Inspection on 31/10/05 for Lyle House

This inspection was carried out on 31st October 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

Lyle House 16/06/06

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 31st October 2005 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 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.V265616.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 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. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over six hours by a regulation inspector on the 31 October 2005. The inspector spoke individually with eleven residents, the manager and five members of staff. A number of records were examined, as well as a tour of the home. What the service does well: What has improved since the last inspection? What they could do better: The home needs to review the roles and responsibilities of care staff with particular reference to cleaning duties. The home must ensure that there are sufficient numbers of staff allocated on each shift to provide a person centred service to residents. Environmental issues concerning the lack of storage space and problems with supporting residents in their ensuite showers are highlighted. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 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.V265616.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Resident’s benefit from their needs being appropriately assessed before admission. EVIDENCE: There is an appropriate procedure to make sure that the individual needs of a resident are assessed before they move into the home. These assessments were in place for two clients whose care plans were examined. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8. Care plans are fully completed and are reviewed each month. The care plans should continue to be developed to be more person centred and reflect the individual’s life, experiences and preferences. The healthcare needs of residents are satisfactorily met. EVIDENCE: Feedback from individual residents was positive regarding the care provided at the home. Comments included “very good”, “its run very well” and “fine”. All residents spoken to said that staff treated them politely. Care plans were observed to be in place for two residents whose documentation was looked at and these were being reviewed on a monthly basis. Information included addressed areas such as mobility, personal care and continence. The inspector identified that life histories are now included within individual care plans. One instance was noted where the care plan stated that the resident would like some input into planning activities. The other care plan stated that the resident was willing to participate in activities and staff should Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 10 encourage this. The home should continue to identify ways to make the care plans more personalised to residents and to clearly say how individual needs / preferences are to be addressed. A review of staff roles may benefit the residents living there and help create an even more person centred service at the home. The introduction of dedicated domestic staff for each unit would free care staff from the cleaning duties they currently perform each morning. The healthcare needs of residents are met. All residents are registered with a GP and arrangements are made for regular dental, optical and chiropody care. Staff consult with appropriate health care specialists as required and residents are supported to attend health care appointments. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15. The dietary needs of residents are well catered for. Residents gave positive comments on the quality of food on offer. An improved programme of activities is available to residents arranged by a dedicated part-time member of staff. There is still scope to further improve the activity provision at the home to ensure that individual social and recreational needs are fully met. EVIDENCE: Residents gave positive comments on the food provided. Two residents said that the food was “very good” and others said “quite good”, “good” and “ok”. A residents meeting is held monthly and this includes discussion around the food on offer at the home. A lunch of pork chops was being served on the day of inspection with a vegetarian risotto as an alternative choice. Residents were appropriately supported in an unhurried fashion. The activities co-ordinator reported that they had received training on the provision of activities since the last inspection took place in June 2005. This staff member arranges the activities programme at the home that includes quizzes, sing-along, reminiscence, board games and bingo. An Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 12 additional eight hours of staff time is also now provided weekly to support the activities co-ordinator in providing these activities. The manager reported that the home now uses local community minibuses and there had been a recent trip out to Richmond Park. A further excursion is planned to see the Christmas lights in London. It is recommended that the activities co-ordinator be given full-time hours to allow for further development of the activities programme. This staff member should also not be used to cover staff breaks on units whilst doing activities with residents. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. A satisfactory complaints procedure is supplied to residents on admission to the home. Satisfactory policies and procedures are in place to protect residents from abuse. EVIDENCE: Systems are in place for recording any complaints made. One complaint has been received by the home since the previous inspection took place in June 2005. This issue was being investigated at the time of inspection. The homes policy and procedure on complaints provides information to residents on how they can make a complaint. This information is included within the Guide supplied to residents on admission to the home. None of the residents spoken to had any concerns at the time of this inspection visit. In order to ensure the protection of residents from abuse staff are provided with training on recognising and dealing with any suspected abuse. The home has a procedure for staff to ensure they are able to respond effectively to any concerns. A copy of the Local Authority Protection of Vulnerable Adults (POVA) procedure is also kept at the home for reference. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26. The home is purpose built and provides a high standard of accommodation to residents. 