Inspection on 18/09/08 for Lynwood House

This inspection was carried out on 18th September 2008.

CSCI found this care home to be providing an Good 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 House 25/09/06

Lynwood House 05/12/05

Lynwood House 20/07/05

Lynwood House 29/10/04

Lynwood House 14/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Lynwood House Durham Road Lanchester Co Durham DH7 0LP Lead Inspector Kathy Bell Key Unannounced Inspection 18th September 2008 10:00 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 House DS0000031189.V372160.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 House DS0000031189.V372160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lynwood House Address Durham Road Lanchester Co Durham DH7 0LP 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) 01207 520292 P/F ann@steadman.durham.gov.uk www.durham.gov.uk Durham County Council Mrs Ann Steadman Care Home 36 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (26) of places Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Learning Disability - LD(E) and LD That 6 places be maintained for those service users in the category of LD(E) and one for a service user in category LD until those service users no longer require this accommodation. 25th September 2006 Date of last inspection Brief Description of the Service: Lynwood House is a long established care home for older people. Durham County Council’s Adult and Community Services Department is the registered provider of the service. All the bedrooms are singles and are on the ground floor. Some are larger than average because they were previously double rooms, and they provide more space for people who need equipment to help them move around. The home provides permanent care for some people and also a unit which is used to carry out assessments of peoples needs so that decisions can be made about the care they need in the future. The home is close to the centre of the small village of Lanchester, with local shops, pubs and church. It is surrounded by a large lawn and garden. The weekly charge is £432.32, although the amount service users pay depends on their personal circumstances. This does not include the costs of hairdressing, which costs between £2 and £8, newspapers and toiletries. There has been uncertainty for a few years about whether the home would continue to stay open, or whether the site would be redeveloped to meet social and health care needs in other ways. A final decision has not been made yet. Lynwood House DS0000031189.V372160.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 2 stars. This means that the people who use the service experience good quality outcomes. This inspection took place during a day and a half in September 2009. During the visit, the Inspector looked around the building, though not in every room, and looked at records. Before the inspection, she had received surveys back from three residents and six staff. During the visit she spoke to seven residents and three relatives, as well as to the manager and four staff. What the service does well: What has improved since the last inspection? What they could do better: Staff must keep up-to-date a care plan for each resident, which explains how their needs and choices will be met. Residents must be involved in producing this plan, as much as they can and want to. It must include how the home will meet each residents leisure needs. Care plans are essential so that staff always know what each person needs them to do for them. Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 6 A photograph of each resident must be in their medication record to avoid any risk of giving drugs to the wrong person. When staff are writing out a medication administration record, they must write exactly the instructions on the label for the medication to avoid mistakes. Staff must always record when residents are self-medicating. Also, the manager must establish one consistent way of recording when a resident has not taken as required medication so that records are clear. Staff must keep asking each resident if there are any activities they might like to do, and record this. Information about individual dietary needs must be written down and be available in the kitchen to make sure that staff are aware of them.More effort must be made to make people aware of how to complain. The information from the surveys of residents and relatives must be used to create an action plan, as to how the home could improve. When staff are writing a medication administration record, a second member of staff should check that the instructions from the label on the medication have been written down correctly, and sign that they have checked this. The home should use only one type of medication administration record, to avoid confusion. 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 House DS0000031189.V372160.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 House DS0000031189.V372160.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are assessed properly before they are admitted so that the home can be sure it will be able to meet their needs. The home does not provide intermediate care so Standard 6 was not assessed EVIDENCE: We looked at the records of the admission of seven residents and all had a copy of the care managers assessment in their files. This included detailed information about their needs. Lynwood House DS0000031189.V372160.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staff are not keeping up-to-date, detailed care plans which explain the help people need. But the home still provides a good standard of care and makes sure people receive the health care they need. Medication is looked after safely but the home should make a number of small changes to avoid the small chance of errors happening. EVIDENCE: We looked at the care plans of seven residents. The care plans should include all the information care staff need to look after people and meet their needs and preferences. They should include information about someones life, and what they used to like to do with their leisure time. There was very little information available in care plans for people who had come in recently. One, for a lady who is terminally ill, did not include current needs or past history. Another had no specific information on personal care needs except for guidance on the help she needed to get around and to bathe etc (a moving and handling risk assessment). Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 10 There was more information in the care plans of people who had lived in the home for a year or two but this had not been kept up-to-date. And some sections had not been filled in, such as peoples history, leisure needs, if they had a history of falls and their preferences about how they liked to live. All the care plans did include the same record of what the home needed to do to keep them safe from the risk of hot water and all had a moving and handling risk assessment. Staff were recording a weekly summary of how people had been when they had come in for assessment. A care manager said that he received useful information from staff during this period of assessment. One file contained good information about nutritional needs and showed that the home had respected a residents choices in this area. Durham County Council, which runs the home, has provided a very detailed format which staff can use to write care plans. It includes prompts so that staff find out what people want, as well as what they need. If this was used, and kept up-to-date, staff would have the information they needed to meet peoples needs. But staff do communicate very well on a day-to-day basis and see this as one of their strengths. They said that for newer residents, they do use the care managers care plan, but as they get to know someone better they find out the details of their needs. They use the communication book and have handovers to pass on information between staff. They admitted that a lot of information is in their memories rather than written down. But where necessary, staff were recording in detail so that they could provide information for healthcare professionals who were looking into a particular problem. So far this has worked well to provide a good standard of care for people. This is partly because the staff are experienced and there are few changes in the staff group. But care plans must be kept up-to-date and provide all the information required, in case someone moves to another home or staff new to the home need to provide care. Also, a resident should be able to look at their care plan and see whether staff are planning to provide the care in a way the resident agrees with. Care managers praised the home. They can bring people in and know they will be looked after. All the staff seem to go the extra mile. They said that staff encouraged people to be as independent as they could. Two district nurses said that attention to health care is excellent. They have a good relationship with staff and would recommend the home. Care staff ask for their help when they should and follow their instructions. In the information provided to us before the inspection, the manager confirmed that no one had developed pressure sores since they were admitted to the home. Relatives also were generally happy with the care provided. Once said that staff care about the residents, knew what his mother wanted and were there Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 11 when she wanted them. Her well-being had improved in the three weeks she had been in the home. In the surveys, two residents said they always received the care and support they needed and one said usually. All three said that the staff listened and acted on what they said and were available when they needed them. We saw that residents who might not have been able to do this for themselves, were nicely dressed, with coordinating clothes, and their hair done. The home has established, generally safe systems for looking after medication. It is stored safely and staff record when medication has been received, when it is given out and when disposed of. They also follow correct procedures for looking after drugs which need special care because they are powerful or could be misused (Controlled Drugs). But there were a number of ways in which mistakes could happen or the records could be unclear. Short-term or new residents receive their medication in the original containers. Staff then write out the record of when the medication is to be given. Some staff were not copying exactly the instructions on the original medication container, for example take four times a day, but changing this to old-style Latin instructions. Staff must write down exactly what it says on the label to avoid chances of an error. It is also good practice for a second member of staff to check this has been done correctly and sign that they have done so. Only some residents had their photograph attached to their medication records. This is an important safeguard to make sure the right person is given the right drug. Some residents look after their own medication because they can do so safely. It is good that the home gives them this opportunity but staff had not always recorded on the medication records that this is what was happening. The home is using two different styles of medication administration records, which have different codes to show when someone has, for example, refused their medication. It would be safer to have only one kind so that staff were not using two different sets of codes, as they sometimes used them on the medication sheet they were not intended for. Some residents have medication which is taken when required. Staff were not using one consistent system to record when somebody did not want or need this medication. Some left the box empty and some put the code for refused. The manager should decide on one system and make sure all staff do the same. This is important because records should make it absolutely clear what happened, without any chance of uncertainty. Lynwood House DS0000031189.V372160.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There is a range of leisure activities available but the home should do more to show they ask people what they would like. People can keep up contact with their relatives and the local community. The home provides a satisfactory, varied diet. EVIDENCE: There is a programme of activities displayed in the home. A church service is available and entertainers have visited the home. A PAT dog visits the home once a week, for residents who like to pet a dog. Twice a week staff invite residents to take part in craft activities, or just a cup of tea and a chat, in the dining room. Twice a month, the CREATE service provides craft activities which residents can take part in. The manager described how they have tried to offer more activities, such as a visit to a coffee morning in another home or video nights but people havent been interested. The daily records do not show when people take part in activities or when they have been offered and care plans do not always show the leisure interests. The manager believes that staff do ask residents what they would like to do. We recommend that staff ask each person what they would like to do, record this in the care plan and ask again from time to time. This would help them be sure they are doing Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 13 all they can to provide interesting activities, to meet each persons interests. One resident said that the staff