Inspection on 21/02/06 for Lyndel Homes

This inspection was carried out on 21st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Lyndel Homes 05/06/07

Lyndel Homes 06/06/06

Lyndel Homes 17/05/05

Lyndel Homes 23/11/04

Lyndel Homes 14/06/04

Lyndel Homes 13/01/04

Lyndel Homes 21/07/03

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

CARE HOMES FOR OLDER PEOPLE Lyndel Homes 9 Radnor Road Handsworth Birmingham West Midlands B20 3SP Lead Inspector Sean Devine Unannounced Inspection 21st February 2006 10:00 X10015.doc Version 1.40 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 Lyndel Homes DS0000016844.V284639.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 Older People. 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. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lyndel Homes Address 9 Radnor Road Handsworth Birmingham West Midlands B20 3SP 0121 507 0708 0121 515 2544 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) Mrs Delores Matadeen Mrs Delores Matadeen Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2005 Brief Description of the Service: 9 Radnor Road is located in a residential street of North Birmingham. It is close to local shops, health services, public transport and places of worship. The building has been sensitively restored into an attractive and useable property. The home has 15 bedrooms located on the ground, first and second floors. These are both single and shared rooms. No rooms are en-suite. The home has a passenger lift which enables access to all floors. On the ground floor is a quiet lounge/ office. This has some seating and access to a TV. There is another smaller lounge also with lounge chairs and access to a TV. The home has a large, bright dining room, which doubles as the smoking area. This was seen to be a popular place for some residents to sit and chat outside of meal times. Bathrooms, showers and toilets were located on all floors. The home has a laundry in which staff can undertake the routine laundry of most clothing. The home has a large kitchen and all meals are cooked on site. At the rear of the property is a garden. The home provides a service to persons of old age with a mental disorder. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis by two regulation inspectors. The inspectors were able to meet with some residents and informally discuss care issues with staff. Records pertaining to care provided and health and safety practices were viewed and a tour of the premises was conducted. On entering the home it was a concern that gas could be smelled, the deputy manager consulted the manager / owner who was not at the home before making the necessary arrangements to make this gas leak safe, further details are reported upon in standard 38 of this report. A letter of serious concern was issued to the home as records regarding the safekeeping of money placed by residents were reported to be at the home of the manager / owner. It is recommended that the previous report dated the 17th May 2005 be considered when reading this report. What the service does well: What has improved since the last inspection? Documents such as care plans and risk assessments are being fully completed in that dates and signatures of the author are being recorded. All care plans are now being reviewed on a monthly basis. The likes and dislikes of residents in respect of food and social activity have been assessed and relevant plans including an update of menus completed. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 6 Fire safety has improved including regular fire drills for staff, which are adequately recorded; frequent fire safety training and ensuring fire equipment is always adequately maintained. 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. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in respect of choice of home were not assessed. No judgement. EVIDENCE: No evidence. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 The health care needs of residents are not adequately met, some practices are not effective to ensure that health risks are reduced and may in turn increase the risk of harm. Medication management is safe and residents are supported to take their medicine when needed. EVIDENCE: Residents care plans were sampled with a focus upon health and personal care. It was evident that residents’ needs are assessed and where needs are identified; care plans and sometimes risk assessments are written. There were concerns that risks including choking when eating food and diabetic management had no corresponding risk assessment, although a care plan had been written, staff also informed inspectors of actions that were contrary to actions in the care plan, in that the resident was not always observed when eating and diet and nutrition were not always monitored. The weights of residents are not always accurately monitored, where residents are not able to stand on weighing scales a body mass index is recorded but not regularly monitored. Calibrated seated scales are needed to accurately record the weights of residents. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 10 The challenging behaviours of one resident were described to the inspectors, although this was being monitored there was no care plan or protocol to guide staff in management of such behaviour. One resident confirmed that she is able to see a doctor when she is unwell; records in regard of healthcare from visiting professionals are well maintained and demonstrate residents see their GP, psychiatrists, social workers, opticians, community nurses and chiropodist when needed. However the deputy manager advised inspectors of a visit to the home by a district nurse for blood tests, available records for one resident did not have this visit recorded. Some residents have been identified as being at risk of falls from bed, risk assessments have been written, which include the use of bed rails. However the risks of using such equipment for example entrapment have not been included in the risk assessment and it is not clear that the resident or their representative are aware of possible dangers. One bed rail was in use without protective “bumpers”. The home manages all medication on behalf of the residents. A weekly supply of medicines is received using a NOMAD system provided by a local chemist. The medication administration records are thoroughly completed for when medicines are received, administered and disposed of. Audits of stock are accurate and all medicines are safely stored. The medicine policy does not include all practices such as providing homely remedies, which must be completed in consultation with the GP. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 Residents activity needs, individually and collectively are met by the home, the residents express what they like to do and where possible the staff will support them. EVIDENCE: Residents have been involved and consulted about their social and recreational interests; this has helped influence a programme of activity available at the home. Activities; social and recreational including culture, religion and lifestyles are assessed and where needed care plans devised. Daily records are completed and some entries confirm that residents are able to take part in activities. One resident confirmed she is happy and enjoys activities such as bingo and board games in the home. One resident said “things were okay but sometimes this time of the year is boring” and “I like spending my time in the garden, but it’s to cold”. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Concerns that are raised by residents and their representatives are taken seriously and appropriate actions are taken to improve services for residents. EVIDENCE: Since the last inspection one complaint has been received at the commission, this was investigated and the complaint was not upheld with one area not substantiated. Records at the home indicate one complaint has been received in the past twelve months; a response was completed in a timely fashion, which detailed how the concerns raised after consulting with a resident were to be managed. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22, 24, 25, 26 The environment communally and in residents’ rooms is not fully safe to meet their needs and to ensure their well-being. Bathing, washing and toileting facilities are unsafe in certain areas and present a risk to the health and safety of residents. EVIDENCE: There is ample seating for all residents in the dining room and two lounge areas. Some seating is unfit for purpose as it is torn and in some cases springs do present a risk of injury. The front lounge has a piano, which was being played by one resident. The furniture in all areas is domestic in style and of a design to meet the varying needs of residents. In communal areas lighting and heating is adequate. There is a range of bathing and toileting facilities on all floors close by residents’ rooms these are adequate to meet the needs of residents. The second floor has a seated bath; the door lock on the bath does not work and needs repair. In some bathrooms the residents’ toiletries have not been returned to their rooms after use. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 14 The door to the shower room close by room 9 cannot be fully opened as the radiator cover hinders it. Some residents’ rooms were inspected, there are ample storage areas in all rooms and although older in design furniture and fittings are of a good standard. The seating in one residents room must be kept clean and the sink unblocked and the water supply reconnected in a shared room. Some residents require bed rails to be fitted, in one room there were no protective “bumpers” on the rails as identified in the respective risk assessments. Toilets throughout the home have wash hand basins, however no appropriate hand-drying facilities are available, such as paper towels. There is a contract and facilities for sanitary and clinical waste. The laundry room is clean and hygienically maintained. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 There are adequate numbers of staff to meet the needs of residents. Recruitment practices are not conducted in a manner to ensure the protection of residents; residents may be put at risk due to these poor practices. EVIDENCE: The staff rota indicates that residents are supported by adequate numbers of staff, both day and night. This includes management and kitchen staff. One resident commented, “There are always enough staff to help when you need it” The inspectors were advised that some records of staff recently recruited were not available in the home, that these were at the home of the owner / manager who was unavailable. One member of staff who had left the home for a significant period of time before returning had no evidence of a newly completed criminal records bureau disclosure or an application form. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 38 The management and administration is not always conducted to promote the safety of residents. Health and safety practices are generally good with minor improvements needed to further promote the welfare of residents. EVIDENCE: The registered manager / owner was unavailable at this inspection due to personal reasons. The deputy manager advised the inspectors that records regarding the money management of residents were at the home of the manager / owner. Following inspection a letter was sent notifying the manager / owner of the serious concerns in regard to not having these records available at the home. On entering the premises the inspectors noticed a strong smell of gas, the deputy manager was informed of this, shortly afterwards another person also raised this concern. It was evident that the smell was originating from the kitchen and on examination the pilot lights on the range cooker were leaking. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 17 The deputy manager was advised by inspectors to make this safe and she contacted the manager / owner and after consultation the gas suppliers were notified. A gas engineer attended the premises and made this safe. This had an initial impact on the heating at the home, which was remedied by arranging repair of the range cooker and following guidance from the gas supplier the gas supply was reconnected. A risk assessment to advise staff on how to reduce the risks of a gas leak was available. Since the inspection the commission have been informed that a new cooker is now in operation. The testing, service and maintenance of utilities is fully completed. Fire safety is well managed including staff training, regular fire drills and the testing and servicing of equipment. The home had a visit by an environmental health officer in May 2005 with minimal requirements issued and a visit from a health and safety inspector in October 2005 where no requirements were made. Kitchen hygiene was found to be of a good standard, however the following areas need to be addressed to further improve standards and to reduce risks: The extraction fan filters above the cooker are dirty and excessively greasy and the floor in the food storage area (cellar) is dirty and must be kept clean. In the shower room next to room 9 there are exposed wires, the deputy manager explained these are from the old call system, it is not clear whether these wires are “live”, however they must be made safe. Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X 2 2 2 X 2 3 2 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 1 X X 2 Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12(1) 13(4) Requirement Health care plans and risk assessments must be written to inform staff in how to meet the needs of residents, including managing diabetes, challenging behaviours and reducing the risk of choking when eating. Timescale for action 14/03/06 2 3 OP8 OP8 12(1) 13(4)(c) 4. OP8 12(1) 14(2) Care plans must identify what action is to be taken and how the staff are to monitor residents with challenging behaviour. Records and the outcomes of 14/03/06 visiting health professionals must be accurately maintained. Residents who need the use of 14/03/06 bedrails must have the risks of such equipment e.g. entrapment included in the assessment. Residents and / or their representatives must be consulted about the assessment. The weights of residents must be 21/03/06 regularly taken and recorded, where this is difficult for the resident a body mass index must be completed. Previous timescale of 31/07/05 not met, this requirement is DS0000016844.V284639.R01.S.doc Version 5.1 Page 20 Lyndel Homes carried forward. Where residents cannot use standing weighing scales then seated scales must be used. The use of homely medicines must be included within the homes medicine policy and a protocol, detailing name of medicine, dose and frequency confirming what it is to be given for signed by the GP. The armchair in the front lounge must be replaced or repaired. 5 OP9 13(2) 31/03/06 6. OP20 23(2)(c) 07/03/06 7 OP20 23(2)(c) 23(4)(a) 8 OP21 23(2)(c) (j) Garden furniture that is heavily stained must be cleaned or replaced. Garden furniture that is damaged must be repaired or replaced. Previous timescale of 31/8/05 not completed, this requirement is carried forward. All furniture must be assessed 21/03/06 and audited for safety, including if it is safe to use and whether or not it meets with fire regulations. Records of the audit must be maintained and unsafe furniture replaced. The seated bath on the second 07/03/06 floor has a lock, which must be repaired. Residents’ toiletries must be returned to their rooms when they have finished using them. Residents who cannot use the shower room due to restricted access (by room 9.) must use appropriate alternative facilities, this must be written into a care plan or risk assessment. The seating in residents’ rooms must at all times be kept clean. The wash hand basin, which is blocked in the resident’s room, must be unblocked. DS0000016844.V284639.R01.S.doc 9 OP21 23(2)(j) 12(1) 21/03/06 10 11 OP24 OP24 13(4)(c) 23(2)(d) 23(2)(c,j) 13(3) 14/03/06 22/02/06 Lyndel Homes Version 5.1 Page 21 12 OP26 13(3) 13. OP26 13(3) 14 15 OP29 OP29 17(3)(b) 19(1)(b) (i) Sch 2 All water supplies to this wash hand basin must be reconnected. The manager must ensure that appropriate hand washing facilities are available for example, liquid soap and paper towels in all communal toilets. Previous timescale of 31/07/05 not met, this requirement is carried forward. The home must use a system that adequately protects staff from the risks of infection is introduced in the laundry, e.g. alginate bags for soiled items of laundry that can be put into the washing machine. Previous timescale of 31/05/05 not met, this requirement is carried forward. Recruitment records of all staff must be available at the home. All staff that are recruited must have a CRB disclosure completed, including those staff that have left the service and have been employed again. An application form must be completed as part of the recruitment process, including when staff who have left the service and have been employed again. The home must have in place a system for reviewing and improving the Quality of Care. The home must elicit the views of family and friends and also other professionals / stakeholders in the service. The findings should be used to implement a plan of continuous improvement. Previous timescale 31/5/05 not met, this requirement is carried forward. DS0000016844.V284639.R01.S.doc 07/03/06 21/03/06 21/02/06 14/04/06 16. OP33 24 31/03/06 Lyndel Homes Version 5.1 Page 22 17 OP35 13(6) 16(2)(l) 18. OP38 17(1)(3) Sch 3(j) 13(4)(a,c) 12(1) 19 OP38 Records of money belonging to residents, which is managed by the home on the residents’ behalf, must be available for inspection at the home. All accident forms must be fully completed. Not assessed and is carried forward. Serious health risks such as gas leaks must be managed speedily and safely as detailed in the gas leak risk assessment. The range cooker must be repaired and maintained safely including gas safety. The kitchen extraction fan filters must be cleaned as a matter of urgency, and kept clean. The floor in the food storage area (cellar) must be kept clean at all times. The exposed wires in the shower room close by room 9 must be made safe and covered. 21/02/06 07/03/06 21/02/06 20 OP38 13(3) 16(2)(j) 14/03/06 21 OP38 13(4)(a) 12(1) 21/02/06 Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 23 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. 2. 3. Refer to Standard OP7 OP38 OP1 Good Practice Recommendations Key worker reports should be completed in line with the provider’s expectations, this being on a monthly basis. The fire risk assessment must be further developed to meet with guidance from the West Midlands Fire Service. The home should further develop the statement of purpose to describe the types of formats or forums the home uses to consult the service users. Not assessed and is carried forward. The manager should complete NVQ 4 in Care & Management or the Registered Managers Award by 2005. Not assessed and is carried forward. 4. OP31 Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lyndel Homes DS0000016844.V284639.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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