CARE HOMES FOR OLDER PEOPLE
Lynwood Lodge 20-22 Broad Road Sale Manchester M33 2AL Lead Inspector
Kath Oldham Unannounced Inspection 9:00 12 March 2006
th 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 Lodge DS0000005620.V275611.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 Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Lynwood Lodge Address 20-22 Broad Road Sale Manchester M33 2AL 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) 0161 973 7210 0161 962 6424 Trinity Merchants Limited To be appointed Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (20) Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 20 service users fall within the category of old age and may additionally have a physical disability. One named service user requires care by reason of mental disorder excluding learning disability or dementia as detailed in letter dated 26 January 1999. 7th November 2005 Date of last inspection Brief Description of the Service: Lynwood Lodge provides residential accommodation with board and personal care for up to twenty-one (21) service users within the category of old age (OP), who could also have a physical disability (PD/E). Trinity Merchants Limited owns Lynwood Lodge. The registered manager has recently left her employment and an acting manager was scheduled to commence at the home on the day after the inspection. Lynwood Lodge is a large Victorian property, which is set in its own grounds. The grounds are enclosed and are accessible and well maintained. To the rear of the property is a patio and seating area. There is car parking space to the side of the property. The home has seventeen single and two double bedrooms. Thirteen single bedrooms are en-suite and both double bedrooms are en-suite. There is a passenger and stair lifts. The home is situated within a residential area of Sale and is close to the town centre, a local park, Metro and public transport. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Sunday 12 March 2006 commencing at 9.00am. The focus of the inspection was to monitor the requirements and recommendations of the previous inspection, which was undertaken in November 2005. Time was spent in conversation with service users and their families and visitors, observing staff practice and routines and examining records, which must be maintained in line with regulations. The registered manager has left her employment at the home and a new manager was to commence at the home on the day after the inspection. Time was also spent with the senior on duty in discussion and also with the staff on duty. Service users were complimentary about the care they receive and said they felt safe at the home. Relatives and visitors were complimentary about the care there cared for relative received. One relative said it was like living in a hotel and requests for drinks when residents were always available and provided to residents. Verbal feedback of the findings of the inspection was given to the senior, at the end of the inspection. What the service does well:
Service users said they had everything that they needed and they were well looked after. A service user said she had put weight on since she came into the home, which she needed to do, as, whilst at home, she tended to neglect herself as she did not have the interest or motivation to look after herself properly. Visitors were seen at the home and they said they could visit at anytime. Drinks were provided to visitors and service users were seen to ask staff when they wanted a drink. Service users said their bedrooms were comfortable and the bedding was regularly changed and the home was always clean. Service users said they liked the staff and enjoyed the company of others. One service user said she was comfortable at the home and it was the next best thing to being in her own home.
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 6 Relatives and visitors were also complimentary about the home, the personalities of the staff and the way that service users were looked after. One visitor said she had the peace of mind that when she goes home her cared for service user was safe and secure. The service has a good relationship with nurses, doctors and other health care and social service professionals this assists in maintaining a good standard of health and social support when required for service users. What has improved since the last inspection? What they could do better:
The care plans need some development as identified on the last inspection. They need to include a nutritional assessment and service users oral and foot care details. One service user who had been at the home since January 2006 did not have any details within her care file. The senior said this had been an oversight and would be attended to. The daily reports used by staff to report on the service users had little detail, on occasions staff were writing judgements on how service users were feeling. The examination of medication administration records found that there needed to be more stringent routines and practices adopted to safeguard service users, making sure that medication is administered as prescribed by the service users GP.
