Inspection on 07/12/06 for Lyons Gardens

This inspection was carried out on 7th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyons Gardens 12/10/07

Lyons Gardens 06/04/06

Lyons Gardens 19/09/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Lyons Gardens 36 Lincoln Road Glinton Peterborough PE6 7JS Lead Inspector Nicky Hone Key Unannounced Inspection 7th December 2006 11:00 Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 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 Lyons Gardens DS0000063991.V322540.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 Adults 18-65. 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. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyons Gardens Address 36 Lincoln Road Glinton Peterborough PE6 7JS 01733 254261 01733 254263 herewardcare@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hereward Care Services Ltd Roslyn Sadie Stone Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users with a learning disability who also have a physical disability or mental disorder may be admitted 6th April 2006 Date of last inspection Brief Description of the Service: Lyons Gardens is a purpose built care home on the outskirts of the village of Glinton, about six miles north of the centre of Peterborough. The home consists of two bungalows which are set back from the main road through the village. Each bungalow has a lounge, dining room, kitchen, toilets, bathroom and shower room as well as a laundry, office and staff facilities. One of the bungalows has five single bedrooms, the other has six. All the bedrooms have an ensuite toilet and washbasin. There is parking space at the front of the bungalows and a large paved patio area between the two. There are also grassed garden areas where service users play a number of outdoor games. The bungalows were commissioned by the Greater Peterborough Primary Care Partnership, to replace an outdated home, and the places are all used for respite care. One bungalow offers accommodation to people who have a greater need for support with their physical care needs. The home has its own minibus, but is also located on a bus route. Peterborough, with its range of facilities such as restaurants, pubs, shops and leisure facilities is within a short drive. People stay at Lyons Gardens for varying periods of time, from four nights a week to one night a month. Sometimes people stay at Lyons Gardens for several weeks while other accommodation is being found for them. Currently there are about fifty people who receive a service at the home. The home accepts service users whose ages range from 18 to 65. Currently there are quite a lot of service users who are making the transition from children’s services to adult services. All eleven places at the home are ‘block-booked’ by Greater Peterborough Primary Care Partnership: one of the directors said that £1326.00 per week is paid for each place (from 01/04/06). Each service user pays a contribution towards this cost, from benefits. There are no other additional charges, except a contribution towards some of the outings. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included a visit to the home by two inspectors. We spent four hours having a look round, talking with service users, staff and the managers, and checking some of the records. At the time of this inspection the registered manager had been on secondment to another care home for several months. The deputy manager had been running Lyons Gardens during her absence and, a week before this inspection, the deputy manager from another of Hereward Care Services’ homes, Paul Gale, had started as acting manager. What the service does well: The staff team have worked hard to ensure that the quality of life for the service users staying at Lyons Gardens is getting better all the time. New service users have their needs assessed fully before they stay at the home, and the care plans give staff good detail on the way in which each person wants to be supported. Service users make choices about all areas of their lives while they are staying at Lyons Gardens. For example, people choose whether they want to go out or stay at home; where they want to go; what they want to do; what they want to eat; and who they spend time with. Service user’s personal care and healthcare needs are met, medicines are looked after properly, and service users know their concerns will be listened to. The home is clean, comfortable and decorated well throughout, although one younger person said the colours of the walls, curtains, bedspreads and so on look as though they are for older people. There were no bad smells anywhere other than a musty smell in one of the bathrooms. Staff are recruited properly, with all checks being carried out before they start work. They receive a good induction and as much training as they need and want to do their jobs well. This includes training in the Protection of Vulnerable Adults, and all topics related to health and safety. Some staff we spoke to said the staff team is much happier than it was for a time last year. The home sends out questionnaires to service users asking for their opinion of the service, and meetings are held regularly so that service users can say how they want the home to be run. The records we checked were completed well, and we saw nothing during our visit to give us any concern about health and safety. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments of service users’ needs are carried out so that service users can be confident staff will know how to support them. EVIDENCE: The personal records of three service users were looked at. All three showed us that full assessments of each service users’ needs had been carried out, both by social services and by the home, before the person was admitted. This makes sure that the home is able to meet each person’s needs. One of the service users staying at the home had been admitted as the result of an emergency and was staying at Lyons Gardens until a suitable new home could be found for her. We were disappointed that she had been moved into several different rooms, in both bungalows during the time she had been at the home. She said she was happy in the room she was in on the day we visited and would like to stay there so we talked to the acting manager about making sure she was not moved again. