Care Home: Lyndhurst

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What the care home does well Lyndhurst provides a homely environment in which residents are well cared for and staff are aware of their individual needs. Routines are flexible and residents are supported to make choices about their lives. The previous inspection report reflected that the provider and manager had worked hard to meet the requirements outstanding prior to the last visit and had improved the service in a number of areas. This work has been expanded upon and existing improvements were evidenced as being sustained during this key inspection. Care plans are of a good standard and the manager has worked hard to make sure that individual risk assessments are more comprehensive, detailed and are reviewed. Staff are well supported and have benefited from training given over the past eighteen months, they have a good rapport with residents and time to spend with them. Comments on surveys from residents and relatives were complimentary about staff and their caring attitude.LyndhurstDS0000013707.V377757.R01.S.docVersion 5.2 What has improved since the last inspection? Individual risk assessments have been broadened and give more detail on potential risks and how they can be managed and prevented. Risk assessments are being reviewed and the date of review recorded. There is more detailed recording on residents’ daily routines and activities and more one to one as well as group activities are taking place. Residents are being offered meal choices every day and are asked what meal they would prefer. Some bedrooms have been redecorated and have new furniture and there has been some redecoration of communal areas. More staff have gained an NVQ in care and are undertaking the training. Some carers have attended Mental Capacity Act training. What the care home could do better: Photographs of residents should be included in the file with their medication recording sheets. The menu needs to be displayed in a format that is more accessible to residents and alternatives to text be considered. There must be no gapping in bathroom flooring in the interests of infection control. The work done to improve the environment is of benefit to residents, current environmental standards need to be maintained and further redecoration and refurbishment undertaken in areas not yet redecorated that are looking a little “tired”.LyndhurstDS0000013707.V377757.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Lyndhurst 67 Byfleet Road New Haw Addlestone Surrey KT15 3JZ Lead Inspector Deborah Sullivan Key Unannounced Inspection 26th October 2009 09:30 DS0000013707.V377757.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address 67 Byfleet Road New Haw Addlestone Surrey KT15 3JZ 01932 842 730 01932 842 730 lyndhurstchome@aol.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Aboo Bakar Seeparsand Mrs Zehra Bibi Seeparsand Mr Aboo Bakar Seeparsand Mrs Zehra Bibi Seeparsand Care Home 16 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 16. Date of last inspection 29th October 2008 Brief Description of the Service: Lyndhurst is a large detached house in a residential road within walking distance of local shops and New Haw and Byfleet railway station. The building is Tudor style with car parking facilities to the front of the house and an enclosed mature garden to the rear. The home can provide care for sixteen older people, up to ten of whom may also be diagnosed with dementia. Bedroom accommodation is single with the exception of one double bedroom. Nine of the bedrooms have en-suite facilities. There is a large combined lounge and dining area and a conservatory overlooking the garden. There is a kitchen and separate utility room. The fees range from 372 to 450 pounds per week. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection of Lyndhurst took place over six hours. During the visit time was spent with the registered providers/managers, staff, residents and a visiting relative. A tour of the building took place which included some occupied and unoccupied bedrooms, communal areas and the kitchen and laundry. A range of documentation including care plans, medication records, risk assessments and staff files were read. Information provided in the AQAA (Annual Quality Assurance Assessment) and survey forms returned by residents, relatives and advocates, staff and health and social care professionals has also been used to inform this inspection. The AQAA was returned within the given timescale. Some comments that were included in surveys have been added in the main text of this report. What the service does well: Lyndhurst provides a homely environment in which residents are well cared for and staff are aware of their individual needs. Routines are flexible and residents are supported to make choices about their lives. The previous inspection report reflected that the provider and manager had worked hard to meet the requirements outstanding prior to the last visit and had improved the service in a number of areas. This work has been expanded upon and existing improvements were evidenced as being sustained during this key inspection. Care plans are of a good standard and the manager has worked hard to make sure that individual risk assessments are more comprehensive, detailed and are reviewed. Staff are well supported and have benefited from training given over the past eighteen months, they have a good rapport with residents and time to spend with them. Comments on surveys from residents and relatives were complimentary about staff and their caring attitude. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Photographs of residents should be included in the file with their medication recording sheets. The menu needs to be displayed in a format that is more accessible to residents and alternatives to text be considered. There must be no gapping in bathroom flooring in the interests of infection control. The work done to improve the environment is of benefit to residents, current environmental standards need to be maintained and further redecoration and refurbishment undertaken in areas not yet redecorated that are looking a little “tired”. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 8 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 Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the home is available to prospective residents and their representatives. Residents can feel confident that a place at the home will only be offered if it is satisfied it can meet their needs. EVIDENCE: Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 10 Lyndhurst provides full time and respite care, no respite beds were in use at the time of the visit and the home was not full. Information about the home is available to prospective residents and their representatives, the service user’s guide was presented in rather small print, the provider and manager said that it can be produced in larger print and other formats if required. Pre admission assessments take place before a place at the home is offered; the majority of residents were well established at the home. One resident had moved in very recently and was at the home on a six week trial basis. Their relative was visiting and said that they had chosen the home having needed a placement at relatively short notice from a number they had visited, as they felt it was more responsive to the needs of someone with dementia than the others they saw. They were happy with the assistance their relative had been given in their early days at the home, felt they looked healthier already and had valued the support the home had given in coordinating health support. The majority of surveys sent in by residents, some of whom had been assisted in completing them, told us that they had had access to information about the home before moving in. The home does not provide intermediate care. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of residents are well met; risk assessments are in place and have now been broadened and give staff more detail on risks and hoe they can be prevented. The medication policies and procedures in place protect residents. EVIDENCE: Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 12 Four care plans were sampled including the care plan of the most recently admitted resident. The new care plan contained sufficient information for carers to be able to understand the persons needs. All the care plans were completed to a good standard, reviewed four weekly, any changes were recorded and a record was being kept of visits by healthcare professionals such as the GP, chiropodist and optician. Residents are supported to access a range of health professionals and any health concerns are promptly addressed, a GP visited during the visit to see three residents. Some residents are privately funded and some are funded by the local authority, evidence of a full review including a care manager held this year was seen, the care manager was satisfied with the service. Residents vary in the amount of personal care they need from being almost totally dependant upon others to being fairly independent with some support and prompting needed. One recently admitted person was being encouraged to be more independent than they had been whilst living at home and they were benefiting from increased stimulation and company. The last report had highlighted a need for risk assessments to be more detailed, risks were recorded but ways in which they could be prevented or minimised were not recorded sufficiently and there was no review of the risk. Risk assessments inspected on this visit had been significantly improved upon; thorough individualised risk assessments are now in place and that are being regularly reviewed. Where necessary relatives and other advocates had been consulted about the level of risk and measures taken for prevention. Daily recording takes place and there is now more detailed recording of the care and support given daily to each person, including information on activities they have taken part in. Staff observed during the day treated residents respectfully. There is one double room which has screening to ensure the privacy of the occupants. A survey form from a health professional included the comments, “Good manual handling techniques-clients are appropriately assessed and aids used as required”, “good standard of continence care” and that the home liaised well with them. Comments from relatives and advocates on surveys about the standard of care include, “They take good care of (resident) who has dementia. She is always clean and tidy when I go and see her-they don’t know when I am going to turn up. They inform me if she has seen the doctor and keep me up to date with her treatments.” “It takes care of the residents’ wellbeing------------ comforts them when they are ill” Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 13 “Since (relative) has been at the home she has been more approachable and has been eating well and regularly-------they are very caring and pander to her needs to keep her happy” Medication is administered by care staff who have had medication training, it is safely stored and medication record sheets had been correctly completed although there were no photographs of residents in the medication folder. The provider and manager said they would address this. