Inspection on 28/02/06 for Lynwood

This inspection was carried out on 28th February 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 26/05/06

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 28th February & 2nd March 2006 08:00 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.V263513.R01.S.doc Version 5.1 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.V263513.R01.S.doc Version 5.1 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.V263513.R01.S.doc Version 5.1 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). 9th May 2005 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.V263513.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Lynwood was unannounced and conducted over two days, with a total of 14 hours being spent on the premises. Time was spent speaking with residents and observing care staff as they carried out their duties. Two meals were shared with residents and time was spent at a staff meeting. A number of the home’s records were evaluated relating to residents’ care and health and safety aspects of the home. Comment cards were provided to residents, relatives and professional visitors prior to the inspection; at the time of writing the report none had been returned. An inspection of the control of medicines was undertaken on 3rd January 2006 and a number of requirements and recommendation were made. This visit looked at the home’s actions to meet those requirements and the ones arising from the previous inspection in May 2005. To obtain full details on how the home operates, the reader is advised to read the current inspection report in conjunction with the report of the May inspection. What the service does well: What has improved since the last inspection? The owner/manager has enrolled on NVQ and the registered manager award training and has employed an assistant manager to aid the development of records and administration procedures within the home. New care plan formats were being implemented and, once complete, they should detail the residents’ individual needs and their preferences for care and how they should be met. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 6 The home has introduced new policies and procedures. A new filing system had been put in to place to improve the security and confidentiality of information. Formal supervision has commenced and some improvements regarding medication procedures could be identified. 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.V263513.R01.S.doc Version 5.1 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.V263513.R01.S.doc Version 5.1 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): 2&3 Residents do not always receive terms and conditions of residency in a timely manner. Residents have their health care needs assessed prior to being accommodated. EVIDENCE: Inspection of two residents’ files identified that one had not received the home’s terms and conditions of residency prior to or at the point of admission. The home completes pre-placement assessments that detail the date of the assessment and where completed and who was involved in the assessment process. However, the actual assessments are brief, such details as ‘Hygiene – needs assistance’ ‘ Mobility – Mobile with frame’ do not provide sufficient detail to enable the home to demonstrate or assess if it can meet the individual needs of the resident or provide a basis from which a care plan can be developed. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 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 Residents receive appropriate health care support but medication administration practices place residents at risk. At times, staff speak and or act disrespectfully towards residents. EVIDENCE: At the time of the inspection the home was in the process of introducing new care plans. The two residents’ files evaluated continued to have old formats in place. It was evident that insufficient detail was recorded. Information such as accidents and behavioural patterns were recorded in communal records rather than in the residents’ individual files. The files failed to contain nutritional assessments, weights and the frequency of chiropody and district nurse support. It was through talking with residents, family members and staff that the inspector could identify that routine health care support was provided appropriately. However, the lack of recorded information places residents at risk of not having their health care needs supported as required or monitored appropriately. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 10 Medication practices continue to be below the required standard in many areas. Medication records contained signature omissions; medication was not administered as prescribed and was handled during administration. Medication administration records failed to identify a number of residents; other records detailed staff could not locate medication when required. Medication was left unattended, whilst the administrator located residents. Creams were found in communal bathrooms and prescribed creams found without labels in residents’ rooms. Dressings, bandages suppositories and enemas, some of which were out of date, were found unlocked and available to residents in a unit on a corridor. The assistant manager explained that new storage facilities were to be devised and that monitoring of administration routines would be taking place in the future. At times, some care staff demonstrated they promoted the dignity and respect of residents, at other times some staff were disrespectful. One staff member was observed sitting with a nervous resident the whole time she had her hair done, offering support and comfort. Another patiently dealt with a resident who did not want to get dressed by late morning, assisting them appropriately from communal areas to dress in their room in a kind and considerate manner. On another occasion a member of staff was heard to say “give it a rest” to a resident who repeatedly called for attention. Another seemed put out when the inspector requested a table for a resident receiving her meal in a lounge area, then saying within hearing of the resident “she will only want something else anyway”. Three staff were observed transferring a resident whose care plan stated they must use the hoist. Furthermore, the resident had been left an unreasonable amount of time in a wheelchair before assistance was given. The practice of two staff ‘hooking’ under the resident’s arms whilst another rolled the waist of the resident’s trousers to get a hold whilst transferring was incorrect, disrespectful and placed the resident at increased risk of harm. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 11 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 The home could not demonstrate it provided sufficient social stimulation. EVIDENCE: The residents of Lynwood live quite sedate lives, daily activities are not routinely provided, however one member of staff was observed sitting with a resident colouring. When spoken with, residents stated they would like more opportunities to socialises and be entertained. One stated they would ‘love to go out’. Residents’ files did not record social activities and there was no information displayed to inform residents that activities were planned for or occurring. Visitors are able to meet with residents in both their private and communal rooms. Some residents confirmed that they were able to choose their own rising and retiring times. They stated they were independently able to go to their rooms when they wished and choose where they received their meals. The more dependent residents had limited choice, it appeared that routines were designed to meet the needs of staff rather than the individual, with residents saying that some are taken to bed “quite early” and “got up early”. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 12 Residents confirmed that night staff woke some residents up to prepare them for the day before the morning staff came on duty. Such practice is unacceptable and routines within the home should be developed to meet the needs of residents rather than the staffing complement. The home provides residents with a varied diet. Staff provided assistance at meal times where required and soft diets were made for individuals. Residents were observed to ask for and receive second portions and alternative meals were served to the main meal option. Residents provided with meals in lounge areas were not appropriately supported. Tables were inappropriate, staff failed to provide suitable trays and one resident was observed balancing a bowl of soup on his knees which increases the risk of accident. Accident records detailed a number of accidents relating to spilled liquids. Residents like to drink both tea and coffee, however only tea was served at drink times. Residents confirmed they were not offered ‘milky’ drinks during the day. Staff failed to offer residents a choice of biscuits; rather, they routinely chose one and gave it to the resident by hand. Currently, the home does not record residents’ individual food intake or meals received and/or eaten at meal times. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 13 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): These standards were assessed at this inspection. EVIDENCE: Information obtained indicated that no action had been taken to fully meet requirements issued at the previous inspection. Until it can be confirmed that the home has met the requirements, they are repeated at this inspection. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 14 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, 20, 21, 23, 24, 25 & 26 Residents’ rooms were personalised and pleasant, but some areas of the home need redecoration and repair. Maintenance of equipment (and installations) in the home were not routinely undertaken. EVIDENCE: Though the home has redecorated and carpeted some lounge areas in the past year, the general upkeep of the home has not been maintained. Paintwork was scuffed and marked, wallpaper was peeling and a number of light bulbs were not working. The entrance of the home looks shoddy and the general appearance of the exterior of the home is uncared for. Bathing and toileting areas are adequate, however they are in need of upgrading. Tiles were absent or cracked in a number of rooms and waste bins were broken or without lids. The general air of the rooms were functional rather than inviting and homely. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 15 The home is fitted with call points, however most, if not all, were without extension cords to aid use by residents. Overhead bed lighting were without diffusers which increases the risk of accident to residents. Radiator covers have been fitted to most radiators and water temperatures are maintained within bathrooms. On both days of the inspection rooms used by residents were not appropriately heated. Residents consistently informed the inspector and staff that they were cold. Staff were observed buttoning up cardigans on residents and suggesting they wear additional clothing if they remained cold. The home’s gas appliances were last inspected in 2005, however it is not known if this included the servicing of the home’s central heating system. The home’s lift was inspected in September 2005 and a report produced identified many areas of work required to ensure the highest standards of safety were maintained. There was no information to confirm the home had complied with the recommendations and requirements issued at that time. Electrical equipment tests (PAT) were not up to date. The home’s electrical wiring was serviced in February 2003. Fire safety records identified test were not completed within required timescales. The fire safety authority inspected the home in March 2004. The report of the inspection details requirements and recommendations, confirmation of how the home has complied with the report is required. Residents’ rooms were personalised, clean and maintained. It was evident that they had brought personal possessions with them from home. Laundry facilities were clean and presentable, with a dedicated laundry person in attendance each day at the home. Staff were not following infection control procedures, in that, soiled laundry was mixed with other non soiled items. Furthermore, disposable gloves and aprons were not routinely worn when required. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 16 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 The number of staff on duty was sufficient to meet service user needs, however they had not been safely recruited nor trained to carry out their duties. EVIDENCE: On the day of the inspection there appeared to be sufficient staff on duty. The registered manager provided the inspector with one month’s rota for evaluation. The rota failed to give the full names of staff and their employment position, therefore it could not be determined how many care staff/seniors and/or managers were on the premises at any given time. Furthermore, ancillary staff could not be identified. The rota failed to record the commencement and completion times of each duty making it difficult to assess numbers of staff at any given time. Residents confirmed that staff attended to them during the night without excess delays occurring. The registered manager confirmed that 45 of staff have completed NVQ training at level 2 or above. Currently, the home completes its own induction with new staff. It has yet to implement induction and foundation training as set by Skills for Care. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 17 Evaluation of four staff files again identified that the home does not consistently recruit staff to the required standard. Two references were not always received before employment commenced. Proof of identity and current photographs were not evident. CRB checks were not always received before employment commenced. Some CRB’s on file related to staff members’ previous employment. Training records were inconclusive and failed to identify that staff had training and development plans in place and that they had received up to date mandatory training for their position of employment. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 & 38 The management of the home had improved in some areas but staff supervision and quality assurance had not been undertaken. EVIDENCE: The registered owner continues to manage the home, she has enrolled for NVQ 4 training and the registered manager’s award. Since the last inspection she has recruited a part-time assistant manager whose main role will be to assist in the development of the home to meet required standards. At the time of the inspection the joint working process was developing and though many areas remain where the home does not meet required standards, some improvements could be identified, in that, there was a plan of development and a more defined leadership role was evident. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 19 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. Insurances are in place. It is not known if the home completes an annual business and development plan, nor if requested, one could be made available to the CSCI. Residents receive support to manage their financial affairs from family, advocates and social services. The home does not manage residents’ finances. Though not all records are maintained and secured correctly, there is some improvement evident. The registered manager spoke of the development of parts of the building to improve staff’s working conditions, particularly administration areas. One to one formal supervision had commenced for some, however night staff had not been included in the process. Health and safety records were evaluated. Accidents are recorded, however those pertaining to residents are not filed on their individual files. Furthermore, there was no indication that accidents were analysed to enable patterns and common occurrences to be identified to prevent further accidents. Environmental Health Officers inspected the premises in June 2005. The report details requirements and recommendations made. There was no evidence of the actions taken by the home to meet those requirements and recommendations. The registered manager has implemented new policies and procedures. The assistant manager stated that he intends to commence training and guidance with all staff and ensure they each receive a personal copy to follow. Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 X 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 2 3 2 2 1 Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation Schedule 4(8) Requirement Timescale for action 01/05/06 2 OP7 3 OP8 4 OP10 5 OP12 The registered person must ensure that all residents receive terms and conditions of residency prior to or at the point of admission. 17(a) The registered person must Schedule ensure that all care plans are 3 appropriately detailed and provide sufficient information relating to the residents’ care needs and preferences and how they should be met. (Timescale of 01/08/05 not met). 8, 13 & 15 The registered person must ensure that residents’ individual records can demonstrate the home’s support to provide health care, including chiropody, optical, dental and hearing checks and treatments. 12(4)(a) The registered person must ensure that residents are treated with dignity and respect at all times. 16(2m) The registered person must provide sufficient social activities to meet the individual needs of residents. (Timescale of 01/07/05 not met). DS0000008603.V263513.R01.S.doc 01/06/06 01/06/06 01/06/06 01/06/06 Lynwood Version 5.1 Page 22 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. 6 Standard OP14 Regulation 12 Requirement The registered person must ensure staff cease waking residents up in the morning to aid morning staffing routines. The registered person must ensure all residents are offered a choice of drinks throughout the day. The registered person must ensure that residents’ individual records detail their continued weight, nutritional assessments and dietary intake. The registered person must ensure that all residents and relatives are made aware of the homes complaint procedure. (Timescale of 01/07/05 not met). 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). The registered person must ensure that all staff, including herself, receive up to date adult protection training and are aware of their responsibility to report all allegations and/or suspicions of abuse. (Timescale of 01/07/05 not met). DS0000008603.V263513.R01.S.doc Timescale for action 01/06/06 7 OP15 16 01/04/06 8 OP15 16 01/06/06 9 OP16 22(5) 01/06/06 10 OP16 22 01/06/05 11 OP18 13(6) 01/06/06 Lynwood Version 5.1 Page 23 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. 