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have improved but need some further work to make sure they give the staff all the information they need to support the service users. EVIDENCE: Generally, the quality of care plans at Lyons Gardens has improved markedly since the inspections in April 2006 and August 2006. The format being used is good and, when completed well and kept up to date, is a good tool for staff so that they know exactly what support each service user needs. The plan consists of brief details about the person under headings such as eating/drinking; washing/dressing; behaviour; emotional well-being; continence and so on. If this indicates that staff need more information about a particular area, the plan refers to a numbered care plan or risk assessment. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 10 We looked at care plans for three service users. These were all acceptable, but we found some areas where the plans could be developed further. For example, one of the plans, completed in June 2006, recorded that the person’s household skills “are unknown and will be assessed in future”, but there was no further assessment recorded. It was not always clear on the care plans that we saw who had written them and when, as they were not all signed and dated. A record has been put into each plan for staff to sign that they have read the plan: on one plan only one member of staff had signed. One person has been staying at Lyons Gardens for several weeks. Her care plan had been completed when she was admitted and gave a lot of information about areas where she needs support. The support she actually needs was not always in enough detail, for example she told us she needs help to rinse her hair but this was not on her care plan. Another topic in this service user’s plan said she needs support around budgeting but there was no detail about what support she needs. Changes in some aspects of this person’s life which had taken place since she arrived at the home, had not been changed on the care plan. For example, one part of the plan said she attends college on five days a week: discussion with the service user and staff confirmed that this had stopped soon after she moved in. We recommended that care plans be developed further by the addition of a personal profile of the person: a pen picture of who the person is, what makes them tick, what they like and don’t like, and what their hopes are for the future. Some goals could also be included. Service users are encouraged to make decisions about their lives, including working towards taking risks. We saw that some risk assessments had been completed, but as with the care plans, these need to be developed further by the staff. We saw nothing during this visit that would suggest service users’ confidentiality is not maintained. All information about service users is in their care plans which are kept in a locked cupboard. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to choose how they live their lives while they are staying at the home, including a choice of activities, outings and meals. EVIDENCE: As this is a respite service, people who stay during the week continue to attend whatever daytime activities they normally attend. Staff support them to make sure they are ready in time for the transport, and have made themselves a packed lunch if they need one. Staff we spoke to told us that there has been a huge improvement in what service users can do to keep occupied in the evenings and at weekends. We looked at the activity record for one of the bungalows. This showed that service users have been able to take part in a wide range of activities, with Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 12 outings, or activities in the bungalow, taking place every day. Examples we were given of outings included going to a Friday Club; Bay Tree; Peterborough shopping and to see the Christmas lights; bowling; eating out; to the local pub and so on. The home has a mini-bus which is used a lot to take people out. In the garden at the home there is a goalpost, swingball and cricket equipment as well as patio furniture and barbeques. In the bungalows service users can play games; do arts and crafts; play board games; do karaoke; and make things such as pumpkin lanterns and Christmas cards. We saw a selection of DVDs, videos, books and toys. Some of these seemed rather childish for the age group of people who visit the home, but staff said that most of the toys belonged to one service user whose mother had supplied the toys. We suggested staff look on a number of websites that will give them ideas for sensory equipment which is more age-appropriate. Staff also told us that service users are given far more choice in all aspects of their lives than previously, and some people now arrive at the home with their own ideas about where they would like to go, what they would like to eat and what they want to do during their stay. Residents’ meetings take place regularly and staff said that service users are all given the chance to make choices. The majority of the time people are able to do what they want to do but sometimes, if completely different choices are made, everyone talks about it and tries to reach a decision which keeps everyone happy. Two service users had decided they would like to go to church on the evening of the inspection: the staff said they would be supported to attend the local church. When service users come to stay at Lyons Gardens they are encouraged to join in with the household chores as much as they can. One person told us she helps staff to hoover the bungalow and she cleans her own room. Staff stressed that service users know they do not have to join in the