CARE HOMES FOR OLDER PEOPLE
Lyndhurst Lyndhurst 67 Byfleet Road New Haw Weybridge Surrey KT15 3JZ Lead Inspector
Kerry Fell Unannounced Inspection 10th August 2006 09:45 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 Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 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. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Lyndhurst Address Lyndhurst 67 Byfleet Road New Haw Weybridge Surrey KT15 3JZ 01932 842730 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) Mr Aboo Bakar Seeparsand Mrs Zehra Bibi Seeparsand Mr Aboo Bakar Seeparsand Mrs Zehra Bibi Seeparsand Care Home 16 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (3) Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER One named individual DE (E) Dementia - 0ver 65 to be added to the registration for the duration of their stay at the home. 16th May 2006 Date of last inspection Brief Description of the Service: Lyndhurst is a large detached house in a residential road within walking distance of local shops and New Haw and Byfleet railway station. The building is Tudor style with car parking facilities to the front of the house and an enclosed mature garden to the rear. The home provides care for sixteen older people, ten of whom may also be diagnosed with dementia and three with physical disabilities. Bedroom accommodation is single with the exception of one double bedroom. Nine of the bedrooms have en-suite facilities. There is a large combined lounge and dining area and a conservatory overlooking the garden. The kitchen has been modernised and there is a separate utility room. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second key inspection for the inspection year 2006/2007. The inspection was unannounced which means that neither the service users nor the staff knew that the inspection was going to take place. The inspection commenced at 9:45 and took 5 hours and 45 minutes to complete. The inspector reviewed policies and procedures, recruitment records, staff training records, and service users records. The inspector took a tour of the premises and garden, and met with service users during lunchtime. Evidence will also be included within this report from the unannounced random inspection undertaken by Mrs Kerry Fell and Mr Joe Croft on 29th June 2006. This inspection was undertaken to assess compliance with the statutory regulation notices served on 3rd April 2006. The Commission for Social Care Inspection considered that sufficient evidence was available to demonstrate compliance with the three Statutory Requirement Notices. What the service does well:
Risk assessments were now being reviewed separately on A4 charts. This allowed better detail to be included in the review. Better descriptions were included in the risk assessments and these had been linked back to the care plan. Service users confirmed during the key inspection of 10th August 2006 that they had their health needs attended to. Service users also stated that they felt supported by the staff and the registered persons to request appointments with health professionals when required. Details of service users wishes in the event of terminal illness or death continued to be recorded within their care plans. A discussion took place during the random inspection of 29th June 2006 about the recorded choices of one service user, as their choice appeared to be in opposition to their religion. The registered persons stated that they would investigate this further following the inspection. It was evident during the key inspection of 10th August 2006 that the registered persons had discussed this issue further with the service user, and had confirmed that the care plan correctly reflected their wishes. The inspector was shown responses to questionnaires sent to relatives about the quality of the service provided by Lyndhurst. All of the responses observed
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 6 were complimentary about the service stating that they had “peace of mind”, and that their relative was always “clean, and well looked after.” The inspector observed that the home held the relevant health and safety and maintenance checks for the lift, portable electrical items, gas and fire safety equipment. What has improved since the last inspection?
