Care Home: Lyndhurst

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What the care home does well There is a very good management system. The residents are encouraged to be independent and to access resources in the community. The residents` cultural, medical and preferences of activities and meals are met by the home`s commitment to encourage independent living and rehabilitation. The home works well with health professionals. The daily records and care plans have enabled the home to monitor the progress of residents care. The admission process has enabled the residents and the home to be clear that the home is the right place for them. The staff are committed and experienced.LyndurstDS0000073052.V376017.R01.S.docVersion 5.2 What has improved since the last inspection? This is the first inspection since the home has been bought by the present owners. What the care home could do better: There is a need for the home to improve care plans and risk assessments. The care plan of the people who are at risk of suicide and those with diabetes conditions need to be detailed and tightened in order to ensure their safety. Care staff must be confident in their knowledge and experience of supporting the residents with diabetes. Care plans or medication administration record sheets must clearly show the allergies that the residents may have. Care must be taken about cross contamination and cleaning brushes must be safely stored, not left in the kitchen. Key inspection report CARE HOME ADULTS 18-65 Lyndurst 28-30 Woodhouse Road Finchley London N12 0RG Lead Inspector Teferi Degeneh Key Unannounced Inspection 16th June 2009 07:20 Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 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 home adults 18-65 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. Lyndurst DS0000073052.V376017.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 Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndurst Address 28-30 Woodhouse Road Finchley London N12 0RG 01707 652053 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) Caretech Community Services Ltd Diana Slavova Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The Registered Person may provide the following category/ies of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disabilities or dementia - Code MD 2. The Maximum number of service users who can be accommodated is: 25 Date of last inspection Brief Description of the Service: Lyndhurst Psychiatric Residential Care Home has been recently registered under a new provider, Caretech Community Services Ltd, a company that also has other care homes in the area. The home is an existing service which means that it used to be operated as a care home under other providers. The home provides a rehabilitation service to adults with mental health problems. It is registered to provide service for up to twenty-five men and women. The home is set in a residential area of North Finchley. Shopping, restaurants and cafés are available on the same road and accessible to the people who use the service. The service is made up of three properties providing enough communal and private areas. There are no gardens to the front of the service but there are well managed gardens at the back for the residents to sit and enjoy the garden whenever the weather allows. There is a large fishpond and green house for the residents to use. A large wooden construction provides an area where the residents can meet socially, listen to music, play pool and follow other interests of their choice. Smoking is not allowed in the house; however, there are areas in the garden where the residents can sit and smoke. Each person at the home has a single bedroom. The bedrooms are decorated to the individual tastes of the service users. There are three main kitchens and two lounges. Two service users share a self-contained two bedroom flat on the top floor. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 5 Staff support the service users with their medication, home-care, social and recreational activities, and cooking. The staff and resources within and outside of the home are aimed at encouraging and empowering the residents to take control of their own lives and to maximise their full potential, making appropriate use of community services. This also includes the taking of reasonable risks, which is felt important to the residents personal development and to promote their independence. Fees for the service range from £985 to £1045.99 per week per person. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a surprise inspection which meant that we had not told the home that we were visiting. The inspection started at 7:20 am and finished around 3:30 in the afternoon. Mr Daniel Lim, the Care Quality Commission Inspector, was present between 9:00 am and 12:00 pm to help with the inspection. The manager was available throughout the inspection. Before our visit to do this inspection, we had received a self assessment form known as the annual quality assurance assessment (AQAA) from the home. An AQAA is a form which we request from care homes every year to complete and send back to us. It gives care homes an opportunity to tell us how they are planning to improve the service. We had look at the AQAA as part of this inspection. The other activities we carried out on the day of this inspection included a tour of the building, the examination of the residents files including care records, the examination of health and safety records, the viewing of staff rotas and discussions with and observation of people who use the service, care staff and the homes management. We have also considered all the other information that we have about the home. What the service does well: There is a very good management system. The residents are encouraged to be independent and to access resources in the community. The residents cultural, medical and preferences of activities and meals are met by the homes commitment to encourage independent living and rehabilitation. The home works well with health professionals. The daily records and care plans have enabled the home to monitor the progress of residents care. The admission process has enabled the residents and the home to be clear that the home is the right place for them. The staff are committed and experienced. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 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. Lyndurst DS0000073052.V376017.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 Lyndurst DS0000073052.V376017.