Inspection on 04/01/06 for Lyncroft

This inspection was carried out on 4th January 2006.

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

The inspector 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyncroft 29/10/07

Lyncroft 25/08/06

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 Harun Rashid Unannounced Inspection 4th January 2006 10:30 Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 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.V275539.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V275539.R01.S.doc Version 5.1 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 Jenniffer M. E. Khan Shaista Yasmin Khan Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Special category - to include one named person with learning disabilities 6th September 2005 Date of last inspection Brief Description of the Service: Lyncroft is a privately run care home for twelve adults with mental health problems. The home is a large detached house situated in a residential area of Leytonstone, which is in the London Borough of Waltham Forest. Immediately opposite the home there is a large open land area close to the London Borough of Redbridge. The area is well served by public transport. Leytonstone underground and local bus stops are in walking distance. 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. M11 link is close by the Green Man roundabout, which makes road communication very accessible to various parts of London. The home has 10 single rooms and one double bedroom. A conservatory was built and is used by the service users who smoke. The home employs ten (full and part time) care assistants and one maintenance staff. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a weekday morning on 4/1/06. The Inspector spoke to five-service users, interviewed one member of staff and the responsible individual (the proprietor). They all expressed their satisfaction with the standard of care provided in the home. What the service does well: 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. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 6 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.V275539.R01.S.doc Version 5.1 Page 7 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 the following standard(s): 2,3 and 4 The home carries out a pre-admission assessment prior to a new admission to the home and is able to meet service users assessed needs adequately. EVIDENCE: The registered manager of Lyncroft and the registered manager of Carmen Lodge (sister home) who is a psychiatric nurse jointly carry out needs assessments of service users prior to the admission to the home. The preadmission assessments were detailed with information which covered all areas of needs. From discussion with staff members, service users and examining care files it was evident that staff can demonstrate if any specific needs are identified, specialist advice is sought, such as community psychiatrist nurse and psychiatrist. All nursing input required by service users is provided through the Primary Care Team or through the Community Psychiatric Nurse. From the discussion with the responsible individual and staff it was clear that a newly admitted service user was given opportunity for a one week trial period during the daytime and one week overnight stay in the home. Service user, family members and social worker are also encouraged to visit the home prior to the admission. The home has a policy of three months settling period. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 8 Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6,7 and 9 All service users have care plans, which were reviewed on six monthly basis. Risk assessments were completed for all service users, however, these to be reviewed with input from health professionals. EVIDENCE: From the examination of care files it was clear that staff completed a detailed ‘strength and needs’ list of all service users, which included service users personal, social, leisure, educational, health, emotional and communication needs. The care plans had been developed with involvement of service users, their family members and professionals. It also identified how the assessed needs of the service users will be met and by whom. The care plans were reviewed on a six monthly basis. The home also arranges yearly reviews, which are attended by service users, family and Multi Disciplinary Team members. Staff of Lyncroft respect service users’ right to make decisions about their lives by providing information, assisting them to manage five service users finances. These were recorded in the care plans. Service users were given information how to get access to advocacy services such as North East London Advocacy (NELA). Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 10 All service users have risk assessments. They are supported to take responsible risks as part of their independent lifestyle and are enabled to take decisions about their lives. Staff encourage them to travel independently in the community within the risk assessment frameworks. However, it was a requirement in the previous inspection report that, the management review service users’ risks assessments with input from health professionals. The responsible individual and the registered manager of Carmen Lodge informed that the consultant psychiatrist informed the home that service users who do not have ongoing psychiatric problems will receive health support from their G.P. instead. However, at present three service users are receiving support from their CPN. Therefore, the management must ensure that service users who have psychiatric input have risk assessments that are reviewed with input from health professionals. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12,13,15 and 16 Service users have opportunities to access local amenities including further education and training. They maintain a good relationship with family and friends. EVIDENCE: Four of the service users of Lyncroft attend various courses for example, computing, hairdressing, art and pottery at Waltham Forest, Epping and East Ham colleges. One of the service users has a classroom-cleaning job in Waltham Forest College. Staff of Lyncroft support service users to find suitable jobs or further education and training. There is a list of activities and events available to service users about what is happening in the local community that is appropriate to their interest and needs. Service users informed that they enjoy visits to the cinema, pub, church and shops. Staff of Lyncroft support service users to maintain family links and friendships inside and outside the home, subject to restriction agreed in their care plans. Families and friends are welcomed to the home. The proprietor informed that they had a BBQ last summer, service users’ families and friends were invited. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 12 Daily routines and house rules promote independence, individual choice and freedom of movement as agreed with service users within their care plans. Service users have keys to their bedrooms, which contain a lockable drawer for personal items and money. Staff do not open service users’ mail without their agreement. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 18,19 and 20 The home can demonstrate that service users health care needs are adequately meet and staff seek specialist support in order to meet service users health needs. EVIDENCE: Personal support is provided in private, intimate care is provided by staff of the same gender. Time for getting up and going to bed, baths, meals and other activities are flexible. The home offers service users choice in areas such as their personal clothes or hairstyle. Service users files indicate that their preferred routine, likes and dislikes were recorded. All service users have designated key workers. Care plans demonstrate that specialist support and advice is made available to service users who would benefit from this, for example, CPN input. Staff or family members accompany service users to outpatients and other medical appointments occasionally. Three of the current service users are able to attend some of the appointments by themselves and staff encourage them to do so. Medication Administration Record Sheets were examined and found to be satisfactory. Staff keep records of all medication administered, received from the chemist and disposed of. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 14 The registered person seeks information and advice from the pharmacist regarding safe administration of medication. At present 3 service users self medicate and staff monitor their medication administration. Staff also assist those service users’ with ordering prescriptions from G.P. surgery and collecting medication from the local chemist. Staff attended a ‘ treatment of anti-psychotic and taking good care of medicine’ course conducted by the pharmacist. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 The home has complaint policy and procedure, which they adhere to. The home provides adult protection training to staff members. EVIDENCE: Lyncroft provides a simple and clear complaint policy and procedures. The complaint policy and procedures were made available for service users, their families and for other relevant parties by displaying information on the notice board. A record of complaints was kept in a complaint book including details of investigation and action taken by staff. The complaint received was minor in nature and those were investigated and resolved accordingly. The adult protection policy and procedure contain sufficient guidance for staff to enable them protect service users from abuse. Staff attended Adult Protection training. The responsible individual informed that another refresher Adult Protection training will take place in April this year. The registered manager understands her responsibility to refer staff who harms service users in their care to the POVA list. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 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 the following standard(s): 24,26 and 30 Lyncroft is suitable for its stated purpose. The home provides comfortable and safe environment for its service users. The home is clean and free from offensive odour. EVIDENCE: The home is a non-institutional building, similar to a large family house. The home is safe, comfortable and well maintained. It offers access to local amenities and local transport including Leytonstone underground station. The furnishing, fittings and adaptations are of good quality. The home has a planned maintenance and renewal programme for fabric and decoration of the premises, with records kept of work undertaken. The home provided each service user with a bedroom that has furniture and fittings sufficient and suitable to meet their needs. Each bedroom has a washbasin. All bedrooms are lockable and service users were offered bedroom keys. Service users were provided with lockable storage spaces (bedside cabinet). From the tour of the premises it was noticed that the home was clean, hygienic and free from offensive odour throughout and a system is in place to control Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 17 the spread of infection. The washing machine has specific programming ability to meet disinfection standards. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Lyncroft operates a thorough recruitment policy and procedure based on equal opportunities and carries out all relevant checks on staff prior to their appointment. Staff are attending NVQ training. EVIDENCE: A wide range of training has been taking place, some of which is arranged inhouse, using the skills of the staff team and others in the community. All staff received equal opportunities training; training and development are linked to the home’s aims and objectives. Two of the care staff have completed their NVQ level 2 qualifications in care and a further four will achieve NVQ level 2 qualifications in care before the end of March this year. The management is confident that 50 of their care staff will achieve their NVQ 2 qualification in care in March 2006. The management of Lyncroft operates a thorough recruitment procedure based on equal opportunities and ensure the protection of service users. Two written references were available in the staff files. The management carried out Criminal Record Bureau checks prior to the staff being appointment. The home has a training and development plan and training budget. All newly appointed staff received a structured induction and this is linked to the aims and objectives of the home stated in the Statement of Purpose. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The service must ensure that the registered manager’s name is included on the staff rota. The registered manager to complete her RMA award. The home ensures service users and staff’s health, safety and welfare at all times. EVIDENCE: The registered manager was not on duty at the time of the inspection and her name was not included on the staff rota either. The responsible individual informed that as she is supernumerary therefore, her name did not show on the rota. The inspector advised that the registered manager’s name must be included on the rota for staff and other relevant parties including service users to be aware when she would be available for advice and guidance. The registered manager to complete her Registered Manger’s Award. The responsible individual informed that she will complete her RMA award by April this year. In addition to this the responsible individual (the proprietor) informed that she intends to commence the Registered Managers Award this year. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 20 There are various systems, which ensure that close monitoring is maintained on all of the home’s services and procedures. The home’s quality programme involves service users and their relatives and seeks their comments on the service. At the time of the inspection the proprietor showed evidence of completed quality questioaanre forms, which were completed by service users/ relatives. The proprietor provides CSCI with a copy of the report of the Regulation 26 visits. The management ensures, so far as is reasonably practical, the health, safety and welfare of the service users and staff. The management ensures safe working practices, including staff training for fire safety, first aid, food hygiene, infection control, treatment of anti-psychotic illness and taking good care of medicine, adult protection and NAPPI (Non Aggressive, Psychological and Physical Interventions). Staff test fire alarms on a weekly basis and carry out fire drills in every three months. The management ensures that all appliances for example, gas and electric are regularly checked. The manager carried out a fire risk assessment for the premises to identify the risk areas of the home and how to eliminate/minimise those risks. The home displayed a valid insurance certificate against loss or damage to the business. Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 x 2 3 3 3 4 3 5 x 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 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 3 x Lyncroft DS0000007246.V275539.R01.S.doc Version 5.1 Page 22 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 YA9 Regulation 13 Requirement The manager must ensure that service users who have psychiatric input have risk assessments that are reviewed with input from health professionals. The management must ensue that registered manager’s name is included on the staff rota. Timescale for action 31/03/06 2. YA37 18 04/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The registered manager to complete her RMA qualification. 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