Inspection on 03/05/05 for Lyncroft

This inspection was carried out on 3rd May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lyncroft 17/04/09

Lyncroft 05/06/08

Lyncroft 02/08/06

Lyncroft 06/10/05

Lyncroft 07/10/04

Lyncroft 13/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Lyncroft 237 Banstead Road Banstead Surrey SM7 1RB Lead Inspector Deborah Yapicioz Unannounced 3 May 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lyncroft Address 237 Banstead Road Banstead Surrey SM7 1RB 020 8786 8381 020 8786 8381 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Walsingham Community Homes Mandy Barton Care Home 3 Category(ies) of Learning disability (3), Learning disability - Over registration, with number 65 (1), Physical disability (1) of places Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7/10/05 Brief Description of the Service: Lyncroft is a residential care home that was first registered in January 1997 to provide care for adults with learning disabilities. There are currently three people living at the home, this includes one service user who has an acquired brain injury.The home is in a period of change and regular meetings are taking place to look at the way forward for the home. The home is currently looking at applications for propective servie users. The home’s ethos is based on Christian philosophies. The home is one of four homes in the Croydon and Sutton area that are owned by ‘Walsingham’, which is a registered charity.Lyncroft is a two storey detached property in keeping with the other houses in Banstead Road. There are 6 single bedrooms, one of the bedrooms is being used as a sitting room for one of the service users. There is a communal through lounge, a dining room and a kitchen. Other facilities include a laundry, staff sleeping in room and staff office.There is an established rear garden with areas of lawn, a pond, mature trees and bushes, a patio area and a brick barbeque. The front of the premises has level access, an in-out drive and off street parking. Lyncroft has its own house car.The home is not adapted to meet the needs of service users who may also have secondary physical disabilities. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the morning of 3rd May 2005 Methods of inspection included a tour of the premises observation of contact between staff and service users and discussion with the home manager. The home currently has three service users. The inspector noted that staff treated service users with dignity and respect throughout the inspection. Overall the inspection confirmed that the home continues to provide a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? What they could do better: The home currently has only three service users as the plans for the home have changed since the last inspection. The home manager is having regular meetings with representatives from social services and the local NHS trust to Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 6 ensure the home can meet the needs of the new service users and there are compatible with the existing service users. The general décor of the home is good and there are plans to redecorate service users bedrooms and other communal areas. The living room however is in particular need of attention. 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 G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. All service users have a full assessment of their care and social needs prior to admission to ensure that the home is able to meet them. EVIDENCE: The home is undergoing a period of change. Previously the home management had considered setting up a service for people with a learning disability and challenging behaviour. This is no longer likely as there have been some difficulties finding a suitable place for one of the current service users .The home manager considers it most likely that the home will probably offer a service to people with a learning disability with a variation to accommodate one of the service users who has an acquired brain injury. Any new service users to the home will only be considered once compatibility with the current service users is established. There is an up to date Statement of Purpose and Service User Guide in place. The home has a procedure for introducing service users to a new residential placement. New Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 9 They would have a gradual introduction to the home with a series of short visits and overnight stays. The time frame would be flexible depending on the service user. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 The service users have comprehensive individual care plans with detailed information on their needs and personal goals. Individual care plans include consultation with service users and are regularly updated by the key-worker to reflect current needs. EVIDENCE: The staff team at the home are in the process of introducing Person Centred Plans. The staff team have recently been on training courses to write Person Centred Plans. The service users are offered opportunities to participate in the day-to-day running of the home, and to contribute to the development and review of policies, procedures and services through regular one to one meetings, user satisfaction surveys and use of advocates. The one to one meetings between service users and their key workers are now recorded in line with a requirement set at the last announced inspection. In the past service users have been on interview panels for new staff interviews. Service users can also join non-confidential sections of the staff handover meetings. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 11 The home operates a risk management system and individual assessments are on service users files. Information is presented with good use of supporting visual information, including pictorial cues, symbols and high contrasting large print text. The home also has used photographs of staff, places and service users for explaining procedures and policies. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 17 The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. The daily routines and house rules promote residents’ rights and encourage independence. Dietary needs are well catered for and a well balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: Each of the service users has a key to their bed rooms and service users right to privacy is encouraged by knocking on the door before entering service users bedrooms. There is a strong emphasis on service users using the community facilities. The service users have a varied programme of social activities organised by the staff team in consultation with service users. The home timetable illustrated the wide variety of activities that the service users access during the week. The staff team at the home encourage service users to remain in contact with family and friends who can visit regularly. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 13 Family and friends are made aware of the home’s visiting policy and there are few restrictions about when people can visit The home has a key worker system and it is part of their role to keep parents and carers informed of their progress. Each service user has an individual menu and are also able to choose alternatives. Any dietary requirements are taken into account for example one of the service users has a diabetic diet. Service users are actively encouraged to be involved in the individual budgeting, shopping and preparation of meals where appropriate. Snacks are always available. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20, Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical and emotional health needs are met by this home. Residents’ medication is well managed to ensure good health. EVIDENCE: The service users need varying degrees of assistance with their personal care. The level of support a service user needs would be detailed at their review and recorded in their personal file. All service users are registered with a local General Practitioner and have access to community health facilities such as opticians, chiropodist and dentists as required. Records examined showed that all medicines administered are recorded on Medicine Administration Record Sheets, which were up to date at the time of the unannounced inspection. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies and training in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a complaints procedure, which outlines how a complaint is dealt with and timescales for action. There are also policies and procedures in place regarding the protection of vulnerable adults. The staff team have attended training on adult protection issues. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25,26,28, 30 On the whole this home is homely, bright and clean and provides the service users with safe, comfortable surroundings that meet their needs. However the communal lounge area is in need redecoration and refurbishment. EVIDENCE: The home is a house in a quiet residential road. It is close to Banstead train station and local shops and amenities. There is a large communal lounge on the ground floor as well as a spacious dining room. The furniture is domestic, flame retardant, and of good quality. The large communal lounge looks shabby, with marked and ripped wallpaper in some areas and is in need of redecoration. The carpet has been recently replaced in the lounge and the service users were also involved in choosing a new suite for the lounge. There are plans to redecorate the remainder of the home once the future service user group has been decided. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 17 The home has a driveway to the front of the property and a garden to the rear, which backs onto the golf course. Each of the service users has their own bedroom, which is decorated to reflect their individual tastes. One of the bedrooms upstairs has been converted to a sitting room for a service user. As there are currently only three service users living at the home there is amble communal space. A handy man attends to repairs around the home on an “as required basis”. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 35,36 The home has an experienced, well-established staff team who have had relevant support and training enabling them to meet the needs of the service users living at the home. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users, although these are all held at the company head-office. EVIDENCE: There are two/three members of staff on duty depending on the service users commitments for the day (not including the manager) At night there is one sleep-in member of staff as well as a waking member of staff for one service user. The home offers training opportunities to staff at all levels within the home. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 19 New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. All staff at Lyncroft are undertaking a National Vocational Qualification at level two or three. Criminal Records Checks are completed before a new member of staff can begin work in the home although it is company policy that Criminal Records Checks are held centrally at the head office. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,42,43 The home appears to be well managed with clear lines of accountability within the home and the management style is open and transparent. Records held at the home provide evidence that maintenance is regularly carried out to ensure the well being and safety of the service users. EVIDENCE: The home is registered with the Commission for Social Care Inspection to manage Lyncroft. Ms Barton has recently completed her National Vocational Qualification level four and is also a National Vocational Qualification assessor. Service user views are considered very important at Lyncroft and since the last inspection the staff team at the home are now recording their key worker sessions as a way of incorporating service users views in the running of the home. Service user has access to advocates. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 21 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. All staff must attend mandatory health and safety training including moving and handling. Copies of the homes policies and procedures are kept in the office and the staff members were aware of where to locate them. Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lyncroft Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 3 G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 35 Regulation 17(2) Requirement All the elements of Schedule 4 must be held on site in the home.Carried over from previous inspections. The manager must ensure the homes communal lounge is redecorated. Timescale for action 30/09/05 2. 24 23(2)(d) 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Lyncroft G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 G53-G53 S07137 Lyncroft unann V211356 030505 Stage 4.doc Version 1.30 Page 25 - 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. 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