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 7 Staff files were again not available on this inspection despite a requirement on the last inspection, which stated that these records must be available. Staff practice, when mobilising service users in wheelchairs, must be improved upon to minimise the risk of accidents to the service user. Footrests were not being used at all, which is against health and safety guidelines. There was a four-week menu in place. The menu did not detail any alternatives to the main meal. At breakfast service users are given a choice of cereal or toast or some have a jam sandwich. A hot option is not currently available and this should be changed. The cook said she had been recently appointed and the menus are to be improved. A record is not kept of the food served to service users in enough detail so that someone looking at the record can tell whether the diet is satisfactory in relation to nutrition. The routines and timing, when assisting service users to the table at mealtimes, needs to be changed as some were sitting for almost twenty minutes waiting for their meal. Moving and handling training has not been provided to all the staff that help service users to mobilise. This has the potential to put service users and staff at risk. Differing techniques were observed dependent on the staff member who was supporting the service user. The method of recording complaints needs to be revised as the current method is restrictive and is dependent on service users making complaints. The recording should be changed so that anyone who makes a complaint can have their complaint recorded. Some of the lounge seating needs to be replaced or upgraded. There was little support in the cushions. Service users commented on not always being comfortable, as “ the stuffing had gone out of the chairs” due to their age. One service user said you have to move around as you become stiff and ache. A member of staff on duty had not received fire drill training and was unaware of what to do in an emergency situation. This has the potential to put service users and staff at risk. An additional member of staff on duty had not received moving and handling training. Fire procedures and tests need to be undertaken in line with the fire authority guidelines to safeguard service users and staff. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 8 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 Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 9 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 Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed as part of this inspection. Readers are referred to the November 2005 inspection report when these standards were reported on. EVIDENCE: Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 Care plans and risk assessments failed to record all care needs, which has the potential for service users not to receive the care, and support they need. The medication administration and routines compromise the health and safety of service users. Service users’ privacy and dignity was respected. EVIDENCE: Inspection of the care files identified that the format used had the potential to include a wealth of detail and information. Three care files were examined and for one there were no care plan or supporting information contained within the record. The care files continue to need some development to include a nutritional assessment and oral and foot care needs. A requirement to attend to this was indicated in previous inspections and is again repeated. The service users or their representative do not currently sign care plans and the requirement from the previous inspection is repeated. Examination of the daily care plans, which are used to detail the care support and interventions, found the detail was in some instances to be minimal. Staff indicated their judgements in the record of how service users were perceived to be feeling.
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 12 A record is maintained of doctor and other health care visits and the outcome of the visit is detailed. A separate record is maintained to record when service users have a bath and when they are weighed. The record of weights is completed monthly for each service user. The previous month’s record was not within the file so it was not possible to see if service users weight was maintained or if there had been a weight loss or gain. The records examined indicated that there were no recent visits by the podiatrist. The senior said that the home is having difficulty and will continue in its endeavours to obtain this service. Observations of the medication administration identified the senior giving out medication in the main in line with good practice guidelines. On a couple of occasions the senior handled medication. No hand washing techniques were observed. Service users were supported to take their medication with sensitivity and patience and explanations were given, as they were needed. Examination of the medication administration records found that there were unexplained omissions in the recording of medication administration. The records appeared to suggest that service users had not had their prescribed medication at particular times. Medication was on occasions handwritten on the records, which was not verified by a second staff member to ensure accuracy of the dosage and frequency. The handwritten medication did not include how often the medication should be given or the dosage prescribed. This can lead to service users not getting the medication they require at the right frequency. On examination of medication storage areas an amount of excess stock was found, the dispensed dates of these items indicated that prior to medication ordering, staff members are failing to check the current stock, to ensure that items are ordered only when they are needed. It was also found that items of medication were prescribed to be administered “as directed”. This does not provide staff members with adequate dosing information to ensure that medication is administered correctly. A variable dose of medication was prescribed to specific service users, for example, one or two tablets; the actual dose administered was not always recorded. The home is therefore not maintaining accurate records of medication administration. Service users are prescribed anti-psychotic medication to be administered as required. The medication is used to quieten or calm residents’ behaviour. A record was not maintained of the differing behaviours that may indicate to staff Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 13 when medication should or should not be administered. This record should also detail any non-drug treatment, which may be effective for the service user. Staff were observed to be discreet and sensitive to service users when providing personal care. Discussions were undertaken in private and support was given courteously. Staff were observed knocking on bathroom and toilet doors or calling out before entering. Service users had access to a telephone; one service user said her family had paid for her to have her own telephone in the bedroom. A service user’s relative rang from abroad, staff prepared and supported the service user to have a conversation with her relative in comfort. Service users said staff call them their preferred name and were respectful to them and their abilities. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 Service users have a flexible lifestyle in the home and maintain contact with their families or friends. Limited choice of meals has the potential for service users being at risk of poor nutrition or deterioration in their health. EVIDENCE: The minister was observed to attend the home on the morning of the inspection. Service users were reminded or supported to take part in the service. A service user said they enjoyed the service and received a lot of spiritual guidance from the minister and the service. One of the service users went swimming supported by a family member. The service users said it kept them fit and active and they looked forward to going each Sunday. Service users said they were able to bring personal possessions with them to the home and a number of service users’ bedrooms seen were personalised and homely. A four-week menu is in place, which did not include an alternative to the main meal. The cook said she was working on changing the menu, which will detail a variety of different meals that will provide service users with an informed
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 15 choice. Service users spoken to said they enjoyed the food but wanted more choice. A record is kept of alternative meals, the record does not detail what specific service users had for their meals. The cook said she would introduce this and the record will be produced within the next week. A service user said it would be nice to have a menu on the table or displayed so you could be reminded of what was for dinner or tea. The breakfast menu did not include a cooked option. Breakfast was cereal, porridge or toast, with fruit also available. Service users commented that they would occasionally like something hot on the menu like bacon or tomatoes on toast, or a lightly boiled egg. Service users said they could have breakfast in their rooms or in the dining room. Service users were observed to be assisted by staff to the dining table in readiness for their lunch. Service users were waiting at the table for twenty minutes before the meal was served. A service user commented on having to be sat for so long on the dining chairs waiting, when they could easily wait sat in the lounge chair. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 16 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 Procedures for dealing with complaints were in place, however the recording needs development. EVIDENCE: A complaints procedure was in place and service users appeared aware of what they would do if they had any comments or complaints about the service. A complaints record is in place, with an individual form for each service user. Entries were seen on service users’ sections to detail there comments or complaints. There were four such entries. The record details the nature of the complaint and the action taken which in the main said, “ contact members of management”. The record did not include the outcome for the complainant nor the actual action taken to deal with the matter. The method of recording used is quite restrictive in that if relatives, visitors, staff or other professionals complain these could not be recorded in the format used. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26 The safety and comfort of service users could be compromised by the practice and routines at the home. The home was clean and free from unpleasant odours. EVIDENCE: A number of service users are dependent on using a wheelchair to mobilise around the home. Staff were observed using wheelchairs without footrests which has the potential to increase the risk of accident or injury to service users. Some of seating in the lounges was uncomfortable. The seats appeared to have lost their firmness through age or wear and tear. The comfort provided from the seating was questionable. The identified chairs need replacing or re upholstering. Some service users commented that “they really need to put more cushions on the chair to sit on, when you have to sit on them all day”. Some service users have in the past brought their own chairs, which are also in the lounges.
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 18 The bathing areas were clean and aids and equipment was available for use. Stored within bathrooms were prescribed creams and lotions in addition to toiletries. Toiletries should be kept in service users’ bedrooms as storage within a bathroom may encourage communal use, which could lead to cross infection. Prescribed creams and shampoos should be kept securely with other prescribed medication. One of the bathrooms had cot sides, and a hostess type trolley, stored, which minimises their use and compromises the health and safety of service users and staff. The gardens are accessible and well maintained, allowing access to service users. There was a small pond within the garden, which did not appear to have any restraint over it, which could safeguard service users. A number of service users’ rooms were seen. These were furnished and equipped to a comfortable standard, with many of the service users being quite self contained in their own rooms. Service users were offered a key so they could lock their rooms. One of the bedroom carpets was buckled and could pose an increased risk of falls. The reason for the buckling should be investigated and a remedy found to minimise the risk of service users or staff tripping or falling. Since the last inspection, new carpets have been fitted in the two combined lounges and dining room and carpet tiles have been fitted in the walkthrough connecting the lounges. Staff said the carpet tiles were a good solution to make sure that they can be easily cleaned or individually replaced. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30 The unavailability of staff files does not enable an evaluation to be made of the recruitment and selection process. The lack of staff training could compromise service users’ health and safety. EVIDENCE: As reported on the last inspection, which was undertaken in November 2005, examination of staff files was not possible, as this information is not held at the home. Keys were obtained during the inspection of the locked filing cabinets in the office but the staff files were not located on the premises. The senior thought that staffing files were kept at the head office. A record has been maintained by the previous manager of training undertaken by staff. Newly appointed staff were not included within the record. A staff member said she had not received induction training and had not received her enhanced disclosure check from the Criminal Records Bureau. Staff were not sure if POVA first checks had been undertaken on their behalf before they started work at the home. A requirement was issued at the last inspection to ensure that staff files were made available for inspection by the CSCI. A timescale for action on this matter was indicated as 17 December 2005. This has not been complied with and the requirement is repeated. The majority of staff who have been employed for some time at the home had received moving and handling training. A staff member on duty had not had
