Inspection on 06/09/05 for Lyncroft

This inspection was carried out on 6th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lyncroft 29/10/07

Lyncroft 25/08/06

Lyncroft 04/01/06

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 Announced Inspection 6 September 2005 10:00am th 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 G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lyncroft Address 11 Bushwood, Leytonstone, London E11 3AY 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) 020 8989 5933 jennifermkhan@hotmail.com Ms Jennifer M E Khan Shaista Yasmin Khan Care Home Twelve (12) Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia (12) of places Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 29th December 2004 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 care assistants and one maintenance staff. The Statement of Purpose indicates that the management of the home offer a highly professional care service with a personal touch for people with mental health problems. The statement of purpose also places emphasis on service users privacy, dignity, independence, choice, rights and fulfilment in their lives. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on a weekday morning of 6th of September 2005. The Inspector received 9 feedback cards from service users, a family member and staff. The Inspector also spoke to six service users, interviewed two members of staff and the registered provider (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 G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 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 standard(s) 2 and 5 The home carry out a pre-admission assessment prior to a new admission to the home. All service users are provided contracts which included terms and conditions of the home. EVIDENCE: The home had an emergency admission on 24/4/05 following the discharge of a service user from a hospital. The manager of Lyncroft and the registered manager of Carmen Lodge (sister home) who is a psychiatric nurse jointly carried out a need assessment prior to the admission to the home. The Inspector was advised that the service user visited the home prior to the admission and she was introduced to service users and staff. Following the recommendation of the previous inspection report service users’ contract letters were amended. The amended contracts have included a description of rooms to be occupied by the individual service users in the home. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 8 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 and 9 All service users have detailed care plans. However, the six monthly review meetings minutes were not available at the time of inspection. All service users have risk assessments, however these will require to be reviewed with input from the 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. All service users had yearly reviews, which were attended by psychiatrist, and community nurses. However, at the time of the inspection, the six monthly review meeting minutes were not available for inspection. The proprietor was confident that the reviews took place but due to the registered manager’s annual leave the minutes were not found. The Inspector advised that the minutes of the six monthly reviews must be available for inspection. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 9 All service users have risk assessments. Service users are supported to take responsible risks as part of their independent lifestyle and are enabled to take decisions about their lives. Staff encourage service users to travel independently in the community within the risk assessment framework. However, the Inspector advised the management to review service users’ risk assessments with input from health professionals. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 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 standard(s) 12,13 15 and17 Staff support service users for developing further education and training within their dependency levels. Service users have opportunities to access local amenities. Choice of menus is offered and service users have opportunity to cook meals. 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 comprehensive 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. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 11 Families and friends are welcomed to the home. The proprietor informed that they had a BBQ this summer and service users’ families and friends were invited. From discussion with staff, service users and examining weekly menus it was evident that Lyncroft provides service users’ meals of their choice and these were varied and balanced. If any service user wishes to cook an individual meal staff support him/her to do so. A service user informed the Inspector that he prefers to buy takeaway meals from time to time. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 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 standard(s) 18,19 and 20 The service can demonstrate that service users health needs are met adequately. Staff seek specialist support in order to meet service users health needs. Staff are provided training on medication administration. EVIDENCE: Care plans demonstrate that specialist support and advice is made available to service users who would benefit from this, for example, CPN input. The home offers service users choice in areas such as their personal clothes or hairstyle. Service users file indicate that their preferred routine, likes and dislikes were recorded. Care files suggest that service users health care needs were assessed and recognised. There was a procedure in place to address these. 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 G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 13 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. At the time of the inspection the proprietor showed evidence that staff attended a ‘ treatment of anti-psychotic and taking good care of medicine’ course on 24th of August conducted by the pharmacist. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 14 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 and 23 The home has a complaint policy and procedures and it was made available to all relevant parties. The Adult protection policy and procedure contain sufficient guidance for staff to enable them to protect service users from abuse. 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 were minor in nature and those were investigated and resolved accordingly. Staff attended adult protection training. The adult protection policy and procedure contain sufficient guidance for staff to enable them protect service users from abuse. The registered manager understands her responsibility to refer staff who harm service users in their care to the POVA list. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 15 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) 24,26 and 30 The home is suitable for its stated purpose. It is safe and well maintained. Furniture and fittings of the bedrooms are suitable to meet service users needs. The home is clean, hygienic 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. Recently 4 bedrooms were re-decorated with service users choices. 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). Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 16 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 the spread of infection. The washing machine has specific programming ability to meet disinfection standards. The proprietor provided evidence to the Commission that Thames Water visited the home to undertake the required check under the Water Supply (Water Fittings) Regulations 1999. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 17 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) 34, 35 and 36 The registered provider operates a thorough recruitment policy and procedure which is based on equal opportunities and ensures service users protection. The home provides training for staff development. The registered manager ensures that regular staff supervision takes place as planned. EVIDENCE: It was evident from discussion with the registered provider, staff and examining staff files that two written references, photocopy of passport, CRB disclosure certificate were available in the staff files. 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. The home has a training and development plan and training budget. All staff received equal opportunities training; training and development are linked to the home’s aims and objectives. The management is confident that more than 50 of their care staff will achieve NVQ level 2/3 qualifications in care before the end of 2005. Staff informed the Inspector that there are regular opportunities for staff for informal and formal supervisions. The registered manager ensures that regular formal supervision takes place as planned. The minutes of supervisions were Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 18 available in staff files for the inspection. The registered manager review staff’s individual performance against the job description on annual basis. The registered provider also visits the home on a regular basis. Staff informed that the registered provider always made herself available during the annual leave of the registered manager. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 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 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 and 42 There is effective leadership; guidance and direction to staff to ensure service users assessed needs are met. There is a quality monitoring system in place to measure the success in achieving the aims and objectives of the service. The home ensures staff and service users health, safety and welfare. EVIDENCE: The registered manager of Lyncroft has relevant experience of working with service users with mental health needs. Prior to managing this service she has worked in Lyncroft as an administrator then as a deputy manager. She has been managing Lycroft for approximately 2 years now. She has attended training on understanding mental health with MIND in September 2004. She was registered by the CSCI on 20th of July 2005. She is experienced and competent to run the care home. She has commenced her Registered Manager’s Award (RMA) course and anticipating to complete this qualification by the end of this year. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 20 There are various system, 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 visit each month. The registered manager ensures, so far as is reasonably practical, the health, safety and welfare of the service users and staff. The registered manager 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 very three months. The registered manager ensures that all appliances for example gas and electric are regularly checked. Gas safety inspection was carried out on 28/2/05 and found to be satisfactory. Fire equipments were checked in November 2004. 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 G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 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 x G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 22 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. Standard YA 6 Regulation 15 Requirement The registered manager must ensure that service users care plans are reviewed on a six monthly basis and these are available for the inspection. The manager must review service users risk assessments with input from the health professionals. Timescale for action 31/12/05 2. YA 9 13 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA 37 Good Practice Recommendations The registered manager to complete her RMA qualification by 2005. Lyncroft G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 4th Floor Gredley House 1-11 Broadway London E15 4BQ 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 G56 G06 S7246 Lyncroft V240722 060905 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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