Inspection on 30/05/07 for Lyme Valley House Care Home

This inspection was carried out on 30th May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lyme Valley House Care Home 01/09/09

Lyme Valley House Care Home 09/06/09

Lyme Valley House Care Home 27/11/08

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lyme Valley House Care Home 115 London Road Newcastle under Lyme Staffordshire ST5 7HL Lead Inspector Mr Keith Jones Key Announced Inspection 30 May 2007 09:00 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 Lyme Valley House Care Home DS0000068766.V334933.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 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. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyme Valley House Care Home Address 115 London Road Newcastle under Lyme Staffordshire ST5 7HL 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) 0115 926 1461 Ravinder Singh Thiara Mrs Gaynor Trinder Care Home 26 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (3), Mental disorder, excluding learning of places disability or dementia (2), Old age, not falling within any other category (26), Physical disability (10), Physical disability over 65 years of age (10) Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. PD - registered for 10, 2 of whom may be aged 55 on admission. PD(E) - registered for 10, 2 of whom may be PD age 55 years on admission. MD(E) - registered for 2, both may be aged minimum of 60 years on admission. Date of last inspection Brief Description of the Service: Lyme Valley House Care Home was a large, Victorian house that had been extended to provide accommodation for a total of 26 people who were elderly; ten may have physical disabilities of whom two may be a minimum of 55 years on admission; three may have dementia care needs; two may have mental health needs and be a minimum of 60 years on admission. The home was situated on a corner plot, fronting the main A34 road. There were small gardens to the front and side of the property. To the rear there was a large secure, paved patio area with raised flowerbeds and a fishpond; there were also car-parking facilities on site. Lyme Valley House has situated close to the market town of Newcastle-underLyme with its wide range of amenities and communal facilities. The A34 road was a main public transport route with access to a wide area. Communal facilities consisted of three lounges, a quiet lounge (used by some as a dining area), a large, attractive heated conservatory and dining room. There were three assisted bathrooms and nine separate toilets. There was a laundry, large kitchen and office on the ground floor. The upper floor was accessed via a shaft lift, stair chair lift and staircase. There was an additional staircase that was used by staff only. Gardens were well maintained with mature planting, a waterfall and small pool and patio area with garden furniture and parasols for the benefit of service users. The current scale of charges was from £325 to £345. It was understood that where accommodation and care needs were publicly funded the home was asking service users for a “top up” of fees. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was conducted by one inspector, with the Care Manager and senior staff. The last inspection report was discussed, and it was noted that all requirements and recommendations made had been addressed. A prepared pre-inspection report was presented in good time, enhancing the inspection process. 15 Comment cards were received from relatives, residents and placement officers, all complimentary. The tour of the home was carried out in a relaxed, courteous and professional manner; everyone concerned expressed confidence in the atmosphere. All the service users and visitors approached were highly complimentary of the care, service and attention they received from a willing, attentive care team. There were 22 residents registered on the day of inspection, seven categorised as receiving dementia care. Three service users were case tracked, confirming the establishment of a well run home, yet comfortable and ‘homely’. Everyone appeared relaxed and at ease with their surroundings. The general state of décor and furnishings is in need of a systematic review for upgrade in both personal and communal areas. A sample review of the administration confirmed solid practice, and effective management. A feedback session was offered at the end of the inspection, with open discussion with the Care Manager and team leader. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: The Home is well organised, with a committed care management team under the direction of a new Registered Provider of care. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Personal care is of a high standard with named, and key workers actively deployed. The emphasis is on the team spirit and family feel, to create an environment conducive to good care practice. Assessment procedures and care planning are of a good standard, offering detailed information on each resident’s progress in the meeting of objectives. Monitoring and review are thorough, achieving sensitivity in applying good personal care and practice. Key maintenance of satisfactory staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 6 Overall the attitude in meeting health, social and organisational demands is recognised. What has improved since the last inspection? 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. Lyme Valley House Care Home DS0000068766.V334933.R01.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 Lyme Valley House Care Home DS0000068766.V334933.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5 The quality in this outcome area is adequate. The Statement of Purpose has been reviewed, and has addressed the major issues, in an impressive document. The Home ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. The Home ensures that prospective residents have the necessary information to enable an informed choice to be made. All residents have contracts of terms and conditions of residence at the home a copy of which is on resident’s files. The document was examined and reflects a realistic agreement of the Home’s terms and conditions. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 9 EVIDENCE: The revised Statement of Purpose represents a much-improved description of the home’s aims and objectives, philosophy of care and terms and conditions. It offers service users and their relatives the opportunity to make an informed choice about where to live. It is stated that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also contains the terms and conditions, which are discussed with service users and relatives prior to admission. This document still refers to the NCSC for addressing complaints. A separate, ‘reader friendly’ Service User Guide would benefit all concerned. A pre-admission assessment, carried out by the Care Manager, or deputy, appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on personal needs and a daily living process. The Home demonstrated, through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The assessor also makes a judgement as to the suitability of each prospective service user using the same criteria. At all times the family is kept fully informed of the situation, offering service users and their relatives the opportunity to make an informed choice about where to live. The home did not provide intermediate care. Lyme Valley House Care Home DS0000068766.V334933.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The quality in this outcome area is good. The Service Users’ assessment provides the base from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has an effective GP provision, that visits the home on request. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. There exists a straightforward, yet effective medicines administration system, secure and accurately monitored and actioned. EVIDENCE: Three case records were examined and found to offer a clear, well balanced, up to date and accurate appraisal of requirements. Reviews were done on a minimum of once a month, usually more often, as needs dictate. Case tracking Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 11 of those three residents confirmed the depth of care planning supported by a solid foundation of organisation and quality services. The Home has good links with specialist services – GPs and District Nurses. A profile of the service user’s social, physical and psychological status offered an individual plan of care, based upon a model of daily living, to be implemented and frequently reviewed. Each service user’s health, personal and social care needs were seen to be assessed in an individual plan of care that is reviewed monthly, including service users and relatives views, to reflect their changing needs. That review is more frequent, dependant upon the individual’s needs and clinical condition. A tour of the premises evidenced that there was a range of pressure relieving equipment, and examination of service users’ plans found that all are assessed in relation to pressure sore risk, falls risk and nutritional risk. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. “ It’s lovely in here”, ”They always try and listen to me, it was really nice” were some of the comments offered by residents. Carers were seen to interact with residents with purpose and compassion. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. The administration of medicines adheres to procedures to maximise protection to service users. The storage and stock was secure. Added security for controlled drugs storage was advised, preferably in a wall-bolted metal cabinet in the adjacent office. A controlled drug register was examined and found to be in order. The procedure for handling accidents and incidents was inspected and found to hold a policy of referral for medical/paramedical opinion if in doubt. Reports were informative, detailed and meaningful. The Care Manager was advised to analyse accidents on a 3 monthly basis. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. There was also an observed knowledgeable, and positive attitude by staff towards residents, and feedback from the residents: “I feel well looked after here, and “ nice home, comfy and friendly” “good staff, very helpful” The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out. The spiritual needs of service users were recorded and observed by the staff, with due respect. Lyme Valley House Care Home DS0000068766.V334933.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is good. This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. Those who wish to bring in personal possessions are encouraged to do so. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The home operated a four-week menu providing a varied, nutritional and well balanced diet; service users had a choice of meals and were also offered alternative choice. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it at lunchtime, when a very attractive luncheon was presented. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 13 EVIDENCE: Discussions with service users and staff clearly identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with, but for a point of familiarity. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are routine events to the day they could relate to. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The good standards of catering offered a satisfactory service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. A very pleasant lunch was served during inspection, with choices available, served in a wellfurnished and clean dining room. Three meals were provided daily, with hot and cold beverages and snacks available throughout the day. Service users that were interviewed confirmed that that the quantity and quality food provided was good. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. It was confirmed that the cook knew each service user, and some of the relatives. Diversity was discussed with the cook, who indicated her awareness in meeting individual needs. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook, and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. Lyme Valley House Care Home DS0000068766.V334933.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The quality in this outcome area is good. The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. No complaints had been received via the Commission since the last inspection. Service users’ legal rights are protected by the systems in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The complaints policy was seen and records examined. The Home has a comments book held at reception, which would better deal with minor complaints if held in a separate record in the Care Manager’s office to evidence the handling of resident’s and families concerns in a meaningful and effective manner. However, on discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. No complaints had been received via the Commission since the last inspection. The overall policy of openness and transparency was acknowledged. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 15 All service users had received information on the procedure to complain, including reference to the CSCI. This process was evidenced on examination and case tracking as previously reported upon. Discussion with the Care Manager confirmed that there continues to be evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. However the policy and procedure for handling issues of abuse was examined, and found to need a review in defining and actioning allegations. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 25 Quality in this outcome area was “adequate”. This judgement has been made using available evidence, including a visit to the service. Service users individual rooms were sufficient to meet individual needs. There was a need to introduce a rolling programme of refurbishment of personal and communal areas of the home to meet the needs of current service users. On inspection, most bedrooms were highly personalised with most displaying service user’s own furniture, and with personal belongings. Lounge areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a good standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 17 EVIDENCE: A tour of the Home, service departments, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The surrounding garden areas were well maintained, following recent attention by a contract gardener, providing a pleasant area for relaxation for the coming warmer months. Internal access was facilitated with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. On admission the Provider or Care Manager assesses each individual service users’ needs for equipment and necessary adaptations. Efforts had been made to provide a homely atmosphere, although it was noticed that wallpaper and doorframes had been damaged, especially in corridor areas around the home. It was understood that a programme of redecoration/refurbishment had been undertaken since the arrival of the new Registered Provider, which had begun to address the lack of investment over the past few years. A development plan based, on a building environmental risk assessment, for 2007/08 and 2008/09 is to be prepared for CSCI examination. The home provided three lounge areas and reception area that were pleasantly decorated, providing essential furnishings and items to provide a comfortable area where service users were able to interact with fellow service users, or to entertain their guests. The conservatory leading to the garden provided a tranquil area where service users could experience the views of the surrounding grounds. There was a spacious dining area where service users were able to dine in comfort. Toilets and bathrooms were located on both floors and were in close proximity to bedrooms and communal areas. The toilet annex on the ground floor is in need of renewal regarding décor and flooring. Staff were reminded to cease storing items on toilet cistern lids. Bath hoists were seen to have been regularly serviced. The boiler room door needs securing. Bedrooms were well maintained to meet service user’s personal preferences. On inspection, most bedrooms were highly personalised, with some displaying service user’s own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration. There is throughout a need to review tired furniture and decoration, although clean, comfortable and homely. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 18 An effective intercom and call system is installed; care staff reacted speedily to tests. The Care Manager expressed a willingness to meet any reasonable demand for special needs. A locked facility and lockable bedroom doors are made available on request, following suitable risk assessment. The evidence seen on recent Fire inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. New locks were seen to have been fitted to five bedroom doors. Kitchen presentation showed good standards of cleanliness, and evidence of sound food hygiene practices. The laundry was organised and equipped to a sound, domestic standard. Consideration to the flow of laundry through the process would enhance cross infection control. Notices regarding chemical handling in the areas that store chemicals are displayed. The process would benefit from COSHH poster displays in all areas dealing with chemicals. Heating and ventilation were found to be satisfactory and lighting was domestic in style. Aids, adaptations and equipment were available throughout the Home. Fire equipment was inspected and seen to be serviced and up to date. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is adequate. Staffing levels were seen to be adequate to meet an expected demand, the daily care staffing rota showed adequate balance between skills and qualifications, although numbers fall short at times for several hours in the evening to provide a good standard of care. The Provider and Care Management have established a procedure for interview, selection and appointment of staff, which requires reinforcement in ensuring the protection of service users. Staff training records complement the effort placed into staff training. EVIDENCE: Three weeks of off-duty were examined, and showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. However, there were times when staffing levels fell below recommended levels, especially in the evening and at weekend. The Care Manager was required to remedy this situation. The Care Manager works 16 hours a week on shift coverage, and is supported by an able team of carers, led by an experienced deputy. Bank coverage has Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 20 been used occasionally to support shortages of care staff, in tandem with overtime and flexible rostering to meet shortfalls. Agency staff are rarely used. At the time of inspection the duty rotas confirmed a staff coverage as thus: a.m - 1 senior 3 carers p.m - 1 senior 1 carer N.D - 1 senior 1 carer It was felt that the geographical layout, and resident activity from 1630 hours to 2200 hours required 3 carers on duty to meet needs. The Care Manager will address a review of shift structures to accommodate