As detailed above sufficient action had been taken by the home to demonstrate compliance with the Statutory Requirement Notices served on 3rd April 2006. The statement of purpose and service users guide had been updated, and better met the National Minimum Standards for Older People. The quality of the document was much improved, and these were now easier to use. There had been improvement in the quality of care plans, health plans and risk assessments, which better identified service users needs and how these would be met. There was better clarity within the service users’ records, especially as the home had reduced the number of “cardex” records used within the care plan. Medication continued to be managed in an orderly manner, and a book was in use to record medication brought into and taken away from the home. The home’s medication procedure had been reviewed twice since the last key inspection. The procedure observed during the random inspection of 29th June 2006 was found to be detailed and gave clear guidance to staff. Action had been taken by the home to ensure that service users privacy was maintained. A questionnaire about the menu and meals served at the home had been developed shortly following the random inspection of 29th June 2006. These had been completed with all service users, and where appropriate service users had signed the completed questionnaire. These forms also recorded where staff had assisted the service users with the completion of the questionnaire. The outcome of the survey was that service users were happy with the meals provided by the home. One service user had informed inspectors at the key inspection of 15th May 2006 that they had not eaten meat prior to moving into the home, but that they now did eat meat. The home investigated this following the inspection and provided the inspector with written confirmation; via the consultation that the service user did in fact choose to eat meat, and that they were happy with the meals provided. The registered persons advised the inspector that there had been other circumstances that may have meant that the service user had
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 7 not eaten meat when they lived at home. These were discussed fully during this inspection. A daily menu board is now displayed each day, and the inspector observed service users checking the board as they passed it. The inspector was advised that staff still consulted service users about meals they would like to be included in the menu, on a week-by-week basis. The inspectors observed during the random inspection of 29th June 2006 that the complaints procedure had been reviewed further and was found to be clear, concise and met the National Minimum Standards for Older People. No complaints had been received by the home. However, one complaint had been received by social services with regard to the loss of personal items by a service user who no longer resided at the home, concerns about prescribed medication and the management of medication, the management of laundry, and infection control. This was being investigated under Surrey’s Safeguarding Adults procedures. A copy of further concerns had been forwarded to the CSCI Surrey Local Office, however these could not be looked at during this inspection as they formed part of the ongoing Safeguarding Adults investigation. At the time of the inspection no actions had been identified by the home with regard to these concerns. Service users met during the key inspection of 10th August 2006 stated that they had never had reason to complain, but were confident that any concerns would be dealt with appropriately by the registered persons. The inspectors also observed during the random inspection of 29th June 2006 that the safeguarding procedures had been reviewed further. These procedures were now more detailed and referred staff to the home’s other policies for example, whistle blowing. There are ongoing senior strategy meetings with regard to a safeguarding adults concern from May 2005. Action had been taken by the home to resolve maintenance issues identified. No further concerns had been identified from staffing rosters about sufficient staff being available. The home had taken action to meet standard 28 of the National Minimum Standards for Older People by registering five members of staff on the NVQ Level 2 in care, commencing in October 2006. One member of staff is also being interviewed with a view to start the NVQ Level 4 in Care. Personnel files had been reviewed and updated, and each personnel record was now held in a separate plastic folder. These were now neater and more orderly, which made the files easier to audit. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 8 A record of training completed by staff was available on personnel files. This record also included a training profile and details of courses that staff were due to attend. The registered persons had booked all of the staff employed at the home onto a “Skills for Care” induction course with accredited training organisations. The inspectors observed evidence during the random inspection of 29th June 2006 that one-to-one supervision had commenced for all members of staff who were available to work. Work had begun on the recommendations made within the fire safety report produced by Paragon. The registered persons must report to the CSCI Surrey Local Office when this work will be completed. What they could do better:
The home did not hold a formal admission policy. During discussions the manager suggested that it would be beneficial to bring all of this information together in the form of a policy. A copy of this policy must be forwarded to the CSCI Surrey Local Office. Although the home had undertaken to review the activities and consult the service users about activities they wished to take part in; this had not been completed. The registered persons must therefore complete a full review of the home’s activity programme, including formal consultation with service users. A report of the outcome must be forwarded to the CSCI Surrey Local Office. The inspector was advised that some staff had attended training in dementia care from an external training organisation. However, it was not evident that activities had been specifically designed for service users with dementia. The home must seek advice about current good practice and appropriate activities for service users with dementia, to ensure that their needs are met sufficiently. No complaints had been received by the home. However, one complaint had been received by social services with regard to the loss of personal items by a service user who no longer resided at the home, concerns about prescribed medication and the management of medication, the management of laundry, and infection control. This was being investigated under Surrey’s Safeguarding Adults procedures. A copy of further concerns had been forwarded to the CSCI Surrey Local Office, however these could not be looked at during this inspection as they formed part of the ongoing Safeguarding Adults investigation. At the time of the inspection no actions had been identified by the home with regard to these concerns. However, the lack of clear inventories of service users personal items did not assist with the ongoing investigations. The home must therefore produce an inventory for each service user that must be signed by both the registered persons and the service user, or their next of kin.
