Inspection on 06/06/06 for Lyndel Homes

This inspection was carried out on 6th June 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 21/02/06

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 6th June 2006 09:00 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.V292910.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.V292910.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.V292910.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 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 are 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.V292910.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection visit was conducted by two regulation inspectors over a period of one day. A pre-inspection questionnaire had been sent to the registered manager prior to the visit, it had not been returned to the commission. During the visit the inspectors were able to meet many of the residents and some staff. The registered manager / owner was available and updated the inspectors on her search for a new care manager. The inspectors were informed that the deputy manager would be leaving the home fairly soon. The inspectors were able to look at residents’ records pertaining to their health and social care, some of their rooms were also seen. A tour of the communal areas including facilities for bathing, toilets, laundry and the kitchen was undertaken. Records regarding managing health and safety were also seen. Immediate requirements being; 1. The registered person must provide evidence that the staff awaiting CRB disclosures are not on the POVA register and inform the commission when CRB disclosures are received, by 30/06/06. 2. Evidence that portable electric appliances have been tested for safety must be available and forwarded to the commission by the 9/6/06. 3. Evidence that staff are receiving training in all safe working practices must be received at the commission by 9/6/06. Were made as a result of the visit. What the service does well: The home has not had any recent admissions, however at previous inspections it was evident that assessments and care plans are made available to the home to enable them to decide on whether they can meet the needs of prospective new residents. Some residents confirmed that they are able to see their doctor whenever they are unwell and that the home does help them with attending any hospital appointments. Some residents were unable to inform the inspectors of the standard of healthcare support, however they did appear well and at the time of inspection staff were receiving training to help reduce the incidents of falls and a physiotherapist was seen assessing the needs of one resident. Some residents’ opinion of staff was that they are helpful and that they treat them well, they have no concerns about being treated unfairly. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 6 Some residents are encouraged to take part in domestic activities within the home; one resident was observed helping prepare for meals by peeling potatoes and others helped tidy the dining room after lunch. In general the residents are provided with a varied and healthy diet and the menus are discussed with residents, they are offered lots of choice. Some residents declared that they have no complaints and are happy at the home. The rear garden has a courtyard available where the home has a dog, several residents described how fond they were of the dog. Some residents commented that they are happy with their rooms and other areas of the home, one said “I have all I need at the home” “I like my room and like to spend time by myself”. There are good numbers of staff available to support the residents, and one resident said “there is always someone available to help if you need it”. It was evident that staff have established good relationships with many residents and that they are trusted, those residents who were able to talk to the inspectors commented that staff are nice and one said “if I want them to they will take me out”. Some residents commented that they see a lot of the registered manager and the deputy. What has improved since the last inspection? What they could do better: Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 7 The home must review and make changes to how they write care plans and risk assessments for residents’, at present they are not clear and concise to direct staff in how to meet the needs of individual residents. There is a need to closely monitor the weight of some residents on a regular basis, to do this accurately the home needs to have access to seated scales for some of the residents. A structured individual plan of activity is needed for some residents, it was evident that many residents were sleepy and did not have the opportunity to take part in purposeful and stimulating interactions either with staff or other residents. Accurate records are needed to evidence that the staff are well trained, some staff confirmed what training they have had (verbally) and the registered manager informed the inspectors of what was planned. There is a need to improve the lighting in bath and shower rooms, at present it is dark in parts of these rooms and could hinder safe support for residents or limit the residents’ ability to self-care. Recruitment practices must be improved in most areas to promote the safety of the residents. It is evident that fire drills are regularly attended by staff, however records indicate that some staff do not respond quickly, it is not evident that this has been addressed and fire safety in the home improved. There is a need to ensure that all hot water outlets accessed by the residents are restricted to 43°C as this will reduce the risk of any scald burns. 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.V292910.R01.S.doc Version 5.1 Page 8 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.V292910.R01.S.doc Version 5.1 Page 9 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 3 and 6. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home ensures the residents needs are assessed prior to admission, this enables prospective residents to make a fully informed choice and for the home to assure the prospective resident that their needs can be met. EVIDENCE: Two residents files were seen, there have been no recent admissions to the home so the quality of pre-admission assessments could not be fully inspected. However at previous inspections the home does ensure these comprehensive assessments are in place’ normally completed by social workers, which detail the needs of residents prior to admission. The home does not provide an intermediate care service. