Inspection on 06/03/08 for Lymewood Nursing Home

This inspection was carried out on 6th March 2008.

CSCI found this care home to be providing an Adequate service.

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

Lymewood Nursing Home 26/03/10

Lymewood Nursing Home 04/02/09

Lymewood Nursing Home 25/08/06

Lymewood Nursing Home 09/02/06

Lymewood Nursing Home 05/08/05

Lymewood Nursing Home 10/02/05

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

CARE HOMES FOR OLDER PEOPLE Lymewood Nursing Home Lymewood Nursing Home Woodhouse Uplyme Lyme Regis Devon DT7 3SQ Lead Inspector Ms Rachel Fleet Unannounced Inspection 6 March 2008 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 Lymewood Nursing Home DS0000061709.V359765.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. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lymewood Nursing Home Address Lymewood Nursing Home Woodhouse Uplyme Lyme Regis Devon DT7 3SQ 01297 445444 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) Lymewood Care Ltd Mrs Helen Mary Gray Care Home 37 Category(ies) of Dementia - over 65 years of age (37), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (37) Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. You may admit up to five service users with Dementia (DE) aged over 55 years, subject to individual assessment by local care management teams. 25th August 2006 Date of last inspection Brief Description of the Service: The home provides accommodation and personal care (including nursing) for people over 65 years of age, who have needs that relate to dementia or a mental disorder. The home can also admit up to five people aged 55 - 65 years old with similar needs. A maximum of 37 people can be accommodated. Lymewood Care Ltd. has owned Lymewood since November 2004, with Mr Paul Stratton acting as the Responsible Individual for the company. Set in a beautiful rural location about two miles from Lyme Regis, access to the home is via the centre of the village of Uplyme. The entrance drive off the Woodhouse road is not used. There are parking areas around the home. The home has a ‘people carrier’ vehicle, used to take people for hospital appointments, etc. Accommodation is on three floors, with all areas serviced by stair lifts, and a passenger lift between some areas. The manager therefore assesses the suitability of bedrooms for prospective residents, considering the room’s location and the person’s level of mobility. Some double rooms are available, and a number of the single rooms have en suite facilities. There are two lounge-diners and a separate dining room off the entrance hall to the home, with a small lounge at the far end of the newer extension from the main house. There is a hairdressing room, with an adapted sink. People who would be at risk should they leave the grounds unescorted can be given a device that alerts staff if they go through the gate into the drive. They can thus walk freely in the home’s extensive gardens, with support given if they go further afield. In certain circumstances, people are able to bring existing pets with them, when they first move into the home. Weekly fees at the time of the inspection were £525 (residential care) - £625 (nursing care). These did not include the cost of newspapers, toiletries, Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 5 hairdressing, and chiropody – which are charged at cost price. Inspection reports produced by the Commission (CSCI) about the home are available directly outside the manager’s office. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place as part of our usual inspection programme. Our unannounced visit to the home lasted 10 hours, which included time spent with the manager Helen Gray discussing our findings. Brian Brown, Pharmacist Inspector, assisted Rachel Fleet with the site visit, to look specifically at how the home deals with peoples’ medication. We had carried out a ‘themed unannounced inspection’ in September 2007, to look at the quality of care people with dementia experience, focussing on dignity as part of people’s quality of life. Two requirements were made as a result of that inspection. Firstly, that care plans are drawn up with the knowledge of the person they relate to and include the action staff must take to meet the person’s assessed care needs. And that suitable activities are provided according to the interests of each individual person. A CSCI questionnaire on the home (the Annual Quality Assurance Assessment, or AQAA) had been returned prior to this visit, completed by Helen Gray. This included current information about the service, staff and people living at the home, some assessment of what the home does well, and any plans to improve the service, including how previously made requirements have been addressed. CSCI surveys were sent to 30 residents or their representative, before our visit. There was an excellent response, with 28 returned (26 completed by or with help from relatives, and one completed with help from staff), 26 of which were positive about all aspects of the service they received. We sent 12 care staff surveys to the home, asking for half to be given to day staff and half to night staff. Seven were returned. Of eight surveys sent to relevant community-based health or social care professionals, three were returned, all being positive about the home. There were 28 people living at the home at the time of our visit. We spoke individually with at least 10 people around the home. Not all were able to give us their views in depth because of their communication difficulties. The inspection incorporated ‘case-tracking’ of three people living at the home, including new residents and people we wished to follow up as a result of information from the AQAA, surveys, a period of observation we carried out at the start of our visit, and the last two inspections (to see if certain issues had been addressed). Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 7 This involved looking into their care in more detail by meeting with them, checking their care records and related documentation (pre-admission assessments, etc.), talking with staff, and observation of care these people received. We spoke with three visiting relatives, four members of the care and ancillary staff, and the manager. Other records seen included those relating to staff, health and safety, and quality assurance. A tour of the building included the kitchen and laundry. Information gained from all these sources and from communication with the service since the last main or ‘key’ inspection (on 25 August 2006) is included in this report. The Commission recently received one complaint about aspects of nighttime care at the home. The responsible individual is currently investigating these allegations, as agreed with the local authority’s Safeguarding Adults team. Since the site visit, we have met with Mr & Mrs Stratton (Mr Stratton being the Responsible Individual), and Helen Gray, the Registered Manager, at their request. They assured us that action has been taken to address the requirements made in this report. What the service does well: When asked this question in our surveys, several people living at the home or their relatives responded. Comments representative of more than one person included: “Seem to have the patience of Jobe – nothing is too much bother for them. Visitors are always made welcome.” “Always clean and tidy, and cared for very well.” “A friendly caring atmosphere at the home.” Someone added “Provides delicious food” and “Creates an atmosphere where staff seem genuinely happy and motivated in their work.” Others also listed other positive aspects - communication, treating people living at the home with respect, organisation of activities, response to medical needs, and cleanliness or freshness of the home, as well as the above. One said, “The care they provide is the best I have seen – a credit to registered providers and staff.” We found the home had admission practices that ensure that the home can meet the needs of those who go to live there. A community-based professional wrote that staff managed two peoples’ mental health problems sensitively and thoughtfully, from the service users’ and their Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 8 relatives’ perspectives. We found multidisciplinary working at the home ensures people receive necessary health care, and they benefit from a balanced, varied diet that is suited to their needs and preferences. The home has an experienced manager, with various strategies used to try to ensure it is run in the best interests of the people living there. This is supported by the home’s recruitment policies. People can be confident that complaints are taken seriously. There is attention to peoples’ privacy, promoting their dignity, as well as practices that promote peoples’ choice and control in their lives where possible, promoting their rights. A professional said the home “Provides a caring, specialist care environment. Recognise residents as individuals, including their sense of humour, fears/worries, their past history and experiences, as well as looking at the group dynamics and needs.” A third felt “The staff know the residents very well and try hard to anticipate and meet all their needs.” We found people benefit from being looked after by a stable, caring staff team, which has a level of knowledge and skills that ensures their basic safety. People have accommodation that is homely and clean, benefiting from ongoing improvement of facilities internally and externally. Social activities, and links with the community outside the home ensure that most people enjoy varied daily lives and beneficial relationships. What has improved since the last inspection? What they could do better: There were some suggestions, in surveys, for improving the service. A relative suggested, “Improve system for informing all carers, on all shifts, of deterioration and changes to residents, plus therefore the necessary action to be taken during their shift.” We found that all care staff have handovers at the start of their shift, and sign a record confirming this. They work under the supervision of a nurse and a senior carer during their shift. We also found that further person-centred improvement in care planning was needed, to ensure that people receive more individualised care or support to meet their current and changing needs. A more person-centred approach to social care also, with provision of more meaningful activities for less able people, would help ensure people have equal opportunities for fulfilment. One person suggested that a secure garden space would be an improvement – where people could safely walk (unaccompanied) from house to garden to house. We are aware, however, that improvements are being made - such as a greenhouse that will accommodate wheelchair Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 9 users, and raised flowerbeds – so that more people can take part in outdoor activities. Medication policies and practices must be revised, to minimise any risk to peoples’ safety. We have been assured this is being fully addressed, with revised policies provided. The home’s safeguarding policies and procedures must be made more robust, so that people are fully protected from abuse. Attention to aspects of risk assessment would help to ensure the safety and welfare of people at the home. More staff training and development relevant to specific as well as shared needs of people living at the home - for all levels and roles of staff or management - would ensure that peoples’ current and changing needs will be met and met competently. 