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Inspection on 09/01/06 for 98 Beeches Road - Lyndel Homes

Also see our care home review for 98 Beeches Road - Lyndel Homes for more information

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has had a stable service users group for a long time with only 1 new admission in the last two years. A good variety of food is provided which was reported to be of a high standard. Good systems are also in place for the control and administration of medication.

What has improved since the last inspection?

Action was taken to meet some of the immediate repairs required such as repairing the glass in the front door and the broken slabs. Work is continuing to improve on the standard of care plans and implementation of a quality assurance system.

What the care home could do better:

Many requirements remain outstanding from previous inspections and improvements have been slow to take effect. A priority for the home is to undertake further refurbishment and replace damaged furniture. Staff recruitment and training procedures must be better organised and efforts must be made to involve service users in the running of the home and provide an increased range of opportunities to take part in activities.

CARE HOME ADULTS 18-65 98 Beeches Road - Lyndel Homes 98 Beeches Road West Bromwich West Midlands B70 6HJ Lead Inspector Mike Kirton Unannounced Inspection 9th January 2006 10:30 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 Adults 18-65. 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. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 98 Beeches Road - Lyndel Homes Address 98 Beeches Road West Bromwich West Midlands B70 6HJ 0121 580 0759 0121 515 2544 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) 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 - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two service users identified in the variation application dated 30 September 2005 may be accommodated at the home in the category MD(E). This will remain until such time that the identified service users placements are terminated at which time the category will revert to 9 service uers in the category MD only. 26th July 2005 Date of last inspection 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. 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 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 - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and included informal discussion with 7 service users, interviews with the registered manager/proprietor, deputy manager, and 2 staff members. Records relating to the health and safety of the home, administration of medication, 1 service users care plan, and the staff files were examined. A tour of the buildings also took place. 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 - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 26th July 2005. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 26th July 2005. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 12, 13, 14, 15, 16, 17 More emphasis must be given to promoting independence and encouraging individual’s skills and abilities. A greater range of activities also needs to be provided with less focus on staff routines. The condition of the dining room also needs improving. EVIDENCE: Service users are free to come and go from the home as they wish and can organise their own daily activities such as going shopping or visiting friends. Records were maintained to show that contact was maintained with relatives and daily reports demonstrated that they were able to choose how they planned their day for example getting up and going to bed. All those spoken to reported to be happy with how they spent their time. From observations made during this and previous inspections the majority of service users spend a large part of their day either in their room or watching TV in the main lounge. Minutes from residents meeting reported that more activities such as day trips out were wanted. It was also evident that some did want to be more involved in the running of the home such as undertaking housework tasks. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 10 The home does organise a weekly exercise group and walks were made to the local park, however these have stopped due to the bad weather. No one was reported to be involved in outside leisure, college, or day centres. All meals and drinks were prepared for them and there was no formal plan for activities that they could be or are undertaking. More consideration should also be given to how tasks are undertaken for example when everyone was sitting watching TV in the lounge a staff member started to vacuum. Set meals are provided throughout the day including toast or cereal for breakfast, a cooked dinner, sandwiches for tea, and toast for supper. Hot drinks were also served at set times in the dining room. Service users were seen to be asked what their preference for sandwiches were and all those spoken to said the enjoyed the standard and variety of meals. A record is made of all the food consumed by residents and their weight is monitored. The dining room, which is adjacent to the smoking room, was not maintained to a very good condition. The room was poorly decorated and chairs were dirty, broken and falling apart. The door to the smoking room was open and notices on the wall were old and discoloured. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20 The procedures for administration of medication were found to be good and ensured service users received the correct prescription. Whilst mental health needs were closely monitored improvements are required to ensure individuals physical health is maintained/improved. EVIDENCE: All service users at the home have a Care Programme Approach (CPA) care plan, which identifies who is their care-coordinator (usually someone from the mental health team i.e. Social Worker or CPN). Records examined demonstrated that outpatient appointments were attended and support was received as needed. All medical appointments are recorded in the homes diary to remind service users when to attend. On examination of individual files it was evident that referrals to the GP or specialist medical services were being made. Not all identified needs however were being followed up, including referrals to the district nurse, chiropodist, dentist, or audiologist. The medical records for the receipt and administration of medication were examined. The home keeps copies of all the prescriptions to check against the delivery from the pharmacist. No service users are self-medicating. There were no errors or gaps noted on the administration record. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 the following standard(s): The standard of information available to service users and visitors to the home must be improved to encourage feedback. The staff and manager are aware of their duties to protect service users from harm however current procedures must be obtained from Social Services and further training provided to all staff as required. EVIDENCE: The home has written a complaints procedure, which meet the required standards including the contact details for the Commission. This however must be displayed appropriately and the old documents removed from the notice board in the dining room. Further improvements could be made such as including introducing feedback forms and a post box to protect anonymity and displaying information on advocacy services. The home has a policy and procedure on adult abuse and whistle blowing. All staff have signed to say they have read and understood these and those interviewed were aware of their responsibilities to report any concerns to the manager. The acting manager also demonstrated during discussions that she would take appropriate and immediate action to protect service users from harm. A copy of the Sandwell Social Services adult protect procedures must be obtained. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 26th July 2005. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 There was insufficient evidence available to demonstrate that staff are appropriately recruited and trained to deliver a good service. EVIDENCE: Due to the limited time that the current manager/proprietor is able to spend at the home the acting manager is applying to the Commission for registration. In addition to their hours worked there is a senior and care worker on duty during the day and a waking and sleep in member of staff at night. Some of the staff at Beeches Road work at Lyndel Homes other establishments which are homes for older people. Not all the staff files for these members of staff were available for inspection. Others were incomplete, poorly structured, and it was not possible to judge whether the correct procedures for employment and induction had been followed. Similarly individual training plans have not yet been implemented following a requirement made on 31/08/04. There was evidence that staff have not received appropriate induction or training. A senior member of staff had not yet completed their NVQ in care and had not undertaken any formal training in the administration of medication. A follow up visit has been arranged for 4 weeks time at which time all the required information must be made available for inspection in a structured format that can be inspected. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41, 42 Good records are maintained to demonstrate that the required health and safety checks are being made. There is insufficient evidence to say that the quality of the service has improved. Some repairs have been undertaken however many outstanding requirements have not been met. EVIDENCE: Beeches Road is beginning the process of implementing a quality assurance system. Feedback is received from service users however this information along with the views of staff, visitors and other people who have contact with the home needs to be collated and an action plan implemented to improve on existing standards. Many documents including service users records are kept out in the main lounge. Action must be taken to improve record keeping and ensure all confidential information is kept securely. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 16 The fridge, freezer, cooked food, and water temperatures were being recorded and monitored. Servicing of the fire equipment, gas, electrics, and portable electrical appliances was been undertaken. A fire risk assessment was in place, and the alarms were tested every week. Fire evacuations/drills must be provided for all staff at least twice a year. 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 17 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 X 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 2 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 2 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X X X 2 X 2 2 X 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 18 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 YA1 Regulation 4, 5, 6 Requirement Timescale for action 01/04/06 2. YA6 12,14,15 3. YA9 17 Due to the age range of the service users the manager must continually review their needs to ensure they can be met within the current environment. The statement of purpose and service users guide must also be reviewed accordingly. 09/01/06 Care plans must be reviewed at least every 6 months and/or as needs change. Actions by staff should only be carried out if identified as a need. These are outstanding requirements from 31/08/04. The care plan must record how all identified needs are being met or reason why they cannot. Risk assessments must be 09/02/06 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. This is an outstanding DS0000004850.V277188.R01.S.doc Version 5.1 98 Beeches Road - Lyndel Homes Page 19 requirement from 27/07/05. 4. YA12 16 More information and/or opportunities must be made available for service users to become engaged in activities both inside and outside the home. 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. All service users must have a weekly plan showing their routines, activities, and responsibilities around the home. The home must ensure referrals for specialist health care needs are made i.e. chiropody and dentistry and that follow up appointments are recorded. The homes complaints procedure must be displayed and old copies removed from the notice board. A copy of the Sandwell Social Services adult protect procedures must be obtained. 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. Where the full range of furniture and fittings specified in the National Minimum standards for Adults is not present in the service users bedroom, the home must either provide the required items, or 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. DS0000004850.V277188.R01.S.doc 01/03/06 5. YA14 16 01/04/06 6. YA16 16 01/03/06 7. YA19 12, 13 01/02/06 8. 9. 10. YA22 YA23 YA24 22 13 23 01/02/06 01/02/06 01/02/06 11. YA26 23 01/02/06 98 Beeches Road - Lyndel Homes Version 5.1 Page 20 12. YA28 23 13. YA32 18,19 14. 15. YA33 YA34 18 18, 19 16. YA35 18,19 17. YA37 8,18 18. 19. YA37 YA37 8 8,9,10 20. YA39 24 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. 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 file must be organised and structured appropriately. All staff working at the home must have a file available for inspection containing all the information required under The Care Homes Regulations 2001 and subsequent amendments. Each staff member must have an accurate, individual training plan, with courses provided and updated as required. This is an outstanding requirement from 31/08/04. The manager to be qualified to level 4 NVQ in management and care. This is an outstanding requirement from 31/08/04. The acting manager must submit their application for registration to the Commission. The registered manager must spend sufficient time at the home in order to meet the required standards and comply with outstanding requirements. This is an outstanding requirement from 27/07/05. Develop and implement a quality assurance and monitoring system based on seeking the views of service users, family, friends, advocates and other DS0000004850.V277188.R01.S.doc 01/02/06 01/03/06 01/04/06 08/02/06 09/02/06 09/01/06 09/02/06 09/01/06 01/04/06 98 Beeches Road - Lyndel Homes Version 5.1 Page 21 stakeholders. 21. 22. YA41 YA42 12 12 All records must be kept secure. Fire evacuations/drills must be provided for all staff at least twice a year. 09/01/06 01/04/06 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 98 Beeches Road - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands 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 - Lyndel Homes DS0000004850.V277188.R01.S.doc Version 5.1 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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