CARE HOME ADULTS 18-65
Lychgate House 145 Shrub End Road Colchester Essex C03 4RE Lead Inspector
Marion Angold Unannounced Inspection 11th January 2006 11.00 Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Lychgate House Address 145 Shrub End Road Colchester Essex C03 4RE 01206 500074 01206 510916 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) Doobay Care (Lychgate) Limited Mrs Natascha Hill Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a mental disorder (not to exceed 12 persons) The manager must undertake NVQ Level 4 in management and care by the end of December 2005 14th September 2005 Date of last inspection Brief Description of the Service: Lychgate House is a detached property, situated in a residential area, close to a range of community activities and Colchester town centre. Accommodation is provided on two floors, with the upper floor being accessed via a passenger lift. Most bedrooms are single occupancy and there is a choice of communal areas. There is a good-sized garden to the rear. This home provides care in a homely and comfortable environment for twelve adults, of varying ages, with mental health problems. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection, assisted by the Manager, took place between 11.00 am and 6.20 pm. The Inspector spoke with the owners, Mr and Mrs Doobay, and a number of residents and staff. The process also involved observation and the examination of records. As part of this inspection, the Manager brought additional records to the Commission’s Colchester office on 25 January 2006. The inspection covered the core National Minimum Standards not inspected in September 2005 and the shortfalls identified in the last report. Of the 18 standards inspected on this occasion, 15 were met, and 3 presented minor shortfalls. What the service does well: What has improved since the last inspection?
Service users had suitable information about their home. Amendments had been made to the Statement of Purpose, Service User Guide and residents’ individual contracts/statements of terms and conditions, in line with a recommendation from the last inspection. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 6 Daily records maintained for each resident were brief, but the Inspector found no further examples of language that implied a value judgement. Staff had attended training on the protection of vulnerable adults. One person said they had found the session gave clear and helpful information about what abuse is and what to do in the event of an allegation, or suspicion that it had taken place. A number of improvements had been made to the premises, including the installation of new bathing and showering facilities. The process of redecorating and renewing other areas was continuing and residents showed their approval of the changes that had taken place. Following a recommendation from the last inspection, one resident, whose needs were not being met in a shared room, had transferred to a single room. They said they were happy with this new arrangement. The Manager had worked out how many staff they needed (using a method, published by the Department of Health) and found they were operating within recommended limits. With two vacancies in the home, and staffing levels maintained, the home had been able to offer residents more support with outside activities. Appropriate procedures had been followed in recruiting the newest member of staff. Records also showed that a range of topics, relevant to their role and the purpose of the home, had been covered in their supervision, although the Manager proposed developing the induction programme, in line with training she had recently attended. Two staff were due to complete training for the National Vocational Qualification (NVQ) in care, Level 2, in February 2006. With 4 out of 7 staff qualified to Level 2, the home will have achieved the 50 target to meet National Minimum Standard 32.6. The Manager had attended several relevant courses and reported that she had registered for NVQ in management and care, Level 4. The Manager had begun recording staff supervision in more detail, thereby showing that the sessions covered the areas they should. The Manager had taken appropriate steps to monitor the quality of care and provision in the home. The Inspector looks forward to seeing this process continued at the next inspection. The Manager had also been keeping the Commission informed of significant occurrences in the home, as the law requires. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 7 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. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Residents had suitable information about their home and clearly stated contracts of residence. Their needs were assessed prior to admission. EVIDENCE: Amendments had been made to the Statement of Purpose and Service User Guide, in line with a recommendation from the last inspection. A pre-admission assessment had been completed for a person, admitted since the last inspection and, from this, a care plan generated. These documents covered the main presenting needs, but could have been more detailed in relation to lifestyle issues and aspirations. Since the last inspection, appropriate amendments had been made to residents’ individual contracts/statements of terms and conditions, in respect of smoking arrangements. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Residents’ goals and aspirations were not fully reflected in their care plans and their records did not show that care reviews were taking place. Appropriate systems were in place for looking after personal money on residents’ behalf. EVIDENCE: Three care plans were inspected. They covered the main presenting needs of the individuals, but lacked information about how staff might support them to achieve their goals and aspirations, or do/have more of what they enjoyed. Although it was clear from discussion with the Manager that one person’s care needs had changed considerably, and were being addressed, this was not clear from their care plan. The reviews of care that had taken place were not recorded in any detail on individual files. Daily records were brief, but the Inspector found no further examples of descriptive words, which implied a value judgement and only one such example was noted in a care plan evaluation. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 11 The Manager had arranged to meet with a representative from the Department of Work and Pensions to discuss appropriate arrangements for people who were no longer able to understand transactions involving their personal money. The Manager was holding small amounts of money for some residents. Two sets of records and receipts were inspected and found to correspond with the balance of money and the Post Office account details. In both cases, the resident or a relative had signed various entries in the records. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Residents were participating in the local community and had contact with the significant people in their lives. EVIDENCE: Residents were taking part in appropriate activities and getting involved in community life, for example, through workshops, college courses, churchbased activities and drop-in centres. They went out for meals and shopping, by themselves or with key workers. They also enjoyed occasional outings beyond Colchester or to the cinema. These excursions involved the use of public transport or taxis. Some residents made use of the mobile library or the one in town. The home continued to receive monthly bulletins about local events. Asked about any recent changes in life at Lychgate House, one resident listed a number of different activities they had recently enjoyed. Residents were supported to keep in touch with family and other people who mattered to them. For example, the home been proactive with arrangements for one person to visit their family at Christmas and supported another to make contact with relatives. Two of the three care plans inspected contained
Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 13 instructions to staff about maintaining family links. The home’s open visiting policy was demonstrated during the inspection. NMS 17 was not fully inspected. However, the Manager reported that menus were reviewed annually in consultation with residents and that the cook spoke with residents on a daily basis to ensure they were happy with what was planned. Residents were offered a choice at teatime and, those who spoke with the Inspector, said they enjoyed their meals. The Manager described how the home accommodated one person’s interest in Chinese cuisine. The Manager should continue to consider ways of increasing choice in relation to menus. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents benefited from appropriate attention to their physical and emotional health needs, arrangements for administering their medication and the way personal support was given. EVIDENCE: Residents confirmed that arrangements for daily living were flexible and this was demonstrated during the inspection, with regard to times for getting up, going to bed, bathing/showering and meal times. Residents confirmed that they were happy with the personal support they received from staff and key workers. It was evident in discussion that residents were supported to choose their own clothes and toiletries. During the inspection staff spent time supporting and encouraging several residents to get ready for a New Year party. In addition to routine optical, dental and chiropody appointments, records showed that residents had annual medicals and flu inoculations and that their weight was monitored by the home. The Manager highlighted the support they received from the medical profession, including regular medication reviews, GP and consultant reviews. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 15 Arrangements for storing and administering medication were found to be satisfactory, as seen at this inspection. There was no written protocol for a PRN (as needed) medication, although both the Manager and person administering medication were familiar with the guidance for its use. A list of people who were trained to administer medication and their signatures was filed with the Medication Administration Records. The only records of residents’ medication were their Medication Administration Record or the lists used for reordering medication from the pharmacy. Following discussion with the Manager, she said she would keep a separate reference of each person’s current medication. This should include details of dosage, purpose and any side effects. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Residents were well treated and listened to but, in the event of an allegation or suspicion of abuse, staff could take the wrong steps, if they followed the protection of vulnerable adults procedures, as they stand. EVIDENCE: Staff had attended a training session on the protection of vulnerable adults, led by their usual training provider. One person said they found the session provided clear and helpful guidance on aspects of abuse and what to do in the event of an allegation or suspicion that abuse had taken place. Handouts supplied by the trainer confirmed that the content was in line with agreed protocols. The Manager agreed to amend the home’s procedures to make clear the boundaries of their responsibilities with regard to investigation. Good interaction was observed between residents and staff throughout the inspection and one resident commented that they were all well cared for. A relatively new member of staff also gave positive feedback about the way residents were treated. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Residents were benefiting from refurbishments to their home and an environment that was kept clean and fresh. More specific procedures for the control of infection, particularly with regard to the laundry, would enhance their protection. EVIDENCE: Following a recommendation from the last inspection, one resident, whose needs were not being fully met in a shared room, had transferred to a single room. They said they were happy with this new arrangement. It was evident from records and discussion that the transfer of two other residents to a shared room had taken place in consultation with the people involved or their representatives. One person was employed as a cleaner and all areas inspected were found to be clean and fresh. Paint was flaking off the walls of the laundry, but the decorator, working in the home at the time of inspection, had this room on their work schedule. The Manager was advised that, if the laundry were to be re-sited, they should install a separate hand-washing facility. In the interim, as part of the home’s infection control policy, there should be a clear set of procedures for washing hands in the existing sink, which is also used for
Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 18 rinsing clothes and linen. The washing machine provided a suitable wash programme for soiled items and discussions evidenced that appropriate instructions had been given to staff for the use of personal protective clothing. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 34 Residents were protected by the home’s recruitment practice and supported by sufficient numbers of trained and supervised staff. EVIDENCE: The home was operating with two vacancies, but had continued to have a minimum of two care staff on duty throughout the 24-hour period, supported at times by the Manager, a third care assistant and/or people cooking and cleaning. Since the last inspection, the Manager had used the Department of Health tool for calculating appropriate staffing levels; on that basis, the home was more than meeting the identified need. However, it was recognised that the home could not operate safely with less than two on duty and that the situation would change as soon as the vacancies had been filled. At the time of inspection, the Manager had just returned from leave and could not locate all the documents requested for inspection. She subsequently brought to the Commission’s Colchester office, by arrangement, the recruitment file for the newest member of staff. This contained all the documents required by regulation and evidenced the required recruitment procedures. Apart from a second reference, shortfalls, identified at the last inspection, in respect of another staff member’s records, had been addressed. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 20 Two staff had the National Vocational Qualification in care, Level 2 and it was reported that two others were due to complete the course in February 2006. With 4 out of 7 staff qualified to Level 2, the home will have achieved the 50 target to meet National Minimum Standard 32.6. Residents commented positively on the support they received from staff. Staff were observed giving their time to residents and interacting with them appropriately. The Manager reported that staff supervision records were being typed off the premises. She subsequently brought to the office of the Commission, as requested, the last two sets of supervision records for the two most recent recruits to the staff team. These showed that a range of topics had been covered in supervision, which were relevant to the person’s role and the purpose of the home. Staff indicated in discussion with the Inspector that they felt well supported in their roles. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 Residents benefited from the increasing experience of the Manager and her efforts to develop the home in their best interests. EVIDENCE: Natasha Hill reported that, on 25 January 2005, she had registered for the National Vocational Qualification in management and care, Level 4. She had also attended a workshop, run by Skills for Care, about introducing common induction standards and a seminar for registered managers about raising standards of care in line with the Care Homes Regulations 2001. Discussion with Natasha Hill showed that she was keen to put this training into practice, particularly in relation to staff induction. Appropriate notification had been made by the home in line with the requirements of the Care Homes Regulations 2001, Regulation 37. As part of the home’s quality assurance system, Natasha Hill and a senior member of staff had supported residents to complete questionnaires about
Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 22 their views of various aspects of provision at Lychgate House. The Manager explained the difficulty she had experienced trying to involve independent people in this process. The Manager’s quality monitoring report included analysis of these questionnaires, a review of action taken in response to CSCI inspection reports, detailed proposals and an action plan for the premises and a general training plan for staff. Discussion took place with the Manager about the need for her report to cover all aspects of the home’s provision and be linked to a costed business plan. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X X X Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 24 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 YA6 Regulation 15 Timescale for action The registered person must 31/03/06 ensure that residents’ individual plans of care are kept under review and that records of these reviews are held on their files. The registered person must 31/03/06 amend the home’s adult protection policy to clarify the limits of their responsibilities with regard to investigation. The registered person must 31/03/06 develop the home’s infection control policy, specifically, to include procedures for washing hands in the laundry room. Requirement 2 YA23 13 3 YA30 13 (3) 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 Good Practice Recommendations Standard YA2YA6YA14 The registered person should ensure that care plans address the individual’s strengths and personal goals. They should also continue, where possible, to work towards residents and staff taking a more active part in
DS0000017874.V277858.R01.S.doc Version 5.1 Page 25 Lychgate House 2 YA20 3 YA39 the ongoing evaluation of care plans. It is recommended that the registered person maintain a record of residents’ current medication, separate from the Medication Administration Records and including details of dosage, purpose and any side effects. The registered persons should ensure that the home’s quality monitoring report covers all aspects of care and provision, and is linked to a costed business plan. If residents need assistance completing satisfaction questionnaires, this should be from someone independent of the home. Lychgate House DS0000017874.V277858.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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