the requirement. There is a satisfactory complement of housekeeping and catering staff. The Provider and Care Management have established a procedure for interview, selection and appointment of staff. Three staff files were sampled and found to be generally well organised. Each staff file would be more informative with a copy of job description, interview record to support the letter of appointment, a suitable photograph of each staff member, and a contract of employment for all staff. Two members of staff were spoken with, each being pleased and satisfied with the professional foundation offered to them through effective management. Service users are supported and protected by these practises and all new staff goes through an induction process that will ensure that they are going to be the right person for the home. The Care Manager is committed to a learning environment. She holds a level 4 NVQ, coaching and D32/33 Assessors Award. Induction programmes are meaningful and well established, forming the base upon which in-service supervision and training are planned. Overall the evidence shows a satisfactory account of a training programme and record, that offers a full understanding of training needs. Eight members of staff hold a valid certificate in first aid, and ten care staff have a NVQ level 2 or 3 qualification. Supervision is conducted by the Care Manager, which would be better maintained with delegated responsibilities, cascaded throughout the staff, to include all staff, on a two-monthly basis. Records should be signed and dated to determine ownership. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. This judgement was based on discussions with the Registered Care Manager, the examination of the home policies and procedures with regards to the effective management of the home, general observations during the process of the inspection and discussions with service users and staff. The Care Manager has consistently demonstrated the appropriate skills and experience to effectively manage the home. There is a confidence apparent in the interaction of residents, staff and the Home’s management, that demonstrated a highly personal and positive relationship that pervades throughout the Home. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Provider and Care Manager have begun to develop a formal approach to monitoring quality across a wide range of activities. This includes a care plan review process that is recorded at least once a month, and a staff training programme. This will be enhanced with completion of a risk assessment programme, in the setting of objectives, effective budgeting of plans and target dates to aim for. Mrs Trinder, the Care Manager, has been able to influence the planning in setting objectives on short-term and longterm planning. Evidence was secured to acknowledge achievements, ongoing and planned objectives. Involved within this process are the views of service users and relatives, confirmed at case tracking and informal discussion. The Provider continues to offer a monthly Regulation 26 report to CSCI. Social Workers’ review meetings are often a vehicle for assessing quality. Three residents’ files inspected evidenced a satisfactory standard of maintenance and security. Care plans were drawn up, implemented and reviewed on a monthly basis. This process would be enhanced with the inclusion of service users and relatives whenever possible. Case tracking and informal discussion provided evidence that participation is encouraged on an informal level. Residents and family meetings were held recently on a Cheese and Wine platform, which has proven popular and informative. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. These included procedures on abuse (needing review), COSHH and management of communicative diseases. Service records for water supply; gas, PAT testing, and disposal of hazardous waste were examined. It was advised that a satisfactory servicing of the water system, with regards to identifying Legionnaire’s disease was appropriate. Routine maintenance ensures that essential services linked to utilities and safety, are monitored and serviced on a regular basis. The manager confirmed in the pre-inspection questionnaire that the home was not involved in any financial transactions on behalf of service users, preferring relatives and professional advocates to undertake these activities. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions. This has been enhanced with a recent (1/06/07) Fire inspection. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. No serious accidents have Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 23 been reported. A three-month analysis was advised, with added security on filing and recording accidents. The administration and management of the home is effective, uncomplicated, and very sensitive to the needs of service users. Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 24 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 2 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 16(2)(c) Requirement The registered person shall introduce a rolling programme of developments to upgrade furnishings and décor, for 2007/08. That staffing levels meet satisfactory levels to provide a good service. Timescale for action 01/08/07 2 OP27 18 1 (a) 01/08/07 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 OP1 Good Practice Recommendations A Service Users Guide needs to be produced to offer easy reference to the aim and objectives, and the facilities available in the Home. Utility rooms be made secure when not in use. A minor complaints book be established, and a 3 monthly analysis take place. 2 3 OP38 OP16 Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 26 4 5 6 7 8 9 5 9 Update procedure manual regarding abuse. That a water certificate be obtained to reflect servicing of the system and checked for routine Legionella clearance. You demonstrate robust recruitment, application and interview procedures within the home. That staff supervision records be signed and dated by both parties. That Controlled drugs be stored in a wall-bolted metal cabinet. That renewal of the toilet annex ground floor be completed. OP29 OP36 OP9.5 OP19 Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 © 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 Lyme Valley House Care Home DS0000068766.V334933.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!