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. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 10 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 Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 11 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 & 3. The home does not offer intermediate care (Standard 6). Quality in this outcome area is good. People benefit from admission practices that help to ensure that the home can meet the needs of those who move in. However, information is not yet available to people with diverse needs, so they may not be able to make a fully informed choice about where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose is available outside the office, giving required information in a standard format. Surveys said people had enough information before moving in, to help them decide if the home would be suitable. Some surveys showed peoples’ families had visited the home to help them choose where to live. One relative told us they felt “very fortunate to have found it through a personal recommendation,” with their relative being very content at the home. One person said they had had no choice of home Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 12 because of the nature of their relative’s needs, but were very pleased with the home now their relative was living there. The manager told us they were hoping to produce information about the home in a more suitable format for people who have more diverse needs due to dementia, once they got some pictures to supplement the text. People we followed up had had assessment of their needs by senior staff from the home, before moving in. We discussed with the manager that quality of these assessments varied regarding levels of information about peoples’ medication, and their social or psychological needs. This knowledge can be particularly important when caring for someone with dementia. The manager agreed to address this, with reference to the National Minimum Standard, when assessing prospective residents in future. The manager told us, before they move in, everyone is sent written confirmation that the home can meet their assessed needs. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 13 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 – 10. Quality in this outcome area is adequate. Multidisciplinary working ensures people receive health care they need, and there is attention to peoples’ privacy, promoting their dignity. However, careplanning procedures do not to fully ensure staff will meet all care needs, including peoples’ changing needs. Planned improvements to current policies and practices will ensure medication is administered properly, avoiding risks to peoples’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two relatives said the home were ‘outstanding’ at meeting the needs of the person living at the home – one adding they were “flexible, ever-present, reasonable in the face of unreasonable requests, endlessly patient”. Of three people we case-tracked, there was evidence that one family had been involved in the care planning for their relative, and another had been Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 14 consulted about one particular aspect. Two care staff told us they did not or rarely saw peoples’ care plans, but were able to tell us peoples’ current basic needs as we saw noted in their care plans or observed during our visit. One survey said, regarding how the home might improve, ‘Improve system for informing all carers on all shifts of deterioration and changes to residents plus therefore the necessary action to be taken during their shift.’ Care plans we saw were generally detailed with regard to peoples’ personal or physical care needs, but there was less regarding their social or emotional needs and what staff should do to meet these - how they should help people spend their time so each individual had positive, meaningful experiences each day, etc. This was also reflected in our findings about pre-admission assessment of peoples’ needs. We saw staff had begun to get information about peoples’ life histories, their interests, important events or people in their lives, etc. This was partly in response to a requirement made following our themed inspection. The home also requests information from relatives, getting a good response from some but no information from others. A district nurse said they visited regularly to assess or review people, and the home sought advice, when required, from the multidisciplinary team. Care notes we saw showed regular contact with medical staff, including recent medication reviews. A staff member said the matron had gone to see one person when they reported the person had not eaten much at a meal; care records showed staff had contacted specialist community staff (SALT team) about someone’s weight loss. Pressure-relieving equipment was seen in use around the home. Service users’ surveys said they always got the medical support they needed, and relatives felt peoples’ needs were usually or always met. We discussed with the manager that the home’s medication policies needed reviewing urgently - regarding decanting medicines into other containers, insulin, and unwanted medications, for example - to ensure good guidance for safe handling of medication. Also, a ‘potting up’ system was used for administering medicines around the home. This is not considered safe, as it is a secondary dispensing system. We were told the home is getting a