist with chores is reviewed to see if it can be made more effective. That a professional “deep clean” is undertaken for the tiled areas in the kitchen to bring it up to a good standard of cleanliness. Lynton Terrace, 1-3 DS0000027756.V257353.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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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