Inspection on 16/05/06 for Lyndhurst

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 29/10/08

Lyndhurst 01/05/08

Lyndhurst 04/12/07

Lyndhurst 10/08/06

Lyndhurst 19/12/05

Lyndhurst 21/06/05

Lyndhurst 12/10/04

Lyndhurst 24/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst Lyndhurst 67 Byfleet Road New Haw Weybridge Surrey KT15 3JZ Lead Inspector Kerry Fell Key Unannounced Inspection 16th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 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 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.V293234.R01.S.doc Version 5.1 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 indivivual DE(E) Dementia - 0ver 65 to be added to the registration for the duration of their stay at the home. 19th December 2005 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.V293234.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report that covers the findings of a number of unannounced inspections of the home incorporating monitoring visits in respect of three Regulation 43 Notices and a key unannounced inspection. The monitoring visits were undertaken on 2nd May 2006, 8th May 2006 and 26th May 2006. Ms Christine Bowman and Ms Sue McBriarty undertook the key unannounced inspection on 16th May 2006. Since the previous inspection, two other monitoring visits in respect of noncompliance with requirements had taken place on January 19th and March 30th and three letters of serious concern had been issued, one with reference to non compliance with the requirements of the previous inspection, a second with reference to the employment of staff without appropriate documentation in place and the third in respect of the registered persons having left the home for ten days without ensuring those left in charge were suitably qualified or experienced. Mr and Mrs Seeparsand were both available at the unannounced inspection and the recently appointed ‘Care Manager’ were available at the unannounced inspections on 8th May 2006 and 26th May 2006. The office, although improved, continued to be cluttered and did not provide a business-like workspace. At the time of the inspection it was necessary to administer a caution under the Police and Criminal Evidence Act 1984 (PACE) to the registered persons during the inspection in order to advise them of their rights. The caution was administered as the Commission had reason to believe that the registered persons had admitted a service user outside of their conditions of registration, in that they had admitted a service user who had a primary diagnosis of mental health condition when the home is not registered for the category Mental Disorder (over 65), (MD (E)). This is an offence under Section 24 of the Care Standards Act 2000. This has been dealt with separately. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Further work is required to the statement of purpose and service user guide in order for these documents to fully comply with standard 1 of the National Minimum Standards for Older People. The language used within this document must also be reviewed to ensure that the document is written in plain English and to ensure that language used is not discriminatory or could cause offence. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 7 Service users spoken to during the inspection did not feel that they had been involved in their admission to the home, nor had their opinions been sought. Although there was evidence of pre-admission assessments having been received or completed by the home, one care management assessment observed had been completed 6 months prior to the service user being referred to the home. The registered persons must therefore ensure that service users are involved and consulted about their admission to the home, and that the most current care management and pre-admission assessments are available. Although it is recognised that there was some improvement to the quality of the care plans, areas of further improvement were identified. This was a requirement made as part of the statutory requirement notices, and as this had not been fully met, timescales were extended. Service users were not aware of the contents of their care plans, and did not feel that they had been consulted about the review of their needs and therefore their care plan; although care plans had been signed by service users or their next of kin shortly after they had been written. Risk assessments also needed to be expanded further to include assessments of risks identified with regard to service users’ specific needs, for example, risks in relation to dementia and confusion, the home’s environment or specific health needs. This was a requirement made as part of the statutory requirement notices, and as this had not been fully met, timescales were extended. The management and administration of medication policy and procedure had been reviewed, however this policy and procedure was not sufficiently clear and detailed to enable staff to undertake the task described. This procedure must be reviewed further. This was a requirement made as part of the statutory requirement notices, and as this had not been fully met, timescales were extended. A number of privacy concerns were identified during the inspection on 16th May 2006. Service users bedroom doors were observed to have obscured glass panels in them, however it was still possible to see through this glass. Another bedroom had a hatch built into the bedroom wall, which could still be opened into the bedroom. The staff WC was observed to have louvre doors which did not offer sufficient privacy. The registered persons must ensure that privacy and dignity is promoted, and a requirement has been made for the registered persons to report to the CSCI Surrey Local Office on what action they will take to ensure that privacy is maintained. Concerns were identified with regard to the activities offered by the home. Several service users stated that they wished that they could go out more often. Although the registered manager advised inspectors of the activities offered to service users, there was only evidence of a music and movement session having taken place. The registered persons must therefore complete a Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 8 full review of the activity programme including a formal consultation with service users. The complaints procedure and the protection of vulnerable