Inspection on 27/11/07 for Lyttleton House

This inspection was carried out on 27th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lyttleton House 10/06/09

Lyttleton House 03/07/08

Lyttleton House 18/05/07

Lyttleton House 04/09/06

Lyttleton House 01/03/06

Lyttleton House 12/09/05

Lyttleton House 24/03/05

Lyttleton House 25/08/04

Lyttleton House 04/03/04

Lyttleton House 09/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lyttleton House 1 Ormond Road Frankley Birmingham B45 0JD Lead Inspector Kulwant Ghuman Key Unannounced Inspection 27th November 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyttleton House DS0000033561.V352214.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. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyttleton House Address 1 Ormond Road Frankley Birmingham B45 0JD 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) 0121 460 1150 0121 457 7302 Not known Birmingham City Council (S) Linda Wohler Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the home is registered to accommodate 30 people over 65 years who are in need of care for reasons of old age which may include mild dementia. Registration category will be 30 (OP) That minimum staffing levels are maintained at 4 care staff throughout the waking day of 14.5 hours. The home must adhere to a laundry policy which ensures that soiled laundry is not transported through dining areas when meals are served or consumed. That additional to above minimum staffing levels there must be two waking night care staff. 18th May 2007 Date of last inspection Brief Description of the Service: Lyttleton House is owned and managed by Birmingham City Council and is registered to provide care for 30 older adults who may have mild dementia. The building is a bungalow construction and divided into three separate units, each with their own dining area, kitchen and lounge. Facilities briefly include 30 single bedrooms, the majority of which are less than 10 square metres and therefore cannot contain all the items of furniture specified in the standards. Each bedroom has a call system. There is a large communal area in which service users can socialise, this is equipped with a TV, video and music system. The home is situated on a corner plot in a cul-de-sac. It has an open plan frontage with lawn, shrubs and flowers. There is level access to the front door and parking to the front and side of the property. Lyttleton House is located close to local shops and facilities, including public transport. Fees at the home are based on the financial assessment carried out by the social worker. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors over one day during November 2007. Prior to the inspection an Annual Quality Assurance Assessment was completed and returned to the Commission and this gave some information about the home. As part of the inspection process the inspectors observed interactions within the home, observed part of a meal time, spoke with six of the people living in the home, eight of the staff through the day and two visitors to the home. Communal areas of the home were looked at and three bedrooms. The inspectors looked at the files of three of the people living in the home and four files staff files for some records as well as some health and safety documents. The Commission had not received any complaints or concerns of adult protection about the service and there had been only one complaint raised directly with the service. This was resolved to the satisfaction of the complainant. What the service does well: What has improved since the last inspection? The bathrooms and toilets had all been refurbished since the last inspection. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 6 The details contained in the care plans (ISS) had improved. They included more information about how the people living in the home were to be assisted and what tasks they could do for themselves. The social activities organised by the home had improved. There had been two holidays organised for the year and internal entertainment had been improved. An art therapist was coming into the home on a regular basis and exercise sessions were being held. 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. Lyttleton House DS0000033561.V352214.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 Lyttleton House DS0000033561.V352214.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): 2,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into the home were assessed before they moved in to ensure that their needs could be met at the home. People were encouraged to visit the home before deciding whether it was suitable for them. EVIDENCE: The file of one person recently admitted to the home was sampled. There was evidence that the individual had been to visit the home before moving in. There was an assessment carried out during the second visit to the home and information was obtained from the placing authority beforehand. There was a residential care agreement on all the files that indicated the room to be occupied and was signed and dated. Lyttleton House DS0000033561.V352214.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): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Details on the care plans had improved. Tissue viability and nutritional assessments did not have appropriate management plans in place to inform staff how to meet these needs. The management of medication in the home could not evidence that everyone was given their medicines according to prescribing instructions. EVIDENCE: The three files sampled all had an individual service statement (ISS) in place. The ISS’s had a good description of how the individual liked to spend their day in the home. This was written from the individual’s point of view and stated what they were able to do. For example: ‘Carer dresses me with clothes I choose. I wear special shoes and carer puts them on. I shave myself but carer assists me.’ Staff needed to be mindful that what was written down had been said by the individual otherwise it should be made clear that it was information that the Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 10 staff had acquired for example, ‘I suffer from dementia. I shout out a lot during the day and at night’. It is unlikely that the individual said this but it is relevant information that needed to be recorded. In addition to this information a strategy for managing this behaviour needed to be recorded. There was also some detail in the ISS’s giving staff information regarding continence management, mobility, diet and medical needs. However some of the detail in these areas could be expanded. ISS’s needed to be updated as situations changed. The inspectors were told that the type of wheelchair used by one individual had changed and that the crash mat was no longer used by the bed, however, this had not been incorporated into the ISS. For another individual daily notes evidenced that the individual needed a beaker and specially adapted cutlery however this was not recorded on the ISS. All the files sampled had a moving and handling assessment in place that had some very good information on them informing staff how the individuals were to be helped moving from bed to chair, into the bath or into wheelchairs. There were tissue viability and nutritional assessments in place however, where the individual was identified as being at risk there was no appropriate management plan in place. There was a flow chart available for the nutritional screening and a pre-printed sheet for the tissue viability however neither indicated what the specific requirements for each individual were and how the staff were to meet these. There was evidence that the medical needs of the people living in the home were being met through access to the GP, district nurses, chiropodist, optician and hospitals as required. Since the last inspection a new format had been introduced for daily recordings. The sheets included headings such as food and drink, personal care, health, social activity, observations and facts. The daily recordings were very repetitive including things such as seems fine, ate and drank well. Prior to the inspection the manager completed the Annual Quality Assurance Assessment (AQAA) which stated “we have produced more detailed risk assessments that are cross referenced to the care plans”. This was not evidenced during the inspection. There was no cross reference in the ISS to the tissue viability or nutritional assessments. The management of medicines in the home was in need of improvement. An audit of some of the boxed medicines showed that it was not always possible to audit painkillers adequately especially where there was a choice of one or two tablets being given. There needed to be a system in place that identified the number of tablets being given. There was also evidence that when Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 11 supplies of boxed medicines were being carried over from one month to the next the amounts being carried over were not being recorded. The medication administration record (MAR) for one medicine indicated that three tablets had been given however, there were 6 tablets missing from the boxes. These boxes had not been booked in on the MAR charts and the label on the boxes indicated that they had been dispensed in October 2007. There were also some occasions where tablets had been signed as given however, the tablet was still in the blister packs. The inspector was told that a daily stock check of medicines was undertaken however there was no evidence of this at the time of the inspection. Bedroom, bathroom and toilet doors all had appropriate locks in place, there were no shared rooms and nothing was observed or heard during the inspection to suggest that the privacy and dignity of the people living in the home was not being promoted. Lyttleton House DS0000033561.V352214.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): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were a number of activities being carried out in and outside the home. There had been a holiday in summer and another to be taken during December 2007. New menus had been introduced in the home following consultations with the people living there. Contact with friends and relatives was encouraged in the home. EVIDENCE: The home was divided up into three units and although each unit had its own lounge and dining areas there was a general policy that people living in the home were able to move around the home and sit where they wanted. A complaint received by the home indicated that not all staff were enabling the people living in the home to maintain relationships and free movement around the home. It would appear that there were a number of activities that were being arranged within and outside the home. On the day of the inspection one unit was seen to be having a singing session and there was an art therapist in the Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 13 home. There were entertainers who came into the home including movement to music and singers. Two people living in the home went out with relatives on the day of the inspection and one went to a day centre. Some of the people living in the home had been on holiday to Butlins during the summer and another trip had been organised to Minehead during December. The records sampled indicated that there had been three meetings with the people living in the home since April 2007. Activities, holidays and menus were discussed. The ISS’s did indicate that the people living in the home were able to choose their clothes, say how they wanted care to be provided, were encouraged to undertake as much of their care tasks as possible and make choices about whether to participate in local elections. During one of the meetings held with the people living in the home a comment was made that some people were bored and it was acknowledged that there had been a shortage of staff and this was the reason for it. Friends and relatives of the people living in the home were able to visit at convenient times and there were a number of visitors to the home during the day. A new menu had been introduced into the home and there was evidence in the meetings with the people living in the home that they had been consulted on the changes and that they were happy with the new menus. There were choices available at mealtimes and the food looked appetising and nutritional. On two of the units it was observed that there appeared to be some food available for extra servings if this was needed, however, as observed at the last inspection there was very little extra food or wastage on the third unit. One of the people on that unit wanted more chips and the staff had to go to the kitchen to get them. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints are listened to and addressed however, there is no clear evidence that the cause of the complaints is looked into and addressed. There have been no allegations of abuse at the home but there is still work that needs to be undertaken in the home to ensure people are being safeguarded. EVIDENCE: No complaints had been lodged with the Commission since the last inspection and no issues of adult protection had arisen. The complaints/compliments folder showed that several compliments had been made about the service provided by the home. One complaint had been lodged with the home and there were several aspects to this complaint but the main issues were that following an incident, that was outside of the home’s control, a relative felt that the belongings of the person living in the home had not been looked after and treated with respect, some equipment had gone missing and that restrictions were placed on the movement of an individual in the home unnecessarily. The complaint was upheld but a satisfactory resolution was arrived at. It is of concern that there was no evidence to show that the staff member allegedly restricting the individual’s movements in the home had been spoken with to determine why Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 15 the restrictions were being put in place despite the manager stating that there weren’t any. At the last inspection it was noted that some complaints made by relatives had not been recorded. In the AQAA the manager stated that ‘We respond courteously to any informal complaints and act promptly to rectify the situation, this has meant we have not had any formal complaints’. There was no record of the informal complaints that had been dealt with in the home. Records sampled by the inspectors showed that one person living in the home had said that staff tried to hurry him along when he was walking. There was no evidence that this issue had been raised with staff or whether it had been followed up with the individual to see which staff were being referred to. No evidence was found in the home that the issues regarding staff responsibilities in respect of adult protection had been discussed following the last inspection. It was evident that there were still issues to be resolved within the staff team and although things had improved somewhat there was still some way to go to achieve a good working relationship throughout the staff team. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a comfortable and homely environment to live in. All the people living in the home have their own bedrooms and there are appropriate bathing and toilet facilities available. EVIDENCE: The home is divided into three units each having its own lounge and dining areas. The home is generally well decorated and furnished. There is a very pleasant entrance area where people living in the home and their visitors can sit or individuals can be alone to watch the television. There are adaptations in the home including hand rails, assisted bathing facilities and nurse call system. The home is accessible throughout as the home is on one level and there is easy access into Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 17 the home for people with additional mobility needs. Bedrooms seen during the inspection appeared to meet the needs of the occupants and were comfortable and individualised according to need and preferences. Since the last inspection the bathroom and toilet refurbishments had been completed. Some equipment in the home was not in working order including two dish washers, a washing machine and a sluice facility. These items needed to be replaced or repaired. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels were falling below acceptable levels during parts of the day or during whole shifts. The training staff had undertaken was not able to be assessed at the time of the inspection. EVIDENCE: Staffing levels on some occasions were falling below acceptable levels and the home was relying regularly on casual and agency staff to maintain staffing levels. The home had 125 hour vacant care hours. During some late shifts the rota’s indicated that there could be periods of time when there were only three staff on duty, including senior staff. On other occasions there were 6 staff on duty during the shift. Staff said that sometimes it was difficult to take their breaks when there were only three staff on duty. Often the telephone remained unanswered due to low staffing levels. There needed to be a minimum of four staff on duty during the day as there were some people who needed assistance with eating, mobility and monitoring due to dementia. Staff were unhappy with rota changes that were taking place and stated that they had to check the rota for the next day to see if the duties had changed. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 19 Rota changes were inevitable and necessary on occasions but staff needed security of knowing what their shifts were to be. Changes to staffing rotas needed to be made only through the senior management team to ensure parity of shifts and minimum changes to the rotas. During the inspection it was observed there were staff in the home who were not recorded on the rota as being on duty and there was no apparent need for them to be in the home. Staff were also moving units on a monthly basis and this was seen as a way of distributing out the work load across the staff as some people on some units needed more assistance. However, the ways in which staff were to be enabled to carry out their key working responsibilities needed to be clear as staff could be allocated to a different unit to the person they key-worked. Inspectors were told that staff had had a lot of training and a training matrix had been set up but it could not be located at the time of the inspection. No new staff had been employed at the home since the last inspection and so the recruitment process was not inspected during this inspection. It was known by the inspector that the Local Authority had robust recruitment procedures. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Several areas of management within the home needed to be improved on including staff relationships, management of medicines, following through of issues of poor practice and some health and safety issues. EVIDENCE: The manager was not available at the time of this inspection. The manager had been employed in the home since 2004. At the time of the last inspection some problems within the staff group were highlighted. It was clear at that time that the staff were not always passing on relevant information and the understanding of their responsibilities in respect of adult protection was limited. Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 21 During this inspection the inspectors were looking for evidence to confirm that these issues were being addressed. However, the evidence could not be found. There were records for 4 staff meetings available at the time of the inspection and the issues raised at the inspection did not appear to have been addressed. Staff supervision notes were sampled to see if the issues had been addressed however no evidence could be found. There was no evidence that issues highlighted in complaints raised with the home were followed through with staff. There appeared to be an ongoing division within the staff group which could have a detrimental effect on the people living in the home. The people who were living in the home appeared to be happy and content. They were able to get up and go to bed when they wanted and they were being consulted on issues such as activities and menus. The home was being audited by another home to ensure it was meeting key performance indicators. These were not looked at during this inspection. The records kept of the monies held on behalf of people living in the home were satisfactory. It was recommended that receipts should be numbered to make cross referencing easier. This used to happen but had stopped. The inspectors were told that the comforts fund had been stopped however, there was a raffle under way and some records would still need to be kept so that it was clear what had been collected and spent and how much had been put into the account held by the league of friends. The inspectors were told that the raffle money did not go into this account at the time of the inspection. The team manager for the home visited the home on a regular basis and completed a report of his visits. Supervision records for 4 staff were sampled and the number of supervisions recorded were very low. The management of medicines in the home needed to be improved and the keys to the COSHH cupboard were left hanging by the door of the COSHH cupboard. No one appeared to know why this was so. The fire records showed that the weekly fire alarm test was not being recorded on a weekly basis although the inspector was told that it was carried on a weekly basis. There had been a recent a fire drill carried out however evacuation of the people living in the home had not been attempted. It is Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 22 recommended that this is tested at the next fire drill. The records showed that fire training was last carried out in October 2006. Lyttleton House DS0000033561.V352214.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 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 1 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 2 X 3 1 X 1 Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 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 OP8 Regulation 13(4)(c) Requirement The registered person must ensure that all risks identified for the people living in the home have a suitable plan for their management in place. This will ensure that the people living in the home receive a service that maintains their health and safety. 2. OP9 13(2) The registered person must ensure that people living in the home receive their medicines as prescribed and that adequate records are kept. This will ensure that the people living in the home will receive their medicines has prescribed. (Previous timescale of 01/07/07 not met.) 3. OP16 22(3)(4)& (8) The registered person must ensure adequate records are kept of all expressions of dissatisfaction. This will ensure that people Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 25 Timescale for action 01/01/08 01/01/08 01/01/08 4. OP16 22(3) using the service will be assured that their views will be listened to. (Previous timescale of 01/07/07 not met.) The registered person must ensure that the issues causing complaints to arise are addressed. This will ensure that poor practices are stopped. The registered person must ensure that equipment in the home is maintained or replaced as required. This will ensure good standards of infection control. The registered person must ensure that there are adequate numbers of staff on duty to meet the needs of the people living in the home at all times. This will ensure that the people living in the home are safe and their needs met at all times. (Previous timescale of 01/07/07 not met.) 01/01/08 5. OP26 13(3) 01/01/08 6. OP27 18(1)(a) 01/01/08 7. OP30 18(1)(c) All staff must undertake mandatory training as required. A copy of the training matrix must be forwarded to the Commission. This will ensure that the people living in the home can be assured that the staff are trained to care for them safely. The registered person must ensure that staff maintain good relationships between themselves and with the people who live in the home. DS0000033561.V352214.R01.S.doc 13/12/07 8. OP32 12(5)(b) 01/01/08 Lyttleton House Version 5.2 Page 26 This will ensure that the people in the home will receive care in a way that makes them feel comfortable and safe. 9. 10. OP38 OP38 23(4)(c) (v) 23(4)(d) The registered person must ensure fire alarms are tested weekly. The registered person must ensure that fire training for staff is carried out on a 6 monthly basis. 14/12/07 01/01/08 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 OP7 Good Practice Recommendations The registered person must ensure that the care plans are clear where the information is coming from. Care plans must be updated as conditions change. This will ensure that the people living in the home get the care that they need based on a clear rationale. The registered person should ensure that each person living in the home is able to access all areas of the home without restrictions from staff unless these have been clearly planned for. This will enable the people living in the home to build and maintain relationships through out the home. The registered person should ensure that there is sufficient food available to offer extra helpings if required by the people living in the home. This will enable people living in the home to have further helpings if they want. The registered person should look at the possibility of access into the laundry by an alternative route. Staff rotas should only be changed via the senior DS0000033561.V352214.R01.S.doc Version 5.2 Page 27 2. OP14 3. OP15 4. 5. OP26 OP27 Lyttleton House management team. This will ensure parity of shift allocations and reduce shift changes. Staffing levels should enable staff to take adequate breaks during shifts. This will ensure that staff are not over tired and people living in the home are safe. The registered person should ensure that there is a system in place that ensures that key working duties are undertaken. This will ensure that the people living in the home have regular access to their key worker. The registered person should ensure that receipts are numbered to make cross referencing easier. This will ensure that the records are easy to audit. The registered person should ensure that records are kept for monies raised in the home that are subsequently transferred to the League of Friends account. This will ensure that the staff and people living in the home are safeguarded. The registered person must ensure that all staff have a minimum of 6 supervision sessions a year. The registered person should ensure that all documentation is stored in a way that enables information to be easily retrieved. The registered person should ensure that a full evacuation is carried out during a fire drill. 6. OP27 7. OP33 8. OP35 9. OP35 10. 11. OP36 OP37 12. OP38 Lyttleton House DS0000033561.V352214.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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