Inspection on 25/06/07 for The Lindens

This inspection was carried out on 25th June 2007.

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

Other inspections for this house

The Lindens 19/11/08

The Lindens 20/06/08

The Lindens 31/01/07

The Lindens 01/08/06

The Lindens 10/11/05

The Lindens 19/04/05

The Lindens 24/09/04

The Lindens 04/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Lindens Stoke Hammond Bucks MK17 9BH Lead Inspector Jane Handscombe Unannounced Inspection 10:00 25 June and 5th July 2007 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 The Lindens DS0000028059.V337555.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. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lindens Address Stoke Hammond Bucks MK17 9BH 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) 01908 371705 01908 375075 N/A Mr Michael Hannelly Linda Rose Howell Care Home 17 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (17) of places The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for up to 17 service users, up to five of whom may have dementia. 31st January 2007 Date of last inspection Brief Description of the Service: The Lindens is a privately owned care home and is registered to provide residential and personal care for up to 17 older people. The home is situated in a rural area on the outskirts of the village of Stoke Hammond and is within easy distance of Bletchley and Milton Keynes. The home is a large detached Edwardian house set in accessible, extensive grounds. The house has been subject to a programme of refurbishment to comply with the current standards. All rooms are single and have en suite shower and toilets. Additional assisted bathrooms and toilets are provided. There are two good-sized social areas for service users on the ground floor. There is a team of carers who provide support to residents during the day and two staff awake at night to assist residents who may need help. Fees range from £386 to £600 per week. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’ which was undertaken by two inspectors on 28th June 2007 and the afternoon of 4th July 2007. It was a thorough look at how well the service is doing. It took into account detailed information provided by the registered provider, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services, staff members and other people seen during the inspection or who responded to questionnaires that the Commission had sent out prior to the visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report, using evidence, made judgements about the standard of the service. The inspector would like to thank the residents, their families, staff members and other health professionals for their time and assistance during this inspection. What the service does well: What has improved since the last inspection? Since the last inspection the service has recognised the shortfalls within the service and have begun to address them. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 6 The service has commissioned an outside consultant agency for support and advice in improving their care planning and assessment procedures and producing methods in which robust audit trails are to be undertaken. Areas of concern around the environment, found during the last inspection, have been addressed; all but one of the bedrooms, which were highlighted as being in need of repainting due to water damage, have undergone the necessary paintwork to provide those residents with attractive surroundings. Contents within the cellar, which posed as a risk to the health, safety and welfare of those living and working at the home, have been removed. 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. The Lindens DS0000028059.V337555.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 The Lindens DS0000028059.V337555.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): 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and current service users are provided with information about the home and services it offers through a service users guide. Prospective service users undergo an assessment of need prior to moving into the home, to ensure their needs can be met. EVIDENCE: Four care plans were examined. All contained evidence that pre assessments had been undertaken. The assessments were completed in full. The documentation used to guide the assessment meets the required standards. Residents’ religious and cultural needs are assessed. The deputy manager said that residents may stay for a trial period and that many stay for a period of respite care before deciding to move to the home on a permanent basis. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 9 From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Management have recognised deficiencies in their care planning and assessment procedures and are in the process of addressing the shortfalls; they have commissioned consultants to help in this area and work has begun. EVIDENCE: The management have recognised that there were shortfalls within their care planning and assessment process during the last inspection and have made progress to address them. The proprietors have taken professional advice on care planning and are in the process of introducing person focused care plans. One residents care plan had been revised using the new format. The other care plans remain in place using the old format. Care needs had been identified and risk assessments were in place. The actions needed to meet identified risks were not always described in detail. This will be addressed when the new format is introduced. They had not all been updated monthly. The care plans contained care manager’s assessments where appropriate. A requirement has been made within this The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 11 report to ensure that all further care plans are reviewed and transferred to the new format within a timescale of 4 months. The home has good working relationships with the local GP’s and community health services and accesses them when