Inspection on 25/11/05 for Lyncroft

This inspection was carried out on 25th November 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 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 12/05/06

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 Matthew Bentley Announced Inspection 25th November 2005 11:30 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.V269397.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 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.V269397.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 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 provided in an established building which, in recent years, 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 new 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. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took 2 hours and 15 minutes and took place on 25th November 2005 between 11.30 and 13.45. The inspection was carried out by one inspector who spoke to a number of service users and staff and a visiting relative. The inspection also included reading documents, speaking to the manager and the area manager, and a tour of the building. Overall the inspection’s findings were positive, and residents expressed satisfaction with the services offered. Comments on the day of inspection included “I give [the staff] top marks” and “I’m very happy here; the staff are very nice”. A number of letters of thanks have been received, including comments that relatives are always made to feel welcome and that the staff have a good sense of humour; one person described the home as being ‘homely and loving’. What the service does well: What has improved since the last inspection? Systems of recording residents’ needs and how they should be met have been greatly improved and care plans have been updated to reflect current needs. A range of training has taken place and a management post has been created to help the manager organise ongoing training. An activities co-ordinator has been appointed and the range and frequency of activities is greatly improved. A level access shower has been provided and the manager’s office has been moved so that she is more accessible and has more space to carry out her management responsibilities. Effective systems of quality assurance have been put in place and action has been taken to rectify identified shortfalls. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 6 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.V269397.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 The home is capable of meeting the needs of older people, and information is provided to allow people who are interested in the home to make an informed choice about its suitability. The home takes suitable steps to ensure that potential service users’ needs are fully assessed prior to their moving into the home to ensure its suitability for the person concerned. EVIDENCE: The home has a statement of purpose which contains the information needed to help people who may be interested in moving in to decide whether it is likely to be suitable for them. The statement of purpose is on display in the entrance hall and the residents’ guide, which includes the complaints procedures, is provided in each resident’s room. Potential residents are usually visited by the manager, and they and their families or other representatives are invited to visit the home so that their needs and requirements can be discussed. When people are referred by the Primary Care Trusts, assessment information is gained from care managers, Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 9 and the manager makes arrangements to get as much information as possible about the needs of the person concerned so that she can be sure, as far as possible, that the home will be suitable. Lyncroft is registered to provide accommodation care and support for individuals over 65 years of age not falling in any other category of registration. A small number of residents have a degree of dementia and the provider is in the process of applying to the Commission to vary the home’s registration so that the individuals concerned can be legally accommodated. Since the last inspection, staff have received training in the care and needs of people with dementia. Aids and adaptations are available to help staff to meet service users’ needs, and observation and discussions with staff, the manager, visitors, and residents, indicates that the home is capable of meeting the needs of older people. The home does not provide intermediate care therefore standard 6 is not applicable. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 The system of care planning gives a good description of what help each person’s needs and how that assistance should be given so that staff can be clear about what they need to do. Arrangements are in place to ensure each service user receives input from relevant professionals to ensure each person’s health needs are met. Personal care is given sensitively so that individuals’ dignity and privacy are maintained. Procedures for managing service users’ medication are satisfactory however, they were not always being properly followed, so that medication is not always safely administered. EVIDENCE: Since the last inspection, the system of care planning has been greatly improved, and care plans now detail the various areas of help that each resident needs and how the help should be given; personal histories and interests are also recorded as are the preferred time for getting up and going to bed, which was a concern arising from the last inspection. The plans have been reviewed every month or when there have been significant changes. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 11 Efforts have been made to involve the individual to whom the care plan relates in its compilation, and relatives have also been involved when appropriate. Regular health checks take place, referrals to specialist health care services (for instance community psychiatric nurses) are made for people who need them, and the manager said that district nurses are very supportive. The home has a policy and procedure for the management of medication, and dealing with medication is limited to members of the management team or senior staff. Since the last inspection training has taken place in relation to medication, and the member of staff responsible for medication on the day of the inspection said that she had been provided with training so that she feels able to administer medication competently and safely. Records relating to the handing and administration of medication examined were generally in order as were the storage arrangements, however, one person was recorded as having been given their medication, but it was still in the blister pack. The matter was discussed with the manager and a requirement has been made regarding the matter. Residents said that they felt their privacy and dignity are respected, and staff use the names that they prefer. Care staff were talking with service users whilst helping them walk from one place to another and at lunchtime; the way they spoke to the individuals concerned, and dealt with the issues they raised was respectful and polite. Residents’ wishes in the event of their death are recorded in the care plans, and the manager said that family members are encouraged to visit and get involved in their relatives care if they wish. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 The range and frequency of organised activities is improving considerably, so that residents’ social, religious, and recreational needs are being met. Staff provide appropriate support to facilitate contact with family and friends. Residents are encouraged to make choices about their lives and are encouraged to maintain their independence. Dietary needs are well catered for, with a balanced and varied selection of food available to meet residents’ individual tastes and choices. EVIDENCE: Since the last inspection, a member of staff has been employed to organise activities within the home, and the manager said that this has improved the atmosphere in the home and people are now more eager to get involved in outings and events within the home (though those who do not want to be involved are not made to join in). The activities co-ordinator said that she enjoys the work very much and confirmed that resources are readily available so that residents don’t have to pay extra for trips out or entertainment brought into the home. Activities that have taken place include reminiscence; church services, bingo, and trips individually, into town to do personal shopping. On the day of the inspection preparations were being made for a forthcoming Christmas fayre. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 13 Visitors are welcome to visit at any reasonable time, and can be received in sitting rooms or, if they wish to have more privacy, in bedrooms or outside in the garden. One relative who was visiting the home said that she feels able to call in without letting the home know, and is always made to feel welcome. Lunch on the day of inspection was fish and chips, or fish pie with vegetables, followed by a choice of sweets. An alternative is provided for those who want a different meal or who need a special diet. Meals are served in the dining areas, which provide a pleasant, homely and relaxed atmosphere. All of the residents, who were asked, said that the food was very good and that they were happy with the quality and quantity of the food provided. Staff were seen helping residents who could not feed themselves to eat their food; the assistance was provided in an appropriate manner, with the staff member sitting beside the person concerned and giving food at an unhurried pace. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 The home’s systems for dealing with complaints are satisfactory so that anyone who feels the need to make a complaint can be sure it will be dealt with properly. The arrangements for ensuring the protection of service users from neglect or harm are satisfactory, so that residents are protected from abuse or mistreatment. EVIDENCE: The home has a procedure to tell people how to make a complaint about the service; these are included in the residents’ guide and the statement of purpose. The procedures include timescales for responses, however, the contact details for the Commission need to be updated; a requirement has been made about this. Residents spoken to said that they would feel able to talk to the manager if they had a complaint or suggestion and they believed that any comments or complaints would be taken seriously. The home has an adult protection policy to guide staff in dealing with allegations of abuse or mistreatment, and there is also a whistle blowing policy aimed at encouraging staff to voice any concerns. Following complaints being made, a number of aspects of the service have been examined using the County Council’s Adult Protection procedures; the provider and manager have co-operated with the professionals involved and significant improvements have been achieved. Staff have had training in adult protection, and those spoken to said that they would have no hesitation in talking to the manager if they were concerned that a resident was not being treated properly. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 The building is suitable for the needs of those living there, and sufficient equipment is provided so that service users’ independence is maximised, though as noted later in standard 38 attention needs to be given to the fire doors in the older part of the home. The home is clean and hygienic, there are no unpleasant odours, and laundry facilities help maintain the control of infection. EVIDENCE: The home is situated near to the shopping centre of the Fenland market town of Wisbech. The building is a large property which has been adapted and extended to provide accommodation suitable for older people. Outside there are large gardens and a patio area, which is easily accessible. Action has been taken to address previous shortfalls in the upkeep of the home, A large room in the newer part of the building is furnished and laid out to provide a dining area and lounge, and a further lounge area is provided in the older part of the building. Lighting in the communal rooms is domestic in character, and furniture is good quality and suitable to the needs of service users. A range of adaptations and equipment is provided, and staff said that Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 16 there is sufficient equipment for them to safely assist people who need help with their mobility. All residents spoken to expressed their satisfaction with the communal facilities provided. The home has one double room which is fitted with screens to provide privacy for the occupants, and work is continuing to convert what was previously a double room, into two singles with en-suite facilities. The home has a total of 12 toilets and 5 bathrooms. En-suite facilities are available in two bedrooms in the older part of the building and in all of the 24 bedrooms in the newer part of the home. Since the last inspection a level access shower facility has been fitted. Bedrooms are well maintained, tidy and clean, and the furniture provided appears to be comfortable and appropriate to the needs of individuals. All rooms have a call system for residents to summon help when needed. Pre-set valves are fitted to the baths and washbasins to ensure that the hot water is delivered at a safe temperature and all rooms are heated either by a radiator or underfloor heating, which can be controlled by the person living in the room, with help if necessary. The Home has appropriate laundry facilities which are sited so that soiled articles are not carried through areas where food is prepared, stored, cooked or eaten. The home was clean with no unpleasant odours, and residents commented that the home is always very clean. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 Sufficient staff are employed to ensure that service users’ needs are properly met. Staff are competent and properly trained and experienced, so that they can safely meet residents’ needs. The home’s recruitment procedures mean that appropriate checks are made on potential staff to ensure that unsuitable people are not employed. EVIDENCE: At the time of the inspection, five staff were on duty, along with the manager and the activities co-ordinator; the area manager was also present in the home. Three waking staff are on duty overnight and an on call system is in place in case management support is needed. Staff are well presented and wear a uniform so that they can easily be identified, and were courteous, welcoming and helpful. The manager has arranged for staff to do the National Vocational Qualification (NVQ) course; three have already completed it and the remainder are in the process of doing the course, however, the target of 50 of staff having NVQ level 2 will not be achieved in 2005. A newly appointed area manager has taken on responsibility for organising training for the staff and a training programme has been put in place, which includes essential core training such as moving and handling, fire safety and first aid, which is needed to ensure service users’ safety and that of the staff. Other training that has taken place includes dementia awareness, adult Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 18 protection, and falls awareness, and the district nurses are arranging to provide training in continence, the prevention of pressure sores, and diabetes. Staff spoken to said that they received ongoing training to allow them to carry our their duties effectively and safely. Staff files include two written references, and Criminal Record Bureau (CRB) checks have been carried out, as has verification of staff members’ identity and other required checks, to ensure as far as possible, that unsuitable people are not employed at the home. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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, 38 The home is being properly managed and there is leadership, guidance, and direction for staff to ensure residents receive consistent quality care. Systems for assessing the quality of the service are good, so that any shortfalls can be identified and corrective action can be taken. One area relating to health and safety has some shortfalls, which may put residents at risk in the event of a fire. EVIDENCE: The registered manager of the home is Brenda Durrington. Mrs Durrington has worked at the home for many years; she started as care assistant but became the manager in 2004 and has since been successful in her application to be registered with the Commission. Mrs Durrington demonstrates a high level of commitment and care to the people living at Lyncroft and to the service as a whole, and is working towards gaining the NVQ level 4 in management and care. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 Page 20 The manager has a high presence in the home; she often works alongside care staff, and demonstrates an approachable and open style of management. Staff, residents, and a relative said that they are happy with the style of management and would feel able to approach the Mrs Durrington if they had any concerns or suggestions. The visitor to one resident commented that Mrs Durrington had been particularly helpful and supportive when her relative was moving to the home, and also said that Mrs Durrington deals well with any issues of concern. Since the last inspection a quality assurance survey of residents’ and relatives’ views of the services provided has taken place. The results of the survey are displayed in the reception area and include action taken to remedy any shortfalls that have been identified, including the appointment of a coordinator to increase the activities provided and encourage residents to take part. Records relating to the money kept on behalf of two residents were seen and were in order, and the home has a system for managing residents’ money so that it can easily be seen what money has been spent, and on what. Since the last inspection the manager has moved her office into the front of the building which has made her more easily accessible and has provided her with more space for storing files and policies and procedures. Files relating to residents are now kept in a locked cabinet, but remain accessible to staff. As noted in previous sections, staff have received training in matters of health and safety such as moving and handling and fire safety, however, a number of the fire doors in the older part of the building are not closing on their selfclosing devices; a requirement has been made about this. Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 X 18 3 3 3 3 3 3 3 3 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 X X 3 Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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 OP9 Regulation 13(2) Requirement The registered person must ensure that the home’s procedures for administering medication are followed The complaints procedures must be updated to include the current contact details of the Commission The fire doors referred to must be adjusted so that they close properly on their self-closing devices Timescale for action 25/11/05 2 OP16 22(6)(a) 15/12/05 3 OP38 23(4)(c) (i) 15/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lyncroft DS0000015124.V269397.R01.S.doc Version 5.0 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.V269397.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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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