12 Standard OP21OP19 Regulation 13 Requirement The registered person must submit, after assessment, the home’s annual plan for maintenance and investment. The registered person must ensure that residents have access to the nurse call system. The registered person must ensure that infection control procedures are followed at all times. The registered person must ensure that all parts of the home used by residents are appropriately heated. The registered person must ensure that staff are trained and competent at safe moving and handling procedures. (Timescale of 10/06/05 not met). The registered person must be able to demonstrate that adequate numbers of staff are routinely rostered for duty. The duty roster must include the full name of staff, their employment position and their duty times. The registered person must ensure that robust recruitment and selection procedures are in place and followed. Timescale for action 01/05/06 13 14 OP22 OP26 23 13. 01/05/06 01/05/06 15 OP25 23(p) 01/04/05 16 OP28 13(4a) 01/06/06 17 OP26 Schedule 4 01/04/06 18 OP29 19 & Schedule 2 01/04/06 Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 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. 19 Standard OP30 Regulation 18 Requirement Timescale for action 01/06/06 20 OP33 21 OP31 22 OP34 23 OP37 24 OP38 The registered person must demonstrate staff receive the training they require to fulfil their employment position and responsibilities. 24 The registered person must complete quality assurance procedures in accordance with Regulation 24. 9 (2)(b)(i) The registered manager must complete training at NVQ at level 4 and achieve the registered manager’s award (Timescale of 31/03/06 not met). 25 The registered person must confirm that the home has a business plan in place, which is reviewed annually and can be made available for inspection upon request. 37 The registered person must Schedule ensure information relating to 3(j) accidents are maintained in accordance with the Data Protection Act 1988. (Timescale of 01/06/05 not met). 16 The registered person must provide evidence that the requirements and recommendations arising from the Environmental Health inspection completed in June 2005 have been met. 01/10/06 01/08/06 01/06/06 01/06/05 01/05/06 Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 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. 25 Standard OP38 Regulation 23 Requirement The registered person must provide evidence that the passenger lift has been maintained as required following an inspection in September 2005. The registered manager must provide evidence that requirements and recommendations of the Fire Safety officer have been implemented. 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 of 10/01/ 06 not met). Timescale for action 01/05/06 26 OP38 13 (2) 01/05/06 27 OP9 13 (2) 04/04/06 28 OP9 13(2) 17(1)(a) 01/05/06 Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 26 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. 29 Standard OP9 Regulation 13(2) 17(1)(a) Requirement Timescale for action 01/04/06 30 OP9 13(2) 13(4)(c) 31 OP9 13(2) 13(4)(c) 32 OP9 13(2) 13(4)(c) The registered person must ensure that an accurate and contemporaneous record is made of the administration of all topical preparations and prescribed nutritional supplements. (Timescale of 10/01/06 not met). The registered person must 01/04/06 ensure that all medication is administered to residents as prescribed. (Timescale of 10/01/06 not met). The registered person must 01/05/06 ensure that a record is maintained of the decision of all members of the multidisciplinary team before medication is administered covertly. Medication must not be crushed until the written authorisation of the prescriber has been obtained. (Timescale of 07/03/06 not elapsed). The registered person must 01/05/06 ensure that all medication in the custody of the home is stored securely and is not accessible to unauthorised persons. (Timescale of 17/01/06 not met). Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 27 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. 33 Standard OP9 Regulation 13(2) 13(4)(c) Requirement The registered person must ensure that medication which requires refrigeration is stored in a secure refrigerator and is appropriately separated from food items. (Timescale of 01/02/06 not met). The registered person must ensure that all items of medication which have exceeded their expiry dates, do not belong to current residents or are not labelled with prescribed directions are returned to the supplying pharmacy. (Timescale of 17/01/06 not met). The registered person must ensure all staff who have responsibility for administering medication are trained and competent regarding safe handling and management of medicines. (Timescale of 04/04/06 not elapsed). Timescale for action 01/05/06 34 OP9 13(2) 13(4)(c) 01/05/06 35 OP9 13(2) 18(1)(c) (i) 04/04/06 Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 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 OP3 Good Practice Recommendations The registered person should ensure pre-admission assessment documentation contains enough details to enable an accurate evaluation of need and enable the home to determine if it can meet those needs. The registered person should ensure that a formal system is in place to identify residents prior to medication administration. The registered person should ensure that the home retains a list of staff members authorised to administer medicines, which includes a record of their signature and approved initials. The registered person should ensure that induction training meets the standards set by Skills for Care. The registered manager should ensure that all care staff receive formal supervision no less than six times per year and ancillary staff periodically. (This was a recommendation in the inspection report of April 2004). The registered person should ensure systems are in place for analysing accidents which are able to identify common occurrences and patterns. 2 3 OP9 OP9 4 5 OP30 OP36 6 OP38 Lynwood DS0000008603.V263513.R01.S.doc Version 5.1 Page 29 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.V263513.R01.S.doc Version 5.1 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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