Inspection on 24/10/07 for Lyles House Residential Home

This is the latest available inspection report for this service, carried out on 24th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

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

CARE HOMES FOR OLDER PEOPLE Lyles House Residential Home 7 The Street Hindolveston Dereham Norfolk NR20 5AS Lead Inspector Ruth Hannent Unannounced Inspection 24th October 2007 09:45 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 Lyles House Residential Home DS0000069806.V353636.R02.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. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyles House Residential Home Address 7 The Street Hindolveston Dereham Norfolk NR20 5AS 01263 861812 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) hina.patel107@btinternet.com Miss Hina Patel vacant post Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category or 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. Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 20 First inspection with the new provider. The last inspection with the old provider was 29/11/06. Date of last inspection Brief Description of the Service: Lyles House is registered as a residential care home for up to twenty older people and is sited in the village of Hindolveston near the market town of Fakenham. It is a two-storey, purpose built home that has the majority of the twenty, single bedrooms on the ground floor. There is two chair lifts to assist service users to the first floor. The home has some bedrooms that benefit from ensuite facilities including shower facilities in some cases. There are assisted bathing facilities on the ground and first floors and additional toilet facilities on the ground floor. Service users have the use of a large communal lounge, small quiet sitting room and two dining areas. There is a garden with patio area and off road parking to the rear of the building. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been completed following a visit to the home and all key standards within the Care Homes Regulations were inspected. This is the first inspection for the new provider who purchased the home in the summer of this year. The inspection took place with the new owner over a period of five and a half hours. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) had been completed by the new owner and forwarded to the Commission to use as evidence in the writing of this report. As the owner has only a few months of experience in this home the AQAA could only reflect on the last few months. The detail written showed lots of areas of improvement already achieved and this was also seen on the day of the visit. A tour of the building took place and records were see that included care plans, risk assessment, new policies and procedures, new statement of purpose and service users guide, training records, personnel files, maintenance programmes, rotas and menus. Out of the 19 residents in the home on the day 5 were spoken to in some detail. 2 visitors and 2 staff were spoken to and some conversation was held with a visiting nurse. Unfortunately comment cards from relatives were delayed and will not be used in this report but will be received at the office and addressed if required. What the service does well: The change to a new owner has been as smooth as it possibly could be with information sharing, meetings and social events taking place to help the residents and families with any anxieties they may have had. The home is inviting with staff greeting any visitors warmly. Rooms are personalised and comfortable with most rooms larger than required allowing small pieces of furniture that are special to the individual to be brought in. Residents are treated as individuals and are assisted to live the way they would wish. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 6 The staff work hard to keep the home clean and tidy with good cleaning schedules in place to ensure the standards are maintained. 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. Lyles House Residential Home DS0000069806.V353636.R02.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 Lyles House Residential Home DS0000069806.V353636.R02.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): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The owner will assess and ensure the service can meet a persons needs before admitting them to Lyles House. EVIDENCE: The new owner has worked hard over the few months she has been responsible. Already in place is a very comprehensive service users guide and statement of purpose that gives all the details of the service including a breakdown of what the fees are used for and what is not covered by the charges. These details are in a presentable plastic folder that is about to be placed in residents rooms (10 have been done to date). The residents have a contract listing their charges and each one has been signed by the resident. The most recent people admitted contracts were seen. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 9 On talking to the Owner each potential resident is visited and details were seen on the admissions form giving information that would enable a decision to be made of the suitability of this service for the individual. The file also contained a four weekly review that showed comprehensive information on how the person had settled and how the care plan had been developing over the previous four-week period. One resident spoken to who had lived in the home for only a few months felt the home understood his needs and although he hated leaving his home felt this place was suitable and that his care needs were met. ‘I have been anxious for many years and the home understand and try and help me’. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans do give the details of care required but improvement in the medication procedures needs to take place to ensure administration is carried out safely. EVIDENCE: The home now has new care plan folders for each resident with clear details of the personal care, health and social needs. The AQAA received also gave all the examples of the forms now in place in each person’s folder. Each one has risk assessments that are relevant to the individuals such as moving and handling or the risk of falls. Three were looked at in detail. Relevant information was seen such as the resident who has to have his door open at all times and the risk assessment for the falls that have happened in the past. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 11 The home has a close working relationship with health professionals. On the day of the inspection one nurse was assisting with one resident and another nurse arrived to give all the flu inoculations to all residents. The GP came to see a resident and left the details with the owner of the treatment required. This is logged in the care plan, on the page designated for all heath care visits that was seen during this visit in three folders. The owner also talked of the great support that is offered by the continence advisor who calls and supports any resident who may require the service. The medication within the home is carried around in a large locked box that is not ideal but the home is waiting for the delivery of a medication trolley. The home has just moved to a blister pack system with the pharmacist support and a few teething problems were noted. One person had not had one medication for three days as the tablets were not in the pack. The pharmacist had been made aware but nothing had been delivered to date. It was also noted that some gaps of staff members signatures were missing on the chart, some medication had been signed for a day ahead of the date and a concern over the administration of one persons warfarin was discussed as the instructions on the chart were confusing and the signatures of the staff did not correspond with the instructions. (Requirement) The creams and eye drops are signed for and used in the residents bedrooms by the staff but these charts are stuck to the wall and available for anyone to see when visiting the room. Risk assessments should be in place for medication held in the bedrooms and the documentation placed away from visitors and not on display. (Recommendation) Throughout the day staff spoke to and assisted residents in an appropriate manner. Residents were all looking very tidy and had recently had their hair done. Unfortunately the village was without electricity for a few hours in the afternoon and some toilets had no natural light so staff were discretely helping residents within these rooms until the power was restored. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily life and social activities for individuals is good but there is room for improvement to ensure the person centred approach cares for aspects of need. EVIDENCE: The owner is aiming to ensure that each resident has some form of occupation/stimulation whether that person prefers to stay in her bedroom or sit in the lounge. Group trips are organised, but most activities take place on a more spontaneous basis to meet individual or group wishes expressed at the time. Although some history information is written on the care plans to guide staff of what a person may enjoy there is little written evidence that this happens and not much in the way of individual recording. (Recommendation) Group events are enjoyed and a recent 100th birthday party was obviously enjoyed by many as this event was logged. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 13 Throughout the day visitors were coming and going with each one being received warmly and offered up to date information about their loved one on asking. Sadly one resident had just past away and the family were treated appropriately and respectfully by all staff. The visitors book is a diary that shows many visitors come and go at different times of the day. The home has areas where people can sit in private if they so wish. Meals are served wherever the person would like to sit. The menu’s were seen that showed 2 weeks meals are rotated but sometimes the choice varies. On the day of the inspection there was sausage pie or vegetable burger with potato or chips and garden peas. One or two comments were negative about the food being cold or not cooked properly but the majority of people were very happy with their meals. ‘I eat much better here than I did at home’ and ‘I can have a choice if I want but I like nearly everything that is offered’. (Noted was all the monthly weight charts with resident’s recordings either stable or slightly increased). Fresh fruit is now in a bowl in the lounge and chocolate treats are often placed in the rooms. One resident was having meals liquidized and it was noted that all the food was in a bowl together. This should be separate to offer colour and flavour individually. (Recommendation) Lyles House Residential Home DS0000069806.V353636.R02.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): 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 will be listed to and acted upon. Procedures are in place to safeguard vulnerable residents. EVIDENCE: The home and Commission have not received any complaints and any concerns have been acted on immediately as stated in the AQAA and repeated by the Owner on the day of the inspection. The complaints procedure is available in the service users guide and also posted around the home in easy to read terminology and in suitable print. On talking to two residents both said they are happy to talk to the Owner if they are unhappy about anything. The Owner has half the staff already through the safeguarding adults training with the other half booked for next month (dates seen). The policies for the home have all recently been reviewed and updated that include the whistle blowing policy. The Owner has recently had to hold one to one sessions with a staff member who was not speaking correctly to a residents and this is recorded in the personnel files. All staff are CRB checked before commencing employment and two references are obtained to ensure suitability. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is well maintained, safe and suitable for the 20 residents who live there. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 16 EVIDENCE: The Owner has only taken over the business a few months ago and already areas of improvement are taking place. Some windows have been replaced and a new conservatory is part built. The gardens have been improved with a large patio area and handrails leading to the back patio are in place for residents to enjoy the garden. The fire officer has visited the home and a company called Security Solutions has completed a check on all fire equipment in the home. (seen) The fire alarm testing is recorded and on a chart on the wall in the office with the last date of testing being the 17/10/07. The fie extinguishers were all dated as service in July 2007. The owner has created a full programme of maintenance checks that are carried out monthly and actioned immediately if a fault occurs. This format list was shown on the computer with the last check not available on the day of the inspection as it is being worked on at the Owner’s own home. A tour of the building took place with some bedrooms