Inspection on 26/10/05 for Lyndhurst

This inspection was carried out on 26th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lyndhurst 27/06/06

Lyndhurst 20/04/05

Lyndhurst 22/09/04

Lyndhurst 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst College Street Leigh Wigan Greater Manchester WN7 5QH Lead Inspector Lindsey Withers Unannounced Inspection 26th October 2005 08:40 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 DS0000005747.V258325.R01.S.doc Version 5.0 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 DS0000005747.V258325.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address College Street Leigh Wigan Greater Manchester WN7 5QH 01942 606319 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) 01942 671246 CLS Care Services Limited Ms Janice Pickup Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (8) Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include:up to 40 service users in the category of OP (Older People) up to 8 service users in the category of PD(E) (Adults with Physical Disability over 65 years) up to 3 service users in the category of DE(E) (Adults with Dementia over 65 years) The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. The Home`s Statement of Purpose must be altered to set out how the services and facilities offered by the Home will meet the needs of service users with dementia by 31 May 2005. The Registered Person must ensure that all staff working in the Home have dementia training awareness and dementia care training, which equips them to meet the assessed needs of the service users accommodated, as defined in the individual plan of care. The service must at all times employ suitably qualified and experienced members of staff, in sufficient numbes, to meet the assessed needs of the service users with dementia. 20th April 2005 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Lyndhurst – part of the CLS group of homes – is situated close the centre of Leigh, near to shops and other essential services. A large three storey buildings, residents are accommodated on each floor. Throughout the building there are a number of lounges and seating areas, and there is a separate visitors’ lounge. The main dining room is located on the ground floor. Each of the 40 bedrooms is for single occupancy. There is limited outside space. However, the courtyard garden is secure, well-maintained and attractive. There is limited car parking for visitors to the home; however, a pay and display car park is located within a few minutes’ walk. Lyndhurst offers accommodation to people aged 65 and over, who require assistance with personal care. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a five hour period and was unannounced. The main focus of this inspection was on those areas not assessed during the previous inspection, so that over the two inspections all key standards were looked at. Part of the time was spent with the Manager going through the paperwork that she needs to keep to show that the home is being run properly. Some time was spent with the Home Services Manager looking at residents’ finances and those records kept that show how health and safety matters are dealt with. The Care Team Leader on duty assisted the Inspector to review practice in relation to medication. Residents and other staff were spoken to over the course of the inspection. What the service does well: What has improved since the last inspection? The new CLS policy and procedure relating to the Protection of Vulnerable People was introduced in August 2005 and was being rolled out to staff at the time of this inspection. Following the training, staff will be better informed about the protection of old and vulnerable people and about the new system for speaking out about poor practice. The training for staff in the National Vocational Qualification in Care has gathered speed to the extent that by the end of the year 18 out of the 20 carers employed at the home will have achieved the minimum level II. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Not assessed on this occasion. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 In general, the policies and procedures followed by the home in relation to medication were adhered to, so that residents could be assured they would be kept safe by the good practice of staff. However, ways to make the system better were identified at this inspection as well as one point against which action must be taken. EVIDENCE: Part of the morning medication round was observed. Carers handling medication have been assessed and completed certified medication training. The home has a policy and procedure that relates to the safe administration of medication. The policy in relation to controlled drugs is displayed on the front of the controlled drugs cabinet. In discussion with the Care Team Leader, she was able to say what she would do if she recognised a problem in the use of medication, and to express the principles of the home’s policy. Records are completed at the time medication is dispensed. The file containing the records has dividers showing the resident’s name and, for the most part, includes a photograph of the resident. Photographs should now be put on the appropriate divider in order to minimise the risk of dispensing medication to the wrong person. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 10 Only one person living at Lyndhurst takes responsibility for one element of his medication. The person has agreed a risk assessment, confirmed that he will keep his medication locked away, and confirmed his acceptance to his tablets being checked periodically. The person retains his own medication and has a locked drawer in which to keep it. Staff take responsibility for the administration of medication for the remainder of the residents. Medication is supplied by the pharmacy in blister packs so far as possible. Other medication, such as drops, syrups, etc. are supplied in their own boxes. Staff follow good practice guidelines and write the date of opening on each bottle or box. Tablets for one person had been centralised into one box. It was not clear that all the tablets had been dispensed for this person as there was no name on the packets; the dispensing date and use by date were also not clear. The Inspector understood that the tablets had been centralised to take up less space, but this is not good practice and could give rise to errors in dispensing being made. Staff follow good practice guidelines in that Warfarin books are kept with the current recording sheet to enable carers administering Warfarin to easily confirm the current dosage. This is particularly important when the prescribed dosage varies from one day to another. Medication returned to the pharmacy for destruction was recorded. However, only one set of records showed the receiving person’s details; receipts had only been signed by a representative of the home. There was, therefore, no firm evidence to show that medication that was no longer required had been returned for destruction. This procedure