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered opportunities to take part in activities and they make choices about their lives. Contact with relatives is supported. Meals are healthy and there is choice offered. Information about the daily menu needs to be displayed more clearly. EVIDENCE: The home has flexible routines and during the visit residents were taking part in activities with staff or spending time by themselves reading papers or magazines or listening to music. There is a part time activities coordinator who Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 15 was not on duty but staff were interacting with residents. They chatted to them or played cards or scrabble. Whilst the home is not full there has not been a substantial reduction to staffing levels and three carers spoken with said they had plenty of time to spend interacting with residents and for activities. One to one time is provided for those who prefer individual activities or need more support. The activity programme includes scrabble, exercise, reminiscence, manicures and singing. A hairdresser visits regularly and religious services are held at the home. Staff confirmed that outings take place to the nearby canal, shopping, for walks and out for tea and in good weather the garden is used. The previous inspection had identified a need for more one to one activity rather than group sessions. The home has acted on this and the daily activities of each person are recorded in three places to evidence what they have done each day, the activity coordinator and manager keep a separate record each and there is information on daily recording. Entries read show activities undertaken and choices made such as “read the paper” or “chose to stay in bed” and where there have been visits from relatives. One resident involved in the inspection said “staff have time to chat with me”. A relative commented on a survey that there are birthday, special event and Christmas parties; another said their relative liked taking part in activities and staff help to involve her. One health and social care professional’s form identified a need for more day trips and external entertainers. Three staff surveys also said they would like to provide more outings. Several visitors arrived during the visit and were made welcome, one resident said they were regularly visited by relatives and went out with them to organise their finances. A relative spoken with said they found the home friendly and there was good communication. Service users contribute to menu planning; the menu is varied and nutritious. Most main meals were based around meat, the provider said this is what residents prefer there are no non meat eaters but if there were their preferences would be met. There was a choice of lunch which was written on the menu board, although it was not easy to read for anyone with sight difficulties and there was no pictorial information. The need to display the menu in a more accessible format was discussed with the manager. The meal was freshly cooked and nicely presented; it was not plated up but served in the dining room with serving dishes for vegetables on the table for residents able to serve themselves. Portions were suitable and those needing assistance with the meal were helped appropriately, the meal was unhurried residents were observed to be enjoying it, those spoken with said they liked the meals. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and others can feel confident that any complaints or concerns will be addressed. Staff are aware of their responsibility to report any safeguarding concerns and the policies and procedures in place protect residents. EVIDENCE: The home has a complaints procedure that is on display, each resident has a copy in their room. No complaints had been received since the last visit and survey forms from relatives and service users reflected that they knew who to go to with any concerns. A resident spoken with said they would go to the provider or manager. Some residents would need support in order to raise concerns, discussion with the provider, manager and staff and observation showed that staff are aware of when someone is not happy. One resident who has no relatives in contact with them has an advocate. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 17 Discussion with the manager and provider and information in the AQAA showed that the home is aware of the Mental Capacity Act and deprivation of liberty safeguards. There is a safeguarding procedure and staff attend safeguarding training. Staff who were spoken with individually confirmed that they had had the training and would feel confident in raising any safeguarding concerns. No safeguarding alerts have been received since the last inspection. Recruitment procedures include the necessary vetting of applicants and staff do not start work without a satisfactory CRB (Criminal Records Bureau) check. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a homely, clean and safe environment. Work undertaken to improve the environment has benefited residents and needs to continue in areas as yet not redecorated. Bedrooms are personalised and reflect the personalities of residents. EVIDENCE: Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 19 The standard of the environment has improved over the past two years, some work to update the decoration and furnishings had taken place at the time of the last inspection and this has continued. During the past year a number of bedrooms have been redecorated and refurbished, and there has been redecoration and some refurbishment of other parts of the building. Some areas still need repainting and freshening up although overall there is good environmental improvement. Occupied and vacant bedrooms were seen, all were fresh and clean and well furnished and occupied rooms were personalised with items such as pictures, family photos and ornaments. The one shared room is occupied by two residents who moved in