appropriate; the care plans seen had evidence that residents are seen by their General Practitioner and other healthcare professionals including the dietician, district nurse, optician and community psychiatric nurse. One survey received from a GP indicated satisfaction with the provision of all aspects of the care provided and stated ‘lovely family run home which supports and cares very well for all patients and staff’. Residents are weighed regularly those three of the four whose care plans were seen had maintained their weight. One had lost weight and the advice of the community dietician had been sought and incorporated in the care plan. The home is registered to take people who may have dementia and the advice of the community psychiatric nurse was sought. This was documented in the care plan. There are medication policies and procedures in place and the storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were mostly accurately completed. There was one gap on one record and one resident had not had two doses of medication, which is prescribed to reduce anxiety. The reason why this had not been given was not recorded. The deputy manager said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision the doctor and family would be informed and a way forward agreed. The training records showed that all staff who administer medication have had training and have been supervised until their competence has been deemed satisfactory. A local pharmacist supplies medication in dosette boxes. This pharmacist audits medication management on a quarterly basis. The proprietors have also asked an external company to audit medication to address requirements made at the last inspection and state in their improvement plan that they will instigate a monthly audit of medication administration records. Some concerns around the recording and administration of medication was voiced to the inspectors, which was fed back to the responsible individual, who assured the inspectors that this would be dealt with appropriately and the Commission would be kept informed of the investigation and outcome. The Lindens DS0000028059.V337555.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 good. This judgement has been made using available evidence including a visit to this service. The home provides a pleasant and relaxed environment in which residents are comfortable and well looked after. Meals are home-cooked, nutritious and nicely presented. Previous lack of activities is being addressed to meet residents recreational needs. EVIDENCE: The home provides a pleasant and relaxed environment in which residents are comfortable and well looked after. Service users are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user themselves. Service users are able to entertain them in their own bedrooms or in the communal lounges. Both the residents and those visiting said that staff always make visitors feel very welcome. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 13 The home provides a varied menu. Cereal and toast are served at breakfast although the staff said that a cooked breakfast could be offered if a resident wanted one. The main meal is served at lunchtime and a light cooked supper or sandwiches are served at suppertime. The last meal is at 6 pm and staff said that drinks and biscuits are served later in the evening. The dining tables were laid attractively on the day of the unannounced visit and the mealtimes were seen to be a sociable occasion for residents. Assistance is given in a discreet sensitive manner to those who require. The residents spoken to, during the inspection, said that they enjoyed the meals provided; one informed the inspector ‘this is as good as home cooking’. The carers said that soft or liquidised diets could be provided, although all residents at present were able to eat a full meal and likewise meals to meet residents religious or cultural needs would be provided where the need arose. One family member spoken to on the day of the unannounced visit said that her family member had regained weight she had lost when in hospital and was feeling ‘ much better for it’. Since the last inspection undertaken in January 2007, the home have been working to address the service users recreational and spiritual needs. Contact with the local church has recently been made to enquire into the provision of a regular service within the home, however this has proved difficult although the monthly church magazine is now provided and available within the home. The inspectors were informed that the home would support residents to access the local churches and attend services when required. The home provides residents with fortnightly themed talks, which all are invited to attend and take part in if required. An outside entertainer regularly visits the home to provide musical entertainment, which the residents enjoy and join in. A recent development is craft afternoons, in which a residents’ family member has been involved in providing residents with the opportunity to take part in art and craft sessions. The inspectors were informed that residents are in the process of making lanterns during these art and craft sessions and the local brownies have been invited to come in and assist. During the second day of the inspection, it was noted that seated movement to music was being provided to those who wished to attend. Staff members informed the inspectors that whilst group activities are provided, one to one sessions are provided to users of the service, by the care staff, during the quieter parts of the day. Residents meetings are held within the home for those who wish to attend. It is recommended that these meetings be minuted and placed within the home to enable residents who are either unable or choose not to attend with the opportunity to access information about the agenda discussed if they require. The Lindens DS0000028059.V337555.