Inspection on 06/10/05 for Lyncroft

This inspection was carried out on 6th October 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyncroft 17/04/09

Lyncroft 05/06/08

Lyncroft 02/08/06

Lyncroft 03/05/05

Lyncroft 07/10/04

Lyncroft 13/05/04

Similar services:

Ashlong House

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Edenvale

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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 Inspection 6th October 2005 09:00 DS0000007137.V254835.R01.S.doc Version 5.0 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 DS0000007137.V254835.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. DS0000007137.V254835.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lyncroft Address 237 Banstead Road Banstead Surrey SM7 1RB 020 8786 8381 020 8786 8381 bansteadrd@walsingham.com 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) Walsingham Mandy Barton Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places DS0000007137.V254835.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3/05/05 Brief Description of the Service: Lyncroft is a residential care home that was first registered in January 1997 to provide care for up to 6 adults with learning disabilities. At the moment the home is registered for three service users. There are currently two people living at the home, this includes one service user who has an acquired brain injury. The home is undergoing a period of change and regular meetings are taking place to discuss the way forward. The number of service users has been temporarily reduced to facilitate the transition. This 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. 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. There is no lift. DS0000007137.V254835.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place in the morning when the two service users were at home. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. The home manager was not on duty at the time of the inspection and Karen Westfield Finnerty facilitated the inspection. The inspection was spent having a discussion with Ms Westfield Finnerty, looking at records, talking to service users and a tour of the premises. Overall the home continues to provide a good standard of care to the people living there. What the service does well: What has improved since the last inspection? The home has recently introduced a Person Centred Plan format to individual plans. The new format is comprehensive and sets out goals and aims as well as care needs. The service users changing needs are assessed regularly and they have access to other healthcare professionals. The general décor of the house is good and there have been some improvements have been completed since the last inspection. The lounge has been redecorated and new furniture purchased giving it a “homely” feel. The premises were generally bright, airy and clean on the day of the unannounced inspection. Many of the bedrooms have been redecorated since the last inspection. DS0000007137.V254835.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000007137.V254835.R01.S.doc Version 5.0 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 DS0000007137.V254835.R01.S.doc Version 5.0 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 the following standard(s): 1,2, The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. EVIDENCE: The home currently has two service users living there. This is because the home is undergoing a period of change. 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. At the previous inspection the home manager has informed the inspector that she 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. The home manager meets regularly with representatives from the local authority to discuss possible future placements at Lyncroft. 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. DS0000007137.V254835.R01.S.doc Version 5.0 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 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 two service users files were looked at during this inspection. The home has recently introduced a Person Centred Plan format to individual plans. One of the Person Centred Plans has been completed and the other plan is in the process of being changed to the new format. The new format is comprehensive and sets out goals and aims as well as care needs. Risk assessments are included as well as information on family and friends. The home has a key worker system. The service users and their key workers regularly review individual goals. 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. DS0000007137.V254835.R01.S.doc Version 5.0 Page 10 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): 12,13,15,16,17 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 catered for with meals that are nutritionally well balanced, nicely presented, and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: The home has two service users at the moment. The service users are encouraged to be as independent as possible and participate in food shopping, choosing and cooking meals and choosing trips and holidays. Part of the role of the key workers at the home is to encourage service users at the home to maintain and develop independent living skills. The service users have a weekly activity timetable and details of the service users weekly commitments are also recorded on service users files. There is a strong emphasis on service users using the community facilities. DS0000007137.V254835.R01.S.doc Version 5.0 Page 11 The service users enjoy visits to the hairdressers, going out for pub meals and going to the local church. The service users have both had an annual holiday to Weymouth and the Isle of Wight. They have also visited National Trust Properties, gone on coach trips and had day rips to the coast in the homes car. 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. The service users are also involved in some domestic chores including cleaning their own bedroom, doing their laundry and watering the plants. There is an open visitors policy. Friends are also welcome to visit The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. At the weekends there is more flexibility with breakfast and bedtimes. The service users are given a choice of having keys to their bedrooms and the front door of the home. DS0000007137.V254835.R01.S.doc Version 5.0 Page 12 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): 18,19,20, 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 detailed in personal plans to offer consist care in this area. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. During the inspection it was noted that there were some gaps in the medication records. The home must ensure all medication records are filled in correctly. The level of personal support a service user needs would be detailed at their review and recorded in their personal file. Personal care is provided in private, and timings of this are also flexible. The home provides consistency and continuity through designated key workers All service users are registered with a local General Practitioner. The staff team at the home monitor the health of each of the service users and would ensure they receive any treatment needed. Incident forms are completed following any accidents. DS0000007137.V254835.R01.S.doc Version 5.0 Page 13 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): 22,23 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 in place to ensure the protection of vulnerable service users. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The complaints procedure is also in picture format. The home has a copy of the local authority Adult Protection Policy on site and staff receive training on these issues. DS0000007137.V254835.R01.S.doc Version 5.0 Page 14 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): 24,25,30 The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: The home is a house in a quiet residential road. It is close to Banstead train station and local shops and amenities. The home’s premises are in keeping with the local community and are suitable for their purpose. 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 general décor of the house has been improved since the last inspection. The lounge has been redecorated and new furniture purchased giving it a “homely” feel. The premises were generally bright, airy and clean on the day of the unannounced inspection. There is also a large garden at the rear of the home which the service users spend time in during the summer months. Each of the service users in the home has a single room, which is decorated and personalised to reflect their individual taste. Many of the bedrooms have been redecorated since the last inspection. On the day of the inspection the home was clean, bright and well ventilated. There was suitable domestic lighting. DS0000007137.V254835.R01.S.doc Version 5.0 Page 15 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): 32,34,35 The staff team at the home have a range of skills and abilities, which enable 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 were two members of staff on duty at the time of the inspection, which effectively means each service users had a “one to one”. 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. 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. Agency staff at the home also has an induction pack, which includes policies and procedures, vulnerable adults Policy information and the management structure of the home. 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 DS0000007137.V254835.R01.S.doc Version 5.0 Page 16 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): 39,42 The management style is transparent and open with clear lines of accountability, which is aimed at ensuring the well being of the service users. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised. EVIDENCE: Mandy Barton is registered with the Commission for Social Care Inspection to manage Lyncroft. Service user views are considered very important at Lyncroft and the staff team at the home record their key worker sessions as a way of incorporating service users views in the running of the home. The home also undertakes periodic quality assurance reviews. Service users have access to advocates. DS0000007137.V254835.R01.S.doc Version 5.0 Page 17 Records required for the safety and well being of service users are in place including accidents, risk assessments, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. Records held at the home demonstrated that fire drills are not being undertaken as often as they should. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards and knives were seen in the kitchen. All staff must attend training relating to health and safety issues including fire safety and epilepsy. A record of training attended is kept on staff files. A representative of the registered provider visits the home regularly and copies of the visit report are sent to the Commission for Social Care Inspection Corydon office. DS0000007137.V254835.R01.S.doc Version 5.0 Page 18 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 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000007137.V254835.R01.S.doc Version 5.0 Page 19 No 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 2 Standard YA42 YA20 Regulation 23. (4)(e) 17 (1)(a) Sch 3 3(I) Requirement The homeowner must ensure regular fire drill are undertaken and recorded. The home manager must ensure all medication records are correctly filled in at all times Timescale for action 06/10/05 06/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000007137.V254835.R01.S.doc Version 5.0 Page 20 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 DS0000007137.V254835.R01.S.doc Version 5.0 Page 21 - 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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