activities and are able to “chill out” if they want to, spending time in their bedroom or the lounge. Families are welcome to visit the home at any time, but as this is a respite service few families do visit. Friendships are encouraged and staff support service users to visit friends and family if they want to. During the inspection one service user decided to bake us a cake. She was supported by a staff member but did most of the work herself and the cake was delicious. She was rightly very proud of her achievement. She told us that lots of people enjoy making their own pizzas on a “pizza night”. Service users are asked what they would like to eat and special choices are put on the menu for the next time they are at the home. Service users are encouraged to help staff with the cooking. Sometimes service users help with shopping for extra items from the local shop, although staff do the main food shopping on a day when most of the service users are at their day services. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records have improved and generally show that service users’ personal care and healthcare needs are met, and medicines are handled safely. EVIDENCE: Generally, the care plans we saw gave information about the way in which service users want to be supported so that their personal care needs are met. Some further information could be included to make sure all aspects of personal care are covered. Staff from Lyons Gardens support service users to attend any appointments that fall during their stay at the home, although as this is a respite service, the responsibility for making the appointments remains with each person’s main carer. The arrangements for service users to see a doctor if they need to during their stay are now much clearer than previously, and any nursing tasks needed are carried out by, or delegated to staff by, the district nurse. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 14 Only one person staying at the home on the day we visited was taking any medicines. The records that staff sign to show that the medicines have been taken were completed and signed correctly, and the service user’s relative had signed a form to consent to the staff giving the medicines to their daughter. The medicines were all counted in and recorded correctly. Staff now have to sign to show that they have read, understood and will comply with the medication policy and procedures. Records were available to show that several staff have received training in giving medicines. We were pleased to note that records were also available to show that the correct procedure is now being followed for the delegation of some nursing tasks. The district nurse is responsible for carrying out nursing tasks, such as dressing wounds and giving suppositories. The district nurse can, if s/he wishes, delegate the tasks for individual service users to staff by training the staff. S/he then signs a delegation form to say s/he is satisfied that the staff can do the task well. The forms were in place and gradually all staff will be trained to carry out whatever tasks are needed for each service user. We showed the acting manager how to complete the form correctly. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know their concerns will be listened to and they will be kept safe. EVIDENCE: We asked one of the service users if she would know what to do if she was not happy about anything. She said she would speak to one of the staff, even if this was about another member of staff. She told us about a time when she had had to do this. She was happy that the matter had been dealt with properly and she had received an apology. Records showed that almost all staff have had training in the Protection of Vulnerable Adults. Staff we spoke to were clear about the procedure to follow if there are any allegations of abuse. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Lyons Gardens offers a comfortable, well-maintained and clean place for service users to enjoy their respite stay. EVIDENCE: We looked round both bungalows and both were very clean and tidy. All the rooms we saw are well decorated and comfortably furnished. The service user who was at home during our visit showed us her bedroom. She had been at the home for a while and had been able to bring some of her favourite things into her room. We asked her about the way her room was decorated, and the colours of the curtains, chair and bedspread, and she agreed that it looked as though it was for much older people. We asked the acting manager to think about whether the rooms could be decorated in a Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 17 more modern style that would be more suitable for younger people, and to bring in some more of this young person’s belongings that she said she wanted. In one of the bungalows all the bedroom floors have washable flooring as it was thought, when the home opened, that there might be some problems with continence. One of the staff said that she could not recall ever having to mop the floors because there had been a problem with continence. This flooring makes the rooms feel very cold and not homely, so we asked the acting manager to think about whether an alternative floor covering could be used. Staff have started to bring more pictures and ornaments into the lounges in both bungalows, and the service user said that, following a residents’ meeting, the photographs had been replaced with pictures of people who currently use the service. We asked the acting manager to think about involving the service users more in ideas for making the lounges more homely, and making sure service users are happy with what is on display. It was good to see that fish tanks were clean and well stocked to make them interesting. Each bungalow has a shower room and in both we noticed that black mould was beginning to form round the seal between the tiles on the walls and the flooring, in spite of staffs’ efforts to clean it. The bathroom in one of the bungalows was cluttered with several items, including a mattress, and smelt musty. Staff said this bathroom was not used very often. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from staff who are recruited, trained and supported well. EVIDENCE: Staff rotas, and discussion with staff, showed that there are enough staff on duty to meet the needs of the service users. Only occasionally, perhaps if one of the service users is having a particularly bad day, do they have to change the plans made for activities. Although the two bungalows have separate staff teams, they work together to support each other, and often arrange outings for service users and staff from both of the bungalows. One of the staff told us that they now have more time to do things with the service users than they used to. One staff member we spoke to told us that she had worked at the home (in its previous location) for many years. She said that the way of working with service users now is very different (in that the service is now service-user led, rather than staff making all the decisions): some staff had taken some time to Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 19 get used to the changes, but she felt that the whole staff team was now “on board for the new direction”. Staff told us that some of the people who are new to the service present different challenges (such as self-harm, behaviour which is more challenging and so on) which staff are not sure how to work with. They said they are supported well by the company and training is arranged as quickly as possible. Staff files seen had evidence that staff have received a range of training, including moving and handling; first aid; communication; fire; medication; autism awareness and Protection of Vulnerable Adults. There was evidence that one person has had training in the control of infections. At the time of the inspection a training session on food hygiene was taking place in one of the bungalows, for staff from Lyons Gardens and staff from other Hereward Care Services. Staff records, and discussion with staff, showed that staff receive training in a range of topics so that they can do their job properly. Staff have training to make sure they know what to do if there is a fire. Part of this training is done by staff watching a video and completing a questionnaire: although the completed questionnaires were on the staff files, there was no indication that the answers had been checked by anyone. Staff also said they receive regular supervision and have regular staff meetings which they find useful. They do not get an annual appraisal. The personnel files of three staff were checked. We were pleased that the information in the files has been rearranged since the last inspection and the papers we needed to see were easy to find. All the files showed that all the checks needed before a person can start to work at the home had been in place when staff started work. This included two written references, a Criminal Records Bureau check, an application form, a photograph and proof of identification. There was evidence on one of the files that senior staff had carried out a thorough induction with this new employee. The form had been signed by the new staff member: it should also be signed by the person doing the training. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the service has improved so that the home is beginning to be run in a way which will give service users a good quality of life. EVIDENCE: The registered manager has been on a secondment to another service for several months. During this time the deputy manager was supported by staff from Hereward Care to manage the home. A week before this inspection, the deputy manager from another of Hereward Care homes, Paul Gale, had started at the home as acting manager. Paul has completed his Registered Manager Award. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 21 The staff team and the company are to be commended on the improvements that have been made to the service since the inspections in April and August 2006, and we have confidence that the service will continue to improve once a stable management team is in place. Staff we spoke with said that the morale among the staff team is now much better. The company checks the quality of the service being provided by sending out quality surveys: one was sent to all service users soon after the home opened and will be done annually. Residents’ meetings are held monthly, with different groups of service users and staff. A record is kept of what is discussed at the meeting, and action is taken to meet service users’ requests whenever possible. Records of tests of the fire alarm and emergency lighting system were checked and showed that the tests are carried out as required. Records were also seen of the checks that were carried out on the hoists in June 2006. The acting manager was aware that these must be done every six months and agreed to make sure the next test was arranged. Staff have received training in topics related to health and safety (see Staffing section of this report), and during our walk round the home we found nothing relating to health and safety that gave us any cause for concern. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X 3 3 X Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15 Requirement The registered person must ensure that a system is in place to ensure that care plans are regularly reviewed and the information is complete and kept up to date. The registered person must find a way to ensure the shower rooms can be kept free from mould. Timescale for action 28/02/07 2 YA27 23(2)(d) 28/02/07 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 YA27 Good Practice Recommendations The musty smell in the bathroom should be investigated and eliminated. This recommendation is carried forward. Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyons Gardens DS0000063991.V322540.R01.S.doc Version 5.2 Page 25 - 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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