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 20 this training and informed the inspector that she is the hairdresser and helps out with care when this is needed. One member of staff was recorded as having NVQ Level 2 and three staff had obtained NVQ Level 3. It was not possible to verify if newly appointed staff had been trained in NVQ qualifications. Eight staff were recorded on the training matrix to have obtained food hygiene training. The newly appointed cook said she had obtained this certification at her previous employment. Two staff have obtained emergency first aid training in October 2005. Four staff had obtained this training in 2003. Staff were reported to have undertaken training in adult protection since the last inspection. A list of staff attendance or certification of this event was not available on the inspection. Staff supervision was not undertaken on a regular basis. There were no records available to demonstrate the routine of supervision. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 Some practices and routines within the home need to be improved upon to ensure that the health and safety of service users are promoted and protected. EVIDENCE: The registered manager has in the weeks prior to the inspection left her employment at the home. An acting manager was scheduled to commence employment at the home on the day after the inspection. The acting manager had spent some time at another of the companies’ homes in the week prior to the inspection. As reported on the last inspection the Responsible Individual for the organisation was unable to conduct monthly-unannounced visits to the home due to ill health. The organisation must appoint a representative for the Responsible Individual to conduct these visits and produce a report, in writing, concerning the conduct of the home. A copy of this report must be forwarded
Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 22 to CSCI. The senior on duty was not aware of such a report and was not able to locate these for examination on the inspection. Residents meetings are not routinely arranged which would provide service users with an opportunity to comment on what they think about the service they receive. Staff meetings were reported not to be undertaken as it is difficult to get staff together. There was a kitchen-cleaning schedule in place, which was signed when the jobs were completed. The kitchen appeared clean and a cook who had been appointed in the weeks prior to the inspection was becoming familiar with the routines and record keeping. The kitchen-cleaning schedule needs to be further developed in line with Environmental Health guidelines. Examination of the fire safety records found that the checks had not been undertaken at the frequency prescribed by the Fire Authority, which has the potential to put service users and staff at risk. Not all staff were recorded as having received fire drill practice or training. A recently appointed staff member was not aware of the procedure in the event of an emergency and had not had guidance in this matter. A fire risk assessment was on file, the assessment was not dated so it was not possible to confirm when this was done. The senior was not aware if the fire authority had seen and verified the assessment. Examination of the accident records found the record did not conform to Data Protection Legislation in that all reports were kept within the accident book. The entries were completed appropriately with the name of the service user, the date of the accident and the location. There were twelve accidents, incidents or occurrences detailed within the record since 30 December 2005. Good practice could be demonstrated by the home undertaking an analysis of the accidents to see if there are any patterns and how the risks identified could be minimised. Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 2 X X 2 2 X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 24 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 15 & 13 Requirement The registered person must review the content of the care plan in the context of Standard 3 and 7. This also includes: a) Each resident having a nutritional assessment and oral care and foot care details. Risk assessments being reviewed as part of the monthly review of the care plan. (Previous timescale of 17/12/05 not met) 2 OP7 15 The registered person must ensure that, wherever possible, the service user or their representative sign the service users plan. (Previous timescale of 17/12/05 not met) 3 OP9 13 The registered person must ensure that medication is handled appropriately. 12/03/06 30/03/06 Timescale for action 30/03/06 Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 25 4 OP9 13 5 OP9 13 6 OP9 13 7 OP9 13 &18 8 OP9 13 & 17 9 OP9 13 The registered person must ensure that medication administration records are signed contemporaneously and accurately. The registered person must ensure that when staff members record the non-administration of medication, they do so using the codes specified on the service users medication administration records, and an additional explanation for nonadministration is recorded if required The registered person must ensure that care home staff administer medication as per a recommended medication administration procedure and that all medication is administered to service users as prescribed. The registered person must ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. The registered person must ensure that on occasions where a variable dose of medication is prescribed an accurate record is made of the actual dosage of each medication administered. The registered person must put in place a care plan for the administration of medication, including “when required” (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given must be in place for each service user. (Previous timescale of 17/12/05 not met)
DS0000005620.V275611.R01.S.doc 12/03/06 12/03/06 12/03/06 31/03/06 31/03/06 31/03/06 Lynwood Lodge Version 5.1 Page 26 10 OP15 16 The registered person must review the menu so that all meals are nutritious, alternative menu choices are provided and a record maintained to confirm that choice was offered to service users. (Previous timescale of 17/12/05 not met) 31/03/06 11 12 OP15 OP16 16 22 13 OP22 23 14 OP24 23 15 OP27 18(2) 16 OP30 18 17 OP31 8 The registered person must introduce a cooked option at breakfast. The registered person must further develop the recording of complaints to include the action taken as a consequence to the complaint and the outcome for the complainant. The registered person must ensure that service users are not mobilised in wheelchairs without footrests in place. Risk assessments must be undertaken if service users elect not to have footrests on their wheelchairs. The registered person should undertake an audit of all the lounge seating to determine the chairs that need to be replaced or re upholstered and attend to this The registered person should arrange for all staff to receive supervision, which is recorded and maintained on file. The registered person must make available staff files for inspection by the CSCI. (Previous timescale of 17/12/05 not met) The registered person should appoint a manager and propose to CSCI for consideration for registration.
