Inspection on 18/12/06 for Lincoln House

This inspection was carried out on 18th December 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 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

Lincoln House 28/10/08

Lincoln House 31/10/07

Lincoln House 05/04/06

Lincoln House 29/11/05

Lincoln House 23/06/05

Lincoln House 07/01/05

Lincoln House 23/06/04

Lincoln House 05/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Lincoln House Lincoln Close, Off Gillett Road Wood Green Banbury Oxfordshire OX16 0EF Lead Inspector Delia Styles Unannounced Inspection 18th December 2006 10:40 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 Lincoln House DS0000035671.V317413.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. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lincoln House Address Lincoln Close, Off Gillett Road Wood Green Banbury Oxfordshire OX16 0EF 01295 257471 01295 266285 manager.lincolnhouse@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust 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) Sally Lyons Care Home 44 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (44), of places Physical disability over 65 years of age (6) Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of persons that may be accommodated at any one time must not exceed 44 As vacancies arise the numbers in the PDE categories will be reduced to 3. The continued registration of this service past April 2007 is dependent upon the physical environment meeting standards. Admittance of one named under age resident effective from 3rd April 2006 5th April 2006 Date of last inspection Brief Description of the Service: Lincoln House is one of a number of care homes run by The Orders of St John Care Trust and provides care and accommodation for older people who may be suffering some dementia related illness, and/or physical disability. The home is situated about a mile from Banbury town centre. It is set in its own grounds and is close to several local shops and amenities. It has four semi-contained care units that comprise bedrooms, lounge/dining rooms and bath and shower facilities. Each lounge/dining room has a kitchenette for the preparation of drinks and snacks. There is a spacious Club Room that provides an area for activities and entertainment for residents. There are 38 single bedrooms and 3 double rooms. Local psychiatric services are available for guidance on treatment of residents and support for staff. There are plans to rebuild the home in order to bring the building up to current spatial requirements - 22 of the current bedrooms are under 10.0 square metres in size and so are below the size needed for residents who need more assistance. It is hoped that a site close to the centre of Banbury will be found for the new purpose-built home. Current fees for the home range from £484 to £580 per week. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. This was the second unannounced inspection of this home undertaken within the last 12 months. The purpose was to re-assess all the standards considered by the Commission to be most important for Care Homes for Older People because there had been specific weaknesses found at the last inspection of the home undertaken in April 2006. Areas where the Commission had found the home needed to improve related to some aspects of the management; the way in which residents medicines were accounted for; lack of risk assessments (for example, where residents’ health and welfare might be compromised); planning and recording and reviewing of residents’ care; a limited range of activities; and failure by the home to act upon some requirements made by inspectors at previous inspections. The inspector arrived at 10.40 am and was in the service for 5½ hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of several residents who live here and staff seen during the inspection. A tour of the building was undertaken and samples of residents’ care plans, medicine records, staff records and other documents, such as maintenance records and the homes policies, were looked at. The inspector would like to thank the residents, manager and staff members for their welcome and help during the inspection, especially as this visit took place during the busy time just before Christmas. What the service does well: The home is warm, welcoming, clean and homely. Staff work well together as a team and are knowledgeable about the individual needs of the residents. This makes for a relaxed and friendly atmosphere because staff and residents have a good relationship. The home owner (The Orders of St John Care Trust - OSJCT) make sure that the home environment is kept well decorated and maintained for residents, while still in the planning process to build a new home to replace Lincoln House because it does not meet the current standards in terms of room sizes and facilities for older people. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 6 The OSJCT are committed to the development of the training programme for all staff and have links with local training colleges and distance learning schemes to give staff a range of opportunities for training and development that fit in with their work and home commitments. What has improved since the last inspection? What they could do better: The written assessment information for new residents should be more detailed especially about residents’ social and recreational needs, so that care staff can develop the residents’ care plans more effectively. Residents’ care plans should show whether the care they have received has met their assessed needs (that is, there should be regular written evaluation of care) and if not, the care plans should be altered in line with any changes that are necessary. Overall the records of residents’ medication are good, but some charts had handwritten changes made by staff (where the doctor had ordered a new Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 7 medication or an alteration to the dose or frequency of a prescribed medicine) and the alteration had not been countersigned by a second staff member. It is recommended, and good practice, that handwritten amendments should be checked and signed by the doctor on the Medication Administration Record (MAR) chart as soon as possible, or the care staff member who has taken the instruction to alter the MAR, should have a second suitably qualified staff member check and counter-sign the entry. This is an additional precaution so that the risk of residents receiving the wrong medicine or dosage is reduced. The inspector noticed that senior care staff had the keys to the medicine store cupboards and trolleys on the same key ring as