together from another home, it has screening for privacy. Rooms are located on two floors there is a shaft lift. There were gaps in the downstairs bathroom flooring; the provider undertook to address this. The bathroom needed general refurbishment to make it more pleasant to use. Some residents have equipment in place for personal use such as wheelchairs and raised toilet seats and chair raisers, there are grab rails throughout the home and areas where there are steps that could be difficult to negotiate such as into the conservatory are fitted with movable ramps. The large through living/dining area has been repainted, further improvements such as new furniture would benefit residents. The conservatory leads onto a large, well kept garden that is fenced and safe. Staff said that it is well used in good weather. Residents spoken with said they liked their rooms, one relative put on a survey that “Mum’s room is light and bright, she has her own toilet and her own art work and furniture”. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by a staff team who are well trained and supervised. Recruitment procedures are thorough and protect residents. EVIDENCE: Four staff files were examined; they contained the necessary recruitment information including references, application forms and evidence of identity.CRB and POVA(Protection of Vulnerable Adults) checks had taken place before they started work at the home. Staff reflected this during discussion and on surveys. A valid work permit was in place for a carer from another country. The staff group is diverse in terms of ages and ethnicity; currently there are no male care staff. New staff receive induction and core training, and some service specific training is given such as in dementia and the Mental Capacity Act. Half of the Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 21 care staff have gained an NVQ(National Vocational Qualification) in care at level two or above and of those spoken with one was undertaking NVQ 2 and one NVQ 3.Other staff are currently on the training as well. The home employs a cook and cleaner as well as care staff. There were enough care staff on duty to meet the care and support needs of residents, one senior carer and two carers were on duty during the visit. Staffing levels have not changed although the home is not full; the provider said that some staff were currently working less hours. Staff observed were confident and had a good rapport with residents. Regular recorded staff meetings take place and staff files contained supervision recording. Staff said they felt well supported, that the provider/managers had an open door policy and they felt confident in going to them for advice. One carer said that there had been some changes in the staff team but it was more settled recently and this had been positive, a comment they made about working at the home was “I love it”. Comments from relatives on surveys included “The staff are very cheerful towards the residents” and “Everyone from carers, cook and cleaner work hard to make the home happy”. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that has a friendly and homely atmosphere and that has been further improved over the past year. The providers are demonstrating that previous improvements are being sustained. Internal quality assurance takes place; survey documentation used needs to be reviewed so that forms are dated. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 23 EVIDENCE: The registered provider/managers are well qualified and experienced in running the service. The home has a friendly, relaxed atmosphere and staff say they like working there. Internal quality assurance takes place, minuted residents meetings are held and there was evidence that residents and relatives are annually surveyed although surveys available for inspection were not dated. The provider and manager have demonstrated over the past eighteen months that they have a commitment to improving the standard of the home; the last inspection found that they had met previous requirements and none were made as a result of that visit. There has been sustained improvement and further development especially in the areas of environment, activities and risk assessment documentation. They provider is also demonstrating that they are taking a more pro active approach in keeping up to date with work needed to maintain and develop the standard of the home and are aware of new legislation and changes being implemented by the Commission from 2010.Material improvements to the home have taken place within the current financial constraints and the home not being full. Whilst attention has been focussed on redecorating bedrooms and some parts of communal areas, the provider is aware this process must be ongoing throughout other parts of the home. One health professional stated on a survey that “The home has improved standards over the last twelve months”. Systems are in place for the safe management of resident’s finances, each person has a power of attorney that is invoiced for expenditure such as hairdressing and papers and personal spending money. The necessary maintenance and equipment checks and servicing take place, maintenance records and certificates sampled were up to date. Fire equipment is tested and regular fire evacuation practices are held involving staff and residents. Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 24 Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 25 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 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 3 3 2 X 3 3 X 3 Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lyndhurst DS0000013707.V377757.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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