Inspection on 29/10/07 for Lyncroft

This inspection was carried out on 29th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyncroft 25/08/06

Lyncroft 04/01/06

Lyncroft 06/09/05

Lyncroft 29/12/04

Lyncroft 21/05/04

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

CARE HOME ADULTS 18-65 Lyncroft 11 Bushwood Leytonstone London E11 3AY Lead Inspector Peter Illes Unannounced Inspection 29th October 2007 09:15 Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 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 DS0000007246.V351935.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 Adults 18-65. 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 DS0000007246.V351935.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyncroft Address 11 Bushwood Leytonstone London E11 3AY 020 8989 5933 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) Ms Jennifer M. E. Khan Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Special category - to include one named person with learning disabilities 25th August 2006 Date of last inspection Brief Description of the Service: Lyncroft is a privately operated care home registered to provide care and support to twelve adults with mental health problems. The home is a large converted two storey residential property. The ground floor comprises: five residents bedrooms, lounge, dining room, kitchen and a conservatory that is a designated smoking area and leads out to a large attractive garden; there are six further bedrooms on the first floor, one of which is registered to accommodate two people. There are sufficient toilet and bathroom facilities on both floors and the home’s laundry facilities are in the basement. The area is well served by public transport with Leytonstone underground station and local bus stops within walking distance. Access to the M11 is close by at the Green Man roundabout, which makes road communication very accessible to various parts of London. There are many easily accessible facilities and amenities within the local community including various local shops, supermarkets, and G.P. surgery, opticians, library and public offices. A stated aim of the home is to provide people that live there with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance. At the time of the inspection, the weekly fee was from £500 per week depending on the person’s assessed need. The provider must make information available about the service, including inspection reports, to people living in the home and to other stakeholders. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took approximately seven hours with the newly appointed manager, Mr Raouf Nauyeck, and the registered provider being present or available throughout. There were eleven people living at the home. One of the home’s bedrooms is registered as a double room although is occupied by one person. The registered provider stated that because of this the home was effectively full. One new person had been admitted to the home since the last inspection. The inspection activity included: meeting and speaking to the majority of the people living in the home, five of them independently; detailed discussion with the manager; discussion with the registered provider; independent discussion with two care staff, and independent discussion by telephone with two healthcare and one social care professionals from different placing authority’s. Further information was obtained from: an Annual Quality Assurance Assessment (AQAA), submitted by the home to the Commission prior to the inspection, a tour of the premises and documentation kept at the home. What the service does well: The home provides a comfortable and domestic scale environment for the people who live there, all of whom have mental health difficulties. People living at the home, when spoken to independently, stated that they liked living there and that they received a lot of support from staff, which they appreciated. One person stated, “this is a very good home, better than my last place”. The home has a relatively low staff turnover that promotes the consistency and continuity of the care and support provided. The home supports and encourages people living there to make a range of informed choices about their day-to-day lives to the extent to which they are able. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate information is available to prospective residents and other stakeholders to make an informed choice about living in the home. People have their needs properly assessed when they first move in to allow staff to assist in addressing these. They also have their needs reviewed once living in the home to ensure staff are aware of any changes in these needs. People accommodated also benefit from clear written information regarding their rights and responsibilities that are part of the terms and conditions of living at the home. EVIDENCE: The home has a satisfactory statement of purpose and service user guide. Each person has a statement of the terms and conditions for living at the home that forms part of the service user guide. Those sampled were satisfactory and had been signed by the person and a representative from the home. In addition the home has a contract for each person with their placing authority and those sampled were again seen to be satisfactory. One new person had been admitted to the home since the last inspection and this person’s file was inspected. The file contained a range of assessment information that was made available to the home before the person’s admission. This included an assessment of need, a risk management checklist, Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 9 a hospital discharge report and a physiotherapist assessment. Evidence was seen that the home undertook its own assessment of the person’s needs as part of the admission process, which included introductory visits to the home. The files of three other people, who had lived at the home for a longer