and all other rooms seen. Each resident has a personalised, individual room that suits their needs. Each one spoken to was happy with their room and felt warm and comfortable. Water taps were tried in three rooms and each one was of a suitable temperature. The bathrooms have thermometers and all bath are tested and recorded before someone takes a bath. Noted were some carpets in individual rooms that were beginning to ripple and look worn and need to be considered shortly for replacement. Some of the corridors have some very dark areas with no windows and the light fitting on the walls are not bright making some areas risky when moving about the home. (Recommendation) The Owner has written a cleaning schedule for the home and on this visit everywhere was clean and no unpleasant odours were detected. The laundry has two washing machines that have a hot wash cycle to manage the washing that is carried out in the home and two washing lines for drying outside when able or tumble dryers inside when not. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the staffing at Lyles House are suitable, trained and of satisfactory numbers to care for the residents appropriately. EVIDENCE: The Owner has mentioned in the AQAA and spoken to the Inspector prior to the inspection on the concern of the staff turnover. With the new Owner taking over in the last few months a number of staff have either been unsuitable or left of their own accord. The Owner has now placed an advertisement in the local paper (seen) for more staff. The staff who remain are dedicated and have helped out greatly when needing to cover the rota. On the day of the inspection 19 residents were in situ with two care staff and the owner assisting residents. Also on duty was a cleaner and a cook. Each Thursday there are two cleaners for the heavier cleaning tasks to be done. Residents appeared cared for appropriately but if the needs grow of the 19 people more care staff may be required. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 18 The Owner is aiming to have all staff trained in NVQ and has made a big effort to get staff qualified. Due to the staff turnover this has not been achievable as yet but in ‘Plans for the next twelve months’ as stated in the AQAA more staff will be employed and placed on the training. The procedures to recruit staff safely and appropriately are in place. 2 personnel files were seen of staff recently recruited and all relevant paperwork was in place. The Owner has just signed up with a company who understand all about employment laws and a new contract has been designed to ensure all staff are contracted safely and correctly. This has still to be tweaked slightly and then issued (seen). Training records are held for each person in their personnel folder. There is a training matrix on the computer that was seen with dates planned for statutory courses. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is carried out well with suitable leadership skills evident. The aim is to improve and deliver a safe and quality service to all residents. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 20 EVIDENCE: The Owner has completed the AQAA, although it did take a little longer than expected as taking over the home only a few months ago created more work than expected. The ethos that the Owner shows is suitable with good leadership skills demonstrated. Already the improvements in documentation and policies and procedures show dedication and determination to provide a good service. The owner is currently undertaking the Registered Managers Award will in due course be applying to the Commission to become the Registered Manager. The AQAA talks of a full quality survey that will be carried out before the end of the year with the results, action and monitoring of the outcomes to be sent to the Commission when completed. Already the start of a meals provision quality check has started with the Manager spending one to one time with residents explaining the process (seen). A good example of how concerns over a resident’s money was discussed in full and how the Owner had identified a risk. A procedure was then formulated to help manage a resident’s money along with a solicitor. All the details were written in a letter and signed by all parties. Staff members were able to help this person maintain his independence by assisting with the money management. All receipts of all transactions are in place. As mentioned in the staff training section the home now has plans and a matrix in place to ensure all staff receive suitable and timely training in all statutory health and safety areas. The safety data sheets (COSHH) for all cleaning chemicals held in the building are all in a folder and easily accessed by all staff (seen). This was a requirement on the last inspection. Accident forms were seen and how the Owner monitors them. Recently two falls were experienced by one resident (seen) so the GP was asked to check her blood pressure and medication to check for any medical reason that could have attributed to the falls. The Commission had not received any notifications since the new Owner had taken over the home as no deaths or incidents had occurred. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 21 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 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 3 x 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 x 3 x 3 x x 3 Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13.2 Requirement The administration and recording of medication must be correct to ensure safe management of medication is in place at all times. Timescale for action 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The home should remove all paper notices on medication related subjects from residents bedroom walls and place the information more discretely in the room for staff to follow. Ways to stimulate and occupy residents should be in place to prevent people just sitting with nothing to do where this is not their preferred choice. Residents who require liquidised food should have the items placed separately on their plate. 2. OP12 3. OP15 Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 23 4. OP19 Some of the corridors have dark areas with poor electric lighting and these areas could be unsafe to people with failing sight. Thought needs to go in to how these areas could be improved. Lyles House Residential Home DS0000069806.V353636.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Lyles House Residential Home DS0000069806.V353636.R02.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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