CARE HOME ADULTS 18-65
Lychgate House 145 Shrub End Road Colchester Essex CO3 4RE Lead Inspector
Neal Wolton-Harragan Key Unannounced Inspection 20th June 2007 10:45 Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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.V342987.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 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.V342987.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Lychgate House Address 145 Shrub End Road Colchester Essex CO3 4RE 01206 500074 01206 510916 mar.doobay@ntlworld.com 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 Dementia - over 65 years of age (2), Mental registration, with number disorder, excluding learning disability or of places dementia (12) Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a mental disorder (not to exceed 12 persons) Two named people, over the age of 65 years, who require care by reason of dementia The total number of service users accommodated in the home must not exceed 12 persons The manager must undertake NVQ Level 4 in management and care by the end of December 2006 13th October 2006 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 accessible 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. The weekly charge for a room ranges from £550 to £650 per week. Residents pay extra for toiletries, chiropody, transport and social activities. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report follows a key inspection of Lychgate House Rest Home that included an unannounced visit to the service on June 20th 2007 as well as subsequent fieldwork. The judgements made within this report are based upon evidence found on the inspection visit along with information submitted by the service and feedback from service users, staff and other parties since the previous inspection. Mrs Natascha Hill, the Registered Manager of Lychgate House, was unavailable at the inspection due to being visit on maternity leave. Mrs Doobay, one of the proprietors was present during the visit to Lychgate House and took an active role in the inspection process. During this inspection 26 of the 43 applicable standards were looked at; 16 of these were met and 10 were nearly met. There are 9 statutory requirements following this inspection, 3 of which are outstanding from previous inspections. During the visits to Lychgate House, people living at the home and staff were spoken with. All were positive about the home and the people living there appeared at ease and were happy to talk to the Inspector. Interactions between staff and the people living at Lychgate House observed during this inspection were positive. The visit to Lychgate House included an environmental tour of the home, discussions with people living at the home, staff and the acting home manager, as well as the opportunity to look at records of how people living at Lychgate House were supported and how the staff were recruited and trained. What the service does well: What has improved since the last inspection?
Since the last inspection, the owners and manager at Lychgate House have developed and implemented a quality assurance system that is based upon the views of those living at the home. All complaints are now logged along with the actions taken and records of these are kept within individual care files. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 6 There has been a programme of refurbishment throughout Lychgate House, many rooms have been redecorated and there are new carpets in much of the home. There has been new furniture purchased for a number of rooms and there are new televisions. There are also plans refit the kitchen and to extend the home to allow for two shared rooms to be converted four singles. 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. The summary of this inspection report can be made available in other formats on request. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 7 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.V342987.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is information available, including opportunities to visit Lychgate House, to allow people to make an informed decision about where to live. Prospective service users cannot be confident that all their needs will be identified before moving into Lychgate House. EVIDENCE: Lychgate House has produced a service user guide to inform those considering moving to the home the nature of services they could expect to receive. This document has been made available to all those living at Lychgate house and since the last inspection has been revised to include information relating to fees charged by the home. The examination of records of people living at the home showed that little evidence of pre-admission assessments being conducted within the persons own home, rather a reliance being upon assessment of the person when they visit Lychgate House. Referring Social Workers using standard assessments within the COM 5 document assessed some people. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 9 People living at the home spoke of having had the opportunity to visit Lychgate House prior to making the decision to move in. This was confirmed by evidence within individual records and from discussions with the acting manager and other staff. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On going assessment of the needs of those living at Lychgate House was insufficient to ensure all needs were being met and the assessment and management of risks did not afford adequate protection and support. People living at Lychgate House contributed to the care planning process within their reviews. EVIDENCE: The examination of care records showed that there were regular reviews of individual plans and there were meaningful entries in daily records. However, there was little evidence of peoples’ whole needs being reassessed since their admission to Lychgate House. This meant that those living at Lychgate House could not be certain that all their needs and aspirations had been assessed and, therefore, that these were being met through their personal plans. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 11 Individual care records showed that although there were risk assessments in place, these had not been reviewed for over a year and may not offer adequate protection or support to individuals. It was not possible to ascertain whether the risks identified within these assessments were current or if they reflected all the potential risks taken within the person’s life. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The rights of those living at Lychgate House were respected and meals were of a good standard recognising the diversity of all people at the home. Not everyone living Lychgate House could expect to have access to meaningful activities. EVIDENCE: Discussions with people living at Lychgate House and the examination of care records showed that there was a range of opportunities for activities made available to people living at the home although this varied between individual. Some were able to go out independently and accessed various day service provisions while others were more dependent upon the availability of staff to leave the home. Not all people living at Lychgate House had detailed activity plans in place.
Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 13 Those able to leave Lychgate House independently were part of the local community and had good access to appropriate leisure activities including shops and cafes although this was less so for the more dependent people. All living at Lychgate House had the opportunity to enjoy appropriate relationships as contact with families and friends was actively encouraged by the home. The examination of care records, discussions with people living and working at the home as well as direct observation showed that people were treated with respect and their dignity was upheld. Meetings were held on a regular basis for those living at the home and records were kept of these. Food provided to those living at the home was seen to be of a good standard. The main meal of the day was served at lunchtime with snack type foods offered at teatime. Discussions with people living Lychgate House showed a general satisfaction with the quality and variety of meals offered and efforts had been made to provide meals that would meet the ethnic diversity of all those living at the home. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Records at Lychgate house showed there were regular meetings for those living at the home to express how they wished to be supported. Records showed that individuals contributed to their care reviews and most understood the contents of their individual plans. As detailed earlier in this report, care records examined as part of this inspection showed the identified physical and emotional needs of those living at the home were being met although due to the lack of reassessment it was not clear as to whether all needs had been identified. Medications at Lychgate House were appropriately stored, administered and recorded and the medication policies and procedures at the home afforded protection to those living there. No one living at the home was administering or controlling their own medications at the time of this inspection.
Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 15 At the previous inspection, there had been concern regarding the storage and administration of controlled medications at Lychgate House. However, no one living at the home is now prescribed medications classified as controlled and this is no longer an issue. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The adult protection procedures are not robust enough to safeguard those living at Lychgate House. EVIDENCE: The complaints procedure had been revised at Lychgate House. While the home’s protection of vulnerable adults procedure was now closer to meeting the needs of the Essex Vulnerable Adults Protection Committee’s (EVAPC) guidelines, it had clauses within it that advised in the event of not taking an allegation further when a person refuses consent to involve the police. This means the home’s adult protection procedure fails to offer complete protection, as a Protection Of Vulnerable Adults (POVA) referral should be made automatically and not be reliant upon gaining consent. A copy of EVAPC guidelines was held at the home. Lychgate House’s complaints policy was on display at prominent points throughout the home. Discussions with people living at Lychgate House gave evidence of a general feeling that views are listened to and acted upon. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Lychgate House is a clean, comfortable, homely and safe place to live. EVIDENCE: An environmental tour of Lychgate House showed that people lived in a homely, comfortable and safe environment. Many rooms had been recently redecorated and new carpets had been laid. There were plans for on-going refurbishments throughout Lychgate House as well as the intention to build an extension to allow the change of 2 shared rooms into 4 singles and to refit the Kitchen. Individuals were happy to allow the Inspector access to their private rooms and all were satisfied with the facilities available to them. There was a variety of sitting areas available as well as a dining room although some people chose to take lunch in their own rooms on the day of inspection.
Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 18 Lychgate House offered an adequate number of toilets and bathrooms/showers to meet the needs of those living at the home and to offer appropriate choice. All areas of Lychgate House were adequately maintained, clean and free from offensive odours. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities for staff training are provided and the staff work well as a team. Staff recruitment practices are not robust enough and staff support and supervision is insufficient to safeguard those living at the home. EVIDENCE: The examination of staff records and discussions with carers and the acting manager gave evidence that those working at Lychgate House had had the opportunity to develop the skills and competences necessary to support those living at the home. Records showed that staff had received appropriate induction along with regular mandatory training in areas such as food hygiene, moving and handling and health and safety. The manager has completed NVQ level 4 and two carers have completed level 2. One carer was about to commence NVQ level 3 at the time of the inspection and the acting manager stated that all new staff would be undertaking NVQ level 2 programmes. Observations and discussions with staff and those living at Lychgate House showed that the staff worked as an effective team and there were records of regular staff meetings.
Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 20 Records showed that although most of the documentation required to ensure the protection of those living at Lychgate House was in place, there was concern regarding the robustness of pre-employment checks undertaken at the home. In one case, while two references had been sought for a person, both referees lived at the same address as the applicant. It is acknowledged that this person no longer works at Lychgate House although there is a need for the home to tighten its reference procedures. Staff records examined showed insufficient support and supervision was being offered to staff. No one working at the home was receiving formal supervision with an acceptable frequency and this would not ensure staff development needs were being fully met or that any concerns regarding carers’ performance were being addressed. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home was competent and there was an effective quality assurance process in place to ensure the views of service users underpin developments at the home. EVIDENCE: The Registered Manager, Mrs Natascha Hill, was on maternity leave at the time of this inspection and appropriate systems had been put in place to ensure adequate cover in her absence. One of the owners had assumed the position of acting manager and the deputy manager had also taken additional responsibilities. Mrs Hill has completed the NVQ level 4 Registered Managers Award and has a good understanding of the systems and processes within the home.
Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 22 Lychgate House have implemented a quality assurance programme since the last inspection and the acting manager believed this process would be used as the basis for future developments within the home. Discussions with people living at the home showed a general feeling that their views were listened to and acted upon, there were records of regular meetings at which changes were discussed and consultation with those living at Lychgate House. Individual records for those living at Lychgate House were appropriately maintained and there were regular meaningful entries in the daily records. There remain concerns regarding the adult protection procedures at the home (see also Concerns, Complaints and Protection), how this is managed and the level of protection afforded to those living at Lychgate House. Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 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 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 2 X 2 X Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA2 Regulation 14(1)(a) 14(2) Requirement Timescale for action 31/10/07 2. YA6 3. YA9 4. YA12 YA13 The home must ensure that the needs and aspirations of any person seeking to move into the home are fully assessed by a person trained and competent to do so before the admission process commences to ensure the home is able to meet the needs of the individual and the person can be sure the home is able to do so. 15 The home must ensure the 31/10/07 needs of people living at Lychgate House are regularly reassessed to ensure plans of care reflect all of the individuals needs and to be certain that these needs are met. 13(4) The home must ensure that risk 31/10/07 assessments are undertaken for all people living at Lychgate House and appropriate risk management strategies devised to ensure individuals are supported to take risks as part of an independent lifestyle. 16(2)(m)(n) The home must ensure that all 31/10/07 people living at Lychgate House have access to meaningful activities and are active
DS0000017874.V342987.R01.S.doc Version 5.2 Lychgate House Page 25 5. YA23 6. YA34 7. YA36 8. YA40 9. YA42 participants within their local community. 13 The home must amend the home’s adult protection policy to clarify the limits of their responsibilities with regard to investigation. They must also ensure that their actions in the wake of an allegation fully protect residents. This requirement exceeded the timescales of 31/03/06 and 31/03/07. 17 Schedule The home must ensure that 4, recruitment procedures protect 19 Schedule residents and that satisfactory 2 information and documentation, as required by these regulations, are obtained before staff begin working at the home. This requirement exceeded the previous timescale of 19/02/07. 13, 18 The home must ensure that persons working at the home are appropriately supervised. This requirement exceeded the previous timescale of 28/02/07. 12 The home must ensure the policies and procedures at Lychgate House comply with current legislation and guidelines to ensure the rights and best interests of people living at the home are safeguarded. 12 The home must ensure the health, safety and welfare of all people living at Lychgate House are promoted and protected. This refers specifically to the design and application of the adult protection policies and procedures. 31/10/07 31/10/07 31/10/07 31/10/07 31/10/07 Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lychgate House DS0000017874.V342987.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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
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