Inspection on 16/11/07 for Lyndhurst

This inspection was carried out on 16th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyndhurst 02/10/06

Lyndhurst 12/08/05

Lyndhurst 09/02/05

Lyndhurst 08/02/05

Lyndhurst 22/09/04

Lyndhurst 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Lyndhurst Hea Road Heamoor Penzance Cornwall TR18 3HB Lead Inspector Ian Wright Key Unannounced Inspection 16th November 2007 13:45 Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 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 DS0000008911.V350611.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 Adults 18-65. 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 DS0000008911.V350611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address Hea Road Heamoor Penzance Cornwall TR18 3HB 01736 331008 01736 331008 H5m006flecknor@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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 David James Flecknor Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: Lyndhurst provides personal care and support for up to 5 adults with learning disabilities. The home is situated in the village of Heamoor, which is a few miles from the town of Penzance. The registered provider is Mencap, which operates several care homes and domiciliary care agencies in Cornwall. The current registered manager Mr David Flecknor. All people who use the service have their own bedrooms. There is a dining room and a lounge for the use of people who use the service. The home is not suitable for wheelchair users without further adaptation. The home has a pleasant front garden, which people who use the service can use. There is parking for two cars at the front of the property. A copy of the inspection report is available in the dining room, and it is suggested a copy is requested from management or CSCI if required. The range of fees at the time of the inspection is between £370.78 to £806.73 per week (figures supplied October 2006). There are additional charges e.g. for hairdressing, newspapers etc. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over four and a half hours in one day. All of the key standards were inspected. The methodology used for this inspection was: • To case track three people who use the service. This included, where possible, meeting and discussing with the people who use the service their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other people who use the service and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: This service has improved a lot over the last two years. It now benefits from stable management and a stable staff team. There is one requirement to improve some aspects of the medication system. For example to ensure there is no oversupply of medication, all prescribed medication is recorded on the medication sheets, and any medication no longer required is returned to the pharmacist. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information received by people living in the home regarding their rights and responsibilities is to a good standard. This ensures people who use the service should have appropriate information to be aware of their rights and responsibilities. Suitable assessment processes are also in place. EVIDENCE: People who use the service receive a tenancy agreement from the housing association which owns the property. People also receive a copy of a social services contract if they are funded via this body. The registered provider has developed a suitable assessment policy and procedure. This includes the opportunity for people being assessed for the service to visit before admission is arranged. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. Suitable information is provided to assist staff to provide appropriate support and facilitate choice. This ensures people who use the service receive a good quality service and they are given appropriate support to make choices about their lives. Improvement is required to record keeping regarding the finances of people who use the service. EVIDENCE: There is a copy of a care plan in each person’s file. Staff said care plans were accessible to them. Some people who use the service said they were aware of their care plans and are involved in drawing them up. The care plan format is comprehensive and gives clear guidance to staff regarding people’s needs. People who use the service and staff said residents are encouraged to make decisions regarding their lives. Suitable risk assessment processes are in place to ensure independence is promoted, and also, where necessary any risks are minimised. Care staff look after the monies of some people who use the service. Although cash held on behalf of them appears to be well looked after and accounted for, Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 10 records regarding any bank / building society accounts held on behalf of people needs improvement. In regard to two people who use the service, records regarding the transactions from savings accounts were not clear. Greater clarity is necessary regarding how money is spent- if this money is looked after on behalf of the people using the service. Management need to improve monitoring the system to ensure it is working effectively. The registered provider has satisfactory policies regarding diversity and equality. There are currently no people who use the service from ethnic minorities, although the registered provider has stated they would be more than happy to accommodate people who use the service from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, and disability seem to be suitably addressed. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have suitable opportunities to participate in the home and the wider community. Food provided is to a good standard. These measures ensure people who use the service can enjoy a varied lifestyle integrated into the wider community. EVIDENCE: People who use the service said they attend a range of day activities including attending day centres, work placements and colleges. Social trips are organised at the weekend or in the evening. People who use the service can have an annual holiday, which they have to pay for. For example one man said he had been to Bournemouth for a holiday which he had enjoyed. People who use the service said they visit friends and relatives regularly, and they are encouraged to maintain contact via the telephone or post. Visiting arrangements are flexible. People who use the service said they could get up and go to bed when they wish. People who use the service said staff work with them in a way, which Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 12 respects their privacy and dignity. Staff knock on bedroom doors, and mail is not opened without the agreement of people who use the service. Locks are fitted to bedroom doors. People who use the service are encouraged to participate in household tasks and cooking. Interaction between other staff and people who use the service was observed to be positive. There seems a positive culture of facilitating choice and promoting independence, whilst ensuring people are not neglected or cared for appropriately. People who use the service either prepare their own meals or eat together. On the day of the inspection people had take away fish and chips. One of the people living in the home collected the food from the takeaway on his own. The inspector had the meal with people living in the home, and everyone said they enjoyed the meal. Suitable records are maintained regarding food provided. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. Personal care and health care support is to a good standard, although some improvement is required regarding the management of medication. Appropriate support with health and personal care ensures people who use the service are encouraged as much as possible to lead healthy lifestyles. EVIDENCE: People who use the service said they received suitable care and support from staff. Even though the people living in the home have diverse needs, the staff seem to provide appropriate support to people. Suitable evidence is available regarding health care support. Any medical interventions from external professionals are appropriately recorded. There seems suitable links with GP’s, dental services, chiropodists and other professionals. Medication is stored securely, and dispensed via a ‘monitored dosage system’. Administration records seem to be kept appropriately. However some improvements to the system are required: • There is some excess medication stored in the medication cabinet. This includes some oversupply of medication e.g. Fybogel. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 14 • Some prescribed medication stored in the cabinet was not on the medication sheets. For example Diclofenac, Sonata and Co-codamol. If this is no longer required it needs to be returned to the pharmacist. The commission on several occasions over the past few years has reported on issues around medication. It is worth management ensuring regular checks occur regarding the system to ensure it is working effectively. Staff appear to have received appropriate training regarding medication. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable systems appear to be in place regarding how concerns, complaints and allegations are dealt with. This ensures people who use the service should be able to be assured any concerns they have will be dealt with appropriately. EVIDENCE: The registered provider has developed a complaints procedure. The registered manager has included a summary of this in the service user guide. The registered manager has provided information to the next of kin of people who use the service so they are aware how to make a complaint. The inspector read the organisation’s complaints policy in the ‘Operations Manual.’ This requires updating, for example the organisational policy refers to the National Care Standards Commission, which has now been superseded by the Commission for Social Care Inspection, which will subsequently be superseded by the Care Quality Commission in April 2009. The policy also regards the complainant’s right to contact the commission as the last stage of the procedure, rather than stating complainants can contact the commission at any time as outlined in NMS 22.3. The registered provider has been notified regarding this in several CSCI reports for Mencap care homes in Cornwall and has consistently failed to subsequently change their policy. This is a concern. Management need to address this issue. However, people who use the service said they would have confidence in staff / management if they had a concern or a complaint, and they felt the matter would be dealt with appropriately. Mencap has an appropriate adult protection policy. New staff attend the Mencap training regarding abuse (Protect Me) as part of the organisation’s foundation training. All established staff have a Criminal Records Bureau (CRB) Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 16 check. Staff and people who use the service said they believed there to be no abusive practices in the home, and were aware who they would approach if they were concerned about abuse. The registered manager said there had been no concerns or complaints raised since the last inspection. There had also been no matters which have had to be referred to the Department of Adult Social Care (social services) to be investigated under their adult protection procedures. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Lyndhurst provides a pleasant, homely and clean environment for people who live there. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for people who use the service. Bedrooms and communal areas are of suitable size to meet the needs of people who use the service. The home was clean and hygienic on the day of the inspection. Suitable cleaning routines are in place. The inspector raised a concern there was no soap in some of the toilets / bathrooms. The member of staff said he would address the matter. This issue was also raised on the last key inspection. Wall mounted soap dispensers should be purchased to assist in ensuring there is appropriate control of infection. Service user bedrooms are pleasantly decorated according to individual tastes. Furnishings in bedrooms are appropriate. Decorations and furnishings in communal areas have improved considerably since the last inspection and generally look modern and fresh. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 18 One person living in the home said the heating in her room was not working very well- the radiator possibly needs bleeding. The member of staff said the matter had been reported to the housing association that day, and staff would ensure the matter was dealt with. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, recruitment practices and training are all to a good standard. This ensures people who use the service should be assured they will receive appropriate support from staff who are suitably recruited, checked and trained. EVIDENCE: Lyndhurst is linked to another Mencap home-Richmond- nearby. Lyndhurst however has a dedicated staff team, and the deputy works exclusively within this home. The manager works at across both homes. Currently there is a minimum of one member of staff on duty. One person ‘sleeps in,’ but is ‘on call’ between 22:30 and 0700. During the week, there is sometimes an additional member of staff on duty either during the day or in the afternoon/ evening. At the weekend there is an additional member of staff, to the sleep in person to assist for example with recreational activities. Staffing levels appear to be generally satisfactory at present, but the registered provider needs to monitor these particularly as people’s needs change- for example as people get older. The inspector observed information kept on staff files. Recruitment records are to a good standard and contain all necessary information required by Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 20 regulation. This includes for example a Criminal Records Bureau check and two references. There are suitable records of staff induction and staff training. Staff have generally completed all training required by regulation, and to meet the needs of people who live in the home. However one member of staff needs to complete a food hygiene course (if the person handles food), and a course regarding awareness of epilepsy (as some people living in the home are diagnosed with this condition). This person however has only been in post a few months. Mencap has a suitable approach to ensuring staff have the opportunity to obtain a National Vocational Qualification in care. Currently 50 of staff have either a NVQ 2 or 3. The inspector read a suitable equal opportunities policy regarding staff recruitment and selection. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are to a good standard. This ensures people living in the home benefit from a management approach and management systems that promote a good quality service to meet their needs. EVIDENCE: Mr David Flecknor is a registered nurse to work with people with learning disabilities. Mr Flecknor is the registered manager for both Lyndhurst, and its sister home Richmond, which is in walking distance of this home. Staff on duty and the people living in the home, who the inspector spoke to, were very positive about Mr Flecknor’s management approach. For example they said he listened to any concerns and got things done which were necessary. Mencap has a suitable approach to quality assurance. A survey of the views of people who use the service has been completed recently. A representative from the registered provider visits on a monthly basis. The registered manager is reminded to ensure any events reportable to the commission under Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 22 the Care Homes Regulations are always notified- for example accident and emergency admissions or medication errors. A full list of notifiable events is include in regulation 37 of the Care Homes Regulations 2001. Staff can always ring up the commission beforehand if they are unsure if something is reportable. The registered provider has a suitable health and safety policy. Regular health and safety checks are completed. Other records kept of checks required by regulation are satisfactory. For example there are suitable records of the testing of fire equipment, the central heating system and the portable electrical appliances. The registered manager has reported to the commission that part of the electrical hardwire circuit needs some remedial work as the electrician’s report stated it was unsatisfactory. Mencap are currently liaising with the housing association to get the work completed. The commission wishes to remind the housing association of its responsibilities under health and safety legislation. Accident records are suitably kept. Health and safety risk assessments are satisfactory. There is a suitable fire risk assessment. Suitable insurance cover appears to be in place. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 13(6), 17 (Schedule 3, 4) Requirement Keep suitable records regarding the management of the finances of people who use the service. This will ensure there is appropriate evidence that the finances of people who use the service are managed correctly. The medication system must be operated according to Royal Pharmaceutical Society Guidelines. Matters in the body of the report need to be addressed. This will ensure the medication of people who use the service is managed effectively. Timescale for action 01/01/08 2. YA20 13(2) 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations Wall mounted soap dispensers should be purchased to assist in ensuring there is appropriate control of infection. Lyndhurst DS0000008911.V350611.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000008911.V350611.R01.S.doc Version 5.2 Page 26 - 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!