period, were also inspected. These included evidence that their needs are reassessed at regular intervals to assist the home to meet their changing needs. I spoke independently by telephone to a community psychiatric nurse (CPN) who supports five of the people currently living in the home. She stated that she visits the home on average every two weeks. She went on to say that she finds the staff friendly and proactive and that staff accept and act on her professional advice regarding care and support to people living at the home. I also spoke independently by telephone to a social worker from L.B. of Newham who had place two people currently living at the home. He stated that he thought the home provided a good service for the people he supports. He went on to say that he thought the home was willing to take people with needs that were potentially difficult to manage and that his two people had made significant progress at the home. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are recorded in their care plans to assist staff in meeting these, however, some care plans need to be reviewed more frequently. People are supported to maximise their independence by making as many decisions as possible for themselves. People are also supported and guided in relation to taking appropriate risks in their lives to assist them to safely achieve their aspirations. EVIDENCE: Care plans were inspected for four of the people living in the home. These were in the form of strengths and needs document that covered the person’s current needs and gave guidance to staff on how to meet these needs. At the last inspection a requirement was made that the home must ensure that six monthly reviews of care plans take place on time and the minutes of review meetings are available for inspection. At this inspection evidence was available that three of the care plans inspected had been reviewed in the last six months Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 11 but not the fourth, which ad not been reviewed since January 2007. The new manager stated that he had identified this as an outstanding task when he was appointed and was in the process of ensuring all the care plans were reviewed as required. Nevertheless, this requirement had been made in August 2006 and I was disappointed that it had not been fully complied with. The requirement is restated. The home operates a key worker system and some key workers are undertaking specific tasks with individuals, generally relating to skills development. When this happens a record is kept of the activity or session. However, if there is not a specific task identified key workers do not currently record summaries of the work undertaken. A good practice recommendation is made that each key worker writes a monthly summary of their key worker sessions with each individual they are key worker for. This will further identify and evidence any changing need or preference the person may have and these records will be able to contribute to the six monthly review of the person’s care plan. People living in the home are encouraged and supported to make decisions about their day-to-day lives and to be involved in any meetings or discussions relating to them. Evidence was seen in the record of monthly residents meetings of this with a record of recent discussions on the decorations and maintenance in the home, management and staff issues, personal care and a recent satisfaction survey that had been distributed to people. Evidence was also seen that a representative from a local independent advocacy had attended the home earlier in October 2007 to talk to residents. The registered provider stated that it was hoped for this to become a regular occurrence and literature had been left for people living in the home on how to make a referral for independent advocacy concerning an identified issue. Two people spoken to independently at the home confirmed the above although indicated that they did not feel the need for independent advocacy at this time. Each file inspected contained a detailed mental health risk assessment relating to that individual that was current and subject to periodic review. A requirement had been made at the last inspection that the home must ensure that people who have psychiatric input have risk assessments that are reviewed with input from mental health professionals. Copies of individual letters to relevant mental health professionals requesting this involvement were seen as a response to this requirement. The manager stated that some mental health professionals responded to this with and were providing more regular input than others. The mental health risk assessments seen were up to date and the requirement is deemed to have been complied with. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are encouraged and supported to participate in a range of activities including within the wider community. They also enjoy contact with relatives and friends to the extent that they wish. People are supported to enjoy healthy and nutritious meals that they enjoy. EVIDENCE: The majority of people living at the home can and do travel independently and have freedom passes to assist with this. A small number of people travel in the community with the support of staff because of their specific needs. This was appropriately recorded on files sampled and one person spoken to independently, who did not travel unaccompanied, confirmed that they had been involved in discussions about this and had agreed to the limitation. One person left the home to visit relatives during the inspection. One person attends a local authority day service and stated that they enjoyed this. Two people belong to the Waltham Forest Black Peoples Mental Health Association Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 13 (WFBPMHA). One of them spoken to independently stated that they enjoyed a range of activities with this group. This included recent outings and