invite people into the lounges so they feel welcome but they respect their wishes if people prefer to sit in their rooms. She is a keen reader and said that staff go to the library for her and have found out what sort of book she likes. In the surveys, three residents who responded, had very different views about whether there were enough social activities. Relatives can visit at any reasonable time and the home maintains links with the local community, for example, by hosting a fundraising coffee morning. In the surveys, all three residents said that staff listened and acted on what they said. One man said that he could do what he wanted, within reason. When we visited, we saw one person still eating their breakfast at 10 oclock, which suggested that people could choose when they wanted to get up in the morning. The home provides a choice at breakfast time but one main meal at lunchtime. A board in the dining room shows the meals for the day. Residents who commented, and the cook all said that if residents didnt like the planned meals, they could have something different. The cooks were proud that they make traditional meals and cakes etc from fresh ingredients. The meals tended to be traditional, meat based meals. This suits the current residents but the home may have to provide greater variety in the future if they have vegetarians or anyone who needs a special diet because of cultural or religious needs. Records of the residents meetings show that people are asked what they think of the meals. During the inspection, residents described the food as, all right, very good, and excellent. One lady said that she empties her plate and has put on weight in the three weeks she has been on the home. One care plan did include information from a speech and language therapist about a residents needs for a special diet. The resident did not agree with her recommendations and the home has recorded his decision and the action they take to reduce the risk to him, while giving him a diet he will accept. There was not an up-to-date list in the kitchen of everyones dietary needs, for example who was diabetic. The cook was confident that they knew who needed what and care assistants would tell them if necessary. It would be safer to always have a list available to make sure people received the food they needed. The manager described how the care managers assessment highlights if someone has problems with their weight and they refer to the GP if they see, through regular weight checks, that someone is losing weight. She also explained that their food suppliers can provide a range of special foods and Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 14 that the county council is currently working with a local university to improve nutrition in its homes. Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 15 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): Standard 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a satisfactory system for dealing with complaints but should try harder to make people aware of this. People are protected from abuse as far as possible. EVIDENCE: The home has Durham County Councils established complaints procedure which includes all the required information. This is given to new residents as part of the Service User Guide which provides information about the home. No complaints have been recorded in the last year. But relatives and a resident said they would speak up if they needed to complain. Although one relative said she could speak to the manager, it seemed that she may not have said all she wanted to. In the surveys, one resident said they always knew who to speak to if they were not happy and the other said usually. One said they knew how to make a complaint and the others did not answer this question. The complaints procedure was not noticeably on display in the home but the manager is aware that she should make greater efforts to make people aware of their rights to complain, and how to do it. The home has recruitment procedures to help them avoid employing anyone who might harm residents. Staff have had training in identifying and preventing abuse and what they should do if they suspect abuse. Some staff Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 16 have had refresher training to remind them of what they learned and the rest of the staff are going to receive this in the near future. The home has procedures for looking after peoples money so that they are protected from any financial abuse. Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 17 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): Standards 19, 20, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is a pleasant, safe place to live which meets peoples needs. EVIDENCE: The building is an older style home which was originally built to provide care for a higher number of residents. This means that there is plenty of communal space. There is one large lounge and three smaller lounges which means people have the choice where they sit. There is also a very large dining room. The home is surrounded by large gardens and lawned areas which are well cared for. Inside, the building is pleasantly decorated in a domestic style with redecoration and improvements carried out from time to time. Outside, the building does need some maintenance but it is understood that major work will not be done when a homes future is uncertain. All the rooms are on the ground floor and all are single. Some bedrooms are of a good size because they were previously used as double rooms. These rooms give plenty of space for people who need equipment to help them be moved around. Sometimes Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 18 one of these rooms is not available and a smaller room must be used. The manager explained that if necessary, they will provide an extra room so that furniture and other belongings can go in one room, leaving one bedroom free for the bed and moving and handling equipment. All the bedrooms seen looked pleasantly decorated and cared for, and people can bring in their own possessions. There are enough toilets and bathrooms around the building. In the surveys and during the visit, residents said that the building was kept clean: lovely and clean. The care managers agreed it was always kept clean and never smelled bad. Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There are enough staff on duty at all times to meet peoples needs. The home has done much better than the target of 50 of the staff qualified to the National Vocational Qualification level 2 in care, which is the recommended qualification for care workers. New staff are checked before they start work to make sure they are suitable to work in a care home. There is a training programme so that staff receive the training they need to work safely. EVIDENCE: There are at least five staff on duty each morning and four in the afternoon, including senior staff. At night, there are two staff awake on duty. These good staffing levels mean that staff have the time to provide the extra support that people coming in for assessment need. It takes up more time to support someone moving to a new place and to get a good picture of their needs and wishes. The manager said that they are able to cover all the shifts if staff are off sick or on holiday, by other staff working extra hours. This means that residents always receive care from the same people. Almost all residents and relatives praised the staff: anything I ask for they are there to do it. This lady also said that they were provided with loving care. Another said that staff were lovely, friendly, do owt for you. A third person Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 20 described them as warm and friendly and her son felt that staff seemed to care about people. The National Minimum Standards recommend that 50 of care workers in the home should be qualified to NVQ 4 in care. All the staff except for two already have this qualification and five of the staff are starting the next level, NVQ 3. The county council has an established system for recruitment which includes getting references and carrying out a Criminal Records Bureau/Protection of Vulnerable Adults List check. This is so they can be as sure as possible that people are safe to work in a care home. The records of recruitment of the last person to begin work in the home were not available on the day, for satisfactory reasons which were explained to the Inspector. The county council has a system to make sure that all staff receive the basic training they need to work safely. All staff have had training in first aid, fire safety, safeguarding (protecting vulnerable adults from abuse), and moving and handling people. The cooks and domestic staff have food hygiene certificates and care staff have received basic instruction in food hygiene. Refresher training is being arranged so that people are reminded about what they have learned before. Staff have also had training in handling medication safely and infection control. There is a written checklist to complete as new staff are taught what they need to know when they first start work. Also new staff have a half day induction session at County Hall which explains, among other things, how the council works. The newest member of staff was booked to do this in October. But she had been working in the home for a few months and had not yet been sent on moving and handling training. In her case, she had had this training in a previous job so this was not a problem. But the council must provide this kind of essential training as soon as possible after someone starts work. It should be a higher priority than understanding the council system. Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a competent, experienced and qualified manager. There are systems to check the home is providing a good service but these should be developed more. Staff look after residents money safely. The home is a safe place to live and work. EVIDENCE: The manager is very experienced and has the recommended managers qualification of NVQ 4 in care and management. There are three supervisors so that one of them is always on duty in the home. Each year the council sends a survey out to residents and relatives to ask them what they think of the home. The manager then receives a summary of what they have said. In the past this was developed into an action plan, to set out Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 22 any improvements the home should make. But the manager said this had not been done the last time. There is also an internal review, when someone from another home checks in detail how the home is running. Each month, a senior manager checks the home and talks to residents and staff. When staff look after money for residents, they keep detailed records to show how it has been spent, and two staff sign for any money used, as a safeguard. There are systems to make sure that the home is a safe place to live and work. The manager has looked at everything in the building which could be a risk to people so that action can be taken to make it as safe as possible. The fire safety system is serviced and checked regularly. There are regular fire drills so that staff can practise what they need to do in an emergency. Records are kept of checks of the temperature of hot water, and the safety of wheelchairs. The electric wiring of the building has been checked this year. Portable electrical appliances are serviced. Staff have the training they need to work safely (fire safety, moving and handling and first aid). Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 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 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 24 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 15 Requirement Staff must keep up-to-date a care plan for each resident, which explains how their needs and choices will be met. Residents must be involved in producing this plan, as much as they can and want to. It must include how the home will meet each residents leisure needs. A photograph of each resident must be in their medication record. When staff are writing out a medication administration record, they must write exactly the instructions on the label for the medication. Staff must always record when residents are self-medicating. The manager must establish one consistent way of recording when a resident has not taken as required medication. Staff must keep asking each resident if there are any activities they might like to do, and record this. Timescale for action 31/10/08 2 OP9 13 31/10/08 3 OP12 16 31/10/08 Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 25 4 OP15 12 and 16 Information about individual dietary needs must be written down and be available in the kitchen. More effort must be made to make people aware of how to complain. The information from the surveys of residents and relatives should be used to create an action plan, as to how the home could improve. 31/10/08 5 OP16 22 30/11/08 6 OP33 24 31/12/08 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 OP9 Good Practice Recommendations When staff are writing a medication administration record, a second member of staff should check that the instructions from the label on the medication have been written down correctly, and sign that they have checked this. The home should use only one type of medication administration record, to avoid confusion. Lynwood House DS0000031189.V372160.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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