Inspection on 04/12/08 for Lyle House

This is the latest available inspection report for this service, carried out on 4th December 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lyle House 31/10/05

Lyle House 25/05/05

Similar services:

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Lyle House 207 Arabella Drive Roehampton London SW15 5LH Lead Inspector Simon Smith Unannounced Inspection 4th December 2008 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyle House Address 207 Arabella Drive Roehampton London SW15 5LH 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) 0208 878 3806 info@rutcht.org.uk Richmond upon Thames Churches Housing Trust Mr Iqbal Musafer Care Home 45 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (15) of places Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2006 Brief Description of the Service: Lyle House is registered to provide care and accommodation for 45 residents, 30 of whom may have dementia. The home is situated close to shops and public transport networks. Richmond Park is a short distance away. Accommodation is provided over three floors. All residents have a single bedroom with en-suite bathroom facilities. The home has produced guide for residents that provides information about the services provided. Fees range from £520 to £671 per week. Lyle House DS0000062953.V373660.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 stars. This means the people who use this service experience good quality outcomes. We used evidence from a number of sources to make this judgement about the home. These included visiting the home without notice on two occasions and talking to residents, relatives, the manager and staff. The inspector joined residents for a meal on both days. We checked a sample of records, including training records and residents’ files. Residents said that they get good care from staff that they know. Residents also said that the home is always clean and tidy and that they enjoy the activities provided. Comments made by residents included: “They [staff] do look after you. They’re generous in doing things for you” “Its clean, its hoovered every day” “Its as if you were at home”. The relatives spoken to during the inspection said that their family member gets good care. Relatives also said that staff make them welcome when they visit and keep them up to date about issues affecting their family member. Staff said that they enjoy working at the home and get good support to do their jobs, including good training. Managers make sure that information is shared so that that staff know residents’ needs. Staff on duty provided good support to residents but had many demands on their time and residents sometimes had to wait for the support they needed. The home needs to assess whether there are always enough staff on duty to meet residents’ needs. What the service does well: Residents have a thorough assessment before they move in to ensure that the home can meet their needs. Residents get consistent care from staff that they know. Residents are consulted about issues that affect them and can exercise choice over their care. There is a stable staff and management team. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 6 Staff communicate and share information well. The home has a skilled and experienced manager. The home is clean, comfortable and safe. There is a good range of activities, events and occasional outings. The menu and mealtimes are flexible to suit residents’ needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ individual needs are assessed when they move in. Prospective residents are able to visit the home before deciding to move there. Residents have contracts setting out their terms and conditions but these must be standardised. EVIDENCE: The home is registered for 45 residents. There were no vacancies at the time of inspection but one person was in hospital. Thirty beds are block contracted to the London Borough of Wandsworth. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 9 Residents’ files contained contracts detailing the terms and conditions of their residency. However the name of the service provider on the contract varied due to changes over time to the organisation’s name. The provider must ensure that the contracts issued to residents are standardised. See Requirement 1. Residents’ needs are assessed before they move in to ensure that the home can meet their needs. Residents funded by local authorities also have assessments by their care managers. The manager said that prospective residents are encouraged to visit the home wherever possible before they make a decision to move there. The home does not admit residents for intermediate care. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care plans reflect their needs and preferences. Residents see healthcare professionals when they need them. Medication is stored appropriately and administered according to clear procedures. Staff interaction with residents was positive and promoted dignity and choice. EVIDENCE: Each resident has an individual care plan, which records individual health and support needs and information about residents’ interests, hobbies, family background and personal history. Care plans were up to date with evidence of regular review. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 11 Residents’ files also contained risk assessments but some of these needed more information to effectively manage the risks involved. For example one resident’s risk assessment addressed the issue of him going out independently but did not identify how the risk factors inherent in this activity can be minimised. See Requirement 2. Care plans demonstrated that staff liaise with healthcare professionals where necessary and that residents get treatment when they need it. A GP visits the home weekly and more often if necessary. Medication is stored securely in the home and there is a written medication procedure. Staff have training before being authorised to administer medication. The manager said that he carries out spot checks on medication recording. One medication error occurred on the day of inspection. This was managed appropriately and reported to the CSCI. Staff spoke to residents with respect and promoted individual choice during the inspection. Personal care needs were met promptly and with discretion. Comments made by residents confirmed that they are consulted on issues that affect them at the home. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good range of activities, events and occasional outings. Residents said that staff are welcoming and friendly when family members visit. Residents are consulted about issues that affect them and are able to exercise choice over their care. Residents have opportunities to give their opinions about the food provided by the home. Mealtimes are flexible to suit residents’ needs. Staff provided good support mealtimes but experience many demands on their time. EVIDENCE: Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 13 The home provides a good range of activities, events and occasional outings. There is a part time activities co-ordinator and a physiotherapist comes to the home to offer weekly exercise. The home has a ‘League of Friends’, a group of people that support the home on a voluntary basis. The manager said that the group primarily raises funds for the home but that some members of the group assist activities as volunteers. Residents said that their friends and family are made welcome when they visit and that important personal and cultural events are celebrated at the home. The inspection took place just before Christmas and staff had put a lot of effort into making the home look festive. There were also events planned to celebrate the season, including a Christmas party. Residents said that they are supported to make choices about their lives. One resident said that she chose to keep her existing GP when she moved to the home. There was evidence that the home has sought the input of Evidence Independent Mental Capacity Advocates (IMCA’s) where residents need support to make decisions. The inspector had lunch with residents on both days of the inspection. Residents were able to eat at the time they chose (some chose to eat after the main group had eaten) and to have alternatives to the menu if they wished. The home has some residents of Afro-Caribbean origin so includes Caribbean food on the menu four times a week. Staff asked residents for feedback about the food during and immediately after the meal and said that they give this information to the manager and the chef. Two staff provided good support during the meals, serving residents their choice of food and interacting positively to create a good atmosphere. However it was clear that providing support during the lunchtime period is a real challenge for two people as there are many demands on their time, particularly if residents need individual support with eating or drinking. For example the inspector observed one member of staff trying to manage simultaneous requests for support to eat, support to leave the table and support to take medication. This issue is addressed further in the Staffing section of this report. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints receive an appropriate response. Residents feel comfortable raising any complaints they have. The home is committed to protecting residents from abuse. EVIDENCE: The home’s complaints record demonstrated that complaints are appropriately investigated and that complainants receive an appropriate response. Residents said that they feel comfortable raising any complaints they have and that they are dealt with appropriately. The home provides training for staff in the Protection of Vulnerable Adults, including advanced training for senior staff. There has been one Safeguarding alert at the home in the last six months. There was evidence that the home informed the CSCI and worked with the resident’s family, placing authority and other agencies to investigate the alert. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 15 Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, safe and well maintained. Communal spaces are homely and welcoming. Residents’ bedrooms reflect their individual tastes and interests. The home is clean and hygienic. EVIDENCE: The home provides modern, purpose built accommodation. A high standard of decoration has been achieved throughout the home. All residents have spacious single bedrooms and en suite bathroom facilities. The bedrooms seen Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 17 were personalised and reflected the tastes Residents are able to bring personal items install a private telephone line should photographs on their bedrooms doors and them to recognise their rooms. and preferences of their occupants. with them on admission and are to they wish. Residents have their often objects of reference to assist Each unit has a large lounge/dining room. There are also smaller lounge areas on each floor, which enables small group activities or for one room to be used as a quiet room or to entertain visitors. There is a small well maintained garden. All areas of the home were clean and hygienic at the time of inspection. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a stable staff and management team. Staff communicate and share information well. Staff feel well supported by their managers. There are times when the home’s staffing resources are stretched thinly. Residents are protected by the home’s recruitment practices. Staff have access to appropriate training. EVIDENCE: The home has a stable staff and management team. In addition to the manager there are three assistant managers, each of whom manages a team leader. Each team leader leads a team of six carers. There are separate staff teams for catering and cleaning. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 19 There was evidence that staff communicate and share information well. Full staff meetings are held monthly and senior staff meet regularly as a group. Staff meeting minutes demonstrated that meetings are used to make staff aware of issues affecting residents and to reinforce good care practices. Staff have individual supervision every two months. The inspector sat in on a handover between shifts. An assistant manager briefed incoming staff about each resident’s progress and condition, including health appointments. The manager said all but two of the care staff team have achieved NVQ level 2 and these two are working towards the award. All the assistant managers have achieved NVQ level 3 and one is working towards NVQ level 4. As highlighted earlier in this report, there are times when the home’s staffing resources are stretched thinly. For example two staff provided support to 15 residents at lunchtime. The staff on duty managed the situation well but it was clear that they had many conflicting demands on their time and that residents sometimes had to wait for the support they needed. There is one member of staff on duty on each unit from 9pm at night until early the following morning. The inspector had some concerns that this may not be enough should an incident occur on one of the units that needs more than one member of staff to manage. The Trust must carry out a review of the home’s staffing levels and demonstrate that there are enough staff on duty to meet residents’ needs at all times. See Requirement 2. The issue of staff availability at night was also raised in the last inspection of the home in June 2006. The inspector spoke to three staff during the inspection, all of whom had worked at the home since it opened. They said that they enjoy working at the home and get good support to do their jobs, including access to relevant training. Most staff records are kept at the Trust’s head office. A pro forma is kept at the home confirming that the Trust’s Human Resources department has obtained two references, proof of identity and a Criminal Records Bureau Disclosure. There was evidence that new staff have an induction when they start work and that all staff attend mandatory training, including medication, moving and handling, fire safety, Protection of Vulnerable Adults and infection control. All staff also attend dementia training provided by the London Borough of Wandsworth. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a skilled and experienced manager. Residents are consulted about issues that affect them and have opportunities to contribute their views about the home. The Trust has a commitment to Quality Assurance and service monitoring. There are appropriate procedures in place for recording residents’ finances. The health and safety of residents and staff is maintained. EVIDENCE: Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 21 The manager is very experienced in the delivery of older peoples’ services and has worked at the home since it opened in February 2005, although was planning to retire in the near future. Residents and staff spoke highly of the manager and his management style. One resident said, “We’ll really miss him – he’s marvellous” and another said, “He’s got time for everybody”. The inspection provided evidence that residents are consulted about issues that affect them and have opportunities to contribute their views about the home. Residents meetings are held monthly on each unit, supported by staff. The manager said that the Trust uses an independent organisation to carry out regular satisfaction surveys, which includes one-to-one interviews with residents. The home keeps small amounts of money for some residents. There are clear procedures for this and the home records residents’ expenditure and issues receipts to people depositing money. The Trust’s finance officer audits a sample of these records quarterly. The home has written fire procedures and an appropriate fire detection system, which was tested and serviced in August 2008. The Fire Officer visited the home in March 2008 and found the premises ‘satisfactory’. The Gas Safety Record was issued in May 2008. The water system was tested in January 2008. The passenger lift was serviced March 2008. The home has a contract with the equipment supplier for the maintenance and servicing of lifting equipment. The home has appropriate Employers Liability Insurance. The manager said that all portable electrical appliances had been tested for safety by an appropriately qualified person within the last twelve months. Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 23 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 2 Standard OP2 OP7 Regulation 5 13(4) Timescale for action Standardise the contracts issued 28/02/09 to residents. Ensure that risk assessments contain sufficient information to minimise risks posed to residents. Demonstrate that there are enough staff on duty to meet residents’ needs at all times. 28/02/09 Requirement 3. OP27 18(1) 28/02/09 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 Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Lyle House DS0000062953.V373660.R01.S.doc Version 5.2 Page 25 - 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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