medicine trolley, but we also discussed other ways of ensuring safer administration. The manager agreed to change to a safer direct administration system. Peoples’ medication charts were handwritten, with two signatures to confirm the entry was correct. There was a good record of medicines received monthly, but incomplete records for medicines received outside of this cycle. Two peoples’ care plans lacked information to help staff determine when certain medicine was to be given, including intervals between doses and other necessary actions. The manager agreed to urgently review such care plans, to Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 15 clarify how ‘as required’ medicines and medication prescribed with variable doses are to be used, and how staff are to make the decision to use it. The controlled drugs cupboard met current regulations other than how it was secured, which the manager agreed to address urgently. One medicine was stored correctly, but not recorded in the relevant register. The home had a medicines fridge, with records kept of current temperatures, but not maximum or minimum temperatures. The manager agreed to ensure this was done. One person wrote that their relative “is treated like a person and an individual, as are all the residents.” Some bedrooms have a particular door lock such that people can leave their room freely but a key is needed (kept on the door frame) to enter it, so that people could not easily walk in uninvited. We saw one person was in a double room but as the sole occupant. A staff member said they used portable screens to promote privacy if two people occupied rooms. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 16 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 – 15. Quality in this outcome area is good. There are practices that promote peoples’ choice and control in their lives where possible, promoting their rights. Social activities, and links promoted with the community outside the home ensure most people enjoy variety and beneficial relationships in their daily lives. However, a more person-centred approach to social care would help ensure less able people have more fulfilling lives. People benefit from a balanced, varied diet in improved surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One person said their relative living at the home was “able to carry on having as normal a life as is possible bearing in mind their Alzheimer’s.” A relative, asked what the home does well, said they always strived to involve people in activities and also relatives wherever possible. Most surveys were positive about activities provided. Three said ‘Not applicable’ or that the person was unable to take part in anything arranged by the home, although one thought their relative enjoyed the atmosphere at the time of activities. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 17 Minutes from a relatives’ meeting in January 2008 included Christmas entertainments and carol singing that had been enjoyed. A staff member said there had been a trip to Seaton recently, with the more able residents going on such trips. Activities planned for the week (Monday-Friday) were listed in the entrance hall: armchair aerobics, Memory lane, art, jigsaws, colouring, with ‘headlines’ and hand massage daily. One person, who told us they used to sing in a church choir, said they attended ‘some sort of service’ at the home. The manager explained that, although the home has been unable to arrange regular church services at the home, a group visit to lead hymn-singing. A notice in the hall showed the home had raised money for outside charities as well as for the residents’ fund. We spent two hours observing in a lounge, in the morning. At least one staff member was always present. Generally, staff interactions were well intentioned and usually friendly. A staff member spent some time encouraging a group conversation with three people. Four people were invited to make Easter cards. But occasionally staff did not engage with people and did not use opportunities to promote their general sense of wellbeing or to show general respect (- see also the section on ‘Staffing’). This was also identified at our ‘themed’ inspection carried out in September 2007. Of four people we particularly observed, staff engaged little with two of them. A third person was more able, and initiated conversations with staff or peers. The care plan for one of the less able people we observed included giving them hand massages, but did not reflect their likes/dislikes, interests, abilities, or individuality well; staff we asked said they were not able to participate in much that was organised. We saw some information in some peoples’ care records about their previous experiences, work, interests, etc., but not for everyone living at the home. Staff are currently addressing this, because such information helps staff understand and engage with people better as individuals. A file kept for recording activities included each individual’s response to the event, which is very good practice. However, there were relatively few entries (one a month in some cases), and it was not clear that these events linked to individuals’ preferences, hobbies/interests, etc. We also discussed with the manager whether separating this information from other care records might prevent a person-centred, holistic approach to care that is important when caring for people who have dementia. The manager said the activities coordinator was soon going on a relevant course, which we were told at our last inspection also, and hoped to subsequently develop the activities or meaningful occupation of individuals’ time. A relative who lived some distance away, when asked what the home does well, said that the home kept in touch with them by phone. One said although Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 18 they visited twice a week they were still kept well informed about their relative’s needs by staff. Another said the home informed them of emergencies quickly. Another answered that the home ‘takes time to understand the importance of family and effect dementia has on them as carers.’ Others reflected these views. Staff used peoples’ preferred name or form of address as recorded in their care notes. Surveys confirmed staff always or usually listened and acted on what people said, one person adding the staff were very attentive. One person’s care plan said they liked to get up early, before 6am sometimes. Bedrooms were personalised with peoples’ own property. We asked staff how they promoted or enabled choice for people who might have difficulty expressing themselves clearly – such as for meal choices, how people got staff attention if they needed it, and bedtimes/rising times. They talked about giving them options (when serving meals, for example), or knowing peoples’ usual routine or preferences. A new staff member said they found out peoples’ dietary preferences from information kept in individuals’ bedrooms. One staff member said night staff sometimes helped people wash and dress if they found them out of bed in the mornings. They also said people were given a call bell, or staff were always in the lounge areas. Comments about the food included, “The food is excellent!”, “The variety is good”, “There is always good home-cooked food both for the residents and at functions, and even home-made cake with your coffee,” and meals “look good and smell appetising.” One survey said the person did not eat well, but the home tried to find things they liked and encourage them to eat. Menus showed a varied, balanced diet was served over the week. We saw fresh vegetables served at lunch during our visit. The manager said the home offers a lot of fortified milky drinks, to ensure people get enough nourishment despite the difficulties experienced by people with dementia. Dining areas have been improved since our last main inspection, with new furniture obtained for all three areas. Meals were pre-plated and taken to individuals, with the different components of pureed meals kept separate so these meals also looked attractive. Staff said people were given the meal of the day, and could then ask for something different if they didn’t want what was brought to them. We noted that people were not told what the meal was, even if a pureed meal, and some confirmed this was not unusual. The manager agreed to address this with staff. We saw catering staff sat with individuals, helping them with their meal in an unhurried manner; communication was limited, and the staff we asked said they had not had training on caring for people with dementia (addressed under ‘Staffing’). Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 19 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 & 18. Quality in this outcome area is adequate. People can be confident that complaints are taken seriously. However, because the home’s safeguarding policies and procedures are not robust, there is a risk that people are not properly protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Surveys from people living at the home and their representatives said they knew who to complain to and how to complain. Some people said they had had no reason to complain. Three relatives said the matron and staff are always approachable and helpful, one adding they always let them know of any problems. A professional said the home always responded appropriately if they or someone living at the home raised any concerns about care. The home’s AQAA said the home has not received any complaints directly. We have received one complaint – anonymous - about the home since the last main inspection, which the provider is currently investigating. This related to lack of choice (- for example, that, to assist the morning staff, people are washed and dressed early by the night staff), privacy is not always being ensured in shared rooms, and aspects of medication management. A care assistant confirmed they had had recent training on safeguarding, and gave examples of abuse that they said were considered unacceptable at the Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 20 home. For example, forcing people to do something. But they also said they would find out why the person did not want to do what was suggested, and address that if appropriate, which is good practice. We found that a safeguarding matter had been dealt with by the home without either the registered manager or responsible individual notifying the local authority Safeguarding Adults team or ourselves, as was required in such circumstances. This was discussed with the registered manager and responsible individual as a matter of serious concern. Most staff have recently had training on safeguarding. Some staff knew of external agencies they could report any concerns about abuse to, but other staff were unsure. The manager was not aware of some local safeguarding arrangements, and agreed to attend relevant training to ensure she, other staff and the home’s written policies were up-to-date regarding procedures to be followed. Staff training to reduce the risk of such an incident recurring had not been arranged at the time. Staff have yearly updates on caring for people with dementia, which is delivered with training on safeguarding. And on their first day of employment, induction for new staff includes dealing with aggression, as one topic amongst many. We did not see evidence that staff had had any other training about challenging behaviour or wider topics, or training in more depth. The Responsible Individual agreed this would be prudent and said he would review staff training. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 21 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 & 26. Quality in this outcome area is good. People enjoy accommodation that is homely and clean, benefiting from ongoing improvement of facilities inside and outside of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a handyman. One person said, “I think Lymewood is caring and well cared for. We are very happy with the care given and the surroundings in which it is given.” People generally seemed at ease and comfortable in their environment, some moving between areas as they wished. Day rooms on the ground floor looked bright and homely, with a small lounge available if people wish to see visitors in private. Visitors told us about the redecoration of lounges, and re-carpeting of areas, in the last year. Wall lights Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 22 have been fitted in the main lounge, improving the lighting around the room, as well as a large-screen wall-mounted television. The AQAA said bedrooms were being upgraded, with redecoration, new furnishings and new furniture as necessary. We saw new fittings in the kitchen, including an Aga cooker, new tiling and flooring, etc. One person who used a mobility aid independently told us they felt safe walking around the home, with regard to tripping hazards, etc. We saw grab rails and raised toilets around the home. A bathroom had a damaged bath, and conversations in the office next door could be overheard. We were told this room is to be rebuilt, in plans to add a conservatory to the back of the home. There are also plans to create raised flowerbeds and a greenhouse. One person suggested that a secure garden space, where people could safely walk ‘from house to garden to house’, would be an improvement; there are no walkways that enable unaccompanied people to walk a route outside that brings them back to the house, for example. We asked if current plans included any other environmental features, specialist design or adaptations specifically to help people with dementia to use the home independently and safely. The manager agreed to find out more about these, having discussed this with us at our last key inspection also. The home looked clean and well kept, and had no unpleasant odours. People who were asked the question said the home was always fresh and clean, one adding, “Its’ hygiene is very impressive.” Staff guided us to use disinfecting hand gel, in the entrance hall, when we arrived. They confirmed there are always enough disposable gloves and aprons available to them. A new staff member said they were currently doing a course about hygiene, as part of their induction. Current food safety guidance was being used in the kitchen. The AQAA said all staff, including catering staff, had had training on food safety. We saw staff wore specific disposable aprons when dealing with food. There were new fittings in the kitchen, which was being re-tiled, etc. The laundry room was orderly, with special bags used for containing soiled laundry to minimise cross-infection. There was guidance for staff on appropriate washing machine programmes for cleaning different types of laundry (soiled, etc.). Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 23 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 – 30. Quality in this outcome area is good. People benefit from being looked after by a caring staff team, which has a level of knowledge and skills that ensures their basic safety. However, current staff training and development practices do not ensure that all staff can meet peoples’ current and changing needs competently. People are protected by the home’s recruitment policies, although aspects of record-keeping could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we arrived, there were six care staff (including a nurse) looking after 28 people, with the manager and four catering or domestic staff also on duty. The manager confirmed there are usually five staff on duty in the evening, and three awake staff overnight. Staff did not appear rushed, but seemed continually occupied around the home; at least one stayed in the main lounge through the day. Staff we spoke with said there were usually enough staff rostered to meet peoples’ needs, although they occasionally ‘worked short’ because a staff member was sick and full cover could not be found at short notice. They reported agency staff are used occasionally. Surveys indicated that people got help when they needed it. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 24 One relative commented there was a very low nursing staff turnover in recent years. Staff we spoke with seemed to know peoples’ current needs, and some peoples’ personal histories. Two of the three care staff who we asked had worked at the home for at least three years. Both had a recognised care qualification, or a health professional qualification in their country of origin. The AQAA stated that of 13 care staff, over half have a recommended care qualification (National Vocational Qualification in Care at Level 2 or higher), and three are undertaking the qualification. The manager has worked at the home for some years, but there are no nurses with a qualification in mental health nursing employed at the home. The AQAA stated the home is trying to recruit nurses with this qualification. Surveys from people living at the home, their representatives and professionals were positive about the majority of staff. One relative felt the home’s strength was that it ‘understands and deals with dementia appropriately.’ Three thought the staff were trained to a high standard or ‘highly experienced dealing with a demanding and difficult type of patient’, and were always friendly and caring. One described them as ‘exceptionally caring’, another as ‘proactive in responding to need, managing “a very wide spectrum of need with great skill.” A professional thought the home managed “extremely well with a very complex group of residents.” One person said in the many visits they had made in recent years, they had never heard or seen any staff behave other than professionally, no matter how difficult the situation. However, another said the majority of staff are “friendly, helpful and listen,” but “one or two are offish and unapproachable.” And someone else, when answering whether staff have the right skills and experience to look after people properly, said, “Looking and speaking to some residents in a derogatory harsh and inappropriate manner does take place at certain times, only by a tiny percentage of staff.” During a period of time spent in one lounge-diner, a carer took time to sit and talk with people, drawing them into group conversations. However, we heard another speak in an inappropriately abrupt manner to one resident, when trying to stop them behaving in a way that was adversely affecting another person. The carer later told us they had had dementia care training that included aspects of communication. The manager agreed to monitor staff skills and practice individually, so as to ensure staff develop competency after training. See also the section on ‘Complaints & Protection’. Staff said there were regular staff meetings for the more senior care staff at the home, but not for those with the title ‘care assistant’. However, they felt senior staff listened to their daily observations or suggestions. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 25 We saw that ancillary staff helped people with their meals, giving one-to-one attention, but with limited communication; one person we asked had not had specific training on caring for people with dementia. The manager said they would be undertaking training in the near future. She also told us the activities organiser is undertaking a recognised care qualification at a higher level, with a module relevant to their additional role. We looked at three staff files, two of whom we were told were the only staff newly employed since our last inspection. Required information had generally been obtained, in a timely way, and registration details for a new nurse had been checked with the Nursing & Midwifery Council. A new staff member’s description of their recruitment confirmed the home had followed appropriate procedures. We discussed with the manager that the references for one person were not robust; the manager explained steps she had taken to try to address this, although records of this action were incomplete. The manager said people underwent the company’s initial induction before actually caring for people. There is then an induction programme that meets nationally recognised standards. A new staff member – who had not worked in a care home previously - confirmed both these points, in that their induction was as described; they recalled they had watched a video on safeguarding and had fire safety training on their first day. They had then worked with a senior carer for two weeks, who still supervised them closely and who was to hold a formal supervision session with them soon. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 26 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, 33, 35 & 38. Quality in this outcome area is good. The manager is a very experienced and valued person, who uses various strategies to try to ensure the home is run in the best interests of the people living there. She would benefit from some further updating, however, which with attention to aspects of risk assessment would better ensure the safety and welfare of people at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manger (Matron) is an experienced Registered General Nurse, who has cared for people who have dementia for many years. One relative’s survey said they wanted to place on record ‘the high standards given by Matron, and her professionalism in all areas.’ Other people said she was open Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 27 and approachable. During our visit, she expressed a keenness to learn from and address any issues identified. Thus, besides using the journal she currently reads relating to care of the elderly, she said she would be seeking more information from various organisations relevant to people who have mental health problems or dementia and their carers. She agreed to take steps to ensure she is fully aware of local safeguarding policies and procedures. She had identified areas for improvement at the home in the AQAA submitted, which gave us most of the information we required. Two people were also positive about the Responsible Individual, who they said visited regularly. Surveys we received were very positive about the home as a whole. Relatives’ meetings are organised regularly, with minutes showing there is open communication with senior management. We saw returned surveys, sent by the home to relatives, and a letter of response from the home sent out subsequently. It was not clear if this was merely clarifying the home’s situation, in response to issues raised in surveys, or explaining improvements made to address issues raised. The manager told us it was the former. We discussed whether surveys would be sent to professionals in future and she is considering this. The home does not hold personal monies for