Inspection on 05/04/05 for Lindhurst Lodge

This inspection was carried out on 5th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lindhurst Lodge 04/12/06

Lindhurst Lodge 08/06/06

Lindhurst Lodge 19/07/05

Lindhurst Lodge 07/07/04

Lindhurst Lodge 01/04/04

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Hawkhills

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The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lindhurst Lodge Lindhurst Road Athersley Barnsley S71 3DD Lead Inspector Jayne Barnett-Middleton. Unannounced 05 April 2005 09.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Lindhurst Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Lindhurst Lodge Address Lindhurst Road Athersley Barnsley S71 3DD 01226 282 833 NA None. Mr Azad Choudhry Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Joan Birtles Care Home - PC Only 37 Category(ies) of OP Old Age (37) registration, with number of places Lindhurst Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 07 July 2004 Brief Description of the Service: Lindhurst lodge is a purpose built care home providing personal care and accommodation for 37 older people. The home is a two-storey building with a passenger lift. It has 33 single bedrooms and two double bedrooms. There is a small car park to the front and large, private gardens to the rear. All areas of the home are accessible to people in wheelchairs. Lindhurst Lodge occupies a central position at Athersley North, and there are shops, pubs, a post office and other amenities within the vicinity. The home is approximately three miles from Barnsley town centre. Lindhurst Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 am to 4 pm Seven service users, seven staff, the manager, one visiting professional, two relatives and the area manager were spoken to. Samples of records were examined, a partial inspection of the building made and the interaction between staff and service users was observed. It was found that many of the previous requirements had been met. All service users spoken to on the day of the inspection stated that they were satisfied with the quality of care that they received. They described the staff team as “ very supportive” and “caring” The home had a relaxing and friendly atmosphere. What the service does well: What has improved since the last inspection? The service user plan and admission assessment had been reviewed to ensure that staff were provided with the information relevant to the care needs of the service users. The daily menu had been reviewed to ensure that service users were offered a more varied choice of meal at lunchtime. Previous requirements to promote the health, safety and welfare of service users and staff had commenced. Valves had been fitted to all hot water outlets to minimise the risk of scalding and light fittings in some service users bedrooms had been replaced to provide sufficient light. All staff had attended training sessions to enable them to meet the assessed needs of service users, which included medication, adult protection and first aid. Lindhurst Lodge Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lindhurst Lodge Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Lindhurst Lodge Version 1.10 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 standard(s) 1,2,3 and 5. Prospective service users and their relatives were provided with the information that they needed to make an informed choice about living at the home. Each had been provided with a written contract/statement of terms and conditions at the point of moving into the home but this needed amending to ensure that it included all of the required information. A full assessment of need was carried out for all which clearly identified the care needs of service users. Service users and their relatives/friends were invited to visit the home prior to admission to asses the quality, facilities and suitability of the home . EVIDENCE: A Statement of Purpose and Service Users Guide were available, these provided service users and their relatives with the information that they needed to make an informed choice about living at the home. Service users were issued with statements of terms and conditions (contract). The contract had not been amended to include extra charges above the standard fee. Two service user files were checked and an assessment of need had been carried out by a qualified social worker for both service users. Service users said that their needs were met and that they were happy with the care provided. Two care plans checked and staff confirmed that a range of services was provided to service users. Lindhurst Lodge Version 1.10 Page 9 Service users stated that the staff were caring, helpful and offered support and assistance where needed. Staff interviewed had a good range of experience and had undertaken training appropriate to their role. Service users said that they and their relatives had been invited to visit the home prior to admission. This home does not provide an intermediate care service. Lindhurst Lodge Version 1.10 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11. Care plans were in place that set out in detail the action that was needed by staff to ensure that all aspects of the health, personal and social care needs of the service user were met. They did not demonstrate that the service user and/or their representative had been invited to contribute to their plan of care. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. Service users privacy and dignity was respected EVIDENCE: Two service user files were checked and they set out in detail the action that needed to be taken by staff to ensure that all aspects of the service users health, personal and social care needs were met. Other healthcare professionals e.g. general practitioner, dentist and chiropodist were visiting service users at regular intervals. Nutritional screening had been undertaken for all service users and weight monitoring records were maintained on a monthly basis. Care plans had been updated on a regular basis to ensure that staff were informed of service users current needs. Files checked did not demonstrate that the service user had been given the opportunity to confirm that their plan of care was a true reflection of their individual needs. Files checked were tidy and information easy to track. Lindhurst Lodge Version 1.10 Page 11 There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis, staff had received medication training all promoting that medication was appropriately administered to service users. Since the last inspection the homes policy and procedure for dealing with death and terminal care had been reviewed to ensure that staff were aware of how to care for service users at the time of their death Throughout the inspection staff were observed to treat service users with dignity and respect and positive interaction between staff and service users was evident. All service users spoken to stated that they were satisfied with the care provided and that the staff team were caring and helpful. Lindhurst Lodge Version 1.10 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. The routines within the home were flexible. Service users were able to spend their day as they wished. There were no restrictions on visiting times and family and friends were welcome at any reasonable time. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: Service users were observed to be spending their day as they wished, Several were using the lounge whilst others were spending time in their rooms or receiving visitors. Service users said that they could choose when they got up and when they went to bed. The manager stated that activities including painting and reading were available, records of activities were maintained confirming who had participated.. Service users said that they were happy with the level of activities provided. Service users spoken to said that they could receive visitors at any reasonable time within the privacy of their bedroom. The homes menus had been reviewed to ensure that a choice of meal was available at lunchtime. Lunch was observed .The meal provided was well presented and looked appetising Tables were attractively set with tablecloths and matching crockery. A good choice of menu was offered and special dietary needs were catered for. All service users and one relative confirmed that the food was “very good”. Lindhurst Lodge Version 1.10 Page 13 There was a relaxed and informal atmosphere in the dining area and service users were given sufficient time to eat in a relaxed manner. The cook said that menus were planned and reviewed in consultation with service users, which gave them the opportunity to suggest ideas on the choice of food that was offered. . Menus were displayed within the dining room of the home. There were refreshments available should service users require a snack in addition to meal times. The home had recently received a visit from the environmental health officer and the manager said that no requirements were made. Lindhurst Lodge Version 1.10 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home had a complaints procedure that was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. The home had an adult protection procedure. All staff employed at the home had received adult protection training, which promoted the protection of service users from harm or abuse. EVIDENCE: There was a complaints procedure that ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Since the last inspection the home had received seven complaints. Records of all complaints were kept within the home. All complaints received had been responded to within 28 days and appropriate action had been taken to resolve the complaint Service users spoken to on the day of the inspection stated that they were satisfied with the care provided. They confirmed that they had no complaints, however they would speak to the manager or staff should they have any concerns regarding any aspect of their care. . There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff confirmed that they had received adult protection training which enabled them to identify and report any allegations or incidents of abuse to service users. Lindhurst Lodge Version 1.10 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 25 and 26. The home in the main was clean and well maintained. Service users said that they enjoyed living at the home and that they liked the environment. EVIDENCE: The home was in the main clean, warm and welcoming. Furniture and fittings were clean and domestic in design. The grounds were pleasant, safe and accessible to service users, who said they enjoyed spending time outside during the summer months. There were sufficient baths and lavatories and these were close to communal areas and bedrooms. One member of staff spoken to confirmed that they were provided with sufficient cleaning materials and equipment to enable them to maintain a good level of cleanliness. The majority of previous requirements in relation to the environment had been completed. Safety valves had been fitted to prevent the risk of scalding, liquid soap and bins with fitted lids had been provided in lavatories to minimise the risk of cross infection and new curtains had been provided in toilet areas to maintain privacy to service users. The carpet in the entrance of the home was stained in places and did not present a clean environment. The communal areas previously identified for redecoration had not been redecorated. Lindhurst Lodge Version 1.10 Page 16 The manager said that these would be redecorated as part of a refurbishment programme. A programme of refurbishment had commenced to service users bedrooms to ensure that they met the required standard. Two accessible double electric sockets were being provided to minimise the risk of fire and brighter lighting was being installed. Lindhurst Lodge Version 1.10 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28,29 and 30. Sufficient staff were provided to meet the individual needs of service users. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. The home operated a recruitment procedure, which needed some amendments to promote the protection of service users. EVIDENCE: A good skill mix of staff was employed at the home to meet the assessed needs of service users. Three staff spoken to confirmed that they had worked at the home for several years and it was evident that they had a good understanding of their role and individual needs of service users. The manager said that Staffing levels were being maintained as agreed. There were no staff vacancies and service users said that there was sufficient staff on duty to meet their individual needs. Staff stated that they worked effectively as a team Staff interviewed confirmed that they had received training appropriate to their job role. A training and induction programme for staff was in place that met National Training Organisation (NTO) workforce training targets to enable them to meet the assessed needs of service users. Induction records were incorporated in staff files, which demonstrated that new staff were given the support and training, needed to care for service users. The manager had devised a staff-training matrix, which clearly demonstrated that staff had attended various training courses that included food hygiene, adult protection, and moving and handling, customer care and aggression management. Lindhurst Lodge Version 1.10 Page 18 The manager confirmed that nine staff held an NVQ qualification, which developed the skills and competence of staff, to enable them to meet the changing needs of service users. A recruitment policy and procedure was in place. Two files that were checked contained a range of information including two references, declaration of health and qualifications/training. The files did not contain a full employment history or two forms of identification. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. Lindhurst Lodge Version 1.10 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38. Service users benefited from the leadership and management approach of the manager and area manager. Staff were supervised on a daily basis, however, formal supervision for staff needed to be increased. Safe working practices were in place to promote the health, safety and welfare of service users. EVIDENCE: The manager had several years experience in the caring profession enabling her give a clear sense of direction to staff and to monitor the care offered to service users. All service users and staff said that the manager was professional and approachable. The area manager visited the home at least once per week to support the manager and to oversee the home. Written reports of these visits were maintained. A copy of the homes recent inspection report was displayed in the entrance of the home. The staff were supervised on a daily basis by the deputy of the home. Lindhurst Lodge Version 1.10 Page 20 The Staff files checked evidenced that staff were receiving formal supervision, which gave them the opportunity to focus on, care practices and training development needs. Records examined indicated that staff were not receiving formal supervision at least 6 times per year. Records checked were in the main up to date and in good order. Policies and procedures were in place that promoted the health, safety and welfare of service users and staff. A room was identified on the ground floor to store wheelchairs. A large amount of wheelchairs were being stored which prevented the door from closing and one fire door was wedged open, which created a fire risk. Staff had received induction and foundation training including first aid, health and safety and moving and handling. Lindhurst Lodge Version 1.10 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 x x x 3 2 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 Standard No 16 17 18 Score 3 3 3 2 3 3 x x 2 3 2 Lindhurst Lodge Version 1.10 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5,17 Requirement The contract must state any charges that are above and beyond the stated fees (Timescale of 1st September 2004 not met) Care plans must be reviewed in consultation with service users or their representatives (Timescale of 1st September 2004 not met). Communal rooms.must be redecorated (Timescale of 24th November 2004 not met) The carpet in the entrance of the home must be cleaned or replaced. Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment must be accounted for and recorded. Staffs’ personal files must contain proof of the employees identity. Fire doors must not be wedged open. Timescale for action 31st May. 2005. 2. OP7 15 31st May 2005. 3. 4. 5. OP20 OP26 OP29 23 16 19 30th June 2005. 30th June 2005. 31st May 2005 6. 7. 8. 9. OP29 OP38 None None 19 23 31st May 2005. Immediate 5th April 2005. Lindhurst Lodge Version 1.10 Page 23 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 OP31 OP36 Good Practice Recommendations The manager should attain the Managers award by 2005. Staff supervision should take place at the required frequency, a minimum of 6 times each year Lindhurst Lodge Version 1.10 Page 24 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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. 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