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 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. New residents are confident that their admission to the home is based on the outcome of their assessments and the availability of staff and services to meet their needs. EVIDENCE: We looked at five residents files and spoke to the manager. The manager told us that new residents are admitted to the home following the completion of their assessments by a competent member of staff and a number of stays at the home. She said that the home receives information about new residents from social workers and health professionals. The residents’ files we examined contained evidence of preadmission assessments completed by the home. The AQAA says that all new residents have to have a series of stays at the home for assessment and to have an opportunity to meet the other residents so that they can have a feeling of what it is like to live in the home. We spoke to six residents and all of them confirmed having been to the home for assessments before their admission. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 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. In spite of the home’s good systems of care planning and risk reviews, some residents are not sure that they are safe. The home needs to have strategies to address all issues highlighted in the risk assessments. EVIDENCE: Five residents files were examined. All these files contained detailed care plans and risk assessments. We noted in the files that the home works closely with all relevant people to review care plans and risk assessments. The manager told us that she liaises with relevant people such as psychiatric consultants, community psychiatric nurses, Ministry of Justice and social workers when and if there are changes to the needs of the people who use the service. Most of the residents who live at the home are independent and could go out to the community and return to the home without being escorted by staff. While the Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 11 inspection was taking place we observed many residents going to their appointments or shopping and returning to the home. There is a system for reviewing and recording care plans and risk assessments. From the files and discussions with the manager it was evident that care plans are reviewed monthly. There was evidence in the files to confirm that families, social workers, and health professionals are involved in the reviews. The home has a system of recording significant events three times a day (morning, afternoon and evening) for each of the residents. This is done with a use of special computer software. We attended a handover session in which the incoming shift staff were updated on significant issues for each of the residents. The case records of a resident identified as being at risk of suicide and as having a challenging behaviour did not contain specific care plans addressing these risks. This was brought to the attention of the team leader. To ensure that all staff are fully informed of how to minimize the identified suicide risk and ensure that this resident is adequately cared for, a suicide prevention care plan is required. We case tracked or identified the file of one resident and looked at it in detail. We noted a letter (26/04/2006) written by the home to a social worker regarding the care of the person. We were also informed by the manager that no changes are made to a resident’s care plans or risk assessments without a consultation with the resident, a consultant psychiatrist and other people involved in the care of the resident. The manager said the home follows the guidelines put in place for each resident to inform, for example, the families or social workers when the resident are away from the home. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 12 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): This is what people staying in this care home experience: 12, 13, 15, 16, and 17 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 residents have good opportunities to engage and develop skills for independent living in the community. EVIDENCE: The residents in the home have access to a range of social and therapeutic activities. The case records examined contained details of activities and training that have been available to the residents. We noted that two residents have been attending courses in local colleges. One resident who was interviewed informed us that there are sufficient activities for them. They further stated that they were involved in household chores and encouraged to be as independent as possible. We also noted from our interviews with staff that they encourage the residents to participate in cooking and other household chores. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 13 The residents’ files and discussions with the manager and the residents showed that arrangements are in place for the residents to have visitors and to visit their families. As we mentioned above, risk assessments are completed for the residents and all people involved are aware of the arrangements put in place when the residents visit families and friends. Meetings had been organised and the residents had been consulted regarding the management of the home. This was confirmed by the residents and staff who were interviewed. The minutes of the residents’ meetings were also available for inspection. The kitchens were inspected and were found to be clean. Daily recorded temperatures of the fridges and freezers had been kept. These were satisfactory. Fire blankets and extinguishers were in place. We noted that the brush used for sweeping the kitchens were kept in the kitchen. This was brought to the attention of the manager. To prevent cross contamination, the brush must be stored either away from the kitchen or in a closed cupboard. The menus we examined appeared to be varied and balanced. One of the team leaders informed us that residents had been consulted regarding their dietary preferences and their cultural preferences had been responded to. The residents who were interviewed informed us that they were satisfied with the meals provided. From records and discussions with the manager and the residents we noted that many of the residents are self catering, which means that they do their own shopping and cooking with the weekly money given to them by the home. This system has allowed the residents to develop independent living skills and an opportunity to choose the type of food and the time they want to eat. The home does not manage the residents’ finance. The manager said each resident has an account which they manage by themselves. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20 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. There are good systems and committed staff to meet the health and personal care of the people who use the service. EVIDENCE: The personal and healthcare of residents were on the whole, well managed. Residents living in the home have access to healthcare services in the local community. There is evidence in the case records that healthcare needs are monitored and appropriate intervention taken. Some deficiencies were however, noted in the care arrangements and in the administration of medication. These may place residents at risk and must be rectified. Staff interviewed demonstrated a caring attitude towards the residents. The residents interviewed stated that they are treated with respect and dignity by staff and they are satisfied with the care they received. The residents were noted to be clean and well dressed. The case records of five residents were examined. These residents had complex and serious mental health needs. Service users individual and specialist health and personal care needs are Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 15 recorded. The records indicated that these residents have access to specialist healthcare services. Appointments with the psychiatrist, community psychiatric nurse, dentist and optician were recorded. We noted that the five residents case records contained care plans and comprehensive assessments. Plans of care had been signed by residents to indicate they agree with them and these plans had been regularly reviewed. There were also details of one to one sessions between staff and residents and guidance to staff on how the mental health needs of the residents are to be met. The care and plans of care of a resident with diabetes was examined. We noted that diabetes was identified as a potential risk. We asked the team leader to show us the diabetes care plan and details of how the diabetes was monitored. The team leader could not find the specific care plan or details of how this residents diabetes was monitored. To ensure that all staff are fully informed of how to minimize risks and ensure that residents with diabetes are adequately cared for, a diabetes care plan together with monitoring details must be provided. In addition, the home needs to provide all care staff with diabetes training. We note that one of the residents have previously exhibited challenging behaviour and there was mention of this person having attempted suicide. The case records did not contain an appropriate risk assessment addressing this. We have asked the home to ensure that all staff are fully informed of how to minimize the identified suicide risk and ensure that this resident is adequately cared for. The risk assessment must include a strategy for minimising the risk of suicide. We examined the administration of medication. The home has the required policy and procedure. Medication was stored in locked cupboards in a separate room. Four residents’ medication administration record sheets (MARS) were examined. There is a photo of each resident in the medication administration record folder. Three of the residents concerned administer their own medication. There was evidence that this had been approved by the responsible doctor and the residents involved had signed in agreement. There was documented evidence that staff regularly check to ensure that residents take their medication. The MARS were appropriately signed. The temperature of the medication room and fridge had been recorded daily. These were satisfactory. We however, note that allergies that residents have were not recorded prominently either on the MARS or in the front of their case records. This must be done to ensure that staff are fully informed and to ensure the safety of residents. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 16 Lyndurst DS0000073052.V376017.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 23 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 people who use the service are confident their concerns are listened to and solved by the home. The home’s safeguarding procedure and the experiences of the staff make the residents feel safe in the home. EVIDENCE: There have been three recorded complaints since the home was registered. All these complaints have been investigated and addressed by the manager. The manager said all people’s concerns are recorded and taken seriously. The AQAA says: We have a clear complaints procedure for complaints by resident against the home. We also encourage residents to use a ‘grievance’ procedure if they have a complaint about another residents behaviour; this is useful in helping to resolve minor problems before they escalate. The residents we spoke to confirmed that they know how to make a complaint. The AQAA confirms that all staff have attended training on safeguarding. Our interview of the staff showed to us that they have knowledge and skills to safeguard people in a care home. The home has reported to us and to the local authority whenever there have been safeguarding issues. The home has policies on safeguarding and whistle blowing. A copy of the local authority’s policy on adult protection was also downloaded from the internet and kept at the home. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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. There are good facilities for the residents to feel that they live in a safe and comfortable home. EVIDENCE: The communal areas and the kitchens were clean and tidy. The rooms are spacious with homely, good quality furniture and television sets. The residents we spoke to said they are satisfied with their rooms and the facilities. Each resident has their own bedroom. The residents also have keys for their bedrooms. The manager confirmed that the residents know how to open the front door independently. The home is situated very close to shops and transport facilities. The back gardens have been improved to allow the residents to use for sitting or growing vegetables. There is also a large fishpond and green house for the residents to use. A large wooden construction provides an area where the Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 19 residents can meet socially, listen to music, play pool and follow other interests of their choice. Smoking is not allowed in the house; however, there are areas in the garden where the residents can sit and smoke. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35 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 home has sufficient skilled and experienced staff to meet the needs of the people who use the service. EVIDENCE: The staff rota was checked and showed that there are usually three care staff on shift during early and late shifts. The manager and the deputy manager work 9 am to 5 pm Monday to Friday. One care staff in each shift is designated as a shift leader with a responsibility for daily records and supporting the other care staff. The manager told us that there is an on-call system which means that the staff on shift can ring a senior member of the company, who is oncall, for advice and support. Even though the home has been recently taken over by the providers, all the staff employed at the home have been retained with their terms and conditions of employment. We looked at five staff files. All these files contained evidence of satisfactory criminal bureau checks, written references from previous employers, job Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 21 descriptions, and training certificates. We interviewed two members of staff and observed the others. We thought that the staff are experienced and treat the residents with respect and dignity. The people who use the service and who we spoke to told us that they are happy with the way the staff support them. The AQAA confirms that all staff have either achieved a national vocational qualification in health and social care at level 3 or have enrolled at an institution to achieve the same qualification. The manager said she has sent a list of staff and the training needed to the training department of the company that owns the home. We saw the evidence on the homes computer. We confirmed from the AQAA and some of the staff files that all new staff undergo a detailed induction programme before starting work at the home. We mentioned above in this report that there is a need for the home to do a care plan which includes care for diabetes. We also said that the staff need to be fully informed of how to minimize the risks that are related to diabetes and ensure that the residents with condition are adequately cared for. In addition to a diabetes care plan, this would need the training of staff on diabetes. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 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 people who use the service benefit from good, forward-looking and creative management system. EVIDENCE: The manager has worked at the home as a team leader for six years. She has been registered as the manager of the home since March 2009. The manager has a work experience in another care home. She said she has completed NVQ level 4 and the registered managers’ award (RMA). The residents and the staff told us that the manager is approachable and helpful. We found her to be cooperative, efficient and well organised whenever we had to contact her, including during this inspection. She told us that she has a lot of ideas and Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 23 plans to make improvement to the services and facilities. We are confident that she will consult the residents and all the other stakeholders to implement her ideas and make the changes that will improve the quality of life for the people who use the service. The company has a quality assurance manager who visits and advises the manager of the home. The residents have been consulted through a survey questionnaire distributed to them by the manager. Samples of the surveys, which were seen, showed that the residents are happy with the service. The manager is also devising surveys for the visitors to seek their views about the facilities and services of the home. She said the residents have monthly meetings in which they talk about different issues relating to the quality of the home. The area manager comes to the home to do a monthly audit of the systems of the home. The manager said this is a helpful tool for improving the quality of the home’s services. We mentioned earlier in this report that risk assessments and care plans have been completed for all residents. We identified a concern that the risk assessment of one person with a challenging behaviour and suicidal tendencies need to be clear. We checked the incident and accident records and found out that there have been twelve incidents. None of these were serious to result in a hospital admission. The AQAA confirms that regular checks and services of the home’s equipment have been done. The manager said all staff have attended training on fire safety and basic food hygiene. The home has a system of allocating tasks to named staff. For example, there is a named member of staff responsible for monitoring and reporting on fire safety, kitchen, and medication and so on. The manager said this kind of job sharing is working well. We noted that emergency lights, fire alarms, and fire drills take place and recorded by the home. Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 3 3 X 2 X X X X 30 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X Version 5.2 Page 25 Lyndurst DS0000073052.V376017.R01.S.doc No Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 12 Requirement The registered person must ensure that there are risk assessments for people who may be at risk of suicide. The risk assessments must include strategies for minimising the identified risks. This is to ensure the safety of residents concerned. The brush used for sweeping the main kitchen must be stored away from the kitchen or stored in a closed cupboard in the kitchen. This is to prevent cross contamination of food. The registered person must ensure that there is a diabetes care plan for the resident identified in the section on Personal Healthcare & Support. This must include details of how the diabetes is monitored. This is to ensure that the resident concerned is well care for. Details of any allergies that DS0000073052.V376017.R01.S.doc Timescale for action 15/07/09 2 YA17 13 15/07/09 3 YA19 13 21/07/09 4 YA19 13 16/08/09 Page 26 Lyndurst Version 5.2 residents may have must be recorded prominently in their files and MAR Charts. This is to ensure that staff are fully informed and to ensure the safety of residents concerned. All care staff must attend training on the care of residents with diabetes. This is to ensure that the residents with diabetes are well cared for by staff. 5 YA32 18 31/08/09 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 Lyndurst DS0000073052.V376017.R01.S.doc Version 5.2 Page 27 Care Quality Commission 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. 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. 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