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 9 The CSCI were not satisfied with the current arrangements for staff sleeping-in and therefore the registered persons must fully review the sleeping-in arrangements, including better clarity about the roles and responsibilities of sleeping-in staff. The registered persons must also ensure that staff facilities comply with health and safety arrangements, and confirmation is required as to whether the room remains part of a fire evacuation route agreed with Surrey Fire and Rescue Service. A report on these matters must be forwarded to the CSCI Surrey Local Office. A copy of the home’s development plan had still not been received by the CSCI Surrey Local Office and must be forwarded without delay. This a requirement carried over from the Statutory Requirement Notice with a timescale of 20th June 2006. The registered persons must have the hoist serviced or remove the hoist from use without delay. The registered persons must report to the CSCI Surrey Local Office when the work to meet the recommendations from the Paragon fire safety risk assessments will be completed. 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. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 10 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 Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 11 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): 1,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has taken sufficient action to ensure that the statement of purpose and pre-admission assessments provide information and support to service users admitted to the home. EVIDENCE: At the inspection on 29th June 2006 the inspectors reviewed the statement of purpose and service users guide held by the home. These documents had been reviewed several times following the last key inspection. The current documents were dated 10th June 2006, and copies had been forwarded to the CSCI Surrey Local Office. No further changes had been made between the random inspection and this inspection. The quality of the document was much improved, and these were now easier to use. The detail was observed to better meet the National Minimum Standards for Older People, and therefore met the requirements of the Statutory Requirement Notice.
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 12 However, the registered persons are advised to be mindful of the changes to the Care Homes Regulations 2001, that come into effect as of 1st September 2006, and should review the statement of purpose in line with these changes. Discussion took place during the inspection about the home’s admission procedures. No service users had been admitted since the last inspection. The manager confirmed that prospective clients and their relatives would be involved in the process and would be invited to visit the home. The manager also stated that agreements would be laid out in writing to the prospective client and their relatives prior to admission. The registered persons further confirmed that they would visit the client to assess their needs prior to admission. The home did not hold a formal admission policy, although some of the information that would be included in an admission policy was held in other documents, for example the statement of purpose and the home’s terms and conditions. During discussions the manager suggested that it would be beneficial to bring all of this information together in the form of a policy. The CSCI would support this, and therefore a copy of this policy must be forwarded to the CSCI Surrey Local Office. Evidence of Care Management Assessments was available on the files of the most recently admitted service users. The home also used the “Standex” care planning record system that includes a pre-admission section that detailed the specific needs of each service user. This meets the requirements of the Statutory Requirement Notice. The home does not admit service users for intermediate care. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 13 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): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been improvement in the quality of care plans, health plans and risk assessments, which better identified service users needs and how these would be met. Medication continued to be managed in an orderly manner. Action had been taken by the home to ensure that service users privacy was maintained. Service users wishes for how the home should support them and their family at the time of their death are recorded by the home. EVIDENCE: The inspectors reviewed a sample of the service users files, during the random inspection of the 29th June 2006. Although service users’ care plans had been reviewed prior to the inspection undertaken on 24th May 2006, the inspectors observed that the manner in which the care plans were being held had been reviewed further. Care plans continued to be reviewed on a monthly basis. The number of different “Standex” care plan sections previously used had been reduced, making the care plans easier to use.
