Inspection on 12/07/06 for Lyndhurst

This inspection was carried out on 12th July 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

Lyndhurst 07/07/08

Lyndhurst 14/01/08

Lyndhurst 07/02/07

Lyndhurst 07/10/05

Lyndhurst 05/05/05

Lyndhurst 27/10/04

Lyndhurst 27/04/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst 20 Oxford Road Dewsbury West Yorkshire WF13 4JT Lead Inspector Helen Battle Key Unannounced Inspection 12th July 2006 09:35 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 DS0000026278.V296195.R01.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 DS0000026278.V296195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address 20 Oxford Road Dewsbury West Yorkshire WF13 4JT 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) 01924 459666 01924455223 Mr Annamalai Subramanian Mrs Meena Subramanian, Dr Mohammed Ismail Kardasha Mrs Jacqueline Cummins Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: Lyndhurst is a care home registered to provide care and accommodation for up to fifteen older people. It is situated in a residential area of Dewsbury, set in extensive grounds. The home was formally a private house that has been adapted for its current use. Many of the property’s original architectural features have been retained. The accommodation is on two floors, with the majority of bedrooms being on the first floor. The first floor is accessed by the chair lift for service users who have mobility problems. The provider informed the Commission for Social Care Inspection, on 12 July 2006 that the fees range from £329 to £340 per week. There are additional charges for chiropody, optician, dentist, hairdressing and newspapers. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit carried out by two inspectors. The inspectors arrived at the home at 9.35am and left at 2.30pm. During this visit the inspectors spoke to some of the service users, some of the staff and the home’s management. The inspectors read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Prior to the inspection, fifteen service user questionnaires were sent to Lyndhurst to obtain the views of service users living at the home. Seven completed questionnaires were returned. There were fifteen service users living at the home on the day of this inspection. Surveys were sent to fourteen relatives and friends of service users, and eight GPs. At the time of writing this report, the inspector had received six responses from relatives and two from GPs. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, and a pre-inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: The staff at the home evidently take pride in their work and put the needs of the service users first. This is confirmed by service user and relative responses in questionnaires with statements like” I am well cared for”, “staff are caring, pleasant and helpful”, “the care is good” and “they look after me well”. Positive statements about the manager were also received from two service users who said that the manager “always comes to speak to me”. Service users are fully assessed prior to admission. Positive comments have been received from all responses to service user questionnaires about the quality and choice of food. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Service users have their needs assessed prior to admission into the care home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Pre-admission assessments were seen for two service users who have been recently admitted to the home. These were fairly detailed and evidently used to form the basis of the initial care plan. Contracts were also seen for these two service users, however the contracts need amending slightly to include all the information as detailed in standard 2 of the National Minimum Standards for Older People (signatures and dates required). Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users’ health and personal care needs are set out in the individual plan of care, however social care needs are not included. Risk assessments are carried out but greater care is required in their monitoring. Generally, the service users are protected by the home’s medication policy and procedure. Service users are treated with dignity, respect and privacy. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records of three service users were examined as part of this inspection. Generally, care plans were of a satisfactory standard with detail of how to meet the personal and health care needs of the individual. There was no evidence, however, of how the social care needs of service users are to be met. One issue was raised with the care officer regarding one particular service user who had recently lost weight over a period of 2 weeks. Although this had been recorded and identified, there was no evidence in the care records to suggest Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 10 that any action was being taken. Another issue was also raised in relation to pressure ulcers which were being attended to by the District Nurse. There was no evidence in the care records of these sores being monitored daily by the staff at the home. Advice was given to the manager of the home to contact the Tissue Viability Nurse for advice and support. Other healthcare professionals in contact with the home include GPs, optician, chiropodist and dentist. Checks were made on the medication of three service users during this inspection. Generally, the medication systems in place are well managed. Records were found to be clear and appropriate codes and explanations for any dose omitted well documented. All the tablets in the monitored dose system tallied with the records held as did two of the three boxed medications. There was a discrepancy with one amount of tablets. This was to be clarified by the member of staff responsible for stock checking medication. A medication fridge has been purchased since the last inspection. Any unused medication is disposed of appropriately. Sit-on scales have also been purchased since the last inspection. It was reported that some of the more physically independent service users do not like to use these and prefer to use the stand on scales. Service users should be able to make the choice of which type of scales they use. The type of scales each service user prefers or requires should be recorded in their care plan. During this visit, staff were observed to maintain the privacy and dignity of the service users and treat them with respect. This was confirmed by one of the service users who was spoken to as part of this inspection. Service user and relative responses in questionnaires were positive about the standard of care received. Statements like” I am well cared for”, “staff are caring, pleasant and helpful”, “the care is good” and “they look after me well” were included. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Generally the service users’ cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Activities are provided to meet the needs of the service users. These are often low key, with staff speaking to service users on a one to one basis about recent events in the news or reminiscence. Other activities include going out for walks, bingo, dominoes, reading newspapers and watching television. The questionnaires received from service users all indicated that they were satisfied with the level of activities provided. One response stated “I don’t like joining in, I like TV”. There was evidence of service users being able to maintain contact with families and friends. All the responses from the relative questionnaires indicated that they can speak to their relative in private when they visit the home. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 12 It was evident that service users are encouraged to make their own choices regarding their day to day life in the home. One service user stated that they can get up and go to bed when they want, that they choose where and how they spend their day and that there are good choices regarding meals. This was also the feedback in the questionnaires received from service users. Comments about food were very positive and there was evidence that service users have input regarding the menus. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 13 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 Service users, their relatives and friends are confident in raising any concerns and complaints. The service users are protected from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection the complaints procedure has been updated to include the details of the Commission. Complaints and compliments forms are available at all times in the signing in area of the home. This is good practice. All service users spoken to, and all the responses in the questionnaires, stated that they found the manager approachable and are confident that they will be listened to and any issues resolved. There have been no complaints received by the home during the last twelve months. All staff have had adult protection training in June 2006. A member of staff spoken to was clear in the action to be taken should any adult protection issue arise. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 14 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 The service users live in a safe but poorly-maintained environment that is generally clean. Areas of the home had unpleasant odours. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The environment of the home is poorly maintained. Many of the bedrooms were showing signs of wear and tear in the decoration, bedding was worn and did not match, facecloths and towels were frayed and worn, curtains were very thin, allowing the light to come through into the rooms, two commode chairs were rusting in areas, carpets were worn and stained in some of the bedrooms, some of the bedroom furniture was worn and damaged. A comment in the relatives’ questionnaires stated “the level of care within Lyndhurst appears to be quite high at the expense of the decoration.” Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 15 It is evident that the environment has been neglected and now requires attention. There were strong noticeable unpleasant odours in three of the bedrooms. The gardens of the home were also poorly maintained. The grounds are extensive, however they are not accessible for service users to use safely. The gardens should be maintained and the possibility of a specific area for service users to access safely should be explored. The registered provider must address the requirements regarding the fabric of the building and provide the Commission with a programme of decoration and refurbishment for the bedrooms. An issue regarding an overlay mattress which was placed directly on a bed base rather than on top of a normal mattress was raised with the manager at the time of the visit. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 16 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 Staff are employed in sufficient numbers and receive induction and ongoing training. The recruitment process could be improved to ensure the service users are sufficiently protected by the home’s recruitment policy. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Rotas examined demonstrated that there are sufficient staff on duty to meet the needs of the service users living in the home. Generally, there are two care assistants on duty at all times, on some days there are three care assistants on duty in the morning. In addition to this, there are the domestic staff, cook and the manager. There has been a great deal of work carried out in the last three months in relation to staff training. All staff have had training in fire safety, movement and handling, health and safety and the protection of vulnerable adults. The manager and the care officer have also completed the movement and handling facilitators’ course. Discussion took place with the manager regarding first aid training. At present, there are only two members of staff who have a first aid certificate, one of Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 17 these is the manager. There should be a member of staff on each shift who has had first aid training. The records of four members of staff were examined regarding recruitment practices at the home. For one of the members of staff, there was a discrepancy in the start date of employment (8.8.05) and the dates of the POVA 1st check (21.2.06) and the CRB check (6.2.06). This is not acceptable. Staff must not commence work at the home until the required checks are in place to ensure service users are protected. Due to the serious nature of this issue, this has had an impact on the judgment for this outcome group. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 18 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): 31,33,35,38 The home is run and managed by a manager who is fit to be in charge. Generally, the home is run in the best interests of the service users. The financial interests of the service users are safeguarded. The health and welfare of service users and staff is not always promoted and protected. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 19 EVIDENCE: The manager has been in post at the home for the past two years and positive feedback has been received about the manager from staff, service users and relatives. Generally, the home is run in the best interests of the service users. However, the provider needs to ensure that the decoration of the home, the furniture in the bedrooms, the quality of the bedding, curtains, towels and facecloths are of an adequate standard. The manager of the home stated that monthly management visits are carried out, however only two copies of the reports relating to these visits were available for February 2006 and April 2006. The quality of these reports were poor and did not contain any information which might improve the service provided for the service users. It is most concerning that the issues raised in this report regarding the environment of the home have not been noted in the two monthly management visit reports carried out by the provider. Monthly management visits must be carried out and a report regarding these visits completed in sufficient detail to form an opinion of the standard of care provided and the standard of the premises. During a tour of the premises, it was noted that there were health and safety issues which would directly affect service users. In some of the rooms there was no hot water. When the records of hot water temperatures were examined, there were temperatures recorded up to 70.8ºC. The records were also incomplete, not all outlets had been checked and the ones that had been checked had not been carried out on a regular monthly basis. This is not acceptable and is putting service users at serious risk. It was reported that the home had had two new water tanks fitted in June 2005 and that there had been problems regulating the hot water. There were no records of any remedial action being carried out to rectify the problem. An immediate requirement letter was issued to the manager of the home at the time of this visit regarding the hot water temperatures. Discussion also took place with the manager regarding the automatic closers on some of the bedroom doors. These closers made these heavy doors shut very quickly, which could knock over a frail service user whose mobility is slow. These closers should be checked and adjusted to minimise this risk. Records of weekly tests of the fire alarm system and emergency lights were in place. There were two instances where there was a gap of two weeks between tests. It was not clear from the records which break glass point had been tested. The break glass points should be tested in rotation. Care must be taken to ensure that these tests are carried out weekly. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 20 Records of fire drills were also in place however these did not detail the names of the staff members involved. The personal monies held by the home for four service users were checked as part of this inspection. These were found to tally with the records held. Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23(2)(b) (d)(m)(o) Requirement Timescale for action 01/09/06 2. OP19 16(2)(c) 3. OP26 13(4)(c) A programme of maintenance, decoration and refurbishment for the interior and exterior of the home should be implemented and a copy of this programme be forwarded to the Commission. Adequate furniture, bedding and 30/09/06 other soft furnishings, including curtains and floor coverings must be provided. New towels must be provided. 01/08/06 The registered person shall ensure that unnecessary risks to the health or safety of the service users are identified and so far as possible eliminated. To promote good hygiene and prevent the spread of infection, communal bars of soap and body cloths must not be used. Previous timescale of 21/10/05 not met. The home should be kept free from offensive odours. Staff must not commence work in the home until the appropriate checks have been made and confirmation received. DS0000026278.V296195.R01.S.doc 4. 5. OP26 OP29 16(2)(k) 19(4)(b) (i) 01/08/06 12/07/06 Lyndhurst Version 5.2 Page 23 6. OP33 26(3) (4)(a)(b) (c) 7. OP38 13(4)(a) Monthly management visits must 31/08/06 be carried out and a copy of the report forwarded to the Commission. The visits must be carried out in sufficient detail so as to be able to form an opinion of the standard of care provided. Measures must be taken to 21/07/06 ensure that there is hot water to all hot water outlets and that this is running close to 43 degrees centigrade. The fire doors must be checked to ensure that the service users are not at risk from them closing too suddenly. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP8 Good Practice Recommendations The social needs of the service users should be included in their individual care plans. All identified risks for the service user should be documented in the individual’s care records, including any action taken. Where service users require facecloths, new ones should be provided. There should be a member of staff who has had first aid training on every shift. The views of the service users should be included in the homes quality monitoring systems. The names of all staff involved in fire drills should be recorded. Fire break glass points should be tested in rotation. 3. 4. 5. 6. OP19 OP30 OP33 OP38 Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst DS0000026278.V296195.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!