adult procedures had been reviewed, however, further work was required to ensure that the procedures were accurate and detailed. These were requirements made as part of the statutory requirement notices, and as these had not been fully met, timescales were extended. A number of issues with regard to the maintenance of the home and the safety of the garden were identified during the inspection, and must be attended to without delay. The registered persons must also complete a full audit of the home to identify all maintenance issues, and a formal maintenance programme must be introduced. The registered persons must also ensure that recommendations made by Surrey Fire and Rescue Service are complied with. Although work had been completed on the personnel files, further work was required to ensure that they contained all of the information detailed within schedules 2 and 4 of The Care Homes Regulations 2001, and that evidence must be available to demonstrate that all overseas staff have the correct documentation for their employment, and if an agency was responsible for the recruitment, confirmation that the agency has undertaken all of the required checks. Staff must also receive formal one-to-one supervision at least six times per year. These were requirements made as part of the statutory requirement notices, and as these had not been fully met, timescales were extended. The registered manager must also ensure that records and filing systems are orderly and that the office is tidy. This is a requirement carried over from the last inspection, and is therefore an immediate requirement. 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.V293234.R01.S.doc Version 5.1 Page 9 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.V293234.R01.S.doc Version 5.1 Page 10 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 poor. This judgement has been made using available evidence including inspections of the home. The home is in breach of its conditions of registration. Immediate action is needed to ensure that the statement of purpose, and service user guide are accurate and are written in positive language, and that the pre-admission procedure promotes service users choice and involvement in their admission. EVIDENCE: At the time of the inspection it was necessary to administer a caution under the Police and Criminal Evidence Act 1984 (PACE) to the registered persons during the inspection in order to advise them of their rights. The caution was administered as the Commission had reason to believe that the registered persons had admitted a service user outside of their conditions of registration, Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 11 in that they had admitted a service user who had a primary diagnosis of a mental health condition when the home is not registered for the category Mental Disorder (over 65), (MD (E)). This is an offence under Section 24 of the Care Standards Act 2000. The Commission is dealing with this matter under separate cover with the registered persons. The statement of purpose made available during the inspections had been reviewed on the 1st May 2006. Although this document had been reviewed there continued to be some factual inaccuracies within it, in that the statement of purpose must accurately and fully detail the qualifications of the registered provider and the registered manager. Although the statement of purpose detailed that the home employed five qualified nurses, this was not accurate because the home is not a care home with nursing, and that these members of staff are registered nurses from overseas, and therefore unless they complete a conversion course, cannot practice as nurses in the UK. These members of staff are formally employed as senior care staff, and this must therefore be accurately reflected within the statement of purpose. The statement of purpose must also fully detail the numbers of staff completing NVQ level 2 training in Care and what other mandatory and specialist training had been completed by staff. The information about the home’s categories and conditions of registration with the CSCI detailed within the statement of purpose also contained inaccuracies, and these must fully reflect the categories and conditions of registration as recorded on the home’s registration certificate. A full copy of the home’s complaints and fire evacuation procedures must be included in the statement of purpose. The service users guide had also been reviewed at the end of April 2006, this document contained the same factual inaccuracies as the Statement of Purpose. This document stated, “a standard form of contract can be provided by the manager”. A copy of the home’s terms and conditions must be made available to all service users. The service user guide still contained statements like service users were ‘suffering from dementia’, and other language that is not perceived as promoting dignity and a positive image of service users with specific needs and disabilities. For example, the continued use of the term ‘handicap’ and the statement that ‘at a glance the dementia is not normally noticeable’. The registered persons must review the language used within the statement of purpose and the service users guide to ensure that the documents are written in plain English, and do not use language that is discriminatory and could cause offence. The documents must also be in a format that is suitable for the service users resident at the home. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 12 The registered persons are therefore required to review the statement of purpose and service users guide to ensure that they fully comply with standard 1 of the National Minimum Standards for Older People and regulation 4 of the Care Homes Regulations 2001. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. Although it was evident that service users admitted to the home in 2006 had been admitted with care management assessments, and that these had been used to develop service users records, care plans and manual handling assessments as part of the “Standex” record system used by the home. In one case, it was observed that the care management assessment supplied to the home had been completed six months prior to the service user being referred to the home. Inspectors also observed that one service user’s care management preadmission assessment detailed that the service user had a mental health diagnosis, this was not reflected in a discharge letter from the service user’s GP. The home was given an immediate requirement to forward confirmation to the CSCI Surrey Local Office as to what this service user’s primary diagnosis is. A second service user was identified as having been admitted outside of the home’s categories of registration. This is an offence under section 24 of the Care Standards Act 2000, and as a result the registered provider was given a caution under the Police and Criminal Evidence Act (1984) (PACE), in order to advise them of their rights. Immediate requirements were made for the home to report to the CSCI Surrey Local Office with regard to how the needs of the service user are being met by the home. The registered persons must ensure that all pre-admission assessments are current, and accurately reflect the needs of service users. Omissions were also observed in service users’ pre assessment documentation; one was not dated and another did not indicate a change in General Practitioner and contact details of the care manager. Service users were asked about their introduction to the home, and they stated that they knew nothing about the assessment, and had not had a choice of home nor had they visited prior to admission. One service user stated that, ‘I was happy to come, but you don’t have to be happy.’ It is not acceptable that service users feel disempowered about their admission, and that they are not involved in their admission to the home. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 13 Service users involvement in their admission to the home must be promoted, and where possible visits to the home must be arranged prior to the service user being admitted. Service users views about the home and the admission process must be sought and taken into account. Service users must be involved in and be made aware of their assessment of need and how the home intends to meet these needs. Standard 6 is not applicable to this service. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 14 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 poor. This judgement has been made using available evidence including inspections of the home. Care plans are in place but areas of further improvement have been identified and better service user involvement is needed. Further work is needed on the reviewed medication administration and management procedure. Little progress has been made in the promotion of privacy for service users. EVIDENCE: Service users’ care plans were set out in three different formats, a short term care plan which had been reviewed once in the last six months, a care plan document which included identified needs. For example, personal hygiene, social stimulation, falls, and specific medical and clinical needs. This document had been reviewed on a monthly basis since March 2006. A third long term care plan was observed on approximately 80 of service users files. The inspectors were advised that where these were absent, care management had advised the home that the long-term care plans would not be needed. The long term care plans in most cases had been reviewed between March and May Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 15 2006, however, in one case the document had been signed by the link worker but had not been completed. Contradictions were also observed between the three care plan documents as to what service users needs were and how services users needs were to be met. Although service users did not know what was meant when they were asked about their care plans, all but one short-term care plan observed had been signed by the service user or their next of kin, in most cases shortly after the plan had been written. However, service users stated that they had not been consulted about their care and only the staff had signed the monthly reviews. It was not evident whether restrictions placed upon service users lifestyles, for example, restricting the number of cigarettes to be smoked per day, were agreed with the service user, and/or their relative, as these were not fully detailed and countersigned in the service user’s care plan. Interviews with service users indicated that they felt they had little control over their lives. One service user stated that they had “No chance to go out, we’re not allowed”. Another resident stated, “I don’t think I’ve got a care plan, but it’s a nice place and I’m happy”. Service users must be involved in the development and review of their care plans, and their needs, choices and views must be taken into account and met. The home must review all care plans, and ensure that the care plans accurately reflect the full needs of service users and how these will be met. The home would be strongly advised to consider using a single format for all care plans. Although specific risk assessments were in place with regard to mobility and the risk of falling, no detailed risk assessments were available with regard to service users specific needs. For example, risks in relation to dementia and confusion, the home’s environment or specific health needs. Additional risk assessments must therefore be completed for all service users. These risk assessments must include details of how the risk will be minimised and when the assessment will be reviewed. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. Records of GP’s visits were observed on the service users’ records. There was also evidence of appointments being made with a range of health professionals, include occupational health and specialist consultants, as required. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 16 The registered manager advised inspectors that staff had received training from the diabetes nurse and in the care of colostomy sites. However, some contradictions were observed within care plans about how members of staff were to support service users with their specific health needs. There was also no evidence as to how staff were trained to support service users with specific mental health needs, or how much input the community psychiatric nurse had into the development of care plans. The registered persons must therefore ensure that service user’s assessed health needs are identified clearly within the care plan, and that the care plan details how these needs will be met and the service users will be supported. The procedure for the safe management and administration of medication had been reviewed as required, however, the procedure made available to the CSCI Surrey Local Office, and to the inspectors during the visit, was not sufficiently clear nor detailed so that staff could undertake the tasks described. The administration and management of medication procedure must be further reviewed, to include a full step-by-step procedure for the ordering, storing, recording and safe administration of medication, and how service users will be supported, based on risk assessment to self-administer their medication. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. Prescribed creams were no longer left in service users bedrooms, and medication was being stored appropriately at the time of the inspection of the 16th May 2006. The Medication Administration Records had been completed correctly and there were no discrepancies in the recording of medication checked. A list of signatures of the staff trained and responsible for the administration of medication was available. The MAR sheet had been stamped by the local Pharmacist to verify returned medications, but a dedicated book in which to record all medication received and leaving the home should be in place for this purpose. Health care needs were included in the care plans and one service user had an appointment planned with the Optician, to which a friend was taking her. The diet of a service user with diabetes was checked and found to be appropriate to her needs. A number of privacy concerns were identified during the inspection on 16th May 2006. A number of bedroom doors had vision panels. It is recognised that obscured glass is fitted in the doors, however it was possible to see into the bedroom, and would not allow sufficient privacy for the service users who stayed in these bedrooms. The registered persons must ensure that these Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 17 vision panels are covered or replaced, ensuring that the door continues to comply with fire safety regulations. A hatch was also observed in the wall of one ground floor bedroom. This hatch could still be opened from outside allowing anybody to look into the service user’s bedroom. The registered persons must report to the CSCI Surrey Local office of what action they will take to ensure that service user’s privacy is maintained in this bedroom. The staff toilet on the first floor has a slatted, louvre style door; this does not maintain the privacy for anybody using this toilet. This door must be replaced. Areas are available around the home, including the conservatory, if service users wish to meet with friends, relatives and other visitors in private. The inspectors were advised that the GP meets with service users in their bedrooms, in order to maintain privacy. Members of staff were observed knocking on bedroom doors before entering. The wishes of service users in the event of terminal illness or death were recorded in service users’ records. However inspectors found during the inspection of 16th May 2006 that there was reluctance on the part of the registered persons to discuss these plans with service users. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 18 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 poor. This judgement has been made using available evidence including inspections of the home. Action must be taken to review available activities and to consult service users about their wishes. Menus are not available and meals provided do not fully meet the specific dietary needs of service users. EVIDENCE: Although the registered manager advised inspectors of a number of activities in which service users could choose to participate, which included set activities some days, and walks to the shops and by the canal, and outings in the owner’s vehicle, service users advised the inspectors that they wished to go out more often, stating that “There are not many things to do and I can’t get out. I never go shopping. I would like some music in my room”. One service user advised inspectors that there were some interesting things to do, that there was entertainment sometimes and the hairdresser comes in, but she doesn’t go out very often. Another service user stated that there was a show at Christmas, that birthday parties were arranged and sometimes they play games such as skittles. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 19 It was not evident whether specific activities or sessions were arranged to support service users with dementia or to promote the independence of service users. Inspectors observed the music and movement session taking place, and this was the only session advertised as an activity for service users to participate in. Inspectors could not confirm that appropriate insurance was held for the use of the vehicle to transport service users; the registered manager must therefore send a copy of the insurance details for his motor vehicle to the CSCI Surrey Local office. The inspectors were advised that some service users attend church services at the nearby Catholic Church, and that a Baptist Minister and a Church of England Vicar visited the home. Evidence was available of contact being maintained between service users and their friends and relatives, and service users received visitors during the inspections. Minutes of service users meetings were seen to consist of an informal chat rather than formal consultation. The manager must consult with service users with respect to their social interests and any activities they wish to participate in and provide a programme of activities. 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 menu was not posted on the notice board and when asked, service users stated they had not seen a menu and that there was not a choice. One service user stated they had been vegetarian when they came to the home but there was not a vegetarian choice. The service user went on to say that they now ate meat, but if they really didn’t like something they would be given an alternative. The majority of service users thought that the food was good and that it was plentiful. The registered persons must ensure that the menu is displayed on a daily basis in a format that service users can understand. The registered persons must also ensure that service users specific dietary needs are met and that service users’ food preferences are taken into account when menu planning. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 20 Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 21 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 poor. This judgement has been made using available evidence including inspections of the home. Although the complaints procedure had been updated, further work is identified. The reviewed protection of vulnerable adult procedures was not satisfactory, and still did not reflect Surrey County Council’s multi agency safeguarding procedures. EVIDENCE: The complaints procedure had been reviewed further following the inspection on 16th May 2006. The document stated that it had been written under guidance from the Registered Homes Act 2000, and Residential Care Homes Regulations 2000, this is incorrect and should read the Care Standards Act 2000, and the Care Homes Regulations 2001. It is of concern that the registered persons are unaware of current legislation. The complaints procedure now contained the contact details for the CSCI, and the procedure stated that the CSCI could be contacted at anytime. However, it additionally referred to the CSCI as ‘National Care Standards’, this needs to be removed. The complaint procedure stated that a complaint should be replied to within 28 days and that any complaints should be made initially to the registered manager. The procedure also referred the complainant to the Parliamentary Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 22 and Health Service Ombudsman, if they remained dissatisfied with the outcome. The registered persons must therefore further review the complaints procedure to ensure that it contains accurate information. The protection of vulnerable adult procedures had been reviewed. However the procedure remained confusing and did not meet the National Minimum Standards for Older People, in that it did not reflect Surrey County Council’s multi agency safeguarding procedures. The protection of vulnerable adult procedures must therefore be reviewed to ensure that it includes a step-by-step guide as to how staff must respond to an allegation or suspicion of abuse. This procedure must be in line with Surrey County Council’s safeguarding procedures. It is not acceptable for the service to undertake investigations without following the proper referral process in the first instance. Any actions or investigating agency must be agreed at the Safeguarding planning/strategy meeting in line with Surrey County Council’s Safeguarding Procedures. This policy must provide clarity for staff. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 23 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 poor. This judgement has been made using available evidence including inspections of the home. Maintenance and the safeguarding of service users through attention to health and safety within the garden was not attended to. EVIDENCE: A number of maintenance and safety concerns were identified during the inspection of 16th May 2006. There was also malodour detected in some bedrooms and in the main entrance to the home. Water pressure was observed to be low in three bedrooms, and a hot water tap was found to be loose. Paper towels were not available in the holders in bathrooms or in the kitchen. No liquid soap was available in the toilet, and at the time of the inspection no toilet paper was available in the bathroom. Broken floor tiles were also Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 24 observed in the bathrooms, and the bathroom mirror was not secured safely to the wall. Other maintenance issues were observed in service users’ bedrooms. The melamine on top of one service users chest of drawers had come away, holes were observed in a service users bedroom ceiling after the smoke detector had been removed and not replaced. Maintenance issues must be resolved without delay, and the home must ensure that an audit of the home is undertaken regularly to ensure that any maintenance issues are identified promptly and are resolved. A ladder was observed propped in the first floor hallway during inspections on 16th May 2006 and 26th May 2006, and must be removed without further delay. The home has a good sized, well-stocked garden, which was observed to be securely fenced. However, garden buildings and the garage were observed to require attention. The wooden shed was observed to be leaning to one side, and was being used to store old furniture and carpets. This presents a health and safety hazard, and the carpets and furniture must be removed without delay and the shed must be made safe. A second smaller shed was also observed to have a broken roof, and the greenhouse had broken panes of glass. This must be made safe without delay. A number of items of furniture had been left in several areas around the garden and had begun to disintegrate. These must be removed without delay. The registered persons must complete an audit of the premises and the garden and identify all required maintenance and health and safety issues. The registered persons must report to the CSCI Surrey Local office on how they will ensure that the maintenance and health and safety issues identified within this report and any additional issues identified by the registered persons’ review of the premises will be resolved promptly. The registered persons must also develop a programme of routine maintenance and renewal for the premises. The room used by the staff for sleeping-in duties was viewed. It was a small space between an external and internal door, which is also used for hairdressing. A makeshift bed was rolled up behind the door. Suitable facilities must be made available for staff. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 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 poor. This judgement has been made using available evidence including inspections of the home. The home must have full regard for the safety of service users by ensuring that staffing levels are sufficient to meet the needs of service users, and that recruitment and training of staff is improved. EVIDENCE: The staff rota was viewed and showed sufficient staff on duty. The rota included the newly recruited ‘care manager’ as part of the team providing the day-to-day care of the residents. Insufficient numbers of suitably qualified staff were found on duty in the home during the inspection on 30th March 2006. At the time of this inspection the registered persons had been on holiday and had left leaving a senior carer who had no management experience, in charge of the home in their absence. However at the time of the inspection, there had been only two carers and two domestic staff on duty until the senior carer was telephoned, as a result of the inspection, to come into the home. A letter of serious concern was sent to the registered persons with regard to this situation. The registered persons must ensure that sufficient qualified and experienced members of staff are available to support service users at all Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 26 times, and that suitable arrangements are made for the management of the home in the absence of the registered manager. The inspectors were advised that the staff recruited who held nursing qualifications from overseas had been certified as holding qualifications that are equivalent to National Vocational Qualification level 3 in care. If the qualifications of these staff are included in the ratio of trained staff employed at the home, 50 of the staff would be considered as holding NVQ level 2 or level 3 qualifications in care. The registered manager also stated that three members of staff had also been enrolled on an NVQ level 2 training course. The home was observed to hold a recruitment procedure that detailed what was required prior to employing a member of staff. The procedure stated that members of staff would be recruited in line with a person specification. However no specifications were available when requested. A person specification for the new “care manager” was forwarded to the CSCI Surrey Local office following the inspection. However, person specifications must be available for all roles. Staff personnel files were better organised, and each member of staff now had an individual plastic file in which all of their personnel records were being held. Personnel files still did not contain application forms with full work histories. It was also not clear from personnel records that the relevant checks had been completed on the staff employed from overseas. The manager advised the inspectors that an agency had recruited these members of staff on the home’s behalf. The registered manager must review all of the personnel files to ensure they contain the information required under Schedules 2 and 4 of the Care Homes Regulations 2001, this must include evidence that all overseas staff have the correct documentation for their employment, and if an agency was responsible for the recruitment, confirmation that the agency has undertaken all the required checks. At the time of the inspection, CRB checks were available for all members of staff employed at the home, and these were held separately in a safe that was only accessible to the registered person. Full recruitment checks had been completed on the two most recently recruited members of staff. However, staff that had worked at the home for some time still did not have full recruitment checks. The registered persons must ensure that where possible retrospective recruitment checks are completed, and that these personnel files contain the information as detailed under schedule 2 of the Care Homes Regulations 2001. Care staff still did not have training plans and there was limited evidence available of what training staff had completed whilst working at the home. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 27 Records of programmes of induction were also not available, although the newly recruited acting manager did confirm that they were undertaking induction. The acting manager also stated that they were in the process of reviewing all of the personnel records and reviewing staff training needs and the time of the inspection. This must be completed. Although it is recognised that work had commenced, all personnel files must be reviewed and a training programme introduced for all staff. These are requirements made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 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): 31,33,34,35,36,37 Quality in this outcome area is poor. This judgement has been made using available evidence including inspections of the home. Management of the home is failing to ensure that policies, procedures and practice within the home safeguard service users. EVIDENCE: Evidence was made available to the CSCI Surrey Local office to confirm that the registered manager had been accepted on a Registered Managers’ Award course. A ‘care manager’ with good experience of care and management and suitable qualifications had also been recruited by the home. It was not clear during the inspection of 26th May 2006 in what capacity the ‘care manager’ had been recruited. The ‘care manager’ informed the inspectors that they were under Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 29 the impression that they were recruited with the intention to make application to the CSCI for registration as manger of the home. The registered persons must report to the CSCI Surrey Local Office what the ‘care manager’s’ role is, and if the intention is for them to apply for registration with the CSCI, the ‘care manager’ must attend the CSCI Surrey Local Office to apply for their enhanced CRB check, and therefore start the application process, by 21st June 2006. Evidence was available to show that the registered manager had been accepted on to the Registered Managers Award, however the CSCI Surrey Local Office have not been advised of when this course was commenced and the expected completion date. The registered manager must confirm what date they commenced the registered managers award, and when they expect to complete the course. This requirement was made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. There was evidence that quality assurance questionnaires had been sent to relatives with positive results. However, in light of comments made by service users detailed throughout this report, service users do not feel that their views are heard or that they are consulted about their needs and the development of the home. The registered persons must therefore develop a formal programme of consultation and quality assurance without further delay. A business plan could not be produced when requested during the inspection. The most recently certified accounts were forwarded to the CSCI Surrey Local office following the inspection. Written records of service users finances and receipts had been kept. It was observed that in some cases the service users had not countersigned transactions. If service users are unable to countersign for financial transactions this must be recorded both on care plans and in the financial records. A new form had been devised for the recording of supervision, but there was no evidence of its use. The manager stated that sessions booked for the afternoon had been cancelled because of the inspection. Service user’s records were stored securely but there was no evidence to suggest they were involved in the review and updating of their records. Although the registered manager could find records and files more easily, the small office continued to be disorderly and untidy. This could prove to be a safety hazard. The registered manager must ensure that records and filing systems are orderly and that the office is tidy. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 30 All the necessary checks and certificates were in place and up-to-date with reference to Health and Safety, including the gas certificate, the electrical installations test, the electrical appliances check, the lift engineer report, the fire alarm and emergency lighting test, and fire drills were recorded. There was evidence that some of the heat detectors identified as requiring replacement in the previous inspection report had been replaced, but not all and there was no date for a follow up visit. The Fire Officer had made recommendations following his visit on April 4th 2006 and these were that key holes in the doors of three bedrooms must be filled with material, which is fire resistant for thirty minutes and the door leading from the dining room to the hallway must be covered in material, which is fire resistant for thirty minutes. This had been completed. No full fire risk assessment was in place, and this had been a recommendation in the Surrey Fire Safety report of November 2004. Although the registered manager was adamant the completion of a fire risk assessment was not yet legally required, the Fire Safety report clearly detailed that the registered persons must have a fire risk assessment completed, and that because of the size of the home this assessment must be recorded. Regulation 23 (4) of the Care Homes Regulations 2001 expect registered persons to take adequate precautions against the risk of fire and to make adequate arrangements for reviewing fire precautions. The registered persons must therefore comply with the recommendations made within the Fire Safety report without further delay. A copy of the fire risk assessment must be forwarded to the CSCI Surrey Local office. Please see comments made under National Minimum Standard 26. Many of the policies were not personalised for the home, and had been transferred from use by a local health authority. These documents referred to ‘patients’, the ‘health and safety department’ and ‘transport within the hospital’. A number of these policies and procedures were in need of urgent revision, for example the racial harassment policy, the fire drill procedure, clinical waste disposal, health and safety and whistle blowing policy. The registered persons therefore must review all of the home’s policies and procedures to ensure that they are relevant to the home and reflect the home’s practice. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 31 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 1 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 2 2 1 1 2 Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 32 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 OP1 Regulation 5 Requirement The registered persons are required to review the statement of purpose and service user guide to ensure that they fully comply with standard 1 of the National Minimum Standards for Older People and Regulation 4 of the Care Homes Regulations 2001. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. The registered persons must review the language used within the statement of purpose and the service user guide to ensure that the documents are written in plain English, and do not use language that is discriminatory and could cause offence. The documents must also be in a format that is suitable for the service users’ resident at the home. DS0000013707.V293234.R01.S.doc Timescale for action 21/06/06 2. OP1 5 21/06/06 Lyndhurst Version 5.1 Page 33 3. OP3 14 The registered persons must ensure that all pre-admission assessments are current, and accurately reflect the needs of service users. Service users involvement in their admission to the home must be promoted, and where possible visits to the home must be arranged prior to the service user being admitted. Service users’ views about the home and the admission process must be sought and taken into account. Service users’ must be involved in and be made aware of their assessment of need and how the home intends to meet these needs. Service users’ must be involved in the development and review of their care plans, and their needs, choices and views must be taken into account and met. The home must review all care plans, and ensure that the care plans accurately reflect the full needs of service users and how these will be met. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. 24/06/06 4. OP3 14(1)(c) 24/06/06 5. OP3 14(1)(c) 24/06/06 6. OP3 14(1)(c) 24/06/06 7. OP7 15(1) 24/06/06 8. OP7 14(2), 15(2) 21/06/06 9. Lyndhurst OP7 12(1), Additional risk assessments must 21/06/06 DS0000013707.V293234.R01.S.doc Version 5.1 Page 34 13(4) be completed for all service users. These risk assessments must include details of how the risk will be minimised and when the assessment will be reviewed. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. The registered persons must ensure that service users’ assessed health needs are identified clearly within care plans, and that the care plan details how these needs will be met and how service users will be supported. The administration and management of medication procedure must be further reviewed, to include a full stepby-step procedure for the ordering, storing, recording and safe administration of medication, and how service users’ will be supported, based on a risk assessment to selfadminister their medication. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. The registered persons must ensure that vision panels in service users’ bedroom doors are covered or replaced, ensuring DS0000013707.V293234.R01.S.doc 10. OP8 13(1) 24/06/06 11. OP9 14 21/06/06 12. OP10 12(4), 23(1)(a) 24/06/06 Lyndhurst Version 5.1 Page 35 13. OP10 12(4), 23(1)(a) 14. 