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 14 Risk assessments had also been changed to include medical/clinical risks. Sufficient improvements had been made by the time of the random inspection of 29th June 2006 to comply with the requirements of the Statutory Requirement Notice; however, further work was required to improve the detail of the care plans and risk assessments. Staff met during the random inspection of 29th June 2006 were able to advise the inspectors about how service user’s clinical needs were met and any risks minimised, for example members of staff described how they monitored the weight of one service user, and introduced specialist nutrition drinks to ensure that they did not fall below their recommended weight. This good practice was not clearly reflected within the detail of the service user’s care plan, therefore the registered persons were required to ensure that these plans were further reviewed to reflect practice. It was evident during the key inspection of 10th August 2006 that the care plans had been kept under review on a monthly basis. Slightly more detail had been included in the care plan, and better description was included of how needs had been met through the month. Risk assessments were now being reviewed separately on A4 charts. This allowed better detail to be included in the review. Better descriptions were included in the risk assessments and these had been linked back to the care plan. Risk assessments observed identified where nothing had changed in the care plan. Service users confirmed during the key inspection of 10th August 2006 that they had their health needs attended to. Service users also stated that they felt supported by the staff and the registered persons to request appointments with health professionals when required. One service users medication was under review, and evidence of this was included within the care plan and the medication records. The home’s medication procedure had been reviewed twice since the last key inspection. The procedure observed during the random inspection of 29th June 2006 was found to be detailed and gave clear guidance to staff; this policy had not changed at this inspection. Discussions took place during the random inspection of 29th June 2006 about the relevance of some elements of the policy, for example the management of oxygen and invasive treatments for example, the administration of rectal diazepam and the management of gastrostomy tubes, that was not currently needed for service users resident at the home. However the registered persons considered that these sections should remain at this time. As these treatments Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 15 had never been used by the home these sections must be removed to ensure staff are given clarity about what medication they are able to administer. The requirements of the Statutory Requirement Notice have been met. GP records continued to be available on file, and where necessary a range of health professionals, including Community Nurses and Community Psychiatric Nurses attend the home. Care plans observed during the inspections of 29th June 2006 and 10th August 2006 included details of specific health needs and how the staff and the home should meet these. Better clarity and consistency was observed between this care plans. The inspector observed during the key inspection of 10th August 2006 that the medication room and medication cupboard continued to be neat and orderly. Records were neat, and well maintained and at the time of the inspection no gaps or errors were observed in the records. The home continued to hold a record of medication received into the home and returned to the Pharmacy. The inspector observed during the key inspection of 10th August 2006 that the hatch into a service user’s bedroom was being filled with a fire safe panel at the time of the inspection. The obscured glass windows in service users’ bedroom doors had been covered with blinds and now ensured privacy could be maintained. Staff were again observed to knock on bedroom doors before entering. The louvre style door had been covered since the last key inspection. Details of service users wishes in the event of terminal illness or death continued to be recorded within their care plans. A discussion took place during the random inspection of 29th June 2006 about the recorded choices of one service user, as their choice appeared to be in opposition to their religion. The registered persons stated that they would investigate this further following the inspection. It was evident during the key inspection of 10th August 2006 that the registered persons had discussed this issue further with the service user, and had confirmed that the care plan correctly reflected their wishes. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 16 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although daily activities are available for service users to take part in, service users need to be consulted to confirm the activities met their needs and interests. Contact is maintained with friends and family. Service users can make choices about their lives. Service users are consulted about the meals provided by the home. EVIDENCE: Service users spoken to during the inspection stated they did not wish for more activities to be arranged. An activity list was displayed in the dining room/lounge area, which included communal activities such as listening to music, time to read, activities such as keep fit and skittles and reminiscence sessions on the weekend. The registered persons advised the inspector that service users were taken out for walks along the canal path as well as in the local area. One service user stated that they wished to go shopping more often, although it was not clear during their conversation with the inspector whether they
