Care Home: Lyncroft Care Home

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What the care home does well People told us they liked living in the home. They said, "I always like to go shopping", "I like to watch the horse racing and go to the pub for lunch and a drink", "I watch my television", "I like going out in the car", and, "I like to play swing-ball in the garden". People told us they liked the staff. They said, "Everybody is nice to me" and, "I like to talk to all the staff". All of the staff at the home had achieved a relevant National Vocational Qualification (NVQ) at Level 2 or above. This exceeded the National Minimum Standard of 50% of staff with NVQ at Level 2 or above. What has improved since the last inspection? The Service User Guide had been revised and made available to all of the people in the home so that they had up to date information about the home. The manager had arranged access to a local advocacy service so that people could have independent advice and support if they wanted to. Some of the bedrooms had been redecorated and new bedroom furniture provided so that people enjoyed a more pleasant environment. The greenhouse and an area of the garden had been used by people living in the home to grow their own vegetables. The manager had achieved the Registered Manager`s Award. What the care home could do better: Although improvements had been made to care plans, they lacked detail of people`s preferences about how care should be carried out, and also of how their privacy and dignity should be maintained. Staff should have specific training about safeguarding vulnerable adults and the correct procedures to follow if abuse was alleged or suspected. This will help to ensure that people are protected. Recruitment and induction of staff could be improved to provide a robust system that ensures delivery of a good service for people living in the home. CARE HOME ADULTS 18-65 Lyncroft Care Home 88 Alfreton Road South Normanton Alfreton Derbyshire DE55 2AS Lead Inspector Rose Moffatt Unannounced Inspection 9th September 2008 11:30 Lyncroft Care Home DS0000069427.V371377.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 Lyncroft Care Home DS0000069427.V371377.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. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyncroft Care Home Address 88 Alfreton Road South Normanton Alfreton Derbyshire DE55 2AS 01773 580963 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) Mrs Sudha Devi Rana Mr Harbansh Rana Mr Patrick Edward Treweek Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Provider may provide the following categories of service only: Care Home only - PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following category: 2. Learning Disability - LD The maximum number of service users who can be accommodated is 7 Date of last inspection 19th September 2007 Brief Description of the Service: Lyncroft is situated near the town of Alfreton with shopping, public transport and other facilities available locally. The home provides accommodation on 2 floors for up to 7 people with learning disabilities. There are 7 bedrooms, 5 with en-suite facilities, and a communal lounge and dining room. There is a large, mature garden to the rear of the home and a parking area to the front. Fees at the home range from £1,484.80 to £2,219.93 per week. The manager provided this information on 18th September 2008. Information about the home, including CSCI inspection reports, can be obtained from the manager or owner of the home. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The focus of our inspections is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the provider’s ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Surveys returned to us by people using the service and from other people with an interest in the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • What other people have told us about the service. We sent out 7 surveys to people living in the home and 6 were completed and returned to us. All the people who returned surveys had been given assistance by staff to complete the surveys. We sent out 5 surveys to staff at the home and 3 were completed and returned to us. We carried out an unannounced inspection visit that took place over 5 hours on one day. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 7 people accommodated in the home on the day of the inspection visit. People who live in the home, visitors and staff were spoken with during the visit. The manager was available and helpful throughout the inspection visit. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although improvements had been made to care plans, they lacked detail of people’s preferences about how care should be carried out, and also of how their privacy and dignity should be maintained. Staff should have specific training about safeguarding vulnerable adults and the correct procedures to follow if abuse was alleged or suspected. This will help to ensure that people are protected. Recruitment and induction of staff could be improved to provide a robust system that ensures delivery of a good service for people living in the home. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 7 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. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 8 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 Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 9 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): 1, 2 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There was sufficient information available, a satisfactory assessment process, and appropriate staff training so that people were confident their needs could be met at the home EVIDENCE: Since the last inspection, the Service User Guide had been updated and made available to all the people living in the home. The Service User Guide was not available in formats that may have been more suitable for the needs of people living in the home, such as in picture format or large print. All people living in the home had a statement of the terms and conditions of living in there. We looked at the care records for two people living in the home. Both included relevant assessment information obtained before the person moved into the home, and updated since then. Five of the six people who returned surveys to us said they had received enough information about the home before they moved in, one person did not understand the question. People told us they liked living in the home. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 10 The staff who returned our surveys and those we spoke with said they had training to help them meet people’s needs. They said they always had up to date information about the people living in the home. The AQAA said that people’s views about the care and support they received were sought through surveys, residents meetings, and one to one sessions. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The approach to care planning and risk assessment was not sufficiently robust and person centred to ensure that people were fully involved and consulted about their needs and preferences. EVIDENCE: Six people who returned our surveys said they could make decisions about what they do each day, and that staff always treated them well and listened to and acted on what they said. People we spoke with told us they knew about their care plans and they knew who their keyworker was. We observed that people were encouraged and supported by staff to make decisions about everyday activities. We observed that staff spoke to people in an appropriate way. We observed spontaneous affection towards staff from Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 12 people living in the home. People told us they liked the staff. They said, “Everybody is nice to me” and, “I like to talk to all the staff”. The home had information about a local advocacy service and people were supported to access this if they wanted to. We looked at the care records for two people. Each had a care plan that covered their assessed needs. The care plans included basic information about the care and support needed, but lacked detail about the person’s preferences. There was little detail of how the person’s privacy and dignity should be maintained. The care plans were not person centred. The care plans had been reviewed monthly by the manager of the home. There was no evidence that people had been involved in monthly reviews. People were involved in care reviews with their social worker, usually once a year. The daily records were informative and there was also a weekly summary. The care records included a photograph of the person. There were some risk assessments in the care records relating to activities such as going out of the home and the risk of falls within the home. There was no evidence that people were involved in risk assessment. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People were encouraged and supported to take part in appropriate activities so that the lifestyle in the home met their needs, preferences and expectations. EVIDENCE: Six people who returned our surveys, and the people we spoke with told us they could do what they wanted during the day, the evening, and the weekend. They said, “I always like to go shopping”, “I like to watch the horse racing and go to the pub for lunch and a drink”, “I watch my television”, and, “I like going out in the car”. Most people at the home went to day centres during the week. Leisure time activities included going shopping, going to a local car boot sale, using the local library, going out for a pub lunch, and growing vegetables in the garden. The manager said that people used public Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 14 transport when possible, and also that they tried to avoid taking everyone out at the same time to the same place as this limited choice. There were two holidays planned for people in the home. Some people were going abroad to Spain and others were going away to Skegness. People we spoke to were looking forward to their holiday. Details of people’s family and other people important to them were included in the care records. One person told us that staff helped them to keep in contact with their family by writing letters. Another person said they were looking forward to their relative visiting soon. People were encouraged to help with domestic tasks, such as keeping their bedrooms clean and tidy, washing and drying dishes, and preparation of meals. There was a rota of jobs so that people shared responsibility. People said, “I hoover up and do the pots”, “I sometimes hoover the lounge and dry pots”, and, “I hoover my bedroom and dust”. Routines were more relaxed at weekend. One person told us they enjoyed a lie in on weekend mornings. People told us they enjoyed the meals at the home. One person said, “We always have a choice”. Menus were discussed at regular meetings and the menu seen appeared varied and well balanced. People ate together in the dining room. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff attitudes and knowledge ensured that people received care and support to meet their needs and preferences. EVIDENCE: Six people who returned our surveys, and the people we spoke with told us that staff listened to them and acted on what they said. The care plans lacked detail of people’s personal preferences about how care should be carried out, however, staff were knowledgeable about the care needs and preferences of people in the home. Staff were able to give examples of how privacy and dignity were maintained. People told us they saw their doctor, optician and dentist when they needed to. There were records of appointments and treatment for each person by their doctor and other healthcare professionals, such as the district nurse and Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 16 the dentist. People’s health was monitored and they were referred promptly and appropriately when there were any concerns. Medication was stored securely in a locked cupboard. All the staff had received appropriate training about the safe handling and administration of medication. There were records of the receipt and disposal of medication. The medication administration records seen were satisfactory, except that handwritten instructions were not signed by the person who wrote them and countersigned by another person who had checked them as correct. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were satisfactory systems in place to ensure that people were protected and their complaints were listened to and appropriate action taken. EVIDENCE: The complaints procedure was displayed on a notice board in the hallway of the home and was also available in the Service User Guide. The complaints procedure did not include a timescale of when complaints would be responded to. The procedure was not available in other formats that may be more suited to the needs of people in the home, such as in pictorial format or in large print. The manager said that no formal complaints had been made about the home. CSCI had not received any complaints or concerns about the home. Notes of meetings with people in the home showed that any concerns were raised and appropriate action discussed. Any concerns raised individually were noted in the person’s daily records with details of the action taken. All of the six people who returned surveys, and people we spoke with, said they would go to the manager or other staff if they were unhappy about anything. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 18 The home’s policy and procedures for safeguarding vulnerable adults did not include reference to the local multi-agency procedures. Most staff had received information about safeguarding vulnerable adults as part of their National Vocation Qualification (NVQ), though had not received specific training about safeguarding issues and procedures. The manager had received appropriate training about safeguarding vulnerable adults. There was a satisfactory system in place for ensuring people’s personal money was safe in the home. The money was stored securely and records were kept of all transactions. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home was well maintained, clean, and suitably equipped so that people lived in a safe and pleasant environment that met their needs and preferences. EVIDENCE: Some areas of the home had been redecorated since the last inspection and new bedroom furniture provided. People told us they were pleased with their bedrooms. One person told us they were pleased with the recent redecoration of their bedroom and with the new furniture. The bedrooms were individual in style and were personalised with people’s possessions and photographs. The lounge was comfortably furnished. Since the last inspection one person had been provided with a suitable chair for their needs. There was a desk with a computer, a chair and filing cabinet in part of the lounge. This was for use Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 20 by staff as there was no separate office in the home. The dining room was pleasant and bright, overlooking the garden. There was no separate room suitable for people to use if they wanted to sit quietly, or they wanted to see visitors in private. The manager said that the provider had plans to extend and improve the home, and the plans included a ‘quiet’ lounge and a separate office. The kitchen and laundry were suitably equipped. The first floor bathroom was spacious, clean and free from offensive odours. This bathroom was carpeted and there were some stains in the carpet around the toilet. The garden and patio were accessible to people in the home. There was furniture provided so that people could sit outside in good weather. People told us they enjoyed using the garden. One person said, “I like to play swingball in the garden”. There was a greenhouse that people had used to grow vegetables. People told us the home was always clean. The home appeared clean and there were no offensive odours on the day of the inspection visit. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 21 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, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The recruitment practices and induction programme were not sufficiently effective and robust to ensure the delivery of a good quality service for people living in the home. EVIDENCE: All of the staff at the home had achieved a relevant NVQ at Level 2 or above. Staff had received training about fire safety, food hygiene and first aid. Most staff had received training about how to deal with challenging behaviour. As noted in the Concerns, Complaints and Protection section of this report, staff had not received specific training about safeguarding vulnerable adults. The induction programme for new staff did not meet Skills For Care standards. We looked at the records for two members of staff. We found that one member of staff did not have an application form, and therefore no full employment history, and only one written reference instead of two. The other member of staff had all the required documents and information in place except for a Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 22 Criminal Records Bureau (CRB) disclosure. The manager said that the documents had been obtained but were not available in the home on the day of the inspection visit. An Immediate Requirement was made that there must be a robust recruitment system so that all the required documents and information are in place and people living in the home are protected. The missing information was to be provided to CSCI within 48 hours of the inspection visit. The manager complied with this requirement by providing the missing information within the timescale allowed. The application form for one member of staff included some employment history, but not full details with dates of previous jobs held. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home was generally well managed so that people received a consistent service that met their needs, preferences and expectations. EVIDENCE: Since the last inspection the manager had achieved the Registered Manager’s Award. Staff told us they found the manager approachable and they were confident he would take appropriate action on any concerns raised. One person said, “I feel my manager provides the support and guidance to enable me and my co-workers to provide our service users with the best possible care we can”. The manager said he felt well supported by the provider. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 24 The AQAA was completed by the manager. The information in the AQAA gave a reasonable picture of the current situation in the home. There were a few gaps in the data section of the AQAA. Quality assurance surveys were used every year to find out people’s views about the home. There was no analysis or report of the findings of these surveys to inform people about any action taken as a result of any issues raised in the surveys. There was a meeting each month for people living in the home to give their views and opinions and to bring any issues. Notes were kept of the meetings with details of action taken to address any issues raised. People had access to a local advocacy service. The AQAA showed that maintenance of equipment and systems was up to date. We looked at fire safety records and these were up to date. Accident records were satisfactory. There was a cupboard used to store cleaning products in the kitchen. The door to the cupboard was not locked. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 26 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 YA22 Regulation 22(2)(4) (7) Requirement The complaints procedure at the home must include: • the timescale by which the person who made the complaint will be informed of the outcome of the complaint and of any action that is to be taken. The timescale must not exceed 28 days. • the correct address and telephone number for CSCI. This will ensure a more robust procedure so that people are confident their complaints are taken seriously. The safeguarding vulnerable adults policy and procedure at the home must include details of the local multi agency procedures so that staff follow the correct procedures and people are fully protected. There must be a robust recruitment system so that all the required documents and information are in place and people living in the home are protected. DS0000069427.V371377.R01.S.doc Timescale for action 30/09/08 2 YA23 13(6) 30/09/08 3 YA34 19(1)(b) 11/09/08 Lyncroft Care Home Version 5.2 Page 27 Immediate Requirement 4 YA35 13(6) All staff at the home must have 31/12/08 training about safeguarding vulnerable adults and the correct procedures to follow if abuse is alleged. The cupboard used to store 30/09/08 cleaning products must be kept locked. This will ensure that risks to people living in the home are minimised. 5 YA42 13(4)(a) 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 Refer to Standard YA1 YA6 Good Practice Recommendations The Service User Guide and complaints procedure should be available in formats suited to the needs of people living in the home, such as pictorial format or large print. There should be more detailed information in care plans about people’s preferences for personal support, and about how privacy and dignity are to be maintained, to ensure a more person centred approach. A policy for continence promotion should be developed to ensure that care and support for people is provided in line with current good practice. Handwritten instructions on medication administration records should have two signatures – one of the person who wrote the instructions, and the signature of another person who has checked the instructions are correct. This will protect people and ensure medication is given as prescribed. The carpet in the first floor bathroom should be replaced as it is stained. This will ensure a more pleasant environment for people living in the home. The induction programme for new staff should meet Skills For Care standards. This will help to ensure staff have the right skills and knowledge to meet the needs of people living in the home. There should be an annual report analysing the results of resident satisfaction surveys and detailing the action taken DS0000069427.V371377.R01.S.doc Version 5.2 Page 28 3 4 YA18 YA20 5 6 YA24 YA35 7 YA39 Lyncroft Care Home to meet any issues raised. The report should be made available to residents / their representatives. Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AP 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 Lyncroft Care Home DS0000069427.V371377.R01.S.doc Version 5.2 Page 30 - 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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