visits including a day trip to Brighton. The person was also keen to tell me that they had been on a holiday to Gambia with the WFBPMHA since the last inspection, which they had particularly enjoyed. Other people attend college and have undertaken a range of courses including one person undertaking a beauty therapy course. Evidence was seen of other activities coordinated by the home including involving people in shopping trips, outings to pubs, to the library, cinema, meals out and day trips, including a recent day trip to Hastings. People are supported to attend places of worship if they wish although most of the people currently living in the home do not wish to do this. The majority of people living at the home have contact with relatives and friends ranging from weekly to annual contact depending on the wishes of the individuals involved. Visitors are made welcome at the home and the signing in book showed that relatives and friends visited the home most days. Daily routines in the home assist to promote people’s independence and people spoken to independently confirmed that they could get up and go to bed when they wished. Staff were seen to interact positively and appropriately with people accommodated throughout the inspection. People are also appropriately encouraged to undertake daily living tasks to assist develop their independence skills and this was documented in their files. This includes people being able to cook meals with appropriate level of staff supervision. Each person living in the home has a key to their bedroom although one person reported to the registered provider that they had just lost theirs and needed a new one. The new manager has introduced a new weekly menu after consultation with people living in the home. This showed a range of healthy and nutritious meals with people being given the option of choosing an alternative of their choice if they do not fancy the meal on the menu. One person has a separate menu with a range of Ghanaian meals that they have chosen and are assisted by some staff who are also Ghanaian in origin in cooking these. The home had sufficient food that matched the menu and that was properly stored. All the people living at the home that were spoken to stated that they liked the food. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home receive appropriate personal support in accordance with their needs. They also are supported in meeting their physical, mental and emotional healthcare needs. However, the medication administration practices within the home need improving as a matter of priority to minimise the risk of misadministration of medication. EVIDENCE: The majority of people living at the home are independent regarding their personal care although may need some verbal prompting on occasion. A few need more direct support from staff in this area and this is appropriately recorded. Staff spoken to independently were able to describe how they provided direct personal care in a sensitive way and in keeping with the individual’s preferences. One person living at the home who was spoken to independently indicated that the personal care provided by staff was delivered in a way that they felt comfortable with. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 15 People are supported with a range of physical, mental and emotional health needs and all people are registered with a GP. Satisfactory records of appointments with health care professionals were seen on the files inspected. This included evidence of appointments with GP’s, mental health specialists, general hospital outpatient departments, dentist, optician and a chiropodist. A community psychiatric nurse (CPN) who supports five of the people currently living in the home was spoken to independently and she confirmed that staff were proactive in promoting people’s physical and mental health. At the last inspection a good practice recommendation had been made by the inspector undertaking that inspection that the home reviewed its system of dispensing medication so that it reflects contemporary community care setting’s practise. This was because that inspector was concerned that the system in use at the time was too institutional. This recommendation had been acted on. At the beginning of October 2007 the home had changed its previous dispensing chemist and was for the first time receiving medication in a monitored dosage system (MDS), this is where medication is supplied in individual blister packs for each person for 28 days at a time. Medication and medication administration record (MAR) charts were inspected for three people living in the home. It was evident from this that staff were still not properly familiar with the new system. On each of the three people’s current month’s blister packs medication had been taken from the incorrect blister for a specified day. On each of the MAR charts there were gaps on individual entries for the month. Staff on duty stated that they were clear that people’s medication was being administered as prescribed although when shown the evidence acknowledged that mistakes had been made. Although records were seen to indicate that staff had received current training in the safe administration of medication it was evident that further work is needed in this area. The manager stated that he would now check the administration of medication on a daily basis and would produce further guidance and supervision for staff as a matter of priority. A requirement is made that all staff that administer medication must receive further training as a priority in the system of administering medication that the home is currently using. This is to minimise the risk of mistakes in the administration of medication. Records of medication received into the home and medication disposed of were inspected and were satisfactory. It was also noted during this inspection that two people were being supported to become more independent in dealing with their prescribed medication. A third person was also being supported with this and kept their own medication locked in their rooms with staff regularly checking that the person was taking their medication correctly. Records relating to this were satisfactory and the registered provider stated that the home’s policy relating to self-administration of medication was being followed. However, there was no record of the prescribing doctor having formally agreed this and a good practice Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 16 recommendation is made. The home should seek written agreement from the prescribing doctor for an individual resident that they are in agreement for staff to work towards self-administration of medication for this person. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People accommodated are able to express their views and concerns and have these acted on appropriately. The home’s safeguarding adults policy and procedures have been improved to further assist in protecting people from abuse. EVIDENCE: The home had a satisfactory complaints procedure that was seen in individual service user guides and included all the elements specified in the national minimum standards. However, the complaints procedure was not displayed in a communal area in the home. The registered provider stated that it was displayed until recently but that she was in the process of getting a copy laminated and this would be displayed. Given the needs of people accommodated, a good practice recommendation is made regarding this. People living at the home indicated that they knew how to raise concerns when they wanted to and that these were acted on when raised. The home had received one complaint since the last inspection and this was seen to have upheld and appropriate action taken. A concern related to the above complaint had been received by the Commission at the same time and the provider organisation had acted on this appropriately when informed. There have been no other complaints made to the home or to the Commission since the last inspection. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 18 One allegation of abuse had been received by the home since the last inspection. This had been investigated under L.B. of Waltham Forest’s safeguarding adults procedure although this was initially complicated by some communication difficulties between the parties concerned. However, independent feedback from both the chair of the safeguarding adults strategy meeting and the social worker involved with the person concerned both confirmed that the allegation was properly investigated, found to be substantiated and the home had taken appropriate action to deal with the situation. This included dismissing a member of staff and reporting them to the protection of vulnerable adults (POVA) list. The home had subsequently reviewed and revised its safeguarding adults policy and procedures. It has also prioritised a rolling programme for staff training in this area, including attending training provided by the L.B. of Waltham Forest. There have been no other allegations or disclosures of abuse made to the home or to the Commission since the last inspection. The L.B. of Waltham Forest is launching a new multi-agency safeguarding adults procedure at the end of November 2007. A good practice recommendation is made that the home obtains a copy of this policy and reviews its own safeguarding adults policy and procedures as a result of this. At the last inspection a requirement was made that the home was required to seek advice from the placing authorities for five people in order to manage their finances in accordance with the regulations. This requirement had been made because the inspector at that time was concerned that the home was appointee for a number of people. This requirement had been complied with and I was informed that residents’ finances were now dealt with by themselves or their representatives. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is comfortable, well decorated and generally well maintained. However, the laundry floor needs identified maintenance and attention is needed to some first floor windows to maximise protection to people living and working in the home. People who live in the home, staff and visitors benefit from the building being kept clean and tidy. EVIDENCE: The home is a large converted two storey residential property. The ground floor comprises: five residents bedrooms, lounge, dining room, kitchen and a conservatory that is a designated smoking area and leads out to a large attractive garden; there are six further bedrooms on the first floor. There are sufficient toilet and bathroom facilities on both floors and the home’s laundry facilities are in the basement. The home is suitably decorated and furnished. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 20 People living in the home stated that they liked their bedrooms and those seen during a tour of the premises had been personalised to varying degrees by the person that occupied them. People spoken to also stated that when rooms were decorated they were consulted about their preferences. The registered provider stated that although one room was registered as a double room it was occupied by one person and the home was therefore considered to be full. It was noted during the tour of the building that one first floor bedroom did not have a window restrictor fitted. A requirement is made that window restrictors are fitted to all first floor windows unless a specific risk assessment has been undertaken for each person regarding risk in this area. This requirement is made to minimise the risk of accidents to people living in the home. At the last inspection a requirement had been made that the partly worn carpet in room ten is replaced and this was seen to have been complied with. The home has a handyperson who deals with routine maintenance and satisfactory records relating to this were seen, the registered provider stated that specialist companies undertake more specialist work. She went on to say that a number of windows in the home were due to be replaced with double-glazed units. The home was clean and tidy during the inspection and the manager stated that people living in the home were encouraged and supported by staff in keeping their rooms clean. The home had suitable laundry facilities and an infection control policy that was seen. It was noted that the floor surface in the laundry was deteriorating significantly in a number of places, was becoming porous and needed a new non-porous surface to maximise infection control arrangements. The home is required to ensure that the laundry floor is replaced or repaired to make it non-porous to maximise infection control protection in this area. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. A staff team with a range of qualifications and competencies, in sufficient numbers, support people living in the home. The home’s recruitment policy must be robustly followed at all times to maximise protection to people living in the home. People are supported by staff who have access to appropriate training and formal supervision to assist in further meeting the needs of people living in the home and in there own personal development. EVIDENCE: At the time of this inspection the home employed a manager, who stated that he had been in post since September 2007, and nine care staff, which included one senior care staff. Of the nine care staff seven had completed the national vocational qualification (NVQ) level 2 in care and two were working towards this qualification. The registered provider stated that three care staff were due to start work on NVQ level 3 in care in January 2008. Two care staff work the morning shift, two care staff work the afternoon/ evening shift and two waking care staff work at night. The manager’s hours are in addition to this. The manager stated that he usually worked during office Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 22 hours although also worked some shifts to ensure that he was aware of what happened in the home on different shifts. Care staff often work double shifts from 8am to 8pm and the night staff work from 8pm to 8am. Staff spoken to independently stated that working long shifts suited them and felt that it worked to the homes benefit by maintaining more continuity of care throughout the day. A copy of the rota was seen and accurately recorded the staff on duty during the day. In addition to the manager one new care staff had been appointed since the last inspection. This care staff’s file was inspected and contained: a copy of the staff member’s proof of identity including a recent photograph, two written references including a last employer reference, and evidence that the person had a current criminal record bureau (CRB) clearance and protection of vulnerable adults (POVA) check that was received before the person started working at the home. However, a CRB clearance and POVA check undertaken by the provider organisation for the new manager was seen to be dated October 2007 and the manager started in post in September 2007. The registered provider stated that the manager had a current CRB clearance and POVA check from a previous employer and had used this clearance while waiting for the new one. However, these recruitment checks are not transferable between employers. A requirement is made that no new staff, at any level, must start work at the home until the provider organisation has received a new and satisfactory CRB clearance and POVA check, or, in exceptional circumstances, a POVA First check while waiting for the full CRB. In the latter circumstances the staff member must be supervised at all times until the full CRB is obtained. This requirement is made to maximise protection for people living in the home from potentially unsuitable staff. At the last inspection a requirement was made that the home must develop a staff training and development programme for the staff team and this requirement had been complied with. At this inspection an overall staff training plan for the home was seen and individual staff training records were sampled; these indicated that the provider organisation was committed to staff training. Training undertaken in the past twelve months included breakaway training, dental/ oral hygiene, safeguarding adults and medication training. Evidence was also seen of staff training in the safe administration of medication. However, given the issues identified in the Personal and Health Care Support section of this report a requirement is made in that section that additional training in this area is needed. I was pleased to see that staff have been booked on training regarding the implications of the Mental Capacity Act 2005 that fully came into effect in October 2007 and that each staff member had been given a guide to the Act. The manager stated that all staff were supervised every six to eight weeks and both documents sampled and staff spoken to evidenced this. The registered provider also showed me a new staff survey form that the home intended to introduce. This survey will seek staff opinions on a range of relevant areas, including equality and diversity, and the Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 23 aim is to assist the provider organisation support staff in undertaking their roles more effectively. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from it being satisfactorily managed on a day to day basis although further action is still needed to comply with legislation regarding registration. The views of people living in the home and of their representatives are sought and acted on regarding the quality of life in the home. Health and safety procedures assist in protecting people living at the home, staff and visitors. EVIDENCE: The newly appointed manager presented as being knowledgeable regarding the needs of people with mental health difficulties and with management of a residential care home. He is a registered mental health nurse and holds a post graduate certificate in management. At the last inspection in August 2006 a Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 25 requirement was made that the registered provider is required to appoint a manager and for the manager to apply for registration with the Commission. The registered provider had made alternative arrangements to manage the home before the appointment of the new manager. However I was concerned that the former temporary manager had not been formally registered as such with the Commission and the requirement had not been complied with. The requirement is restated; the provider organisation must ensure that an application for registration is made to the Commission in respect of a suitable manager for the home. This is to comply with legislation and to verify to the Commission that the appointed manager is qualified, competent and experienced to run the home. Unmet requirements impact on the welfare and safety of people living in the home, therefore continued failure to meet restated requirements may lead to the Commission considering enforcement action against the registered person. The home has a range of effective ways of monitoring the quality of care provided. At the last inspection a requirement had been made that the home publishes the results of residents surveys once they are completed and made available to people living in the home, family members and to the CSCI. This requirement has been complied with. Evidence was seen at this inspection that people living at the home are invited to fill in regular satisfaction questionnaires and these were sampled. In September 2007 the registered provider had produced a report summarising the findings from the last questionnaire and areas for improvement had been identified in the report. The home is using a key worker system to assist in better understanding people’s wishes and preferences. The registered provider undertakes regular visits to the home and provides monthly reports on these, which were sampled and judged to be satisfactory. A range of health and safety documentation was inspected. A requirement was made at the last inspection that the electrical wiring at the home was inspected. This had been complied with and a current electrical installation certificate was seen. Satisfactory documentation was seen at this inspection regarding gas safety and portable appliance testing. Evidence was also seen that the home’s fire fighting equipment had been serviced and of a current fire plan and fire risk assessment. Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(2) Requirement The registered person must ensure that all care plans are evaluated and reviewed at least every six months and more frequently if the person’s needs change (previous timescale of 30/11/06 not met). The registered person must ensure that all staff that administer medication receive further training as a priority in the system of administering medication that the home is currently using. This is to minimise the risk of mistakes in the administration of medication. Timescale for action 30/11/07 2. YA20 13(2) 30/11/07 3. YA24 13(4) 4. YA30 13(4) The registered person must 30/11/07 ensure that window restrictors are fitted to all first floor windows unless a specific risk assessment has been undertaken for each person regarding risk in this area. This requirement is made to minimise the risk of accidents to people living in the home. The home must ensure that the 30/11/07 laundry floor is replaced or DS0000007246.V351935.R01.S.doc Version 5.2 Page 28 Lyncroft repaired to make it non-porous to maximise infection control protection in this area. 5. YA34 19(5) The registered person must ensure that no new staff, at any level, start work at the home until the provider organisation has received a new and satisfactory CRB clearance and POVA check, or, in exceptional circumstances, a POVA First check while waiting for the full CRB. In the latter circumstances the staff member must be supervised at all times until the full CRB is obtained. This requirement is made to maximise protection for people living in the home from potentially unsuitable staff. The registered person must ensure that an application for registration is made to the Commission in respect of a suitable manager for the home. This is to comply with legislation and to verify to the Commission that the appointed manager is qualified, competent and experienced to run the home (previous timescale of 30/11/06 not met). 30/11/07 6. YA37 8 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Lyncroft Refer to Standard YA6 Good Practice Recommendations The home should ask each key worker to write a monthly DS0000007246.V351935.R01.S.doc Version 5.2 Page 29 summary of their key worker sessions with each individual they are key worker for. This will further identify and evidence any changing need or preference the person will have and these records will be able to contribute to the six monthly review of the person’s care plan. 2. YA22 The home should seek written agreement from the prescribing doctor for an individual resident that they are in agreement for staff to work towards self-administration of medication for this person. The home should display a copy of its complaints procedure in a communal area of the home to maximise its accessibility to people living in the home and to other stakeholders. The home should obtain a copy of the L.B. of Waltham Forest’s revised safeguarding adults policy and review its own safeguarding adults policy and procedures as a result of this. 4. YA22 5. YA23 Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyncroft DS0000007246.V351935.R01.S.doc Version 5.2 Page 31 - 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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