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 17 meant that they did not have the opportunity, or did not feel capable to go shopping in the same way that they had when they lived at home. Service users confirmed that they were able to choose whether they participated in activities offered. The hairdresser also attends the home on a weekly basis. The inspector was advised that some staff had attended training in dementia care from an external training organisation. However, it was not evident that activities had been specifically designed for service users with dementia. The home must seek advice about current good practice and appropriate activities for service users with dementia, to ensure their needs are met sufficiently. Although the home had undertaken to review the activities and consult the service users about activities they wished to take part in; this had not been completed. The registered persons must therefore complete a full review of the home’s activity programme, including formal consultation with service users. A report of the outcome must be forwarded to the CSCI Surrey Local Office which must also detail how more independent service users will be supported to remain as independent as possible and what activities will be introduced specifically for those service users who have dementia. The home must make this a priority, as this is a requirement carried over from the key inspection of 15th May 2006. Visitors attended the home during both the random inspection of 29th June 2006 and the key inspection of 10th August 2006. The home had an open visiting policy (within reasonable hours), and service users talked about being able to be visited by friends and family. Service users can meet with visitors in private if they wished. Private meetings could be arranged in the conservatory area or in the service users’ bedrooms. The registered persons spoke again about community groups and church groups visiting the home. The inspector was also advised that one service user had, until recently, met regularly with friends from outside of the home, and would go out for day trips with them. The registered persons explained that there had been plans to make arrangements for them all to attend a day centre, although this had not come to fruition as yet. The registered persons stated that private cars were not used to transport service users, but that in most cases taxis were arranged. The inspector was also advised that if a large group of service users were going out on an activity the home would hire a minibus. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 18 Service users are able to bring personal items into the home, and a service user invited the inspector to see their bedroom. The inspector observed that it had been highly personalised with the service users precious items and small items of furniture. The inspector was advised that the home did not hold responsibility for any of the service users personal finances and that they did not act as appointee for any service user. The registered manager advised the inspector that in most case relatives took on this responsibility. At the time of the inspection, the home paid for all personal items, newspapers, chiropody and hairdressing, required on a day-to-day basis, and that it was agreed with relatives how often the home would produce an invoice for these items. Records and receipts were observed during the inspection. A questionnaire about the menu and meals served at the home had been developed shortly following the random inspection of 29th June 2006. These had been completed with all service users, and where appropriate service users had signed the completed questionnaire. These forms also recorded where staff had assisted the service users with the completion of the questionnaire. The outcome of the survey was that service users were happy with the meals provided by the home. One service user had informed inspectors at the key inspection of 15th May 2006 that they had not eaten meat prior to moving into the home, but that they now did eat meat. The home investigated this following the inspection and provided the inspector with written confirmation; via the consultation that the service user did in fact choose to eat meat, and that they were happy with the meals provided. The registered persons advised the inspector that there had been other circumstances that may have meant that the service user had not eaten meat when they lived at home. These were discussed fully during this inspection. The inspector met with service users during lunchtime. Service users stated that they had enjoyed their meal, and that if they did not like what was offered an alternative would be offered. One service user stated that they did not want a large roast dinner, so had asked for boiled eggs instead. The inspector observed that the home had facilitated this. A daily menu board is now displayed each day, and the inspector observed service users checking the board as they passed it. The inspector was advised that staff still consulted service users about meals they would like to be included in the menu, on a week-by-week basis. The inspector was further advised that as the supermarket is so close by, the home could shop in a family style, which allowed them to buy seasonal food. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 19 At the time of the inspection lunch was roast chicken and roast potatoes with vegetables. Meals had been prepared to the service users specific needs for example, pureed, cut small or just softened. The home kept a record of the weekly menus, which had been updated where supplies had not been available. This record included details of which meals service users had on each day. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 20 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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Policies and procedures with regard to complaints and protection from abuse now better safeguard service users. EVIDENCE: The inspectors observed during the random inspection of 29th June 2006 that the complaints procedure had been reviewed further and was found to be clear, concise and met the National Minimum Standards for Older People. This procedure had not changed and was freely available within the home during this inspection. Copies of the complaints procedure were displayed in service users bedrooms. The complaints procedure detailed how complaints should be made to the home, and that the CSCI could be contacted at any time. The procedure also identified external agencies for example the Local Government Ombudsman, if the complainant was dissatisfied with the outcome of the home’s investigation. No complaints had been received by the home. However, one complaint had been received by social services with regard to the loss of personal items by a service user who no longer resided at the home, concerns about prescribed medication and the management of medication, the management of laundry, and infection control. This was being investigated under Surrey’s Safeguarding Adults procedures. A copy of further concerns had been forwarded to the CSCI Surrey Local Office, by a relative however these could not be looked at during this inspection as they formed part of the ongoing Safeguarding Adults
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 21 investigation. At the time of the inspection no actions had been identified by the home with regard to these concerns. However, the lack of clear inventories of service users personal items did not assist with the ongoing investigations. The home must therefore produce an inventory for each service user that must be signed by both the registered persons and the service user, or their next of kin. Service users met during the key inspection of 10th August 2006 stated that they had never had reason to complain, but were confident that any concerns would be dealt with appropriately by the registered persons. The inspectors also observed during the random inspection of 29th June 2006 that the safeguarding procedures had been reviewed further. These procedures were now more detailed and referred staff to the home’s other policies for example, whistle blowing. The whistle blowing procedure advised staff of the procedure in the event that an allegation was made against a member of staff. The home would be advised to include the detail of this within the protection of vulnerable adults procedure as well as in the whistle blowing procedure. This evidenced that the policies and procedures now met the requirements of the Statutory Requirement Notices. There are ongoing senior strategy meetings with regard to a safeguarding adults concern from May 2005. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 22 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): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Action had been taken by the home to resolve maintenance issues identified EVIDENCE: Action had been taken by the home to resolve maintenance issues identified in both the key inspection of 15th May 2006 and the random inspection of 29th June 2006. Broken glass from the greenhouse had been removed. Commodes, walking frames, broken chairs and unused furniture that was being stored in the sheds and in the corners of the garden had also been removed. Potholes in the lawn had been filled and made safe. Most of the nails that were found to be protruding from the wooden bird table had been removed, although a few still remained and must be made safe. Rope, electric cable and cords had been removed from the tree.
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 23 A number of garden seats that were rotten had been removed, although one further seat had now broken and this was waiting to be repaired. This must be repaired. Pots of paint were still being stored on the patio and must be removed to a safer place without further delay. Wooden sheds and out buildings in the garden had now either been removed and were waiting for disposal in a safer place, or were in the process of being repaired. The fire evacuation route along the side of the house had been gravelled and now allowed safer evacuation. Maintenance issues identified within the home were being dealt with at the time of the inspection, and a maintenance contractor was working on these during the inspection. The ladder was no longer being stored on the first floor landing. The home must ensure that the remaining maintenance issues are attended to promptly. A discussion took place during the inspection about the area allocated as a staff sleeping-in room. The inspector observed this to be a small space that had a sink and was also used as the hairdresser’s room. This room also appeared to have a door to the outside, and may have previously been used as a fire escape route. A fold out bed was available to staff, however this was stored in a cupboard away from the room. The registered persons advised the inspectors that sleep-in staff generally rested in a lounge chair. This is not acceptable, and leaves service users at risk from over tired staff who may not be able to respond appropriately in an emergency overnight, or who may be working shifts the next day. The inspectors also had concerns that waking night staff may be distracted by sleeping-in staff that stayed up talking to them. The registered persons advised the inspector that sleeping-in staff never worked the morning shift, but would go home, and return for the afternoon shift. The inspector was also advised that the registered person was due to purchase a new fold out bed that would stay in the sleeping-in room permanently. The CSCI do not consider the current arrangements satisfactory, and therefore the registered persons must fully review the sleeping-in arrangements, including better clarity about the roles and responsibilities of sleeping-in staff.