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which is accessible to service users and family members. Policies and procedures are in place to safeguard service users from abuse. EVIDENCE: Information about the complaints procedure is given to service users on admission. The complaints procedure is displayed within the home and copies are also available on request from the manager. The timescale for dealing with complaints is 28-days, as stated in the homes written procedure. There have been no complaints received into the service since the last inspection. However, during the inspection there were some allegations made directly to the inspector around medication issues. These were fed back to the registered responsible individual who agreed to take appropriate action and keep the Commission informed of the investigation and the outcomes. The Commission has received correspondence that this is being dealt with. The safeguarding of vulnerable adults is taken seriously, and staff members receive training at induction and regularly thereafter. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the standard of environment have been made to provide service users with an attractive, safe and homely place to live. EVIDENCE: All but one of the bedrooms have been redecorated since the last inspection and the water damage to resident’s room’s ceilings has been repaired. There is still some water damage to the ceiling outside the first floor bathroom and to one empty bedroom. This should be repaired. The proprietors stated that they would ‘tour the building monthly to identify issues of maintenance and health safety hazards, which will be recorded, and a system for monitoring completion will be implemented’. This has not yet been implemented and should be to ensure that environmental maintenance and faults are dealt with in a timely manner. Whilst the communal areas of the home were cleaned, residents rooms had not been dusted for some time. The carers spoken to The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 16 said that the housekeeper was away for family reasons until at least Christmas and one carer is undertaking some additional hours on an infrequent basis to clean the home. The proprietor should ensure that sufficient cleaning hours are available to ensure that resident’s rooms can be cleaned regularly. Whilst touring the home there were no offensive odours present. A number of the sash style window frames were in need of repair and one in bathroom needs an appropriate window restrictor applied. There are infection control policies and procedures in place. The staff were observed to be washing their hands and wearing appropriate protective aprons. The washing machine is sited away from the kitchen. There are paper towels and liquid soap in all rooms. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 17 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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff are provided to meet the service users needs although additional staff during peak times of the day would be beneficial. EVIDENCE: No new members of staff have been recruited since the last inspection to ascertain whether there had been an improvement on the recruitment process and the necessary paperwork in place. However, the service is in the process of recruiting one new member of staff, and awaiting references. Whilst viewing the paperwork in place it was noted the necessary checks have been instigated as have the collection of two references. Whilst the application form asks for an employment history, there was nowhere to record dates relating to this history. The deputy manager assured the inspectors that the dates would be followed and if any gaps were evident they would also be followed up prior to the person being offered employment. It is a good practice recommendation to keep interview notes on personnel files. All members of staff undergo induction training, upon appointment to their posts, are provided with mandatory training and are offered ongoing training and support which equips them to meet the assessed needs of the residents The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 18 within the home. Staff members are encouraged to undertake the National Vocational Qualification (NVQ) in care. Of the twelve permanent care staff, five possess the NVQ level 2 or above in care with a further 3 working towards achieving the qualification. Since the last inspection training has included food hygiene, dementia awareness and medication training. Staffing levels on the day of the inspection appeared sufficient to attend the residents needs, however staff did voice some concerns around the level of staffing during the busy periods of the day such as meal times. Likewise comments from relative/family surveys provided to the commission prior to the visit include; “my only problem here is that often you have to look for staff as there does not always appear to be many on duty. If nobody about residents can get very agitated calling for attention” and one other which states “I think that it is ‘convenient’ to get the residents into one room and encourage them to stay there and the impression I get is that ‘freedom’ depends on staff numbers on the day” There were fourteen residents on the day of the unannounced visit. From 8am to 9am there are two members of staff on duty including the manager. From 9am to 11am there are four and between 11 am and 1 pm there are two. There are two carers and a manager or senior carer on duty between 3pm and 9 pm and two waking night staff. The staffing levels are reduced at weekends to three staff members on duty during the day including the manager or senior carer. The care hours meet the recommendations of the Department of Health based on fourteen residents however the staffing levels should be monitored carefully and increased if more residents move to the home or their dependency increases. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 19 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, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed, delivering a consistent service to those who live there and is run in their best interests. EVIDENCE: Whilst the manager has the experience and competency to run the home and has obtained the relevant Registered Managers award she does not possess the National Vocational Qualification at level 4 in care and therefore this means that Standard 31 cannot be assessed as ‘fully met’ until this qualification is obtained. There is also a deputy manager, who has also gained the NVQ level 4 Registered Managers Award although likewise hers does not include the level 4 care component either. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 20 The registered Manager, Deputy Manager and a senior carer, cover the rota, to ensure that an experienced person is on duty on all shifts. Carers expressed some concerns about the management arrangements during the visit. These were reported to the proprietor who is following them up. Areas of improvement, which were highlighted during the last inspection, have been recognised. The areas of concern around the environment have been addressed appropriately to provide service users with a safe homely environment to live in. Shortcomings found within the care planning and assessment process are being dealt with appropriately and when all the remaining service users care plans and risk assessments have been completed will ensure the health and care needs for the users of the service are documented fully and give clear instructions how their needs are to be met. Activities for residents are now on the agenda to provide for their recreational needs. These improvements evidence that the service has recognised their shortfalls and by acting upon them is being run in the best interests of those living at the home. The home does not act as agent or manage any monies on behalf of residents. A small amount of personal allowance can be held in the home on behalf of residents. Records are kept and receipts are given. One account was checked and found to be accurate. A number of concerns were expressed about the quality assurance systems in the home at the last inspection. Since then regular residents meetings have been re-established and minutes were seen to confirm this. A consultancy has been commissioned to seek residents and family’s views on the care in the home, although the outcome is not yet available. The manager and her deputy hold regular staff meetings during which staff are able to voice any concerns. A requirement was made at the last inspection for the proprietor to undertake regular quality assurance visits in line with Regulation 26 of the Care Homes Regulations 2001. This has not yet been complied with and the proprietor does not yet undertake a regular systematic review of the quality of the service and care delivered in the home. At the meeting held to feed back the initial findings of this report he said that he would commission the external consultancy that he has been working with to do this for him and agreed to confirm in writing to the Commission when the first three quality assurance visits have been undertaken and prepare a written report of the findings and the actions to be taken to improve the service. Following the last inspection, the Commission for Social Care Inspection asked that an improvement plan be drawn up to address the concerns identified. This was done within the timescales set and progress has been made towards meeting most of the requirements made. There remains a need to address the regular environmental surveys and the quality assurance reports referred to above. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 21 A fire risk assessment has been undertaken. The combustible material in the cellar has been removed since the last inspection. The fire log was checked and regular fire drills are undertaken and fire alarms are tested. The pre inspection documentation completed by the proprietor showed that annual maintenance of equipment had been undertaken with the exception of the gas appliances. This must be completed. The staff spoken to said that they had had manual handling training. Training records showed that staff have had first aid training and that there is a first aider on each shift. COSSH assessments have been undertaken and information is kept for all substances which are hazardous to health. The Lindens DS0000028059.V337555.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 23 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 2 Standard OP7 OP9 Regulation 15 17 (1)a Schedule 3, 13(2) 23 26 Requirement Ensure that all residents care plans are reviewed and transferred to the new format Instigate a monthly audit of medication administration records to ensure correct procedures are adhered to. Residents rooms must be cleaned and kept dusted on a regular basis a system for identifying and monitoring any maintenance and health and safety standards must be put into practice. The registered provider must undertake monthly quality assurance visits to the home and prepare a written report of the findings and the actions to be taken to improve the service. This requirement remains outstanding from the previous report. Previous timescales of 31/7/05, 01/10/06 and 30/04/07 not met. Timescale for action 07/11/07 05/09/07 3 4 OP26 OP19 06/08/07 06/08/07 5 OP33 26 06/08/07 The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 24 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 2 3 Refer to Standard OP27 OP29 OP33 Good Practice Recommendations Consideration should be given to increasing the number of staff during peak times of the day and if residents dependency levels increase. It is recommended that interview notes be held on staff personnel files. The initial work, undertaken by the external consultants, to review the quality of care offered in the home should be put into practice by the homes management team on a regular basis. The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 The Lindens DS0000028059.V337555.R01.S.doc Version 5.2 Page 26 - 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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