DS0000005620.V275611.R01.S.doc 31/03/06 30/04/06 12/03/06 31/05/06 30/04/06 12/03/06 30/04/06 Lynwood Lodge Version 5.1 Page 27 18 OP33 26 The Responsible Individual for the organisation must appoint a representative to conduct monthly-unannounced visits to the home and must produce a report, in writing, concerning the conduct of the home. A copy of these reports, produced in accordance with Regulation 26 of the Care Homes Regulations must be forwarded to CSCI each month. (Previous timescale of 17/12/05 not met) The registered person must provide service users with the opportunity to have regular residents meetings so they can make their views known and influence the way the home is run. The registered person must arrange for the fire risk assessment to be dated and be subject to consistent review so that it accurately reflects the risks from fire at the home. The advice of the fire department must be sought concerning this. (Previous timescale of 09/11/05 not met) 31/03/06 19 OP33 12(2)(3) 31/03/06 20 OP38 23 31/03/06 21 OP38 23 Fire safety checks of the means of escape and fire alarm must be conducted on a weekly basis and the outcome recorded in the fire logbook. Monthly tests of the emergency lighting must be undertaken and the outcomes recorded. (Previous timescale of 09/11/05 not met) 12/03/06 Lynwood Lodge DS0000005620.V275611.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 OP7 Good Practice Recommendations The registered person should ensure that the language used in the daily recordings are not staff judgements about how they perceive service users to be feeling and are more meaningful in their content. The registered person should amend the current method of recording the weights of service users ensuring a comparison can be made of previous weights to see if there is any weight loss or gain. The registered person should ensure that the directions of medication prescribed as ‘as directed’ are clarified with the service users’ General Practitioner and the prescriptions altered accordingly. The registered person should ensure that stocks of medication are rotated regularly and that stock is checked each month prior to medication ordering to prevent the build up of excess medication. The registered person should ensure that the date of opening is recorded on all items that have a limited shelf life once opened, to ensure that the health of service users is not put at risk by the administration of expired medication. The registered person should ensure that if the prescriber amends the dosage of medication, the current record is discontinued and a new record is commenced. If a record is handwritten it must be signed and dated and the details validated by an additional member of staff. The registered person should provide menus on the table or displayed where service users could be reminded of the meals of the day. The registered person should review staff practice and the routine of sitting service users at the dining table so long before meals are served. The registered person should review the current recording of complaints ensuring the system used enables all complaints from whatever source can be recorded. 2 OP7 3 OP9 4 OP9 5 OP9 6 OP9 7 8 OP15 OP15 9 OP16 Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 29 10 OP25 11 12 13 OP25 OP28 OP38 14 OP38 The registered person should research best practice in relation to ponds ensuring if covers or other strategies are recommended to reduce the risk to service users these are installed. The registered person should remove prescribed creams, shampoos or lotions, toiletries and stored equipment from the bathrooms and store them safely and appropriately. The registered person should produce a plan to show how 50 of care staff will obtain NVQ level II or above The registered person should develop the kitchen cleaning schedule to include all cleaning which should be undertaken within the kitchen on a daily, weekly or less frequent basis. The registered person should ensure the recording within the accident records conforms to Data Protection Legislation Lynwood Lodge DS0000005620.V275611.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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