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 24 The registered persons must also ensure that staff facilities comply with health and safety arrangements, and confirmation is required as to whether the room remains part of a fire evacuation route agreed with Surrey Fire and Rescue Service. A report on these matters must be forwarded to the CSCI Surrey Local Office. At the time of the inspection the home was free from malodour, and the domestic team were cleaning the home throughout the inspection. Laundry facilities are sited away from areas of the home where food is prepared. Policies were in place for the safe management of laundry. The manager confirmed that sluicing and high temperature cycles were available on the washing machines. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 25 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The improved staff recruitment procedures and training now better safeguard the service users. Staffing levels currently meet the needs of service users. EVIDENCE: No further concerns had been identified from staffing rosters about sufficient staff being available. Rosters observed during the inspection detailed that four members of staff, including either of the registered persons were available during the day shift, with additional support from a Chef and a member of domestic staff to undertake cleaning duties. One member of waking night staff was available over night with the support of one member of staff sleeping-in. At the time of the random inspection on 29th June 2006, and the key inspection on 10th August 2006 no concerns about staffing levels were identified. Service users meet during the key inspection on 10th August 2006, confirmed that they felt that staffing levels were adequate. No staff currently hold NVQ qualifications, however the home had taken action to meet standard 28 of the National Minimum Standards for Older People by registering five members of staff on the NVQ Level 2 in care, commencing in October 2006. One member of staff is also being interviewed with a view to start the NVQ Level 4 in Care. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 26 One recently recruited member of staff held the NVQ Level 4 in Care and the Registered Managers Award. All other staff were qualified nurses from overseas. The inspectors observed during the random inspection of 29th June 2006 that the home held a policy and procedure with regard to recruitment of staff. This was seen to reflect sound recruitment practice. Personnel files had been reviewed and updated, and each personnel record was now held in a separate plastic folder. These were now neater and more orderly, which made the files easier to audit. It was observed during the random inspection of 29th June 2006 that each member of staff had completed an application form, which contained a full work history. Some gaps were observed in the application forms, and staff were able to explain these when asked. The registered persons were asked to follow this up with the staff following the random inspection, and the inspector observed that this had been completed, during the key inspection of 10th August 2006. Two written references were now available on each member of staffs’ file. One member of staff had provided two referees from the same organisation, and the home had followed this up with the recruitment agency as required. At the time of the key inspection the registered persons were still waiting for the additional reference to be forwarded. Evidence of identification and authority to work in the UK was available for all but one member of staff during the random inspection of 29th June 2006. This member of staff had left their position by the time of the key inspection. Enhanced CRB checks were held for all members of staff. These were held separately in the home’s safe. The inspectors were able to evidence during the random inspection of 29th June 2006 that all recruitment checks and POVA first checks were completed for the most recently recruited members of staff. Both the registered persons and members of staff confirmed that they were not left unsupervised whilst awaiting return of the enhanced CRB disclosure. Recruitment practices had not changed, and sound practice could still be evidenced during the key inspection. A record of training completed by staff was available on personnel files. This record also included a training profile and details of courses that staff were due to attend. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 27 The registered persons had booked all of the staff employed at the home onto a “Skills for Care” induction course with accredited training organisations. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 28 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): 31,33,34,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Action has been taken by the home to ensure that policies, procedures and practice better protected service users. EVIDENCE: Evidence was provided to the CSCI Surrey Local Office to demonstrate that the registered manager who is also the registered provider had registered on the Registered Managers Award. The new “Care Manager” who was recruited and in post at the last key inspection, was no longer present at the home. The registered providers were in the process of clarifying whether they were returning to the post. The registered persons were therefore still considering the recruitment of a qualified manger to be registered with the CSCI.
Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 29 This meets the requirement of the Statutory Requirement Notice. The inspector was shown responses to questionnaires sent to relatives about the quality of the service provided by Lyndhurst. All of the responses observed were complimentary about the service stating that they had “peace of mind”, and that their relative was always “clean, and well looked after.” The registered persons had been required to forward a development plan to the CSCI Surrey Local Office. This had not been received, and must be forward without further delay. The home does not manage service users finances; relatives undertake this. A copy of the home’s verified accounts had been forwarded to the CSCI Surrey Local Office as required, which meet the requirements of the Statutory Requirement Notice. The inspectors observed evidence during the random inspection of 29th June 2006 that one-to-one supervision had commenced for all members of staff who were available to work. The inspectors were advised that those staff members who had not received supervision were on leave. One member of staff had their supervision session postponed, but evidence was provided to demonstrate that this had been rearranged. Evidence was still available during the key inspection to evidence that one-to-one supervision was still ongoing. Records of supervision sessions also evidenced that newly recruited members of staff had received an increased frequency of supervision. This meets the requirements of the Statutory Requirement Notice. The inspector observed that the home held the relevant health and safety and maintenance checks for the lift, portable electrical items, gas and fire safety equipment. Work had begun on the recommendations made within the fire safety report produced by Paragon. The registered persons must report to the CSCI Surrey Local Office when this work will be completed. The inspector was advised that the home had one mobile, manual hoist that had not been used for some time. The hoist had not been serviced or maintained as required; therefore the registered persons must have the hoist serviced or remove the hoist from use without delay. The inspector observed that fridge and freezer and water temperatures were checked as required. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 30 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 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 3 3 3 X 1 Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 31 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. 2. Standard OP3 OP9 Regulation 14 13(2) Requirement A copy of the new admission policy must be forwarded to the CSCI Surrey Local Office. The sections within the medication administration procedure with regard to the administration of invasive treatments and oxygen must be removed to ensure staff are given clarity about what medication they are able to administer. The home must seek advice about current good practice and appropriate activities for service users with dementia, to ensure that their needs are met sufficiently. The registered persons must complete a full review of the home’s activity programme, including formal consultation with service users. A report of the outcome must be forwarded to the CSCI Surrey Local Office which must also detail how more independent service users will be supported to remain as
DS0000013707.V309388.R02.S.doc Timescale for action 10/10/06 10/10/06 3. OP12 16(2)(n) 10/10/06 4. OP12 16(2)(n) 10/08/06 Lyndhurst Version 5.2 Page 32 5. OP18 13(6), 17(2) independent as possible and what activities will be introduced specifically for those service users who have dementia. The home must make this a priority, as this is a requirement carried over from the key inspection of 15th May 2006, with a timescale of 29/07/06, and is now an immediate requirement. The home must produce an 10/09/06 inventory for each service user that must be signed by both the registered persons and the service user, or their next of kin. The registered persons must fully review the sleeping-in arrangements, including better clarity about the roles and responsibilities of sleeping-in staff. The registered persons must ensure that staff facilities comply with health and safety arrangements, and confirmation is required as to whether the room remains part of a fire evacuation route agreed with Surrey Fire and Rescue Service. A report on these matters must be forwarded to the CSCI Surrey Local Office. A copy of the home’s development plan must be forwarded to the CSCI Surrey Local Office. This a requirement carried over from the Statutory Requirement Notice with a timescale of 20th June 2006. This is now an immediate requirement. The registered persons must have the hoist serviced or remove the hoist from use without delay. The registered persons must report to the CSCI Surrey Local
DS0000013707.V309388.R02.S.doc 6. OP19 23(3) 10/10/06 7. OP33 25 10/08/06 8. OP38 12(1), 13 (4), 23 23(4) 10/09/06 9.
Lyndhurst OP38 10/09/06
Page 33 Version 5.2 Office when the work to meet the recommendations from the Paragon fire safety risk assessments will be completed. 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 registered persons are advised to be mindful of the changes to the Care Homes Regulations 2001, that come into effect as of 1st September 2006, and should review the statement of purpose in line with these changes. Lyndhurst DS0000013707.V309388.R02.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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