people living at the home, but bills them in arrears for any expenses they incur. The home does not act as appointee for anyone, leaving control of peoples’ financial affairs to those chosen by or for them. Staff we spoke with said they were soon attending or had had recent training on manual handling, first aid, fire safety and food hygiene. Training notices seen and staff records supported this. A new member of staff said they currently looked after ambulant people only because they had not yet had manual handling training. This is safe practice. Few baths we saw had access on both sides, so staff could assist people more safely. The manager said the new bathroom would take this into account. We saw two people had bedrails fitted to their bed. Records showed their risk of falling was monitored monthly, and the risk was high; they also showed bedrails had been discussed with the person’s family – bedrails potentially being a form of restraint. Care staff we asked knew what practical checks they should make whenever they put the bedrails up. However, recorded risk assessments were minimal. The manager agreed to address this. Window restrictors were in place where we checked at random. One bath of three checked had hot water of at least 50°C, with the others running at a safer temperature; records kept by the home had not yet identified a problem. The manager asked the handyman to address this issue during our visit. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 28 Monthly safety checks had been recorded for window restrictors, bedrails and call bells, with plans to introduce a more detailed risk assessment record, to identify more specifically what had been checked. We saw a new disposable razor and toiletries in two bathrooms. The manager agreed to risk assess this. A copy of a Periodic Inspection Report dated 28/12/05 was provided as evidence of the safety of electrical wiring at the home. The home’s fire risk assessment included it was due for review in February 2007. The Responsible Individual told us later that it had been reviewed, but hadn’t been re-signed and dated. He agreed to address this when next at the home. Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 29 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 N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 30 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 15 Schedule 3 (1)(b Requirement The registered manager must ensure that care plans are drawn up with the knowledge of the individual, and that it sets out in detail the action which needs to be taken by staff To ensure that individuals’ assessed social and emotional care needs are met. Original timescale of 25/09/07 not fully met. The registered person shall make 07/04/08 arrangements for the safekeeping and safe administration of medicines in the home. Arrangements must be made to ensure that all medicine cupboards are affixed in accordance with the current regulations Arrangements must be made to develop an action plan and review current policies such that medicines are administered directly from the containers in Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 31 Timescale for action 30/06/08 2 OP9 13(2) which they are dispensed by 6th September 2008. Arrangements must be made to ensure that there are clear directions available to members of staff on how and when medicines prescribed to be used “when required” are to be used. The registered manager must consult people living at the home, and or their representatives, about their social interests and provide suitable activities according to the interests of each individual – To ensure everyone has the same opportunities for fulfilment. Original timescale of 25/09/07 not fully met. The registered person must make arrangements, by appropriate staff training and other measures, including training related to meeting the diverse needs of people living at the home and following local Social Services’ safeguarding procedures To ensure that people living at the home are safeguarded from abuse and neglect through deliberate intent, negligence or ignorance. The registered manager must ensure that staff (whatever their job title) have training appropriate to the work they are asked to do – To ensure all staff are able to fulfil the aims of the home and meet the needs of people living there. The registered manager must DS0000061709.V359765.R01.S.doc 3 OP12 16 (2)(m)(n) 30/06/08 4 OP18 13(6) 31/05/08 5 OP30 18(1)(c) (i) 30/06/08 6 OP31 10 31/07/08 Page 32 Lymewood Nursing Home Version 5.2 undertake appropriate training/updating, in safeguarding, dementia care, regulatory matters or requirements, etc. To ensure that she continues to have skills and knowledge necessary to run the home and meet it’s stated purpose, aims and objectives. 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 Daily records should reflect the care plan and the good care provided - To show that people’s social welfare needs are being met as well as their physical needs. It is recommended that further work be done to provide stimulation or occupation, for people living at the home, which reflects their interests and capabilities - To increase their wellbeing. Clear records must be kept regarding decisions made in recruitment of individual staff. More should be done to ensure there are robust risk assessment systems, with environmental risks identified, and full written guidance on how risks are to be managed - To ensure to people living at the home are free of unnecessary risks or hazards to their wellbeing. 2 OP12 3 4 OP29 OP38 Lymewood Nursing Home DS0000061709.V359765.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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