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. Individual bedrooms provide comfortable accommodation for residents. All were observed to be kept clean and free from offensive odour. Comments from residents included “very comfortable”, “ok” and “I have a nice view”. As highlighted in the last report, members of staff again spoke about the difficulty in helping residents with a shower in their ensuite bathrooms. The inspector tested a shower and found that it would be difficult for a staff member to keep their lower body clothing and footwear dry whilst helping a resident shower. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 15 Hoist and weigh chair equipment was stored in the quiet lounge areas of two units during this inspection visit. The inspector was informed that there was a lack of available storage areas for this equipment. It is recommended that continued consideration be given to additional appropriate signage or colours of door surrounds to help residents with dementia to more easily find their rooms. The manager reported that work had already begun in this area. Requirements have also been stated within this report about the following minor maintenance issues: second floor adapted bathroom – a wall mounted electrical switch requires repair. bedroom 44 – the ensuite bathroom light requires repair bedroom 29 – the water supply in the ensuite shower was cold. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The roles and allocation of care staff within all three units requires immediate review. This is to ensure that appropriate numbers of staff are on duty at all times for the health and welfare of the residents accommodated. An organisational training programme is in place and care staff attend a wide range of training courses. The residents accommodated would benefit from staff attending further dementia training courses. Residents are protected by the homes recruitment procedures. EVIDENCE: Residents gave very positive comments on the staff. Staff were described as “wonderful”, “nice”, “ok” and “very helpful”. One resident stated that staff “can’t do enough for you”. Three staff members spoke individually of the need to increase staffing levels at the home and to also reduce the amount of cleaning undertaken by the care staff. All three individuals said that the scheduled room cleaning each morning prevented them from spending time with the residents. The inspector saw two instances where residents were looking for staff who were then observed to be cleaning in bedroom areas. The management of the home stated that individual staff roles and responsibilities were being looked at and this process would then allow for a further review of how staff are allocated on duty in each unit. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 17 As stated earlier in this report, the introduction of dedicated domestic staff for each unit would free care staff from the cleaning duties they currently perform each morning. The home carries out appropriate checks including Criminal Records Bureau (CRB) checks on staff before they start work in the home. This process helps to ensure the protection of residents. The organisational training programme includes NVQ training and a wide range of courses such as food hygiene, equal opportunities and supervision. A mandatory one day course for staff regarding dementia is provided – it is recommended that this training be further developed to ensure best practice by staff in this area. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 18 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, 33 and 35. A well organised and effective management structure is in place at the home. There are systems in place for consultation with residents and their representatives. Records of residents’ money are maintained with suitable secure storage provided. EVIDENCE: The management team is well established and was previously in place at Chestnut Lodge prior to the relocation of the service. The registered manager’s hours are supernumerary. There are three assistant managers who each head up a team that includes a team leader, key workers (senior carers) and general care assistants. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 19 The home holds monthly resident meetings and minutes from October 2005 were seen to include discussion about food and the activities on offer. The manager stated that a full review of the service was planned for early 2006, as the home would have then been open for one year. An organisational procedure is available for resident’s finances. Individual records are kept for residents who are supported with their money. A record of falls is now maintained for each unit that can be easily used for auditing purposes. Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 2 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 X 3 X 3 X X X Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 21 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 OP19 Regulation 23 (2) (b) Requirement The Registered Persons must ensure that: the wall mounted electrical switch in the second floor communal bathroom is repaired the ensuite bathroom light in bedroom 44 is repaired the water supply in the ensuite shower of bedroom 29 is maintained at a suitable temperature. 2 OP21 23 (2) (b) (c) (n) 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. 3 OP22 23 (2) (l) The Registered Persons must ensure that suitable storage is provided for equipment in use at the home. DS0000062953.V265616.R01.S.doc Timescale for action 01/12/05 14/02/06 14/02/06 Lyle House Version 5.0 Page 22 4 OP27 12 (1) 13 (4) 18 (1) The Registered Persons must conduct a review of the staff roles and the allocation of care staff on each shift at the home. 01/01/06 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. Full-time hours should be allocated for the activities coordinator. This staff member should not be routinely used to cover staff breaks whilst doing activities with residents. It is recommended that continued consideration be given to additional appropriate signage or other methods to ensure that the first and second floor units provide enabling environments for residents. It is recommended that the dementia training for care staff be further developed at the home. 2 3 OP12 OP22 4 OP30 Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Lyle House DS0000062953.V265616.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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