15. OP10 OP12 23(3) 12(1) 16. OP12 16(2)(n) 17. OP15 12(2), 16(2)(i) 18. OP15 14(1), 16(2)(i) 22 19. OP16 that the door continues to comply with Fire Safety Regulations. The registered persons must report to the CSCI Surrey Local office of what action they will take to ensure that service users’ privacy is maintained in bedrooms. The louvre style door to the staff WC must be replaced. The registered manager must send a copy of the insurance details for his motor vehicle to the CSCI Surrey Local office. 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 independent as possible and what activities will be introduced specifically for those service users’ who have dementia. The registered persons must ensure that a menu is drawn up and displayed on a daily basis in a format that service users can understand. The registered persons must ensure that service users specific dietary needs are met and preferences are considered. The registered persons must review the complaints procedure to ensure that it contains accurate information. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been 24/06/06 24/06/06 24/06/06 24/07/06 24/06/06 24/06/06 21/06/06 Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 36 20. OP18 13(6) 21. OP19 23(2)(b) 22. 23. OP19 OP26 23(3) 13(4), 23(2)(b) fully met and timescales within the statutory requirement notice were extended. The Registered Manager must develop further the policy for the protection of vulnerable adults for the home based on The Surrey Multi Agency Guidance. This was a requirement of the previous inspection. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. Maintenance issues must be resolved without delay, and the registered persons must ensure that an audit of the home is undertaken regularly to ensure that any maintenance issues are identified promptly and are resolved. Suitable facilities must be made available for staff. The registered persons must complete an audit of the premises and the garden and identify all required maintenance and health and safety issues. The registered persons must report to the CSCI Surrey Local office on how they will ensure that the maintenance and health and safety issues identified within this report and any additional issues identified by the registered persons’ review of the premises will be resolved promptly. The registered persons must also develop a programme of routine maintenance and renewal for the DS0000013707.V293234.R01.S.doc 21/06/06 26/06/06 26/06/06 26/06/06 Lyndhurst Version 5.1 Page 37 24. OP27 25. OP29 26. OP29 27. OP29 premises. The registered persons must ensure that sufficient qualified and experienced members of staff are available to support service users at all times, and that suitable arrangements are made for the management of the home in the absence of the registered persons. 12(1)(b), Person specifications must be 18 available for all staff roles, as detailed in the home’s recruitment procedures. 19 The registered persons must ensure that where possible retrospective recruitment checks are completed, and that personnel files contain information as detailed under schedule 2 of the Care Homes Regulations 2001. 17, 18, 19 All personnel files must be reviewed to ensure that they contain all information detailed under Schedules 2 and 4 of the Care Homes Regulations 2001. This must include evidence that all overseas staff have the correct documentation for their employment, and if an agency was responsible for the recruitment, confirmation that the agency has undertaken all of the required checks. 18(1) 16/05/06 26/06/06 26/07/06 21/06/06 28. OP30 18(1)(a) This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. A training programme must be 21/06/06 introduced for all staff. This is a requirement made as part of DS0000013707.V293234.R01.S.doc Version 5.1 Page 38 Lyndhurst 29. OP31 10(3) the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. The registered manager must confirm what date they commenced the registered managers award, and when they expect to complete the course. This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. The registered persons must report to the CSCI Surrey Local Office what the ‘care manager’s’ role is, and if the intention is for them to apply for registration with the CSCI, the ‘care manager’ must attend the CSCI Surrey Local Office to apply for their enhanced CRB check, and therefore start the application process, by 21st June 2006. The registered persons must develop a formal programme of consultation and quality assurance. If service users’ are unable to countersign for financial transactions this must be recorded both on care plans and in the financial records. The Registered Manager must ensure that staff receive regular formal supervision at least six times a year. This was a requirement of the previous inspection. DS0000013707.V293234.R01.S.doc 21/06/06 30. OP31 10(3) 21/06/06 31. OP33 24 26/07/06 32. OP35 17(1)(a) 17(2) 26/06/06 33. OP36 18(2)(a) 21/06/06 Lyndhurst Version 5.1 Page 39 This is a requirement made as part of the statutory requirement notice served on 6th April 2006. This requirement had not been fully met and timescales within the statutory requirement notice were extended. 34. OP38 23(4)(a) The registered persons must comply with the recommendations made within the Surrey County Council Fire Safety report without further delay. A copy of the fire risk assessment must be forwarded to the CSCI Surrey Local office. This is a requirement carried over from the last inspection with a timescale of 10/01/06. This is an immediate requirement. The Registered Manager must ensure that records and filing systems are orderly and that the office is tidy. This is a requirement carried over from the last inspection with a timescale of 19/12/05. This is an immediate requirement. 24/05/06 35. OP37 17 24/05/06 Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 40 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 home would be strongly advised to consider using a single format for all care plans. A dedicated book in which to record all medication received and leaving the home should be in place for this purpose. Lyndhurst DS0000013707.V293234.R01.S.doc Version 5.1 Page 41 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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