Inspection on 24/08/05 for Lymehurst

This inspection was carried out on 24th August 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

Lymehurst 30/10/07

Lymehurst 21/11/06

Lymehurst 11/07/06

Lymehurst 28/11/05

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 Lymehurst 112 Ellesmere Road Shrewsbury Shropshire SY1 2QT Lead Inspector Terry Woods Unannounced 24 August 2005 09.30 th 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 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. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lymehurst Address 112 Ellesmere Road Shrewsbury Shropshire SY1 2QT 01743 351615 01743 351416 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs G Ibrahim Care Home 32 Category(ies) of 24 Old Age registration, with number 8 Dementia of places Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 32 elderly persons of which a maximum of 8 persons may be suffering from Dementia. Date of last inspection Registration Visit - 15th December 2004 Brief Description of the Service: Lymehurst is a private care home registered with the Commission for Social care Inspection to provide a full residential service for up to thirty two older people. The home is situated on Ellesmere Road close to the centre of Shrewsbury. The homes owners Mrs Ibrahim and her family operate the business with Mrs Ibrahim having day-to-day management responsibilities. The property has been converted from a large double fronted victorian family style residence and extended at ground floor level to provide comprehensive and spacious accommoidation. The Home stands in its own grounds entered from the road onto a large forecourt. There is an established staff group providing residents with consistency in a warm homely atmosphere. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 24th August 2005 over three hours and was carried out as a routine unannounced visit. A full tour of the premises took place and a sample of three staff files and three residents’ care records were inspected. Four of the staff on duty, eleven residents and four visitors were spoken during the day. What the service does well: 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. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 7 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 standard(s) 3 The home has a satisfactory and functional admissions procedure providing an effective needs assessment and evaluation of suitability for both privately funded residents and those placed by the local authority. EVIDENCE: Prospective residents at Lymehurst are admitted via either the local social work team, directly from hospital or through a private arrangement with no social worker involvement. In all cases, and confirmed in the residents’ files inspected the home’s pre admission assessment is completed to identify the person’s individual needs and to ensure that an appropriate service can be provided. It was reported that the process takes a holistic approach with consideration given to existing people in residence. It is also further complemented, in some cases, by a community care assessment or a hospital discharge document. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7, 8 & 9 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents’ personal and health care needs. A safe and effective system for the administration of medication is employed with correct records being kept. EVIDENCE: Within the care plans inspected there is good evidence of maintained health care for residents with clear and detailed notes being kept. These also demonstrated the use of professional input throughout times of need. The two proprietors reported confidently and knowledgeably about the health care needs of all residents. One resident had received hospital treatment prior to admission and spoke of the support and kindness being afforded by the home since she arrived. A member of staff competently demonstrated the administration of medication procedure. A safe and effective system is employed with correct records kept which includes a controlled drugs register as a matter of good practice. It was reported that all staff involved with the administration of medication have received comprehensive training from the local pharmacist confirmed by the presentation of completed workbooks by staff ready to be assessed. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 9 Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13 & 14 Lymehurst provides a good balanced lifestyle for the people in residence. EVIDENCE: Residents said that they are in touch regularly with friends and family members and spoke about receiving their visitors throughout their daily routine. The visitor’s book showed considerable activity. Four of the six visitors were spoken with during the morning, all of which reported that they were pleased with the service being provided for their relative. They are made welcome and were observed being offered refreshments during this time. Residents reported taking part in activities that match their individual preferences, which could include reading, walking or watching television. A large number of residents take a daily newspaper to keep up with current affairs. One resident recovering from an illness reported how he preferred to stay in his room to watch television as he could then watch whatever he wanted. He also reflected on his life together with his visiting son. He spoke of his involvement with trades unions and support for the Labour Party and further mentioned his interest in writing poetry and how in recent years he has had three books published. Residents reported on group activities organised throughout the week, which included quizzes, bingo, exercise games and visits from a ‘craft lady’. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 & 18 The home has a satisfactory and user-friendly complaints system. The arrangements for the protection of residents from abuse are satisfactory but with recognition that formal training is needed for both management and staff. EVIDENCE: The home has a complaints procedure and a complaints / compliments folder book is available on site. The home reported that they had not received any complaints within the last year. The Commission for Social Care Inspection has not received any complaints with regard to the home in the time since the last announced inspection. Residents reported that they knew what to do to make a complaint however had not found it necessary as the staff and owners were “very helpful and kind”. The home has a policy and procedure with regard to Adult Protection and the prevention of abuse, which includes whistle blowing. The home has the current edition of the county’s adult protection procedure document. Management advised however that no one has yet attended ‘Protection of Vulnerable Adults’ training. In discussion it was therefore noted that this is an identified training need for both the proprietors and all staff in future. The home has no involvement with service users’ financial affairs and residents either manage their own affairs or rely on family members for support. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19, 23, 24, 25 & 26 The home is constantly improving the environment to benefit those in residence. EVIDENCE: The home has recently been extended by adding a new wing to provide ten more bedrooms all on one level. This is now being occupied by residents. A further development being considered is an older wing, which will be demolished and rebuilt to higher standard. The bedrooms were all seen to be equipped with appropriate furnishing, sinks and window restrictors. It was seen that most of the bedroom doors had been fitted with appropriate locks and those that are not are unlikely to remain in use for much longer. The building was seen to be warm, bright and well ventilated. The communal space within the home currently consists of a large lounge area, two dining rooms and two further sitting rooms. A paved terrace area to the rear of the building was installed as part of the upgrade programme. Furnishings in communal rooms are in an acceptable condition. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 13 The appropriate number of toilets and baths were available in the home. One bathroom will be demolished and replaced as part of the second phase rebuild. The home was seen to be clean and with the exception of one room is reasonably odour free. Issues of incontinence are being addressed and in this particular resident’s room a new floor covering has been ordered that will make this more readily cleanable. Another resident’s room (15) had frayed carpeting at the doorway, which presented as a trip hazard. The owner gave assurances that this would be attended to immediately. Laundry facilities were seen to be appropriate and included a sluicing washing machine. The floor was seen to be of an impermeable material with hand washing facilities being available. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 There is a stable staff group working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations EVIDENCE: A fully detailed staff duty rota was seen. Appropriate staffing levels were seen to be in place with extra staff being on duty in the mornings, when doctors and district nurses are most likely to visit and may require the attention of staff. All staff are over the age of eighteen and those left in charge of the home are all over twenty-one. The care staff are supported by two cooks and domestic support staff. The home’s recruitment procedure is robust and includes an application form, interview process and two references. All staff have a Criminal Records Bureau check completed prior to starting. These documents were observed within a separate file inspected. Staff files are kept to the standard required and current photographs have also been inserted. Records confirmed that the home has adopted the TOPSS induction and foundation training schemes. They also confirmed that all staff have completed their statutory training courses including food hygiene due to all staff being required to handle or serve food. The manager reported that the home had joined Shropshire Partners in Care and are benefiting from their input and of the training on offer. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36 & 38 The systems for monitoring the quality of the home including resident consultation are good with evidence suggesting that their views sought and acted upon. The home does not provide staff with satisfactory formal supervision. EVIDENCE: The current manager, Mrs Ibrahim, has many years of experience in the care profession and of managing the home. However she has no desire to pursue further qualifications and her son Mr Tay Fun Siuri who is nearing the completion of the Registered Managers Award / NVQ level 4 will be submitting an application to register as manager in the near future. Some residents at Lymehurst are articulate and able to voice their views and opinions and reported that staff listen to them and issues are acted upon to their satisfaction. The home also carries out a resident / family satisfaction Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 16 survey regularly every six months. These however were not made available to the inspector. Positive comments were seen though from a compliments folder used regularly by family members and friends of service users in residence to reflect the quality of their relatives care. There is now evidence of staff appraisals being completed however the supervision of staff still has not commenced. The recording of incidents was seen to be carried out in a Data Protection act compliant format and filed appropriately. The required policies and procedures were seen to be in place with evidence that these have been reviewed. Records showed and staff confirmed that they had received appropriate manual handling, first aid and infection control training. Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x x 2 x 3 Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 18 yes 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 18 Regulation 19.5.b Requirement The home is required to ensure that all staff and managers receive appropriate ‘Protection of Vulnerable Adults’ training. The home is required to replace the carpet in the previously identified resident’s room with a more readily cleanable floor covering as discussed The home is required to repair the frayed carpeting at the doorway of room 15 The home is required to provide formal and recorded staff supervision at least six times a year. Timescale for action 27.10.05 2. 24.4 23.2.d Immediate 3. 4. 24.4 36.2 13.4.a 18.1.c.i immediate 27.10.05 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 Good Practice Recommendations Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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 Lymehurst E56 E01 S61052 Lymehurst UAI V217036 240805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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