Inspection on 18/06/08 for Lynwood

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lynwood 30/04/09

Lynwood 20/06/07

Lynwood 19/10/06

Lynwood 26/05/06

Lynwood 28/02/06

Lynwood 09/05/05

Lynwood 14/10/04

Lynwood 19/04/04

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Lynwood Lynwood 57 Mersey Road Heaton Mersey Stockport Cheshire SK4 3DJ Lead Inspector Mrs Fiona Bryan Unannounced Inspection 18th June 2008 08:45 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 Lynwood DS0000008603.V365494.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. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lynwood Address Lynwood 57 Mersey Road Heaton Mersey Stockport Cheshire SK4 3DJ 0161 432 7590 0161 613 0633 lynwoodresthome@hotmail.com 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) Mr. Mohsin Munif Mrs. Anne Munif Mrs. Anne Munif Care Home 23 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (20) Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 20 OP, up to 10 DE(E) and up to 3 MD (E). 20th June 2007 Date of last inspection Brief Description of the Service: Lynwood is a large Victorian detached house that has been converted into a care home and is set in its own extensive grounds. The accommodation consists of 21 single rooms and one shared room, which are spread over three floors. Three of the single rooms and the one shared room have en-suite facilities. There is one large dining room, which has a small seating area overlooking the garden, two further lounges and a conservatory. The home is owned by Mr and Mrs Munif and is managed on a day-to-day basis by one of the registered providers, Mrs Munif. Lynwood is registered to care for 23 older people. The registration also allows for up to ten service users who are suffering from a dementia type illness and three service users who may have a mental health problem. The home is located in the Heaton Mersey area of Stockport and is close to local shops and other amenities. Stockport town centre, motorway network and public transport are easily accessible. The fee structure at the home ranges from £408-£418. The previous CSCI inspection report was available on request. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection, which included a site visit, took place on Wednesday, 18th June 2008. The staff at the home did not know that this visit was going to take place. All the key inspection standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people who live at the home, the manager, visitors and other members of the staff team. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of staff and care records was examined, including medication records, training records and staff duty rotas. Before the inspection, we asked for surveys to be sent out to residents, relatives and staff, asking what they thought about the care at the home. Four residents, seven relatives and eight staff returned their surveys. Comments from these questionnaires are included in the report. What the service does well: In response to the question in the survey about what was done well at the home, people made the following comments: “Gives respect to the residents – uses their name, shows patience with people when they are disorientated, changes clothes during the day as necessary”. “Lynwood give a very high standard of care, the staff are attentive and helpful at all times. It is very well organised, very clean and visitors are made most welcome”. “Always very considerate, extremely kind both to my husband and myself. My husband seems to be settled and as happy as he can be”. “The care service copes with aspects of disability very well”. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 6 “Personal hygiene seems a strong point. X is kept very clean”. “The staff always appear considerate and attentive”. Residents were complimentary about the food provided at the home saying, “Food is very good” and “Very nice food, nicely cooked”. Relatives who returned surveys wrote, “X has always commented favourably on the food”, “The food is excellent” and “I have eaten at Lynwood and think the meals are extremely good”. The meal seen on the day of the site visit looked appetising and residents said they enjoyed it. Residents, relatives and staff generally thought that enough staff were provided to meet the needs of the residents. Staff felt that the training they received ensured that they had the skills and knowledge to care for the residents properly. The manager reported in the AQAA that 90 of staff had achieved a minimum of an NVQ level 2 qualification. What has improved since the last inspection? What they could do better: The atmosphere within the home was welcoming and staff were caring and dealt with residents very well. However, the quality of records kept at the home lowers the overall rating. Records that are not accurate and up to date and are not reviewed appropriately could lead to a risk to residents, for example, if their care needs are not evaluated effectively. The manager should review the procedures currently in place for storing and recording controlled medicines, to ensure they meet the regulations since the Misuse of Drugs (Safe Custody) Regulations 1973 were amended in 2007. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 7 Mental stimulation for service users was lacking and staff need to speak with residents to find out what sort of activities and events they would find interesting, so they would not get bored and feel unfulfilled. Although policies and procedures were in place for safeguarding adults and although a copy of the Stockport Local Authority’s policy was available, the manager and staff lacked some awareness as to the type of incidents that needed to be referred to other agencies for advice and had not involved these agencies when they should have. This means that some residents were potentially at risk due to the behaviours of other residents. The manager and staff need to revisit the policies and procedures and, if necessary, undertake further training to ensure they recognise and deal with situations in the home appropriately. The owners have employed an external management consultancy to undertake annual quality assurance reviews to highlight areas of good practice and also areas for development. Whilst this is a positive step forward, there now needs to be more evidence that comments and recommendations made by the consultant are used to develop the service and drive forward improvements. 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. The summary of this inspection report can be made available in other formats on request. Lynwood DS0000008603.V365494.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 Lynwood DS0000008603.V365494.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): 1 and 3 (Standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People are provided with satisfactory information about the home and prospective residents have their needs assessed before admission. EVIDENCE: A statement of purpose and a service user guide were displayed in the reception area of the home, together with a copy of the last CSCI report. Information contained in these documents appeared to be reflective of the services offered at the home. Three residents were case tracked. Two of the residents had lived at the home for several years so their pre-admission assessments were not examined in detail. The third resident had come to live at the home quite recently and a pre-admission assessment had been undertaken before they were admitted. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 10 Risk assessments had been undertaken for this resident shortly after admission but had not been reviewed since. This is discussed in more depth in the next section of this report. Lynwood DS0000008603.V365494.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Care plans do not always provide staff with the information they need and care plans and risk assessments are not reviewed properly. Systems for monitoring the healthcare needs of residents are not consistent. This presents a risk that residents’ personal, health care or social needs may not be met. EVIDENCE: Three residents were case tracked. Although all had care plans that, in the main, reflected their care needs, further work needs to be done to make sure a full record is kept of the care each person needs and receives, and to ensure paperwork is easy for staff to use and extract information from. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 12 There were a number of different types of care plans being used and in some files residents had more than one set of care plans detailing the same needs but in different formats, which was not necessary and led to a possibility that some information would be missed as there was so much paperwork to read through. The deputy manager said she was in the process of reviewing all the residents’ care files and ensuring that the same documentation was used in all of them. Some care plans were quite detailed and described what residents could do for themselves and what they needed help with, but others were very basic and most had not been reviewed regularly. Some actions stated as being required in the care plans had not been carried out in practice, for example, the care plan for one resident who was reluctant to drink said they should be weighed monthly but this had not been done. The manager acknowledged in the AQAA that monitoring the weight of some residents was still difficult as there were no suitable scales to use for residents who were unable to weight bear. This issue was identified at the last inspection. Suggestions were made for other methods staff might use to determine if residents were losing weight if they could not weigh them. Risk assessments had generally been undertaken for moving and handling, risk of falls, nutrition and pressure areas. However, many had not been reviewed for a number of months. Accident records showed that one resident had suffered a total of ten falls between April and June 2008 but their falls risk assessment had not been reviewed since March 2008. There was no corresponding care plan for one resident who was identified as being at high risk of developing pressure ulcers. Records showed that residents had seen other health care professionals, such as their GP and the chiropodist. Staff had started to complete a “service user’s choice” form which was useful, as it was person-centred and provided good information about people’s likes and dislikes and preferences. Residents, in the main, looked clean and tidy; their nails and teeth were clean and their hair had been brushed. Residents spoken to said staff were kind and treated them well. Staff were observed dealing with residents in a patient and compassionate way. One resident was observed to be quite agitated at lunch time and one member of staff dealt with them in a calm and reassuring manner, so they became more settled and were able to eat their meal. Staff were able to describe the care needs of residents and knew what their preferences were with regard to their daily routine. Residents’ diverse needs were understood and acted upon, for example, it was identified that one resident preferred female carers to attend to her personal hygiene and this was recorded and respected. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 13 Two visitors to the home said that they had no complaints with the care their relative was receiving. They commented that staff were always attentive to residents and kept them up to date with any changes or concerns regarding their relative’s welfare. Comments from residents and relatives that returned surveys included “Staff have been very understanding of my old role of carer to mum before she went in the home. They have now taken over that role and I feel reassured that Mum is in safe hands”, “Lynwood gives a very high standard of care, the staff are attentive and helpful at all times. It is very well organised, very clean and visitors are made most welcome”, “(They are) always very considerate, extremely kind both to my husband and myself. My husband seems to be settled and as happy as he can be due to his circumstances”. When asked what the home did well, responses included “The care service copes with aspects of disability very well”, “Personal hygiene seems a strong point. My mother is kept very clean” and “Gives respect to the residents – uses their name, shows patience with people when they are disorientated, changes clothes during the day as necessary”. Examination of a number of residents’ medicine administration records indicated that medicines were generally stored, recorded and disposed of satisfactorily. It was noted that Temazepam for one resident was stored in a safe in a cupboard in the manager’s office. An Amendment in 2007 to the Misuse of Drugs (Safe Custody) Regulations 1973 means that every care home must store controlled drugs in a CD cupboard that meets specified requirements. It was also noted that staff were recording the administration of Temazepam only on the resident’s medicine administration record (MAR). The manager said that they did not have a Controlled Drugs Register. In the case of most controlled drugs, the administration would have to be recorded in a CD register, the administration of Temazepam does not legally have to be recorded in this way but it is good practice to do so. Lynwood DS0000008603.V365494.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. A lack of person-centred care planning means that people’s social and recreational expectations are not always met. EVIDENCE: The manager reported that one of the carers had been assigned to co-ordinate activities and was spending an hour per day specifically undertaking social activities with residents, such as board games and word games. An “armchair exercise” session had recently been arranged and, as residents had enjoyed it, arrangements had been made for a session to be held once a fortnight. Another session had been organised for the day of the site visit and a number of residents were taking part. The manager said residents sometimes enjoyed watching films and musicals in the evenings. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 15 Residents did not have care plans to address their social care needs and a more person-centred and organised approach may help staff identify ways in which residents’ social interests and need for social and mental stimulation can be recognised and met. One resident said she had enjoyed knitting when she was in her own home but she had no needles or wool. Staff said that the key worker system was in the process of being changed; development of the key worker role could allow staff to spend time with individual residents finding out how they want to spend their time and facilitating this. Some relatives who returned surveys thought that more mental stimulation was needed. The manager acknowledged in the AQAA that activities needed to be reviewed and was looking at a more person-centred approach and ways of consulting residents about activities and events they would like. Visitors said they were made welcome and were encouraged to visit at any time. A varied menu was available for the residents. Menus rotated over a fourweek period. It was reported that a decision had recently been made to serve soup as a starter at teatime rather than at lunchtime, as staff had noticed that residents were struggling to eat a three course meal at lunchtime and the evening meal was lighter. Typical meals at lunchtime included stews, roasts and fish, whilst at teatime typical meals included sausage and beans, quiche and toasted sandwiches. At breakfast residents could choose cereals, porridge and toast or have a cooked breakfast if they wished. Lunch on the day of the site visit was served at 12.30pm. The main meal was scampi, chips and mushy peas. Residents were offered either apple or orange juice to accompany the meal. Condiments such as salt and vinegar and tartare sauce were offered. Staff were overheard asking residents if they wanted more. The atmosphere was relaxed and unrushed with staff patiently assisting those residents that needed help. Residents were generally positive about the food provided. Comments included “Very nice food. Meals are good, nicely cooked”, “Food very good” and “The food is excellent”. Relatives who returned surveys commented “(Staff) check if they (residents) eat – will offer alternative food”, “Where people need help feeding, the staff assist and talk to the people treating them as the adults they are” “X has always commented favourably on the food” and “I have eaten at Lynwood and think the meals are extremely good”. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 16 Although there was no official choice offered on the menus, staff and residents agreed that if a resident did not want the meal specified they would be offered an alternative. Lynwood DS0000008603.V365494.