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 10 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): Standards 7, 8, 9 and 10. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The health and personal care needs of residents are almost met, care planning and risk assessment processes need to be improved to provide clear and concise instruction for staff. EVIDENCE: The two residents files seen both included typed care plans, these had been developed following a comprehensive assessment of need. It was evident that many of the care plans were not always clear and concise in their instruction to staff, in what they must do to meet the needs of residents. Care plans were very informative and contain great detail, this often meant that they were repetitive and although some guidance to staff was recorded it was often lost in additional information. It was evident that a one page form to review these care plans was in use, however the information recorded did not determine whether the care plan had been effective or not in meeting the needs identified. It was a concern that some care plans included staff supporting residents with accessing community facilities for leisure and recreation, yet several residents Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 11 informed inspectors that they very rarely go out, daily records and key worker reports had very few entries of residents’ being supported to use community facilities. Risk assessments were available these had been completed for food and drink, mobility, tissue viability (Waterlow scale) and also for falls. The home uses standing scales to monitor the weight of some residents, other residents who cannot stand on the scales had some records of body mass index (BMI) recorded, staff were unaware of when BMI records would be a concern. There is a system to review the risk assessments, however there were no recordings to inform whether the risk management plan was effective or not. It was evident that for one resident the Waterlow assessment had not been reviewed since March 2006, for a resident who is identified as high risk and for another resident the falls risk assessment had not been reviewed after a recent fall. It is evident from other health records that residents do have appointments with a GP, district nurse, community psychiatric nurses and social workers when they are required. It is also evident that residents see chiropody, opticians and dental services, some routinely others when needed. However the log called “Records of Medical Services Received” is not kept upto date. Within residents files a record of a review of medicines is available. Medication is provided by a local chemist, mainly on a weekly basis using a cassette system. Some medicines are boxed, these are provided on a 28 day cycle. The ability of the residents to manage and administer their own medicine is assessed by the home. At present the home manages and administers medicines for all residents. The registered person informed the inspector that the medicines policy was in the process of being revised to ensure it reflects recent changes affecting the community chemists. The inspector was also advised that the GP will prescribe homely remedies for residents, so as such the home does not keep their own supply of medicines for minor ailments. Medication administration records (MAR) were fully recorded for medicines administered to residents and when medicines are received into the home. Stock of medicines were found to be accurate however the homes internal procedure for regularly checking stocks was at times inaccurate. Facilities for controlled drugs are available including storage and a register. Ointments and creams are often kept in residents rooms, however some are kept in the medicine cupboard, the dates when creams and ointments are opened need to be recorded. On the day of inspection a physiotherapist visited a resident, this was managed in a discreet and professional manner ensuring the privacy of the resident as much as possible. Staff have a good relationship with residents and were seen to be respectful when talking with them. Residents’ opinion of staff was that they are helpful and that they treat them well, they have no concerns about being treated unfairly. One shared room Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 12 was seen by an inspector, it was evident that screening was available and that clothes, toiletries and other personal belongings are kept separate. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 13 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): Standards 12, 13, 14 and 15. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home demonstrated they have the capacity to meet most of the daily life and social activity needs of residents, however improvements are needed to ensure the residents do receive care as planned including access to individually planned activities. EVIDENCE: The two residents files included care plans for social contact, activities, community contact including the involvement of family and friends and also for nutrition and food and drink. Inspectors did not observe any in-house activities, however as one inspector left an early evening ball game commenced in the lounge. The registered person advised that many staff on the day of inspection had taken part in a training day at the home and unfortunately some activities had not happened. One resident advised that he will often go to the local shops, another resident stated she had not been out of the home for some years, that this was her choice. One resident was observed helping prepare for meals by peeling potatoes and others helped tidy the dining room after lunch. As identified in standard seven, records to evidence that there are activities for individual residents as detailed in their care plans are not available. One Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 14 resident advised that her family do come and visit and another said he used to visit a friend who lives locally, unfortunately he has lost contact. Visiting times are displayed on the hallway notice board, the hours are flexible, however busy periods such as meal times are not included. Many residents have their personal allowances paid direct to the home, however some residents do have families that help manage these affairs. The home has recently acted on behalf of one resident, raising some concern about access to personal allowance. The residents have a varied and healthy diet, with lots of choice. Staff were heard discussing the menu with residents and several residents were very complimentary of the cook and the food she produces. A meal was sampled by one inspector, it was found to be pleasant and tasty. Some residents are assisted by staff to eat their meals and this was done in a dignified and relaxed manner with lots of encouragement from staff where needed. Some residents who do not eat so well are provided with food supplement drinks. A detailed daily record of all food eaten by residents is maintained to identify any possible problems at an early stage. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 15 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): Standards 16 and 18. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not fully made arrangements to adequately protect residents in respect of the risk of abuse, measures to include appropriate staff training are needed to fully afford this. Residents’ complaints are recorded together with outcomes of any subsequent investigation. EVIDENCE: The home does have a complaints policy, this is on display in the dining room. The policy is in need of a review, no date for review was recorded on the document yet it contains details that are now out of date such National Care Standards Commission, it should also detail how residents and their representatives can make a complaint to the relevant Social Care and Health area office. A complaints log was available, the last recorded complaint was seen at the last inspection and no more have been recorded since. Residents were asked if they had any concerns about the service they receive from the home and no residents had any concerns. The home has a policy on adult protection, it guides staff to recognise the different forms of abuse, what to do and how to keep the resident safe. It however fails to mention the role of the police and does not include Social Care and Health contacts, it does not cross reference the staffs’ Whistle-blowing Policy. Detailed training records of staff were not seen on staff files to confirm that staff routinely receive training in protecting vulnerable adults from abuse, Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 16 however at previous inspections it was evident that staff attend informal training sessions and that adult protection is discussed with staff during supervision. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 17 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): Standards 19, 21, 24, 25 and 26. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. Many environmental areas of the home support the needs of groups and individual residents, some improvements are needed to ensure it is safe to use at all times. EVIDENCE: A tour of communal areas was undertaken and also two residents’ rooms were seen. The home has two large lounge areas, one is very popular with residents, in here there is adequate seating for all residents, yet some are far away from the television and it was evident some residents could not see it. In the second lounge it is used when residents wish for some quiet time, e.g. reading or for playing the piano. The rear garden has had the old garden furniture replaced with four benches. One resident was seen to use this area frequently, the homes dog has a kennel in this garden and some residents described how fond they are of the dog. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 18 The dining area is also used as a designated smoking area when food is not being served or eaten. There are four large dining tables with in excess of fourteen seats available. All furniture is of an adequate standard. The dining area also has a lockable cupboard containing residents’ files, this was found to be left open. There are toilets available for use by residents on all three floors of the home, these are sited close to many residents rooms. All toilets had good hand washing facilities. On the ground floor there is a fully accessible shower / wet room, this is large and can be used for residents with mobility needs. Lighting in this shower room was very poor and could hinder safe support for residents or limit the residents’ ability to self-care. It was also seen that several tiles had come loose, with some missing. The shower room on the first floor has a door that cannot be fully opened as a radiator cover prevents it fully opening, the registered owner / manager advised that this room is only used by a few residents who are fully mobile and does not present a risk. The temperature of the shower (which is a step-in shower) can be adjusted, when turned onto hot it was found to be extremely hot, the temperature is evidently not restricted. On the second floor there is a bath, which opens using a door and residents are able bath in a seated position, at present this cannot be used, as there is no door. As previous in the shower room, the lighting over the bath is very poor and could again hinder the safe support for residents or their ability to self-care. Two residents rooms were seen, one is a shared room and the other a single room. The shared room had screening available when needed to maintain the privacy of residents, there were individual wardrobes, chest of drawers and cabinets, yet there was only one comfortable arm chair in this room. The single room had a large amount of furniture and facilities as required by the national minimum standards. Both rooms had wash hand basins, call systems and thumb turn locks inside the door. The laundry facility includes good practice to maintain hygiene and reduce the risk of spread of infections. There is a clinical waste facility used, the inspector advised that the clinical waste bin in the shower room should have a foot operated lid and that the Health Protection Agency be contacted to conduct an assessment of safety. Some residents commented that they are happy with their rooms and other areas of the home, one said “I have all I need at the home” “I like my room and like to spend time by myself”. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 19 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): Standards 27, 28, 29 and 30. The quality in this outcome area is poor. This judgement has been made using available evidence and a visit to the home. Staff training, their competencies and their recruitment are not adequate to meet the specific needs, the protection and health and safety of residents. There are adequate numbers of staff to meet the needs of residents, yet the staff abilities are not fully evident. This may put residents at risk of poor care, abuse and affect their well being. EVIDENCE: Staff rotas indicate there are adequate numbers of staff on duty to meet the needs of residents day and night. The registered manager / owner, staff and residents confirmed this, one resident said “there is always someone to help if you need it”. The registered manager / owner did not return the pre inspection questionnaire, a section on this form asks for information about how many staff have achieved NVQ’s, thus it is not evident that the qualifications of staff and their competencies are in excess of 50 of the care workforce. The registered manager / owner advised that training records were included in staff files, sporadic records were found in the two sampled files. Two staff files were sampled, both included an informative application form detailing work history, life experiences and motivation. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 20 One member of staff had recorded details of an operation, due to the work to be undertaken a risk assessment is needed to ensure safety. Both files included two written references, yet the inspectors advised the registered manager / owner that they were concerned of the validity of two of the references as both referees had made the identical spelling mistake spelling the same word and that the writing was evidently similar. Criminal records bureau disclosures (CRB) were available on both files, one was completed by another service in October 2005 and not by the home, on the second again it had not been completed by the home but by the previous employer, yet this time it stated that a new CRB had been applied for. The registered manager was left immediate requirements to provide evidence that the staff awaiting CRB are not on the POVA register and to inform the commission when CRB’s are received. The registered manager / owner provided the inspectors with a list of staff for whom places are being sought for the NVQ 4 / Registered Managers Award, Safe Handling of Medicines and Dementia Care. As previously recorded the registered owner / manager advised that training records were included within staff files, these were very limited. The inspectors were advised that there is not at present a training matrix, however all training regarding safe working practice is undertaken. One staff member had records including essential skills for day care 7/9/04 and moving and handling and hoist training dated 15/2/05, there were no other records. One staff supervision record indicated that training for protection from abuse, fire, food hygiene and communication was due to commence in January 2006, yet there were no further entries or records of training. This member of staff advised inspectors that the basic food hygiene training was due to expire and that it needed renewal, this staff member also indicated that she would like to complete the intermediate food hygiene certificate. On the day of inspection many staff attended a training session by the PCT regarding the management of residents at risk of falls. The registered manager / owner was left an immediate requirement to provide evidence that staff are receiving training in safe working practices by the 9th June 2006. Residents were complimentary of the staff, one resident described them as being “nice” another said “if I want them to they will take me out” she also said “staff are friendly”. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 21 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): Standards 31, 33, 35, 36, 37 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The ability for the home to meet the needs of residents through good systems of management and administration is not robust or fully effective and may lead to the needs of residents not being met. EVIDENCE: The registered owner / manager advised of her efforts to employ a care manager, it was evident that recruitment had commenced through adverts with employment agencies and at the job centre. Applications had been received and interviews are planned. The inspectors were advised that the registered manager / owner will be completing the Registered Managers Award by the end of July 2006. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 22 The inspectors were informed that the deputy manager had given notice to terminate her employment. One resident commented “the managers were good” and” “I see them all the time”. The registered manager / owner confirmed that consultation with residents, staff and relatives had been completed and that she was in the process of drafting the results of the questionnaires sent out. As yet, there is no annual quality assurance report available at the home to provide information about quality of the service provided. The home does manage money for residents. Some residents’ personal allowances are received at the home and kept in safekeeping. Two residents accounts were sampled, one was subject to a Court of Protection order, the balance of the account was not accurate, receipts for purchases made of on behalf of this resident were available, however a recent purchase had not been added to the record sheet causing the balance to be incorrect. Upon the second residents account the balance had a six pound shortfall, the registered manager advised that recently five pounds had been spent on toiletries, there was a receipt for five pounds but it did not indicate what it was for. Two staff files regarding supervision were seen; it was evident that one member of staff receives frequent supervision yet the other had no recent records of supervision available. As identified in outcome area for the environment the cupboard in the dining room used to safe keep many of the residents files was found to be left open and easily accessible throughout the day. The management of health and safety includes a well maintained fire system with regular tests and service. Other utilities and equipment are maintained and regularly serviced. At a recent fire drill it stated that two staff were very slow to respond, yet it is not clear what action had been taken to improve upon this and improve fire safety within the home. A fire risk assessment was available and health and safety action plans are completed both were seen to require imminent review. Staff training regarding fire safety was recorded as November 2005, this did not appear to include all staff. Portable electrical appliances had not been tested since June 2004, the registered manager / owner was left an immediate requirement to complete this test by the 9th June 2006. Two residents did not have any concerns in respect of health and safety in the home, one resident informed the inspector “I do feel safe and I have not had any accidents”. Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X 2 X X 2 2 3 STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 2 2 Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 24 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 15(1) Requirement Timescale for action 31/08/06 2 OP7 3 OP8 4 5 OP8 OP8 Residents must have care plans that are informative for staff, stating clearly and concisely how the residents’ needs are to be met. 15(2)(b)(c The monthly review of care plans )(d) must record whether the care plan has been effective or otherwise. 15(1) Residents risk assessments, 12(1) which identify a high risk to their health, safety or well being must be regularly reviewed and state whether the risk management plan is effective or not. 12(1) Records of medical appointments 17(1)(a) must be kept upto date and reflect outcomes. 12(1)14(2 Where residents cannot use ) standing weighing scales then seated scales must be used. Previous timescale of 21/03/06 not met, this requirement is carried forward. Medicine audits on stocks must be completed accurately and reflect current stocks. 31/08/06 31/07/06 31/08/06 31/08/06 6 OP9 13(2) 31/07/06 Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 25 7 OP9 13(2) 8 OP12 16(2)(m)( n) 9 OP16 22(1)(2)( 5) 13(6) 12(1) 10 OP18 11 OP18 13(6) 12 OP19 23(2)(b) 13 OP21 23(2)(a) 14 OP24 16(2)(c) 23(2)(c) 15 OP25 23(2)(p) 12(1) All external preparations including ointments and creams must have the date opened recorded. The registered manager must ensure that individual activities as required in care plans are available to residents and that they are recorded. The registered manager must ensure that the complaints policy is reviewed, updated and shared with residents and staff. The registered manager must ensure that the adult protection policy includes details of the role of other agencies, specifically the police and also detail contact information for local Social Care and Health offices. The registered manager must ensure that all staff do receive appropriate training to protect vulnerable adults from abuse. The registered manager must ensure that the cracked and missing tiles in the downstairs shower room are repaired and replaced. The registered manager must ensure that the bath on the second floor is repaired and available for use. The registered manager must ensure that all residents’ rooms have adequate amounts of comfortable seating, including shared rooms. The registered manager must ensure that all bathrooms and shower rooms have adequate lighting to enable individual residents and staff to safely meet personal care needs. 31/07/06 31/07/06 31/08/06 31/08/09 30/09/06 31/07/06 31/07/06 31/07/06 31/07/06 Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 26 16 OP28 18(1)(c)(i ) 17 OP29 18 OP29 19 OP29 20 OP30 21 OP30 22 OP31 The registered manager must ensure that as a minimum there are 50 of care staff trained to NVQ level 2 in Care, evidence of this must be available at the home. 19(4)(a) The registered manager must 19(5)(c) ensure that staff who disclose illnesses, disabilities or who have special requirements on recruitment and there after, have a risk assessment completed. 13(6) The registered manager must ensure that the references received as part of recruitment are valid and ensure systems and measures are introduced to ensure the security of gathering written references. 19(1)(b)(i The registered manager must ) Sch 2. provide evidence that the staff awaiting CRB disclosures are not on the POVA register and inform the commission when disclosures are received. 17(2)(3) The registered manager must Sch 4 ensure that staff training records (6)(f) are fully available at the home and that these records reflect that all staff are receiving training in all safe working practices. 18(1)(c)(i The registered manager must ) provide evidence that staff are receiving training in safe working practices, this must be received at the commission. 9(2)(b)(1) The registered manager must ensure she has the required qualifications to manage the home. 30/09/06 31/07/06 31/07/06 30/06/06 30/09/06 09/06/06 30/09/06 Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 27 23 OP33 24 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. The registered manager must ensure that the accounts and balances of residents’ money in safe keeping is at all times accurate and that receipts are available to reflect expenditure by staff on the residents behalf. The registered manager must ensure that all care staff are adequately supported through receiving supervision on a regular basis. The registered manager must ensure that staff respond effectively at fire drills and address the concerns on fire drill records. 31/07/06 24 OP35 13(6) 31/07/06 25 OP36 18(2) 31/08/06 26 OP38 23(4)(d)( e) 31/07/06 27 OP38 28 OP38 The registered manager must ensure that all staff receive training in fire safety at least annually. 13(4)(a)(c The registered manager must ) provide evidence that portable 23(4)(a) electrical appliances have been tested and provide evidence to the commission. 13(4)(a)(c All hot water outlets used by ) residents including those on baths and showers must have the hot water restricted to 43°C. 09/06/06 31/07/06 Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 28 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 OP1 Good Practice Recommendations The home should further develop the statement of purpose to describe the types of formats or forums the home uses to consult the residents about standards and the quality of service at the home. Not assessed and is carried forward. It is recommended that the Health Protection Agency be invited to do an assessment of the homes infection control practices and also that the clinical waste receptacle have a foot operated lid. 2 OP26 Lyndel Homes DS0000016844.V292910.R01.S.doc Version 5.1 Page 29 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. 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