Inspection on 29/11/05 for Lincoln House

This inspection was carried out on 29th November 2005.

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 18/12/06

Lincoln House 05/04/06

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 Jane Handscombe Unannounced Inspection 29th November 2005 11:15 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.V264735.R02.S.doc Version 5.0 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.V264735.R02.S.doc Version 5.0 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 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) The Orders Of St John Care Trust 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.V264735.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. As vacancies arise the numbers in the PDE categories will be reduced to 3. The total number of persons that may be accommodated at any one time must not exceed 44 The continued registration of this service past April 2007 is dependent upon the physical environment meeting standards. 23rd June 2005 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. Local psychiatric services are available for guidance on treatment and support for staff. The home is due to be rebuilt in order to bring the building up to current spatial requirements and will remain close to the centre of Banbury. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 29th November 2005. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents in order to ascertain their views upon the care and the services they receive at the home, the staff members and the manager of the home, viewing care plans and assessments, whilst observing the general day to day operations of the home. The home presented as one, which was clean and tidy throughout. Residents were going about their daily activities in a calm relaxed manner. Staff were seen to provide care and support in an unhurried manner whilst respecting the residents’ dignity and respect at all times. Comments received from residents during the inspection included: ‘The staff are very good.’ ‘It’s a happy home.’ ‘the food is marvellous.’ ‘They are all very good and caring.’ And comments received from visitors during the inspection included: ‘They are all very pleasant, I come and visit and they make me ever so welcome.’ ‘I come over on a Sunday to have dinner with him.’ The inspector would like to thank the residents, their families and staff members for their assistance during this inspection. What the service does well: Staff were observed to work well as a team and were seen to be respectful and interacting with the residents in a manner that was thoughtful and considerate of their needs. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 6 Meals provided at the home are varied, well balanced, offer choice and are well presented. All residents spoken to were complimentary of the meals provided at the home. Regular meetings are held for residents in which they are able to openly discuss any concerns or complaints that they may have regarding the care and facilities provided at the home. These meetings also provide a way in which the residents are able to keep updated on any issues regarding the home and to put forward any thoughts and ideas that they may have. 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. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion, all key standards were assessed during the last inspection in June 2005. EVIDENCE: Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 All residents have a plan of care drawn up from an assessment of needs, although these are not always comprehensive. The care planning and review process is of a poor standard and needs to be addressed to ensure that residents’ needs are met in full. The inspector is of the opinion that there is little improvement since the previous inspection and this needs to be addressed immediately to ensure the health, welfare and safety of all those in their care. EVIDENCE: The inspector examined a sample of care plans and generally found them to be incomplete, risk assessments were not always being undertaken and the monthly reviewing of the risk assessments was being undertaken at inappropriate intervals, one resident’s not having been reviewed since March, some 8 months prior to the inspection. One resident’s file informed the inspector that their individualised care plan was drawn up from a poor assessment which failed to cover all areas as required by the national minimum standards, thus placing the resident at risk of his needs not being met fully. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 10 Evidence to show service user involvement in the care planning and assessment process, and their agreement to the care plan was not evident in three of the four files observed on the day of inspection and one resident’s file failed to contain their photograph. The inspector was informed that an advocate would be sought to aid those residents who have no family and are unable to sign these themselves. Requirements have been made to address these failings immediately, since these failings were highlighted in the previous inspection carried out in June 2005 and place the residents’ health, safety and welfare at risk. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The daily life and social activities provided at Lincoln House match the residents’ preferences and interests. Residents receive a wholesome nutritious diet, and every effort is made to ensure that meal times are a pleasurable experience. EVIDENCE: The home provides a daily programme of activities to suit the varying needs of the residents within the home which include, bingo, quizzes, handicrafts, music and movement, singalongs, skittles and darts. Besides a programme of daily activities, the home has been planning for the Christmas festivities. Dates have been arranged for a Christmas shopping trip, a raffle and bazaar and a Christmas party with an outside entertainer. Relatives and friends have been invited to join the residents for Christmas lunch if required. During the inspection, residents were taking lunch in a calm relaxed atmosphere and staff were observed to be at hand helping those who required help in an unhurried, discreet supportive manner. Residents were complimentary about the food offered at the home, one resident whilst speaking with the inspector mentioned that ‘the food is marvellous’. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 12 The inspector was informed that visitors are invited to join the residents for a meal if they wish and one visitor confirmed this stating ‘I come over on Sunday to have dinner with him.’ The home undertakes a monthly monitoring of meals and gains residents’ views and comments in order to ascertain their preferences and dislikes. Whilst the home displays a menu on a wipe board within the dining areas, it was noted that they were difficult to read and it is recommended within this report that they be written legibly in larger print. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The inspector did not make a judgement on the outcomes in this section as all the standards were assessed during the last inspection in June 2005. EVIDENCE: Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 24, 25 and 26 The home provides comfortable surroundings, which are equipped to meet the residents’ differing needs and presents as clean and tidy throughout. EVIDENCE: Lincoln House has been targeted by The Orders of St John Care Trust as a home in need of complete redevelopment. It is planned that the new home will be built on an alternative site within Banbury. This new development will be fully compliant with environmental National Minimum Standards, and provide totally single accommodation with en-suite facilities once a suitable site has been sought. There are sufficient bathrooms and lavatories to service the residents’ needs, all of which are within close proximity to the residents’ bedrooms and clearly marked. However tablets of soap were found in a couple of these communal areas, which could pose as a threat to the possibility of cross infection; a good practice recommendation has been made within this report to address this. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 15 Service users are encouraged to bring personal possessions and whilst viewing a number of rooms, it was established that many have decorated their rooms with their possessions and some have pieces of their own furniture. Whilst touring the premises, it was noted that space under the stairs was being used for storage. The inspector felt this was not appropriate for storage purposes. The acting manager informed the inspector that she would speak to the fire officer regarding the matter and forward the response to the Commission for Social Care Inspection. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 The home follows a thorough recruitment process to ensure that residents are in safe hands and training opportunities are readily available to all staff to ensure competency in their roles and to allow for personal development. EVIDENCE: A sample of staff files was observed which highlighted a thorough recruitment procedure, based on equal opportunities and ensuring the protection of the service users is followed. However, two files failed to contain a recent photograph, this omission was addressed immediately during the inspection. All members of staff undergo induction training, upon appointment to their posts, and are offered ongoing training, which equips them to meet the assessed needs of the residents within the home. A training matrix has been implemented to allow identification of staff who require their training to be updated. Planned training to be undertaken by staff by the end of the year includes, health and safety, infection control, medication training, food hygiene. Dementia awareness training is planned for the New Year; the home is awaiting dates from the organisation’s county office. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 In view of the findings during the inspection around risk assessments, the inspector is of the view that the home is not presently protecting the health, safety and welfare of the residents appropriately. EVIDENCE: Residents and members of staff reported that the home is run in an open, positive inclusive way and they would have no worries in highlighting any concerns, if the need arose, and were confident that they would be listened to and dealt with appropriately. Regular residents meetings are held, which keep residents informed and allow for any concerns to be discussed. The meetings are minuted and distributed around the home. Systems are in place within the home, and adhered to, in order to safeguard the residents’ financial interests. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 18 Whilst there are policies and procedures in place to promote and protect the health, safety and welfare of the residents, these are not being adhered to (see section Health and Personal Care), thereby potentially placing the service users at risk of not having their needs met fully. Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X 3 X X 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X X 3 X X 2 Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 20 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 OP7 Regulation 24(1)a Requirement The home must ensure that all assessments of needs and risk assessments are undertaken and kept up to date to reflect the needs of the service users, and to provide staff with clear information as to the management of those needs. The home must ensure to gain the signature of a family member/advocate, where the service user is unable to do so themselves, to evidence that appropriate consultation with the service user or their representative regarding the care planning and assessment takes place, as was required during the last inspection. The home must ensure to place a photo of the resident identified within this report upon their care plan. Timescale for action 29/11/05 2 OP7 14 16/12/05 3 OP7 17(1)a Schedule 3 30/11/05 Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 21 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 2 Refer to Standard OP15 OP21 Good Practice Recommendations It is recommended that the menus on display in the home are presented legibly. It is a good practice recommendation to ensure tablet soap is removed from all communal bathing and toileting facilities, and the provision of liquid soap remains available. It is recommended that a permanent manager be sought as a matter of urgency. 3 OP32 Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Lincoln House DS0000035671.V264735.R02.S.doc Version 5.0 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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