Inspection on 12/08/05 for Lyndhurst

This inspection was carried out on 12th August 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyndhurst 16/11/07

Lyndhurst 02/10/06

Lyndhurst 09/02/05

Lyndhurst 08/02/05

Lyndhurst 22/09/04

Lyndhurst 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Lyndhurst Hea Road Heamoor Penzance Cornwall TR18 3HB Lead Inspector Ian Wright Unannounced 12 August 2005 1600 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address Hea Road Heamoor Penzance Cornwall TR18 3HB 01736 331008 01736 331008 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap Society Care Home 5 Category(ies) of Learning Disability (5) registration, with number of places Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: An unannounced inspection was completed on 9th February 2005. Brief Description of the Service: Lyndhurst provides care for up to 5 adults with learning disabilities. The home is situated in the village of Heamoor, which is a few miles from the town of Penzance. The registered provider is Mencap, which operates several care homes in Cornwall. Ms Rachael Lee has submitted an application to the Commission for Social Care Inspection to become the registered manager. All service users have their own bedrooms. There is a dining room and a lounge for service users use. The home is not suitable for wheelchair users without further adaptation. The home has a pleasant front garden which service users can use. There is parking for two cars at the front of the property. Date of last inspection Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three and a half hours. The inspector was able to speak to all service users, and the staff member on duty. The inspector examined care and service records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: A number of previous requirements remain outstanding. These include expanding the complaints procedure to give appropriate information to service users as required by regulation. Training needs to be improved. In regard to epilepsy and handling medication training an immediate requirement was made. This means Mencap must take immediate action to inform the Commission for Social Care Inspection when this training will be delivered. The inspector was concerned that failure of Mencap to provide this training could result in serious risk to service users. The inspector was also very concerned regarding the maintenance of appropriate staffing levels. The registered provider should provide two members of staff in the evening, and during the day at weekends to assist service users e.g. with day activities etc. Currently the registered provider is having significant difficulties maintaining agreed levels of staffing due to annual leave, vacancies etc. Although a recruitment campaign is under way, in the interim period other measures must be taken. For example agency staff should be used. The existing situation could put service users and staff at risk. An immediate requirement has been issued for the registered provider to Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 6 provide the Commission for Social Care Inspection with a report outlining what action will be taken regarding this issue. The Commission for Social Care Inspection recognises there have been a number of major changes within the home. For example the current manager has only recently come in to post, one of the deputies is also relatively new and there has also been some staff turnover. However the registered provider must take appropriate action to to maintain service standards and address the shortfalls highlighted in the report. 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 D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,5 The registered provider has an appropriate pre-admission assessment policy and procedure which ensures service users aspirations and needs will be assessed appropriately. Each service user has a suitable written contract or statement of terms and conditions outlining service users rights and responsibilities. EVIDENCE: There have been no recent admissions although the Mencap policy regarding pre admission assessment is satisfactory. Service users have a copy of terms and conditions of residency or a contract on their files. Service users also have an assured tenancy agreement. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8 Appropriate policies, procedures and documentation are in place regarding care planning. Service users are consulted about major and day to day decisions. EVIDENCE: A copy of a care plan is in each service user’s file. These are reviewed appropriately. Service users said staff regularly consult with them about major decisions regarding the home and their care. Service users are involved in cooking, and day to day tasks. There is evidence that regular resident meetings occur. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11-15 Suitable opportunities are available for service users to be part of the local community. Service users have a wide range of day activities available to them. Visiting times are flexible. Contact with family and friends is encouraged. EVIDENCE: Service users and the member of staff on duty said service users are involved in cooking and cleaning. Advocacy services are used. Service users have support with speech therapy and psychiatric services where appropriate. Service users can attend religious services if they wish. Service users said they are given suitable opportunities to participate in the community for example local events, and using local facilities such as leisure centres, pubs and clubs. Service users have opportunity to have paid jobs, work placements, and attend further education and day centres. All service users have comprehensive day activity plans. Service users have been or will be going on an annual holiday if they choose to do so. Service users said they have appropriate opportunities to maintain links with their families and friends. Visiting arrangements are appropriate. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21 The registered provider has appropriate links with relevant professionals so service users physical and emotional health needs are met. Arrangements regarding the management of service users medication are inadequate and could put service users at risk. The registered provider does not have a suitable policy regarding ageing, illness and death, which could be detrimental to service users care as they get older. EVIDENCE: There has been one admission to the hospital accident and emergency department, which appeared to be dealt with appropriately by staff. The member of staff on duty, and service users said links with health care professionals are appropriate. Any appointments with health care professionals are documented in individual service user files. The registered provider has a suitable policy regarding the storage and handling of medication. The medication system was inspected and subsequently a number of concerns were identified: • Several items of medication were not recorded on medication sheets. It was not clear whether this prescribed medication is now required. If not, is must be disposed of or otherwise recorded. • A bottle of eye drops in the medication cabinet was not labelled and not recorded on a medication sheet. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 12 • • • • • • Lactulose medication dispensed on 22.12.04 was not being used; although a bottle of this medication subsequently dispensed was being administered. Two packets of the same medication for epilepsy, dispensed on different dates appear to be administered currently, rather than being used in date order. The system of medication audit is poor. For example totals of medication kept in stock at the end of the previous dispensing period are not carried forward. Therefore stock totals on current medication administration record sheets do not tally with medication kept in the medication cabinet. One dosage each of two items of a service user’s medication appeared to be ‘missing’ (presumed ‘dropped’ or lost) although no record was made regarding why this was or how it was disposed of. Several administrations of medication were not signed for on the current and previous medication sheets. Several staff do not appear to have received appropriate training regarding the operation of the medication system, and medication administration, despite a previous requirement. An immediate requirement was issued for the registered provider to provide an action plan regarding when staff will receive appropriate training. The registered provider must provide an appropriate system regarding the storage, handling, administration and disposal of medication. The previous requirement for the registered provider to expand the Mencap policy regarding death and dying to include issues regarding ageing is still outstanding. The Commission understands the registered provider is in the process of expanding this policy. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The registered provider does not have an appropriate complaints procedure. The current procedure does not provide appropriate information and is not accessible to service users. EVIDENCE: The registered provider has a generally suitable complaints policy. However this still requires some amendment as outlined in the previous report i.e. the following information should be appended to the policy in the home: • To include information (address, phone number etc.) how service users can contact the Commission for Social Care Inspection (CSCI). • To inform complainants they can contact the CSCI at any time as outlined in NMS 22.3. This information must be available for inspection and issued to service users and where appropriate their representatives e.g. as part of the service user guide. The registered provider has potentially an excellent system where service users can notify a senior manager when they have a concern or complaint via sending a prepaid postcard. However as the postcards are kept in the office the system has not been implemented as intended. Currently service users would have to ask staff for a postcard if they wished to send one to management. Service users should be given copies of the postcards so they can send these off to management should they wish to do so. There is however evidence the system has been used by service users in the home. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30 Although Lyndhurst is generally a suitable environment for service users accommodated there, the kitchen requires improvement. Soap must be provided at all communal wash hand basins to improve hygiene and infection control. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. Bedrooms and communal areas are of suitable size and meet the needs of service users. The kitchen units still require replacement as has been outlined in previous reports. The gaps between e.g. the cooker, and dishwasher is a trap for food waste and needs to be cleaned regularly. The member of staff said the housing association had recently informed the registered provider the kitchen units would be replaced shortly. Service user bedrooms are decorated according to individual tastes and furnishings are appropriate. The home was clean on the day of the inspection. Some bathrooms and toilets did not contain soap, and the previous requirement regarding this issue is renotified. