Inspection on 26/05/06 for Lynwood

This inspection was carried out on 26th May 2006.

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

Lynwood 30/04/09

Lynwood 18/06/08

Lynwood 20/06/07

Lynwood 19/10/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lynwood Lynwood 57 Mersey Road Heaton Mersey Stockport Cheshire SK4 3DJ Lead Inspector Sylvia Brown Unannounced Inspection 26th May 2006 09:00 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.V297017.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.V297017.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 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.V297017.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). 28th February 2006 Date of last inspection Brief Description of the Service: Lynwood is a large Victorian detached house which 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. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the overall inspection process two site visits were undertaken at Lynwood. The first was unannounced and focused on the day to day routines of the home. The inspector sat and talked with three service users and obtained their views of the services offered. Comment cards were also provided to service users, staff and visitors. At the time of writing the report, 14 had been returned by service users, however a number were incomplete due to the service users’ deteriorating mental health. Six staff survey forms were returned. There were no relatives’ comment cards returned at the time of writing the report. Comments received are, where appropriate and relevant, included within the report. A number of records were evaluated and two service users were case-tracked. The care file for one service user was not available. As a consequence, a second site visit was arranged to evaluate the record, clarify outstanding issues and provide feedback to the registered owner/manager. On the second visit the required record to be inspected was not available. The service user and their records had been transferred to a home more suitable to meet their assessed needs. The registered owner/manager was provided with feedback regarding the outcome of the inspection. What the service does well: From talking with service users, evaluating records and from comment cards received, it appears that Lynwood provides service users with all the care and support they require. Service users spoke positively of the staff team, registered manager/owner and of the overall services provided. The service users have all their health care needs met and are able to make individual choices regarding their day to day routines. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 7 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.V297017.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (standard 6 is not applicable to this home) Quality in this outcome area is good. Service users receive information about Lynwood and have their needs assessed prior to moving into the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: One service user spoken with stated her family had received information about the home and visited on her behalf before any decisions were made about moving in. Comment cards returned by service users confirmed that 11 of them had received information about the home prior to being accommodated. Evaluation of care files identified that service users have their needs assessed before moving into the home. The assessments were kept under review and updated when required. There was minimal information regarding whom the assessor consulted with during the assessment process. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. Service users have their health care needs met and are happy with the care and support provided. Some routines for providing personal care support were not appropriate and some records do not sufficiently detail enough information. Medication administration continues to fall below the required standard. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The evaluation of care files identified that the home has continued to improve care planning and assessment processes. The care files looked at had the required details and were up to date. There were numerous assessments and all care needs were, in the main, recorded. It is recommended to have a comprehensive working summary of the service users’ needs and preferences for care, which will enable care staff to have access to easy and understandable information. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 10 The care file for one service user was not available and a second site visit was arranged to evaluate the record. On the second visit the record was not available. The service user and their records had been transferred to home more suitable to meet their assessed needs. Additional records indicated professional visitors supported the service users to maintain their health. These visits were not always recorded, as required, within the service users’ individual files. Though service users confirmed that their health care needs were met and escorts were provided to support them attend health care appointments, their records did not consistently detail the information. Daily records failed to record the day to day routines and activities of the service users. There was no indication of rising and retiring times or the frequency of support provided throughout the day. Such routine recordings of ‘fine this a.m., helped with washing and dressing, ate her lunch time meal’ were not sufficient. Staff were observed to be courteous and understanding with service users. Though personal care was provided in a timely manner, the collective toileting of service users is not acceptable. Two service users were observed on the second visit to have been left in a corridor, one in the doorway of a bedroom, whilst staff were attending to another service users in the toilet. Furthermore, the practice of leaving service users in wheelchairs and then collectively seating them continues. Three service users were observed sat in wheelchairs in a lounge waiting to be seated. When asked if they were treated with respect and were listened to, one service user stated “I am satisfied with most people”. Seven comment cards stated that service users were always listened to. Another service user stated, “They are all very nice”. Service users were, in the main, happy with staff. One service user stated “its home from home for me”. Another, “staff do very well”. Notwithstanding those comments, a number of staff do not have English as their first language and this does cause some concern to service users. One stated “You have to keep shouting, they should learn English”, whilst another stated “They don’t listen to me when I ask them something and they walk away”. Yet another stated “They are not very good at speaking English or understanding, they are very nice though”. There were no issues raised regarding care practices and service users appeared happy with the support they received. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 11 The inspector observed that some staff were softly spoken and had limited conversation, also some staff had strong accents which made them difficult to understand. Discussions were held with the registered manager/owner regarding this matter and how staff could be assisted to develop an improved vocabulary. Some inadequate medication administration procedures continue as previously identified. The home does not have a formal routine for evaluating administration records which would enable them to identify and rectify errors in a timely manner. Evaluations of a sample of medication administration records, identified signature omissions. Furthermore, variable dosages were not recorded. Medication is administered at in the dining room at breakfast time. This often culminates in the administrator leaving the medication trolley unattended when they assist service users or administer medication to someone in a different area. The administrator was seen leaving the room to take medication elsewhere, leaving the trolley open. On another occasion, a second administrator assisted and was observed to sign records collectively, rather than individually. All these practices fail to meet the required standard. On the second visit, the home had purchased a small dedicated refrigerator to store medication, however its placement within the dining room is not appropriate and it was unclear if the temperature of the refrigerator was confirmed as correct prior to use. The home has compiled a medication policy, however it does not contain all the required details. Improvements have been made regarding the storage of medication currently not in use and stocks held on the premises have been reduced. Residents stated their health care needs were met, with one stating “If I wanted help, I could have it because they were all good to me when I wasn’t well”. One relative spoken to stated that they were satisfied with the care provided and were finalising arrangements to have their parent admitted permanently following respite and day care at the home. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. Residents were satisfied with their lifestyles and are able to make their own decisions and choices. Residents receive a varied, enjoyable diet. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: When speaking with service users they appeared satisfied with the home’s activities. Comment cards indicated that two were always satisfied with the arrangements. One service user stated there was enough activity and that they “don’t really want any more than they have”. Information received indicated that service users have opportunity to join in Bingo sessions, singing and watching movies. There were no records maintained regarding the frequency of activities and who had joined in. Service users’ individual daily records did not record any activities undertaken. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 13 The registered owner manager stated that the home used to provide much more events and activities, however due to the increased needs, most service users no longer wish to join in structured actives. Advice is given to consider seeking specialist advice to occupy and socialise service users who have dementia type illnesses. A number of service users continue to receive visitors at the home and visit places of interest with them. During the inspector’s visits one service user was observed going out with a family member and two were receiving visitors within the home. The home’s record of visitors is not maintained accurately and staff do not prompt visitors to complete the record. Daily records do not routinely record visitors or visits out of the home. Rising and retiring times were not recorded within service users’ care files. During the visits they were observed rising at different times and receiving their breakfast throughout the morning. Comment cards from service users indicated they had choice in joining in activities, what they eat and who they see. Service users were observed sitting where they wished including their rooms. One breakfast and lunchtime meal were observed. Tables were nicely set in a clean and more organised dining room. Service users were offered bacon at breakfast. Alternative options to the main meal and second helpings were offered at lunch time. Service users were observed being informed about various meal options and sweets and were able to say what they liked and didn’t like after tasting. Service users requiring assistance at meal times were given one to one support. Alternative seating arrangements are currently being considered to ensure that the most dependant service users receive the attention they require and that others are not disrupted when eating their meals. A menu was in place, however it does not detail all the meals served throughout the day, including breakfast, tea and supper options. Evaluation of food temperatures also identified that the menu was not followed. The home does not currently record the meals served to all individuals. Comments received from service users confirmed they enjoyed their meals, particularly roast lunches. One service user stated the food “is always lovely and plenty of it”. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. Service users are protected from abuse but complaint procedures are not fully implemented which may compromise the quality of services provided. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Service users were asked if they felt confident that their complaints would be listened to, taken seriously and acted upon. They clearly indicated that they were satisfied and confident in the complaints system. Eleven stated they knew the complaints procedures and would tell someone if they were not happy. One service user stated she would “Tell a senior or the one in charge” if she was not happy. Another stated “I could talk to Anna (registered owner/ manager) about any concerns”. She also stated she felt well cared for and safe. There were no complaints recorded within the home’s complaint record. The registered manager stated that the home “used to write everything, but more often than not, they were trivial”. A discussion was held regarding the recording of all complaints to enable the full and accurate evaluation of the home’s systems and identification of areas where there may be failings. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 15 Adult protection procedures are in place and the registered owner/manager and the management team have completed adult protection training. Training has commenced with the staff team, with six staff confirming they were aware of the procedure. The home has commenced a rolling programme of training each month within the home which includes adult protection. One allegation of abuse has been received, the outcome of which has not yet been reported to the CSCI. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 24 & 26 Quality in this outcome area is adequate. Service users live in surroundings that are clean, homely and, in the main, free from odours, but require some upgrading. Fire safety is compromised. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: On arrival at the home it was found to be clean and tidy. The rear lounge had a large TV and service users have access to a remote control. Some new sidetables were in place which were domestic in appearance and homely. Three service users indicated they used their rooms during the day and found them comfortable. Mr Munif has decorated two rooms since the last inspection and continues to decorate additional rooms. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 17 The majority of service users’ bedrooms were appropriately decorated and personalised. Domestic routines ensured that service users received timely support to maintain their rooms. One bedroom had a strong odour, the registered manager stated that due to service users’ persistent behaviour, consideration is being given to removing the carpet. However, this will not be done until consultation and agreement with relatives and professional services have been completed. Whilst Mr Munif takes responsibility for maintaining the home, additional assistance may be required to ensure the home is redecorated and maintained in a timely manner. Parts of the home are looking tired and worn. Wallpaper and paint had scuffmarks and personalisation was required in bathing and toileting areas. Furthermore, fire safety was compromised. Doors were observed to be wedged open and one door guard was faulty. The home had not taken sufficient action to comply with requirements arising from the fire safety inspection in March 2006. When asked, four service users stated that the home was always fresh and clean. Although one stated, “My son sat on a wet chair the other day”. Another stated “there are odours sometimes”. Routines should be stringent to ensure that such occurrences are rare, if at all. The laundry area was evaluated and found to be clean and well organised, however investment in basic equipment, such as new laundry and storage baskets, is advised. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. Staff were in appropriate numbers and trained to meet the needs of residents. Recruitment procedures continue to require development. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: At the time of the visits, staff were in appropriate numbers to meet the needs of service users. The home had three vacancies and care staff were able to meet the needs of the service users accommodated. Staff deployment required improvement. On the first visit all staff were observed by the inspector taking their breaks together. When asked if service users felt well cared for, one service user stated, “when they go on breaks, there is no-one to look after you”. Another stated, “they are always on a break, when I shout they come running”. Another, “ When they go on breaks there is no-one to look after you.” One service user’s file stated that the service user should “always be observed”. This was not maintained during the inspection. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 19 Staff deployment was discussed with the registered acknowledged that arrangements were not satisfactory. manager, who Most staff had achieved NVQ training, with two staff currently attaining level 2. Four staff had completed NVQ level 3 and two stated they wished to complete level 4. Though detailed training records are not maintained, basic systems confirm that training is ongoing for all staff. As stated previously within the report, the home has secured a training programme which will be conducted on a monthly basis throughout the year. Staff confirmed that they receive training and speak well of the home’s support to ensure they are trained correctly. One staff stated “The home does well, ensuring all members of staff undergo essential training and they also fund the training and pay you to attend”. Two more staff commented that the home provided good training to improve the quality of their work. Two staff files were looked at. Recruitment procedures were, in the main, satisfactory, however one file failed to contain appropriate references. There were no details of the interview process for either staff, no indication that the staff had seen a job description and one file failed to contain a contract of employment. Letters of appointment were not evident and induction procedures could not be identified. In addition, there was no information to support that staff had received a code of conduct set out by the General Social Care Council. Of the comment cards returned by staff, six stated they had received a contract of employmen,t four of whom had received a job description. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. The home is managed and run in the interests of service users. Their health, safety and welfare are not fully promoted and protected. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Mrs Munif is the registered manager and one of the registered providers. She has managed the home since 1989. Staff stated she was a supportive and caring manager. Service users indicated that they trust her and would go to her if the had any concerns. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 21 The registered manager is commencing training to achieve the Registered Manager’s award which is required should she wish to continue managing the home. Throughout the visit the registered manager was open and honest, and spoke at length about issues arising within the home and the management processes being considered to bring about positive changes. Quality assurance procedures are not in place at the home and direct feedback from users of the service is not actively sought to influence practice. The registered manager is considering ways to meet routinely with both service users and their families in order to discuss day to day routines and their satisfaction with the service. The timescale for full quality assurance procedures issued at the previous inspection had not expired at the current visit. The home does not manage residents’ finances. Expenditures are billed monthly to the service user or their representative. Service users receive support to manage their financial affairs from family, advocates and social services. The home has commenced formal supervision processes, however not all staff had received it at the time of the visit. Insurances are in place and up to date. Health and safety records were evaluated and, as stated previously, fire safety was compromised. Though new record keeping has commenced in respect of kitchen management, they still require development. Kitchen cleaning schedules were not maintained appropriately. Omissions were evident and they failed to record all required cleaning. Accidents were recorded, however details were not contained within the service user’s file. The home could not evidence that it analyses accidents and occurrences to monitor common occurrences and reduce further accidents. Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 1 3 1 X 1 Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 17 & Schedule 3 Requirement The registered person must ensure service users’ individual files contain the required detail, including rising and retiring times, day to day routines, activities undertaken and health care visits and visitors, etc. The registered person must ensure that the medicines policy is developed and expanded to reflect current guidance issued by the Royal Pharmaceutical Society and comply with the National Minimum Standards. (Timescale of 04/04/06 not elapsed). The registered person must ensure that medication administration records are signed contemporaneously and accurately, including when medicines are not administered. (Timescale from 10/01/06 not met). The registered person must cease providing personal care and assistance with seating in a collective manner. Timescale for action 01/10/06 2 OP9 13(2) 01/08/06 3 OP9 13(2) 17(1)(a) 01/06/06 4 OP10 12 & 13 01/07/06 Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 24 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. 5 Standard OP16 Regulation 22 Requirement Timescale for action 01/07/06 6 OP19 7 OP27 8 OP29 9 OP30 10 OP31 The registered person must ensure that all complaints are recorded and that details include the nature of the complaint and the action taken to find a positive resolution. (Timescale of 31/11/04 not met). 13 The registered person must submit, after assessment, the home’s annual plan for maintenance and investment. (Timescale of 01/05/06 not met). 18 The registered person must ensure staff are deployed in appropriate numbers at all times and cease taking their breaks together leaving the residents unsupervised. 19 & The registered person must Schedule ensure that robust recruitment 2 and selection procedures are in place and followed. (Timescale of 01/04/06 not met). 18 The registered person must maintain evidence to support all levels of staff receive training appropriate to the work they are to perform. 9 (2)(b)(i) The registered manager must complete training at NVQ level 4 and achieve the registered manager’s award. (Timescale of 01/08/06 not elapsed). DS0000008603.V297017.R01.S.doc 01/09/06 01/07/06 01/07/06 01/10/06 01/08/06 Lynwood Version 5.2 Page 25 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. 11 Standard OP33 Regulation 24 Requirement Timescale for action 01/10/06 12 OP36 18 13 OP38 17 & Schedule 3 23 14 OP38 The registered person must complete quality assurance procedures in accordance with Regulation 24. (Timescale of 01/10/06 not elapsed). The registered person must 01/09/06 ensure care staff receive supervision at the required frequency and ancillary staff periodically. The registered person must 01/07/06 ensure all accidents are recorded and detailed information retained on the service users’ individual files. The registered manager must 01/07/06 provide evidence that requirements and recommendations of the Fire Safety officer have been implemented. (Timescale of 01/05/06 not met). Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP3 OP12 OP13 OP15 OP30 Good Practice Recommendations The registered person should, wherever possible, include consultation when completing assessments and developing care plans and obtain signatures of agreement. The registered person should seek professional advice and training in ways to occupy, entertain and socialise service users with mental health frailty. The registered person should ensure staff promote the signing of the visitors book when visitors are entering and leaving the home and ensure it is maintained up to date. The registered person should ensure that, as far as possible, the home’s menu is followed. Where amended, reasons should be evident. The registered person should ensure that induction training meets the standards set by Skills for Care and recorded information can confirm when training was undertaken and for how long. The registered person should ensure that the home’s cleaning schedule complies with the standard required by the environmental health department. The registered person should ensure systems are in place for analysing accidents which are able to identify common occurrences and patterns. 6 7 OP38 OP38 Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lynwood DS0000008603.V297017.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!