Inspection on 12/05/06 for Lyncroft

This inspection was carried out on 12th May 2006.

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 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

Lyncroft 15/04/08

Lyncroft 25/11/05

Lyncroft 27/01/05

Lyncroft 04/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lyncroft 81 Clarkson Avenue Wisbech Cambridgeshire PE13 2EA Lead Inspector Alison Hilton Key Unannounced Inspection 12th May 2006 09:50 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 Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 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. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lyncroft Address 81 Clarkson Avenue Wisbech Cambridgeshire PE13 2EA 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) 01945 475229 01945 475229 www.countrycourtcarehomes.com Mr A Kachra Brenda Jean Durrington Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 25th November 2005 Brief Description of the Service: Lyncroft is a care home providing accommodation, care, and support to up to 39 older people. The home is situated approximately half a mile from the centre of the Fenland market town of Wisbech. The home is in an established building, which has been substantially extended. All of the newer rooms are on the ground floor and all have en-suite facilities and meet the requirements of the National Minimum Standards for care homes for older people. The majority of the rooms in the older part of the home are on the first floor, which is accessed by a stair lift. There are five care staff on duty during the daytime and three staff are on duty at night. The current charges are between £340 and £450 per week. There are extra charges for hairdressing, chiropody, toiletries and papers/magazines. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 12th May 2006 between the hours of 09:50 and 16:00 and was conducted by Alison Hilton and Lesley Richardson (Inspectors). The manager was present and the operations manager arrived at the end of the inspection. Residents and staff were spoken to, and questionnaires had been sent out to residents and their relatives. 12 residents questionnaires and 11 relative/visitor forms were returned prior to the inspection. 2 relatives felt that at times there were not enough staff on duty and 3 were not aware of the homes complaints procedure. One relative would like more 1-1 time spent with their mother, but did understand this was not always possible. Residents were happy with the care they received and felt safe at the home. One resident did feel that their privacy was only respected sometimes, and one was not aware who to speak to if they were unhappy with the care they received. These concerns were discussed with the manager. Another resident would like a bar and a running machine. A tour of the building was made and staff and resident files were inspected together with other records. The home has made an application to the Commission to vary its condition of registration to include six named residents, over the age of 65 years, who have dementia. What the service does well: What has improved since the last inspection? Staff have completed training on administering medication and the procedures for administering medication are being followed. This meets the requirement from the last inspection. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 6 The complaints procedures have been updated and a copy is in the service user guide kept in each bedroom. This meets the requirement from the last inspection. The fire doors have been adjusted so that they close properly on their selfclosing devices. This meets the requirement from 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. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 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 Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home ensures that potential residents needs are assessed prior to their admission to the home to make certain it is suitable. EVIDENCE: The statement of purpose is in the hallway of the home and there have been no changes since the last inspection. The home will need to update this if the variation, in relation to six residents with dementia, is made. Residents were aware that they had a service users guide in their rooms. This document also contains details of the homes complaints procedure. The manager said that prospective residents and their families were encouraged to visit where that was possible. However since many are discharged straight from hospital that is not always possible for the resident. The manager or another senior member of staff visits the prospective resident to assess them prior to their admission. There was evidence on the two files seen during the inspection that pre-admission assessments had been Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 9 completed. There were other assessments from placing authorities and discharge letters from the hospitals. Risk assessments had been completed in areas such as bed rails, pressure areas, falls, nutrition and behaviour (in relation to a resident with dementia). This will be discussed further under Standard 7. Aids and adaptations were evident around the home and the manager was clear that any necessary equipment would be provided by the home. Lyncroft is registered to provide accommodation for residents over 65 years of age, not falling within any other category. At the last inspection it was noted that a number of residents had a degree of dementia and the provider was in the process of applying to the Commission to vary the homes registration so that the residents concerned could remain at the home. This application is still under assessment. Standard six is not applicable, as the home does not offer intermediate care. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The system of care planning provides details of what care needs a resident has and how these are to be met by staff. Procedures for the safe administration of medication are in place and are being adhered to. EVIDENCE: Two residents files were inspected. Details in the care plans were good and had been reviewed. Information of the residents’ wishes in the event of their death has been recorded. One resident had only recently been admitted from hospital and information to create a care plan was still being gained. The home had managed to complete some basic information and risk assessments. Bed rails had been requested by the family and there was evidence that this had been discussed and agreed by all parties. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 11 On another file there were details of risks in relation to the difficult behaviour of one resident. The information provided showed what the resident did but did not provide the reader with any information on how to recognise what preceded an incident, a strategy on how to deal with the situation when it arose, or how to act afterwards. The home needs to be pro-active in getting advice from the Community Psychiatric Nurse and ensuring this is documented. The parent company has just employed an Occupational Therapist (OT), which will allow the home access to their professional input. The Operations Manager who arrived at the end of the inspection confirmed this. Two residents spoken to were not aware of their care plans but commented that they were “not bothered” about seeing them. One questionnaire from a resident indicated they felt their privacy and dignity was only upheld sometimes. Observation and conversations with residents on the day of inspection did not provide further evidence of poor practice. Procedures for the safe administration of medication are in place and are being adhered to. This meets the requirement from the last inspection. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are given opportunities to make choices so that they can take control of the way they lead their lives. EVIDENCE: Residents spoken to during the inspection said that they could choose whether to be involved in activities or not. They said that a mobile library calls and leaves books. They can have newspapers or magazines delivered if they wish. Staff spoken to said that reminiscence; music sessions (sometimes spontaneous using pots and pans from the kitchen) and trips out are available to residents. Residents spoken to confirmed this. Some residents said that their families visit and take them out. Information on the pre-inspection questionnaire also indicated that the home had pampering sessions, reminiscence, quizzes, slide shows and use of the park. Residents said that visitors are made welcome and it was evident during the inspection that there are visitors in and out of the home all day. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 13 Residents said the food was “quite good, but not like home” but there was a choice. Residents confirmed that they had enough to eat and drink. Details of lunch were on a blackboard in the dining room but the use of abbreviations such as bat fish for lunch, or spag for tea, would not help those whose memories or understanding were failing. Lunch on the day of inspection was bat (battered) fish or fish fingers with peas and chips, and banana custard for dessert. Tea was beans or spag (spaghetti) on toast and cake. The cook has been providing themed meals around countries of the world such as an American Day, Italian Day and Indian Day and alternatives are always provided. The manager said she was surprised at how much some of the residents enjoyed the days and commented on how nice the food was. Residents are also provided with sherry and beer/lager if they wish. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The information available to residents in relation to complaints was provided in the service users guide. It was clear and understandable. EVIDENCE: The home has a procedure in place for making a complaint, a copy of which is in the statement of purpose and service user guide (a copy of which is kept in each residents room). Residents spoken to during the inspection said they knew who to tell if they were unhappy, although one resident questionnaire returned indicated that the resident was not sure who they would talk to. Three relatives who responded to the questionnaires stated they were not aware of the homes complaints procedure. Staff have had training in the protection of vulnerable adults (POVA) with evidence provided by staff on duty and records kept in the office. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ benefit from living in a home that is clean and has a maintenance programme. EVIDENCE: Some pipes leading to radiators were too hot to touch and an immediate requirement was made to ensure the safety of residents is maintained by covering them. Some windows did not have restrictors to prevent them opening enough to allow an accident to occur to a resident. An immediate requirement was made to ensure the safety of residents. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 16 The home should not be using or leaving hand towels and bars of soap in bathrooms because of the possibility of cross contamination. An immediate requirement was made on the day of inspection. The provider responded to the immediate requirements stating that the home had recently had an inspection by a privately employed Health & Safety consultant. According to the provider the report did not comment on the need for window restrictors on the ground floor windows or that the radiator pipes were too hot. The provider is however intending to cover the pipes. A letter was received from the consultant who stated that in his view there was no risk in relation to the ground floor windows not having restrictors. Bedrooms were personalised with lots of individual belongings. The manager said that the home intended to purchase further seating and shelter for residents. The home has a large garden but its use will be limited unless the home provides shaded areas for residents to sit. The home has had no structural changes and continues to provide adequate bathing and toilet facilities. The home has a continuing programme of decoration and there was evidence of this on the day of inspection. The home had no unpleasant odours on the day of inspection. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home makes appropriate checks on prospective staff and the recruitment procedures are followed. The number and skill mix of staff on duty is sufficient to meet the needs of the residents EVIDENCE: Staff said they had received induction training, moving and handling, fire, infection control, abuse and dementia training. The manager confirmed that staff had received training in infection control and most staff had received training in POVA and dementia. Certificates in relation to dementia training were seen as part of the application for a variation. The manager said that pressure area care was also going to be introduced to the home as residents discharged from hospital sometimes had wounds. Staff said they did not receive specific training on nutrition for older people but did undertake food hygiene course. Two staff have NVQ Level2, 8-10 will have completed this qualification before the end of May 2006. Three more are waiting to receive funding before they can start. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 18 The manager said that the staff training matrix was being updated and she was asked to provide the inspector with a copy when the training manager for the company (Pauline Waller) had completed it. Although staff stated they are receiving statutory and other courses there was concern that this information was not informing their practice, as it should be. For example towels and bars of soap were found in bathrooms, this is an area covered on infection control courses in relation to cross contamination. The manager said that bars of soap were not purchased by the home. After further investigation the manager stated that the towels and soap bars belonging to individual residents had been left in the bathrooms after their baths. Paper towels and liquid soap were available in all bathrooms and toilets. Not all staff spoken to were clear about the different needs of residents with dementia. There was further evidence on one residents file that the home has not put procedures in place in relation to behavioural issues and how staff should deal with them. The staff rota was seen and this indicated that 5 care staff were on duty throughout the day, plus the manager. This was confirmed during the inspection and detailed in the pre-inspection questionnaire. Staff said that the shift patterns suited them and that every effort is made to accommodate staff needs. The home has a good recruitment procedure, which is followed. On the two staff files seen during the inspection there were application forms, two references, POVA First checks (completed before staff began employment) and items confirming identity. The home was awaiting Enhanced CRB checks. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is being managed in an open and friendly way with evidence of leadership and guidance to ensure residents receive consistently high levels of care. EVIDENCE: The manager of the home has an open door policy and staff confirmed that. The manager works in the home at least once a week to ensure she knows that the staff are meeting the needs of the residents. Fire extinguishers checked 01/06. Due to the home being refurbished one of the signs denoting a fire exit was held on by blue tack but the manager stated it would be placed back on the wall when the decorating concluded. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 20 Staff on duty said they receive regular supervision and every six months have an appraisal. The manager or deputy supervises care staff and the cook supervises kitchen staff. The home does not hold savings for residents. One resident handles his/her own finances. Records are kept of the management of personal allowances. Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO 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 17 (1) (a) Requirement The registered person must ensure that risk assessments contain sufficient information for staff to understand and deal with difficult behaviour. The registered person must ensure that the residents live in safe surroundings. This is in relation to the covering of radiator pipes and window restrictors on the ground floor. Timescale for action 16/06/06 2 OP25 13 12/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Lyncroft DS0000015124.V288383.R01.S.doc Version 5.1 Page 24 - 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. 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