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents feel their concerns are listened to and acted on but a lack of awareness regarding safeguarding adults procedures means that residents may not be protected from abuse. EVIDENCE: A copy of the home’s complaints procedure was available in the reception area of the home. All the residents who returned surveys said they knew how to make a complaint if they needed to. Only 57 of relatives said they were aware of the complaints procedure, although 85 said if they had complained the response from the manager had been appropriate. All the staff that returned surveys said they were aware of their responsibilities in respect of the complaints procedure. Examination of the complaints/incidents record showed that there had been at least one incident that had not been referred to the appropriate agencies under safeguarding procedures. The manager and the deputy manager were not fully aware of the procedures they should have followed, although a copy of Stockport’s Adult Protection Policy was available for reference. There was also a copy of the Department of Health guidance “No Secrets” but neither of these documents were given a high profile and were not readily accessible for reference. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 18 A discussion took place about the procedures to follow where residents were at risk due to the challenging behaviour of another resident. The manager and staff need to ensure the safety of residents at the home, under these circumstances by inter-agency involvement and following the correct procedures. Lynwood DS0000008603.V365494.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents benefit from having a homely, clean and pleasant environment in which to live. EVIDENCE: A tour of the building was completed. The majority of the home was clean and free from unpleasant odours. Furniture, fixtures and fittings were clean, although some furniture looked well worn. The deputy manager said the dining rooms chairs were being replaced. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 20 Since the last inspection all the communal areas had been refurbished, including new carpets in the lounges, dining rooms and hallways. Two new large disabled toilets had been installed near the dining room and one smaller toilet created near the lounge. In addition, a new disabled toilet had been provided on the first floor and a new hairdressing room. The conservatory was bright and airy but it was noted that the roof was leaking in two places and buckets had been placed beneath to catch the drips. Work needs to be done to ensure the roof is sound. In the AQAA the manager reported that a recent infection control audit had highlighted the need for liquid soap and paper towel dispensers in bedrooms and this was being arranged. As at the last inspection, it was noted that storage space was limited, which made some parts of the home untidy. The landing on the first floor contained chairs, baskets, trolleys, wheelchairs, odd cups and packets of incontinence pads. The fluorescent lighting strip in the hallway outside bedrooms 14 and 15 was not working, causing the hallway to be quite gloomy. Most bedrooms seen were fairly clean and tidy and many had been personalised with the occupants’ own ornaments and pictures. It was noted that the shared room did not have a privacy screen or curtain provided and the deputy manager was asked to ensure one was obtained. All the residents who returned surveys said the home was always or usually fresh and clean. Lynwood DS0000008603.V365494.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents at the home benefit from a well trained and skilled staff team. EVIDENCE: On the day of the site visit there was one senior carer on duty and three carers to look after 20 residents. Examination of staff duty rotas for the weeks commencing 16th and 23rd June 2008 showed that there was normally one senior and three carers between 8am-3pm and one senior and two carers between 3pm -8pm. At 8pm another carer usually came on duty to assist and at 10pm the three late staff went off duty and a second member of staff came on for sleeping duty. Staff, visitors and residents all said that there were generally enough staff on duty to meet the needs of the residents. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 22 The recruitment record for one member of staff was examined. The application form did not contain sufficient detail about the candidate’s employment history. A reference from the person’s last employer had been obtained although this was limited, as they had only worked for the referee for a few weeks. It was not clear what the relationship was between the candidate and the person providing the second reference. A POVA First check had been undertaken before the staff member started working at the home and a CRB had been obtained. The AQAA said that 90 of the care staff employed at the home had achieved NVQ level 2 or above. Training records and certificates showed that staff had undertaken training in various subjects, including stoma care, equality and diversity, food safety awareness, positive caring (professional development workshops on anxiety and depression, care of the mouth, diabetes, epilepsy and stroke), safeguarding adults, fire safety, moving and handling, first aid awareness and Health and Safety awareness. A member of staff who was quite new to the home said she felt her induction training had provided her with the knowledge to carry out the job. Lynwood DS0000008603.V365494.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Quality assurance processes are not fully followed through and this slows down the improvements necessary to improve the service. EVIDENCE: The registered manager was only available for a short period on the day of the site visit and we gave feedback to the deputy manager who had been able to assist during the inspection process. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 24 The manager (who is also co-owner) has managed the home since 1989. In the AQAA the manager confirmed that since the last inspection she had completed the Registered Manager’s Award. Two senior carers were due to start this qualification now and another senior was undertaking an NVQ level 4 in direct care. Staff stated the manager was supportive and caring. Comments from staff included “We are always free to go in and discuss with her (manager) the problems that we face at work, as well as that of the service users. We are always free to give our suggestions”. Service users indicated that they trust her and would go to her if the had any concerns. Staff said they had occasional meetings and the minutes seen showed that one had been held on 16th April 2008 and one was held on 26th September 2007. The deputy manager said the manager had tried holding meetings for residents and relatives in the past but these had always been met with poor attendance. It was reported that the manager had a strong commitment to fostering an open culture in the home and this was confirmed by residents and relatives spoken to on the day of the site visit. The owners employ the services of a management consultancy agency, which undertakes an annual Quality Assurance review on their behalf and provides a report on their findings. The review looks at many aspects of the home and measures them against the National Minimum Standards and other indicators. A consultant from the agency visited the home in March 2008 and provided a report about their findings in respect of topics such as the environment, admission procedures, care planning and reviews, policies and records, complaints and protection, catering arrangements, care practices and staff recruitment and management amongst others. The establishment of a quality assurance system and audit by an external agency is good practice. However, the manager needs to be able to further demonstrate that where the consultant made recommendations, these have been considered and, where necessary, acted on to develop and improve the service. The report of the review undertaken in March 2008 contained several references to recommendations that had been made the previous year and had not been followed up. Some advice made in the 2008 report, for example, with regard to the safe storage of residents’ care files had to date still not been dealt with although three months had elapsed. Personal money is not managed at Lynwood House. People or their relatives are billed each month for all expenditures undertaken on their behalf. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 25 Maintenance records showed that the building and equipment were checked and serviced frequently in accordance with health and safety guidelines. A fire risk assessment had been carried out and various issues had been highlighted as requiring action, for example, some equipment needed PAT testing and the external stairway needed cleaning and painting. It was not clear from the records whether the work had been done. The manager needs to confirm with us that these matters have been addressed. The manager returned the AQAA to us promptly. From the information provided it was evident that she had identified many of the areas that still need improving. All sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the service. There were areas where more supporting evidence would have been useful to illustrate how it is planning to improve. Lynwood DS0000008603.V365494.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13 Requirement Timescale for action 15/08/08 2 OP18 12 Risk assessments must be reviewed regularly and updated and where risk to the resident is identified, this must be addressed by a corresponding care plan. The manager must ensure that 15/08/08 she and her staff are fully aware of the type of incidents that are reportable under Safeguarding Adults procedures and when such incidents occur must ensure that there is the correct involvement of appropriate agencies. Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 28 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 Refer to Standard OP7 Good Practice Recommendations Care plans should set out in detail the action which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the resident are met. Care plans should be reviewed at least once a month and updated to reflect changing needs. A system should be in place to monitor the nutritional intake and weight of people so that they always receive the most appropriate assessment and support. Controlled drugs should be stored in a metal cupboard, which complies with the Misuse of Drugs (Safe Custody) regulations 1973. A controlled drugs register should be obtained. Further consultation should take place with the residents to determine the type of social events and activities they would find enjoyable. Consideration should be given especially to suitable activities for people with dementia. The key worker role should be developed to enable staff to identify with individual residents recreational outlets that are meaningful to them. The manager should explore any gaps in a person’s employment history to ensure they are suitable to work at the home. The manager should use the feedback from the quality assurance review to plan how the service can be developed. The manager should confirm with the CSCI that actions advised following a fire risk assessment undertaken at the home, have been carried out. 2 3 OP8 OP9 4 OP12 5 6 7 OP29 OP33 OP38 Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Lynwood DS0000008603.V365494.R01.S.doc Version 5.2 Page 30 - 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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