Inspection on 26/07/05 for 98 Beeches Road - Lyndel Homes

This inspection was carried out on 26th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

98 Beeches Road - Lyndel Homes 12/02/08

98 Beeches Road - Lyndel Homes 21/09/06

98 Beeches Road - Lyndel Homes 09/01/06

98 Beeches Road - Lyndel Homes 07/02/05

98 Beeches Road - Lyndel Homes 31/08/04

98 Beeches Road - Lyndel Homes 18/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 98 Beeches Road Lyndel Homes 98 Beeches Road West Bromwich B70 6HJ Lead Inspector Mike Kirton Unannounced 26th July 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 98 Beeches Road, Lyndel Homes Address 98 Beeches Road, West Bromwich, West Midlands, B70 6HJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 580 0759 0121 515 2544 Mrs Delores Matadeen Mrs Delores Matadeen Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 7th February 2005 Brief Description of the Service: 98 Beeches Road is a residential home providing 24-hour care and support for 9 people experiencing mental ill health. The property is an extended 3 storey, mid-terrace, Edwardian building forming part of the Lyndel Care Homes Company. Situated in a residential area it is close to West Bromwich town centre and has good transport networks. The home aims to provide a relaxed homely atmosphere whilst encouraging service users to maintain their independence. On the ground floor there is one single bedroom, lounge, kitchen, shower room including a toilet and wash hand basin, two toilets, and a two-roomed conservatory used as a dining area and smoking area. Access from the conservatory leads to a secure paved area. On the first floor there is one double bedroom, three single bedrooms, one bathroom with bath, toilet, wash hand basin and the staff office. Finally on the second floor there is three single bedrooms, one shower room with toilet and wash hand basin. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours and included a tour of the buildings, and interviews with the registered manager/proprietor, deputy manager, 2 staff members, and a representative from Lyndel Homes. Additionally all 7 of the service users were met and spoken with informally and 3 individual files were examined. What the service does well: 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. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1&2 The current service user group has been settled for some time, however a decision must be made whether the home is able to meet their needs, as they get older. The structure of the building is not suitable for anyone with physical disabilities. EVIDENCE: There have been no admissions to the home for the last 18 months. Currently there is one vacancy, which they are trying to fill. The admission procedures do however comply with the minimum standards. The homes statement of purpose and service users guide along with a copy of the latest inspection report is left out in the main lounge. The needs of the service users must be re-assessed. One is already over the age of 65 and is outside the current registration requirements. Within the next 2 years half will be over 65 whilst the remaining will be in their 50’s. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9&10 Whilst the assessments and care plans were found to be very comprehensive and detailed there was a lot of duplication of information and they were difficult to follow and understand. Service users were not being assessed as individuals and their lifestyle and choices were being limited without prior agreement. EVIDENCE: Three individual service user files were examined. Each contained a copy of their Care Programme Approach (CPA) assessment and care plan. They also contained the following documentation: daily records, fortnightly key worker reviews, fluid and fluid intake charts, hygiene monitoring form, daily living tasks chart, activity diary, weight monitoring, smoking assessment record, medical monitoring sheet, hospital appointment record, care plan checklist, care plan, risk assessments, care plan action sheet, care plan monthly review sheet, care plan six monthly review record and family and friends record. There was also a homes diary book and cigarette handing in book. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 9 The majority of the above records were completed for all service users without their individual needs being taken into account. Nutritional risk assessments were not completed whilst all had their food and fluid intake recorded. These however were not an accurate record and often only mentioned a few cups of tea a day and the amount of food eaten was not mentioned. The cigarette monitoring book required several service users to hand in their packets before going to bed. No agreement to this was found in their care plan. Similarly a daily record described the request for a cup of tea being refused as they had recently had one. Drinks are offered at set times during the day and served in the dining room. Service users were called there from the lounge to have them. There was limited evidence available to suggest involvement in the running of the home or that they were encouraged to make their own decision. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. EVIDENCE: 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. EVIDENCE: 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. EVIDENCE: 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24&30 Whilst the majority of the home was found to be clean and tidy there were areas, which were very badly maintained. The environment was very poor with no action being taken to replace furniture or undertake essential repairs. EVIDENCE: A tour of the communal lounge, kitchen, conservatory, bathrooms, toilets and outside areas was carried out. Although the interior had been recently redecorated a lot of work is still required. The front paved area had a cracked slab and the front step was broken. A lead lined window above the front door was broken and held together by clear stick tape. The majority of lounge chairs were old and had cracked/broken arm rests. Similarly the dining room chairs had bolts missing, loose, or on the floor and several back supports were missing. Carpets around the home needed cleaning or replacing and the main first floor bathroom had a loose toilet seat and wet tissue paper thrown and stuck on the wall. Finally the paved rear courtyard had a broken patio chair and fence. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 14 All food was found to be stored correctly and temperature checks were being taken of all fridges, freezers, and cooked meats. The kitchen was clean however needed some repair work undertaken. The food storage area had food spillages left on the floor. The laundry was not fully inspected however it was noted to be left unlocked with the keys in the door allowing access to cleaning chemicals. There were also a lot of staff information displayed around the home and out of date information on notice boards. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The home is being run with insufficient management support and night staff on duty. Service users followed a set routine and little individual work was being undertaken. EVIDENCE: It was made a requirement at the last inspection for the duty rotas to be forwarded to the Commission due to concerns that there was insufficient staff on duty particularly with management support. These have not been sent as required. On the day of the inspection the manager was recorded as being on duty from 8AM till 5PM but was not on the premises. The night staff levels had also been reduced from 2 to 1 due to staff shortages. There is no domestic or cook employed and there was often just 2 staff on duty throughout the day. Service users records often recorded the same daily routines with little activity going on or being organised other than an exercise group on the weekend. No assessments or consultation had been made with the Commission regarding the reduction of staff hours. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37&41 The home is poorly managed and standards have been allowed to fall. Incidents are not being recorded correctly and previous requirements made have not been complied with. EVIDENCE: Over the last 6 month the registered manager has failed to comply with requirements made and has not spent sufficient time at the home to undertake the required duties and responsibilities. On this and previous inspection, follow up visits and phone calls made to the home she has not been present as stated on the duty rota. The accident book was inspection, which was implemented on 28/04/04 however no entries had been made. On examination of other records however there were found to have been incidents, which had occurred several times without being appropriately recorded. Similarly the Commission was not being informed as required under Regulation 37. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 17 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 98 Beeches Road Score x x x x Standard No 37 38 39 40 41 42 43 Score 1 x x x 1 x x E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 19 Yes 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 2 Regulation 14,15 Requirement The needs of the service users reaching or are over the age of 65 must be re-assessed. A variation request form with appropriate fees must be submitted to the Commission. Care plans must be reviewed at least every 6 months and updated as necessary. Actions must only be carried out if identified as a need. Both short and long term goals must be identified. These are outstanding requirements from 31/08/04. Risk assessments must be reviewed and updated. These must be used to plan Individual actions and interventions. This is an outstanding requirement from 07/02/05. Any restrictions on a service users daily life must be recorded in their care plan. Service users must have the option of a 7-day holiday as part of the basic contract price. This is an outstanding requirement from 07/02/05. Care plans must identify service Timescale for action 03/08/05 2. 6 12,14,15 01/09/05 3. 9 17 01/09/05 4. 14 16 01/12/05 5. 17 12,15 01/10/05 Page 20 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 6. 24 23 users who need assistance with preparing meals. Nutritional assessments will be carried out on all service users. These are outstanding requirement from 07/02/05. The home must put in place a planned maintenance and renewal programme for the fabric and decoration of the premises with records kept. This is an outstanding requirement from 31/08/04. The broken front window above the door must be repaired. Where the full range of furniture and fittings specified in the National Minimum standards for Older People is not present in the service users bedroom, the home must either provide the required items, document the service user was offered and did not wish to have certain items, or provide risk assessments if it is considered unsafe. This is an outstanding requirement from 31/08/04. The smoking area needs an extractor fan to reduce smoke levels. New chairs are required in the lounge and dining rooms. These are outstanding requirements from 31/08/04. The food storage area must be cleaned. Staff must receive training in mental health. This is an outstanding requirement from 31/08/04. There must be two staff on duty at the home at all times. Each staff member must have an accurate, individual training plan, with courses provided and updated as required. 27/07/05 7. 26 23 01/09/05 8. 28 23 01/10/05 9. 10. 30 32 16 18,19 27/07/05 01/10/05 11. 12. 33 35 18 18,19 26/07/05 01/04/05 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 21 13. 37 8,38 14. 37 8,18 15. 40 18 16. 17. 42 37 12,13 8,9,10 18. 41 17,37 This is an outstanding requirement from 31/08/04. The registered provider must submit staff rotas for the next four weeks detailing in advance what hours she will be working at the home as the manager. The proprietor must submit an application to vary the registration for service users over the age of 65. These are outstanding requirements from 07/02/05. The manager to be qualified to level 4 NVQ in management and care. This is an outstanding requirement from 31/08/04. The homes policies and procedures to be read and understood by all staff. This is an outstanding requirement from 31/08/04. Risk assessments must be carried out on staff in relation to lone working. The registered manager must spend sufficient time at the home in order to meet the required standards and comply with outstanding requirements. The accident book must be maintained. The Commissions must be informed of any notifiable events. 07/02/05 01/04/05 01/04/05 01/04/05 27/07/05 27/07/05 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. 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 22 Refer to Standard Good Practice Recommendations Commission for Social Care Inspection Mucklow Office Park West Point Halesowen B62 8DA National Enquiry Line: 0845 015 0120 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 98 Beeches Road E55 S4850 Unannounced 98 Beeches Road V238695 260705 Stage 4.doc Version 1.40 Page 23 - 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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