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 Although staff appear to have a clear understanding of their roles, the registered provider currently does not provide sufficient staffing levels to meet service users needs. Staff training is inadequate to meet the needs of service users accommodated. EVIDENCE: All staff are issued with a job description when they commence employment. Staff appear to have a clear understanding of their roles. The inspector is concerned appropriate staffing levels are not maintained. Only one member of staff was on duty from 0900 on the day of the inspection until 0930 the following day. However it is acknowledged the manager was sick and would have been on duty from 0900-1600. Rotas indicate only one member of staff is on duty for significant periods of time. Staffing levels agreed with the Commission for Social Care Inspection do not appear to be maintained i.e. two staff on during the evenings, and during the day at weekends when service users are at home. The Commission for Social Care Inspection recognises the registered provider has staff shortages due to vacancies, annual leave etc. Although some additional hours have been authorised for part time staff, the use of agency staff should be considered so staffing levels are maintained to agreed levels. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 16 An immediate requirement was issued at the end of the inspection for the registered provider to provide satisfactory staffing to meet service user needs. Subsequently the registered provider must provide the Commission with a report outlining how Mencap will meet this requirement. The inspector was unable to fully assess whether staff are receiving appropriate training as required by regulation. This was due to records being appropriately locked away due to the manager’s absence. However through discussion with staff on duty training regarding the administration of medication, and the awareness of the needs of people with epilepsy does not appear to have been implemented. This requirement was made in the previous report dated 9.2.05. The failure to provide this training places staff and service users at risk. Subsequently an immediate requirement has been made for the registered provider to provide the Commission with an action plan outlining how the requirement will be met and within what timescale. The report must be provided to the Commission by 1.9.05. Other standards will be inspected at the announced inspection. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41, 42 Records, policies and procedures are suitable. Health and safety is generally well managed although inadequate training regarding medication and epilepsy could put service users at risk. EVIDENCE: Mencap has a suitable range of policies and procedures, and suitable records are maintained. Mencap has a suitable approach to preventing any health and safety risks. Suitable procedures are in place to test fire prevention and electrical equipment, and there is satisfactory evidence that testing is completed. For example portable appliance testing was completed in March 2005. Appropriate checks appear to be in place regarding the prevention of Legionella. Concern regarding medication training, and epilepsy are highlighted elsewhere in the report and this could put service users at risk. Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 x 1 x 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lyndhurst Score x 3 1 2 Standard No 37 38 39 40 41 42 43 Score x x x 3 3 2 x D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2), 18(1)(c) Requirement All staff must receive appropriate, accredited training regarding the handling, administration and recording of administration.(Previous deadline not met. 2nd Notification). An immediate requirement has been made for the registered provider to provide the Commission with an action plan regarding how they intend to meet this requirement. This is required by 1.9.05 The registered provider is required to expand the home’s death and dying policy to cover the care of service users who are ageing or ill, with reference to the national minimum standard. The registered provider must amend the homes complaints procedure to: · Include information (address, phone number etc.) how service users can contact the Commission for Social Care Inspection (CSCI) · State that complainants can contact the CSCI at any time as outlined in NMS 22.3 Timescale for action 1.11.05 2. YA21 12(1-4) 1.12.05 3. YA22 22 1.11.05 Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 Page 20 4. YA24 23 5. 27, 30 16, 23 6. 35 18 7. 33 18 This information must be available for inspection and issued to service users and where appropriate their representatives.(Previous deadline not met 3rd Notification) The kitchen units must be replaced, the kitchen lighting replaced or refurbished, and the room redecorated. The registered provider’s responsible individual should deal and resolve these matters of concern due to the failure of the housing association to deal with this matter.(Previous deadline not met 4th Notification) The registered provider must provide soap in bathrooms / toilets at all times. The registered persons could consider the provision of towel / soap dispensers. (Previous deadline not met. 2nd Notification.) The registered provider must ensure: · all staff have appropriate training as required by regulation (i.e. Infection control, fire prevention, food handling, first aid, moving and handling). · Staff receive other training so they can effectively carry out their roles e.g. training regarding epilepsy, handling medication. An immediate requirement has been made for the registered provider to provide the Commission with an action plan regarding how they intend to meet this requirement. This is required by 1.9.05 (Previous deadline not met 2nd Notification) The registered provider must 1.11.05 1.11.05 1.11.05 22.8.05 Page 21 Lyndhurst D52-D04 S8911 Lyndhurst V233131 120805 Stage 4.doc Version 1.40 provide satisfactory staffing to meet service user needs. Subsequently by 22.8.05 the registered provider must provide the Commission with a report outlining how Mencap will meet this requirement. 8. 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 22 Good Practice Recommendations Service users should have copies of complaints postcards so they can send these off to management confidentially. 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