keys to other storage areas in the home. Medicine keys should be kept separate from other keys, to reduce the risk of unauthorised people having access to medicines. Staff acted promptly on the inspector’s recommendation and separated the keys before the end of the inspection. The sample of staff files looked at are well set out and show that the required checks are made by the home to minimise the risk of employing unsuitable staff in the home. However, managers and other senior staff involved in the interviewing of new staff should ensure that records are fully completed, for example, that any gaps in employment histories are fully explored and evidenced and that the records are signed and dated. The doors to the activities lounge and two ground floor offices were wedged open. Fire doors should not be propped or wedged open as they will not form a barrier to slow the spread of smoke or flames in the event of a fire, and this will put residents and staff at increased risk of injury or death. The fire officer must be consulted about the fire safety precautions in the home especially in relation to containing fires. 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. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 8 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 Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 9 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): 1 and 3. Standard 6 does not apply, as the home does not provide intensive rehabilitative care. Quality in this outcome area is adequate. Prospective residents are provided with sufficient information about the home in order to make an informed decision about whether the home is likely to be right for them. The personalised needs assessment means that people’s needs are identified and planned for before they move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home is contained in a folder that contains a summary of the Statement of Purpose and Service Users Guide and a colour leaflet/brochure about the home. These documents are informative, written in plain English and easy to understand. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 10 The OSJCT produces a colour printed quarterly magazine ‘Trust in Care’ that contains interesting features about OSJCT care homes, staff and residents’ news and events in the four counties where the organisation operates. Copies of the winter edition were available for residents, staff and visitors to read All prospective residents undergo an assessment of their care needs and are given the opportunity to spend a day, or part of the day, at the home to meet with residents and staff, to help them make an informed choice about whether the home is likely to suit them when choosing where to live. One resident confirmed that this had been the case and that s/he had wanted to move nearer to Banbury so that family and friends could visit more easily. The home manager undertakes assessments with the individual and/or their representative. The inspector looked at the care assessments for a sample of 3 residents. Other social and health care professionals’ assessment information is also taken into account, though the written assessment details seen by the inspector in the homes commercially produced care plan system were brief; for example, there was little information about prospective residents’ social and recreational preferences and needs. Residents’ care plans are based on the initial assessment and developed more fully over time. It is important that key care staff have access to all the information available, so that the care plans can be as accurate and detailed as possible and so that carers have enough information about the resident’s needs and how these should be met. There was evidence that residents and/or their representative are invited to read, agree and sign the initial assessment form. This was a requirement made at the last inspection and has been addressed by the home. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 11 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 adequate. The standard of care planning show marked improvement since the last inspection and residents’ records were generally complete, as is the case with the standard of medication record keeping. Further improvement is needed to show that the planning and delivery of care for all residents is sufficiently detailed to evidence that residents’ health, social and personal care needs are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector looked at a sample of 3 residents’ care plans and records. The care plans are much improved, with evidence that care staff refer to the care plans when writing their daily report. The inspector considers that there should be more written evaluation of the care – that is, has the care met the assessed needs of the residents, and if not, what changes have been agreed and written into the care plans? For example, a resident told the inspector that s/he had not walked or exercised, as they should according to their care plan. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 12 The resident was not confident of the staffs’ ability to assist him or her correctly. Staff told the inspector that the resident often refused their assistance to walk with the prescribed walking aid, but this was not documented. Care plans focus on the physical care needs of residents, with very little information about their emotional and social care needs. Many of the residents have short-term memory problems or dementia, and their care plans in particular should demonstrate that staff have enough information about the kind of care interventions and activities that will help residents’ well being, when they are not able to express their own needs. Risk assessments were generally complete in the care plans seen, although the home does not fully complete the nutritional assessment information for each resident on admission or routinely thereafter. Residents are regularly weighed, but there are other factors other than weight gain or loss that may indicate if a resident is ‘at risk’ of malnutrition. The inspector has been informed that the OSJCT is working on developing a comprehensive nutritional assessment and monitoring tool for use in all its homes. One resident whose care plan indicated that they were ‘at risk’ of poor nutrition, had no evaluation of their dietary intake, though staff said that this was much improved since the resident’s admission. The home has good support from local GPs and NHS community and mental health nurses. Residents assessed as being at risk from falls, are now referred to the NHS Falls Service for a complete review of their