Inspection on 16/06/06 for Lyle House

This inspection was carried out on 16th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Lyle House 31/10/05

Lyle House 25/05/05

Similar services:

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

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

CARE HOMES FOR OLDER PEOPLE Lyle House 207 Arabella Drive Roehampton London SW15 5LH Lead Inspector Jon Fry Unannounced Inspection 11:30 16th June & 6th July 2006 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 Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyle House Address 207 Arabella Drive Roehampton London SW15 5LH 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) 0208 481 7277 Richmond upon Thames Churches Housing Trust Mr Iqbal Musafer Care Home 45 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (15) of places Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: Lyle House is registered to provide care and accommodation for 45 residents, 30 of whom may have dementia. The home is operated by Richmond Upon Thames Churches Housing Trust and is situated near the East Sheen shopping area and is well placed for public transport. The service is organised on three floors with two units providing dementia care situated on the upper levels. The ground floor unit provides care for older people with lower dependency needs. All bedrooms are single with en-suite facilities. The home has produced a Service Users Guide information on the aims and objectives of the service. that includes The charges for Lyle House are between £559 and £580 per week. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over eight hours by a regulation inspector on the 16th June and 6th July 2006. The inspector spoke individually with twelve residents, the manager and five members of staff. A number of records were examined, as well as a tour of the home. Three residents, three staff and two care professionals returned written surveys about the home. What the service does well: What has improved since the last inspection? What they could do better: The staffing levels at night must be reviewed to make sure residents are safe. Further discussion should take place around the use of keypads on each unit. These restrict freedom of movement for residents who cannot remember the code in use. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 6 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. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents are assessed prior to admission to make sure that the home can meet these. Good information is available to help individuals make a decision about moving to the home and they are able to visit and spend time at the home. EVIDENCE: A Service Users (Residents) Guide is made available to both prospective and existing residents and gives good information about the home. Copies of the most recent inspection report are also made available in the home’s reception areas. Prospective residents and their representatives are able to visit the home and meet the staff and other residents before making any decision about moving in. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 9 A satisfactory procedure is in place to make sure that the needs of a resident are assessed before they move into the home. A pre-admission assessment had been completed by the manager for one individual who was due to move into the home within the next week. This document was being used to write a care plan for staff to use once the person had moved in. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are fully completed and are reviewed each month. The care plans could be developed to be even more person centred and fully reflect the individual’s life, experiences and preferences. Individual assessments must be reviewed following any incidents or accidents to make sure that they fully address the potential risks to the individual. Medication is generally well managed but some improvements to recording are needed. EVIDENCE: Care plans for four residents were looked at during this inspection. All the care plans had been reviewed regularly and included satisfactory information for staff to be able to meet individual care needs. Areas covered include personal care, continence, communication and diet. Social histories are included and these help to personalise the care plans to each individual. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 11 The home should continue to look at how the information in each care plan could be even more detailed and ‘person centred’ to give a complete picture of the individual and their specific care needs. Objectives stated for residents such as ‘promote socialisation’ should be reviewed to state specific and achievable goals. Staff at the home must review resident’s risk assessments following any incident or accident. This is very important particularly around falls and their possible future prevention. The healthcare needs of residents are satisfactorily met by the home. All residents are registered with a GP and arrangements are made for regular dental, optical and chiropody care. One issue was highlighted where the service has difficulty accessing a GP for some residents, as there are so many practices involved with the home. It is recommended that this situation be looked at to make sure that residents always have good access to a GP. This may be by formally addressing problems with individual practices and by looking at how residents can been given choice without compromising access to a GP when needed. Records examined for the administration of medication to residents in one unit were generally well maintained. One instance was however found where an item of medication had been signed for as given but was still in the container. Satisfactory procedures are available to staff and medication is appropriately stored. It is recommended that the service look at the current use of keypads that restrict the movement of residents out of the units. Displaying the exit codes by the keypad on each unit should be considered. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities continues to improve at the home. Information within care plans could be improved to make sure that all care needs are met. Residents are able to keep contact with friends and family. The meals served are of a good standard. EVIDENCE: The home has now employed extra domestic staff and care staff no longer have to perform cleaning duties. Staff spoken to reported that they now had more time to spend with residents as they no longer spend so much time cleaning. Good records were seen to be kept on one unit documenting what activities residents had taken part in. Comments from residents included “plenty of activities here”, “always something going on” and “we have a social evening every week”. One resident said they would “like to go out on more trips”. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 13 Activities include gardening, bingo, manicure and art. An activity room is provided and a massage / aromatherapy session was taking place on one day of the inspection. A visit to a local pub for lunch also took place and the manager said that the home now had some access to a minibus provided by the organisation. As noted previously the care plans for individual residents could be further improved by being more specific. Better individualised information will help staff to provide activities to meet the needs of each resident. Activity records could then be used to measure the success of the care plans in place. Residents spoken to said that they were able to have visitors at any time. Feedback about the food provided was generally positive. Comments received included “no complaints”, “very good”, “alright” and “not too bad”. A fourweek revolving menu is in place at the home and residents confirmed that they were given a choice at mealtimes. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 the following standard(s): 16 and 18. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Residents are protected by policies, procedures and practices regarding complaints and the Protection Of Vulnerable Adults. EVIDENCE: The home has a clear complaints procedure with timescales for responding to complaints. Information is included on what action to take should a complainant not be satisfied with the response received from the home. The home keeps a record of any complaint along with actions taken and outcomes. This is checked and signed by the manager. Three complaints had been recorded in 2006 and these had or were being appropriately responded to. A Protection of Vulnerable Adults (POVA) issue was responded to appropriately by the home at the time of inspection. In addition to Local Authority procedures, Richmond Churches Housing Trust has its own procedures on abuse. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 the following standard(s): 19 and 26. Quality in this area is good. This judgement has been made using available evidence including a visit to the home. The home is purpose built and provides a high standard of accommodation to residents. The home is kept clean and hygienic. EVIDENCE: The communal areas of the home are well maintained with each unit offering a dining room, two communal lounges and a small kitchen for residents use. Additional facilities provided include a large ground floor communal lounge area, an activities room and a landscaped garden. Residents made positive comments about the home and particularly how clean it is kept. One resident reported “my room is kept nice and clean” and another resident said “it is always clean”. A care professional commented “new, clean, pleasant smell and light”. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 16 No maintenance issues were seen during this inspection. Requirements made in the last report have been repeated about the showers and storage facilities. The manager said that these issues had not yet been satisfactorily addressed. Further thought needs to be given to how to help residents with dementia find their bedrooms more easily. This may be through the use of colours, signage, pictures or objects on doors or surrounds. The home was clean and hygienic at the time of the inspection visits. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The changes made to the roles and responsibilities of care staff benefits the residents living at the home. Staffing levels at night must however be reviewed immediately. An organisational training programme is in place and care staff attend a range of training courses. Residents are fully protected by the homes recruitment procedures. EVIDENCE: Feedback from residents was generally positive about the care staff. Comments included “quite nice”, “all very nice”, “fine” and “good”. Other feedback included “some are nice and some are grumpy” and “they never grumble”. Feedback from care professionals in surveys included “staff all appear motivated and friendly and seem to have good rapports with service users” and “seem sensible and liaise appropriately”. All the care staff spoken to said that they now had more time to spend with residents because they no longer had to undertake the daily cleaning duties in each unit. Three care staff however raised issues about the night staffing Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 18 levels saying they were “not enough” and that some units could be left unattended at night if a resident needed more than one member of staff to provide care. A Requirement has been made to review this situation to make sure that sufficient cover is provided at night on all three units. The organisational training programme includes NVQ training and a range of courses such as First Aid, equal opportunities and safety awareness. A mandatory one-day course for staff regarding dementia is provided and the manager reported that this training is now to be extended to two or three days. This will help to ensure best practice by staff in this area. The home should now look to introduce the Skills for Care Common Induction Standards for new care staff. The use of the Skills for Care Knowledge Sets around areas such as medication and infection control may also be useful to develop good practice. Recruitment records seen for two members of staff were well organised and included all required documentation such as Criminal Record Bureau (CRB) checks. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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 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): 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service continues to develop under the leadership of the registered manager. Financial records are well maintained and kept up to date. There are systems in place for consultation with residents and their representatives. Health and Safety records are well maintained. EVIDENCE: Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 20 The registered manager has considerable experience and continues to develop the service with his staff team. Individual staff spoken to were positive about the support they received to do their jobs. Residents meetings take place every month. Minutes seen included discussion on menus, staffing and activities. The organisation arranges for monthly quality audits of the home. These include checks on key areas. An external advocacy service visits the home annually and they ask residents about their experiences and make observations as part of a quality assessment. This year’s visits were taking place at the time of this inspection. There is an organisational procedure for resident’s finances. Individual records are kept for residents who are supported with their money. These are fully audited on a quarterly basis by a finance officer. Health and safety records for hot water temperatures, Fire Safety, electrical appliance testing and hoist equipment are all well maintained. Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X 3 X X 3 Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 22 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 OP7 Regulation 13 (4) Requirement Timescale for action 01/09/06 2. OP9 13 (2) 3. OP21 23 (2) (b) (c) (n) The Registered Persons must ensure that individual risk assessments are reviewed following any incident or accident with records kept. The Registered Persons must 01/08/06 ensure that medication is administered as prescribed with full and accurate records kept at all times. 01/12/06 The Registered Persons must ensure that suitable en-suite shower facilities are provided. This is with particular reference to ensuring that carers can give appropriate assistance to residents without getting wet themselves. (Previous timescale of 14/02/06 not met). The Registered Persons must ensure that suitable storage is provided for equipment in use at the home. (Previous timescale of 14/02/06 not met). 4. OP22 23 (2) (l) 01/12/06 Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 23 5. OP27 12 (1) 13 (4) 18 (1) The Registered Persons must conduct a review of the night staffing levels. This is to ensure that sufficient numbers of staff are on duty within each unit at all times to ensure the health and welfare of residents. 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the care plans continue to be developed to ensure that they are person centred. The information presented should fully document how individual needs and preferences are to be met. Objectives / goals set should be specific and achievable. Review situation to make sure that residents have good access to a GP as and when required. It is recommended that the current use of keypads be reviewed within each unit. It is strongly recommended that consideration be given to additional appropriate signage or other methods to ensure that bedrooms can be easily found by residents. The home should make sure that the induction training materials for new care staff are to Skills for Care common standards. Consideration should be given to the use of Skills for Care knowledge sets. 2. 3. 4. OP8 OP10 OP22 5. OP30 Lyle House DS0000062953.V306543.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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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