care so that any particular risk factors, such as a change in medication, or visual and balance problems, can be identified and treated if possible. The inspector examined the home’s system for receipt, storage, recording, administration and disposal of residents’ medication in the home. This aspect of care has markedly improved since the last inspection. The manager and a senior care leader have totally reviewed the medication system in the home. The inspector found that the medication storage room was well organised and that the records for the receipt and disposal of unwanted medications were correct. The sample of Residents’ Medication Administration Record (MAR) charts seen by the inspector was up to date and complete. There were some handwritten entries made by the homes staff, where a doctor had given a verbal order to alter or add prescribed medications for residents. The hand written entries were not checked and countersigned by the GP or a second staff member, which is recommended best practice, to reduce the risk of staff making an error when amending the charts. It is recommended that this best practice guidance is followed. The home now undertakes monthly audits of medication in the home and the supplying pharmacy (a large national company) also undertakes regular checks in the home. The manager said that a 12- week distance learning course in Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 13 medications had been booked with a local college for all care staff who are responsible for administering medications. The inspector noted that the keys for the medication storage areas are held on the same key ring as other storage cupboards. The keys for the medicine area should not be part of the master system of the home because access to medicines should be restricted to authorised members of staff only, and there may be occasions when other staff may need to ‘borrow’ the keys to other locked storage areas in the home. Staff acted promptly in response to the inspector’s recommendation and separated the keys for the medicines from others during the inspection. There is more cultural and racial diversity amongst staff members than the current resident group in the home, but the inspector considers, on the basis of the discussions with residents, staff and the manager, that this home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The home’s staff training programme includes sessions on equality and diversity. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 14 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, 14 and 15 Quality in this outcome area is adequate. The range of activities within the home and community has improved since the last inspection and give more residents the opportunities to take part in activities that suit their individual needs. The home supports residents to maintain contact with their family and friends and the local community and they are able to exercise choice about how they spend their day. Meals and mealtimes are an enjoyable and social time for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that a new part-time activities organiser has been appointed to the home. Since the last inspection, care staff organise some activities for residents in the evenings. Staff will now have training in activities and care arranged through a local college, as part of their mandatory training. A programme of activities was on display in the ground floor reception and in each unit. A group of residents were enjoying word games organised by the activities organiser in the ground floor lounge during the morning and a conjuror visited to entertain in the afternoon. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 15 One resident who spoke with the inspector said they did not feel the activities offered by the home suited their particular interests and ability. The manager said that she will discuss with the resident and activities worker the kinds of activities and hobbies s/he would like to do and as far as possible, provide the resources and opportunities for these to be available. Residents spoken with said that they could choose how they spent their day and could opt to spend time in their own room or with other residents as they wish. The home was attractively decorated ready for Christmas, and residents had helped choose the decorations. Additional Christmas entertainments were planned, with local singers and schoolchildren visiting to sing carols. The inspector joined residents in one unit dining room for lunch and talked with 3 residents and a care leader about life at the home. Residents agreed that the food was usually very good and they enjoyed the choice and quality of meals. The home completes regular spot resident satisfaction questionnaires with residents as part of the quality monitoring of food and mealtimes. The lunchtime meal choices looked and smelled appetising. The staff did not know one resident’s dislike of one type of vegetable, but this was rectified with the cook, who visited the unit to check residents’ satisfaction with the meal. Each unit has its own kitchenette and dining area, so that residents can meet together and enjoy meals close to their rooms (or in their own rooms if they prefer). The menu choices for the day were displayed in the dining rooms. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 16 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 adequate. Residents feel safe and listened to in this home and the home’s complaints procedures are available and understood. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is included in each resident’s agreement and publicised on the home’s notice boards. Residents spoken with were confident about whom to speak to if they had a concern and said this would be either the manager or care leader. One complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The homes own record of complaints showed that this had been investigated and dealt with appropriately by the home and to the satisfaction of the complainant as far as possible. Adult safeguarding matters – how to recognise and report suspected adult abuse – are included in the induction training for all new staff and regularly thereafter. All new staff receive the General Social Care Council code of conduct for employees and employers as part of their induction information. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 17 An independent advocacy service is available for residents to access if the need arises. Residents have information about how to access an advocate, or staff can assist them to do this. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is adequate There is a programme of redecoration and routine maintenance so that the residents have a comfortable, homely and safe environment in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector walked around the home and found it to be clean, warm and homely, with no unpleasant odours. A programme of redecoration is continuing, and the new wall colours have made the home lighter and brighter according to staff (the inspector has not visited this home before). The main corridor and one lounge and kitchens have been redecorated since the last inspection, The manager said that some old and worn furniture is to be replaced by newer items from two other OSJCT homes that have closed (residents have moved into the new purpose-built Isis Care and Retirement Centre in Oxford). Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 19 Residents are encouraged to bring their own small items of furniture and memorabilia to personalise their rooms and this was evident to the inspector when touring the home. The manager said that there has been no further development in the plans for Lincoln House to be rebuilt in Banbury. Many of the rooms in the home are below the newer minimum room size standards for care homes for older people. There are 38 single rooms and 3 double rooms none of which have en-suite facilities but all have a washbasin. This does limit the way in which furniture can be arranged in residents’ rooms, and the space for the use and storage of residents’ mobility aids if needed. Residents spoken with were happy with their rooms. One resident, who spends much of their day in a wheelchair, is accommodated in a first floor room that is under the recommended minimum size of 12 sq.m. of useable floor space. However, the resident is able to manoeuvre him/herself around the home and use the lift to access the ground floor and gardens. The bathrooms have added domestic touches – pictures and ornaments – to make them look less clinical. Liquid soap and paper towels were noted to be available in communal areas, as recommended at the last inspection to improve the infection control for residents and staff in the home. The inspector checked the hot water temperature at bath outlets and found them to be within the ‘safe’ range of close to 43°C. Routine hot water temperature checks are undertaken by the maintenance man. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 20 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 adequate. The provider organisation and home manager are committed to improving the training available for staff and this capacity to improve should result in better outcomes for residents. The homes recruitment policies and procedures around recruitment and selection of staff are in line with equal opportunities and are non-discriminatory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were sufficient staff to meet residents’ overall needs. A staff member on one of the units confirmed that in their opinion staffing levels were satisfactory and that they appreciated the training provided by the home (although fitting in training commitments with residents’ care did add to their workload). The inspector sampled the recruitment and training records for 3 recently employed staff and found that the recruitment procedures were generally good, with evidence that there are the required checks in place to protect residents by screening out any potential employees who are unsuitable to work with vulnerable older people. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 21 However, one person’s file showed that a former employer’s reference was not positive but there was no written evidence in the file to indicate that the home’s managers had followed up the reasons for this, and/or the justification for employing the person, despite one apparently poor reference. Another employee’s file showed a past police caution; again, there was no written evidence that this had been noted by the managers and that the home was satisfied that, through employing this person, the level of risk to residents is considered minimal. The inspector recommends that the staff files are fully completed, and interview schedules are signed by the persons accountable for recommending people for employment in the home. This will demonstrate that the employer has made informed choices about whether individuals whose references or police disclosure records give information that may be relevant to the applicants’ suitability to work with vulnerable adults. All new care staff undergo a period of induction training and ‘shadow’ experienced senior carers to make sure that they have the skills and competence to provide safe care to residents. The induction records for the 3 staff whose records were looked at by the inspector were complete. Two of the three had not had their first formal supervision meeting because they were only recently appointed. All staff now have regular supervision during which they are able to discuss their progress in their work and any training needs that they may have. The manager explained that an additional new system of training using a computer programme is being introduced in January 2007. The training programme covers a number of the required induction topics that are to be completed by new care staff over a 6-week period. Care staff undertake this at work, with the manager and senior staff support. Each module of the Etraining has to be passed before the carer can proceed to the next, so that staff can learn at their own pace and ability. The proportion of care staff that have achieved National Vocational Qualification (NVQ) at Level 2 or above, has increased since the last inspection though remains below the 50 that was the minimum percentage target to have been achieved by 2005. The manager confirmed that approximately 25 of staff currently have NVQ Level 2; 4 staff have almost completed their course and a further 4 staff have enrolled to undertake Level 2 training. Two care leaders have also enrolled for NVQ Level 3 courses. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 22 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 adequate The management of the home meets the needs of the service in the home. Excellent financial systems are in place within the home, safeguarding residents from financial exploitation. The home monitors matters affecting the health, safety and welfare of residents and action is taken to address any problems that may compromise residents’ safety and wellbeing. This judgement has been made using available evidence including a visit to this service. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager for this home, Ms Sally Lyons, took over management of the home in October 2006, when a trainee manager stepped down to return to her previous role as head of care. She has been the registered manager for an OSJCT home in Oxfordshire and had been transferred to Lincoln House after being acting manager in another OSJCT home for approximately one year. She has extensive experience in managing residential homes and care of older people. A formal application process for Ms Lyons to become the registered manager for Lincoln House has yet to be completed The home has had a period without a registered manager in post and this had meant that management and leadership in the home had been inconsistent. The inspector noted that there was a good relationship between residents, staff and the manager and that Ms Lyons and the staff team have worked hard to successfully address the shortfalls found be inspectors at previous inspections. At the last inspection, the home had failed to notify the Commission for Social Care Inspection under Regulation 37 of incidents affecting the welfare of residents. The number of notification reports received by the Commission and those sent by the home (there were copies available in the home) still did not tally and the inspector concluded there has been problem with destination of the faxed information (the home’s practice has been to fax Regulation 37 notifications to the Commission and copy these to the OSJCT County Head office in Oxford). The manager agreed to send copies of recent Regulation 37 notifications by post retrospectively and to ensure that copies are posted in future in order to meet this requirement of the Care Homes Regulations 2001. Regular residents meetings are held, that keep residents and their families informed about any developments and allow for residents to discuss any concerns and suggestions. The meetings are minuted and distributed around the home for residents, visitors and staff to read. The inspector met with the administrator for the home and discussed the management of the residents’ finances. The records and receipts for a sample of residents was seen and provided a clear account of any transactions or purchases made on their behalf – in cases where residents do not wish to, or are unable to manage their own finances independently, or do not have a relative to do this. The OSJCT has a quality monitoring programme in place and send questionnaires to residents and their relatives regularly: managers then analyse the responses and respond to any individual concerns as they arise. The manager confirmed that a senior manager for OSJCT regularly undertakes the required (Regulation 26) unannounced ‘provider visits’ to the home to talk Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 24 with residents, staff and the manager to check that the home continues to meet the Commission’s and OSJCT organisational standards. There was no written report available in the home for the most recent visits undertaken, but the manager confirmed with the inspector that she had since received copies of the reports after Christmas. The inspector spot checked the accident records for residents and the fire safety log and found these to be complete and up to date, with one exception an accident report that not been completed for an incident that had occurred the previous evening. The member of staff who had witnessed the incident had contacted the home manager when s/he realised their omission and said they would be rectify this when they came to work that night. A report of the accident had been made in the resident’s care record at the time. The inspector observed that three room doors were wedged open – the manager and administrator’s offices and the activities lounge. Room doors should not be wedged open because, in the event of a fire in the home, the open doors would not provide the intended barrier to smoke and flames spread. Residents, staff and visitors are put at unnecessary risk. The fire officer must be consulted fire safety precautions in the home so that where, for example, closed fire doors impede residents’ ability to move around the home and access all the rooms easily, approved automatic door closer devices may be fitted. The manager confirmed that she was already in the process of consulting with the fire officer about fire precautions and signage in the home and would ensure that the appropriate action is taken in line with their advice. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 25 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 3 X 2 X X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 26 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 OP38 Regulation 13 Requirement The home must contact the fire officer and seek advice and take appropriate action about the fire protection measures in the home, particularly in relation to fire doors and automatic door closers. Timescale for action 10/02/07 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 OP7 Good Practice Recommendations * Improve the detail of assessment information accessible to staff, so that there is sufficient written detail upon which care staff can base their initial care plans and carry out care that best meets the assessed individual’s needs. * Improve the written evaluation in care records, to demonstrate to what extent residents’ assessed care needs are met in the home. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 27 2. OP9 3. OP29 * Implement an evidence-based nutritional assessment tool so that residents’ nutritional status is accurately assessed on admission to the home and regularly thereafter, linked with effective care plans and evaluation for those residents who are at risk of malnutrition. Where the home’s care staff make handwritten amendments to residents’ Medication Administration Records (MAR) good practice recommendation should be followed. Ideally, the GP should sign and check the MAR sheet in person at the time or shortly after amending the prescription order. If not, a second staff member should check and countersign the first carer’s entry. The managers and staff accountable for completing the recruitment and vetting processes should sign the recruitment checks and interview schedules for prospective new employees or people in regular contact with vulnerable adults in the home. The records should evidence informed decision making on the part of the employer where references or other checks indicate a potential risk to vulnerable adults. Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Lincoln House DS0000035671.V317413.R01.S.doc Version 5.2 Page 29 - 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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