needs to be made more rigorous. Medication is stored in a lockable trolley that, when not in use, is secured in a locked room. The medicines trolley was clean, tidy, and well-ordered. Controlled drugs and those drugs that need to be treated as if controlled are stored appropriately. A register of medicines is kept. Two signatures are entered when medication is received or dispensed. The records for controlled drugs showed that an audit had taken place recently, an arithmetical error had been found, and that a correction had been made. The refrigerator used for storing medication was in good working order; temperatures had been taken regularly and the records were available to look at. During a recent pharmacy audit, a comment had been received regarding the need for the fridge to have a lock. The Inspector agreed to clarify this with the CSCI Pharmacy Inspector on behalf of the home. The CSCI Pharmacy Inspector said that, because the treatment room is used by district nurses, chiropodists, etc. at times when they are unsupervised, it would be good practice to have a lock fitted to the fridge. As a consequence of the advice, the manager took immediate steps to replace the fridge. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Not assessed on this occasion. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 12 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 and 18. There is a complaints procedure that is widely advertised. Residents and their supporters can be confident their complaints will be dealt with quickly, will be listened to, that they will be fully investigated, and that any remedial action will be taken. Residents can be assured that they will be protected from abuse in any form. EVIDENCE: A complaint had been made to the home since the last inspection, following which a full and frank investigation had taken place, in line with the organisation’s policy and procedure. A number of elements within the complaint had not been upheld by the home as the records were able to demonstrate that staff had acted in the best interests of the resident. However, the home accepted criticism in relation to other elements, for which an apology had been given. As a result of the complaint, and staff having reflected on it, some changes to procedure are being made in order to prevent a similar complaint being made in the future. A new policy and procedure had been issued by CLS in August 2005 in relation to the Protection of Vulnerable People. The Manager had attended for training in September 2005 and was in the process of rolling out the training to the staff group. Some work has already been done with members of staff on an individual basis during supervision, and the records were available to confirm what was discussed, for example, the signs and symptoms of abuse, and the different forms that abuse might take. All staff have received their own copy of the policy and understand they must read it before attending the training session. The policy has also been discussed at meetings with the Care Team Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 13 Leaders in preparation for them to begin to instruct the staff for whom they are responsible. The Manager did not have a copy of the most recent PoVA joint procedures for Wigan. She had not been made aware that it had been published. The Inspector left a copy for her to print off and circulate. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Not assessed on this occasion. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 15 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 and 30 Staff morale is good, with low levels of sickness and turnover. This ensures residents are provided with care by people they know and are familiar with. Staff are properly trained to deliver the care that residents need. Staff are interested in the work that they do. Recruitment of new staff is good, with all appropriate checks being made to make sure that a person is suitable to work with older people. The practice of retaining two staff on duty overnight needs constant review to ensure residents’ needs are met. EVIDENCE: Shifts during the day comprise one Care Team Leader and three Care Assistants. This reduces to one Care Team Leader and one Care Assistant over night for a maximum number of 40 residents, located on three floors. This is not always sufficient to meet the needs of residents, and, looking at the staff rota, it could be seen that additional staff have been brought on duty when residents’ needs have been greater than usual. The Manager has some autonomy to increase staffing numbers on the rota, so long as it can be justified. The shift patterns have been adjusted a little so that there are more staff on duty at rising and retiring times, and so that, during the handover period, there are always staff available to assist residents. National Vocational Training in Care (NVQ training) has been progressing well. 11 members of staff had achieved the level 2 – with three going on to the level 3 – and 7 members of staff were on target to achieve the level 2 before the end of the year. By this time, therefore, 18 out of the 20 care staff working at Lyndhurst will have been successful in achieving the award, which is well in Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 16 excess of the 50 of care staff recommended by the National Minimum Standards. A sample of 5 staff personnel and training records were looked at. Staff information is being consolidated into one, well-organised file for each person which makes it very easy to see whether there are any gaps in the recruitment process, and to measure the extent of a person’s induction, training and development during their employment. No gaps were found in the recruitment documentation. Appointments had been made only after receipt of satisfactory references and following completion of a satisfactory police check and checks with the Protection of Vulnerable Adults’ register. Each new member of staff follows an induction programme within the first six weeks of employment. The induction booklet for one person was not looked at because she was working on it at home. A second person had undergone a three week induction programme as she had transferred from another CLS home. The training programme for the coming months includes Continence Awareness and Tissue Viability (November) and several small group awareness sessions in relation to Visual Impairment. All staff have attended basic dementia awareness sessions. A small number of staff will be taking a longer, more in-depth training course in the coming months. Also planned for the future are sessions on moving and handling, infection control and fire safety. A moving and handling training course was in progress during the morning of this inspection. The trainer commented that this had been “an excellent group” of staff, with one person in particular being highlighted to the Manager for her learning ability and competence in the practical exercises. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 17 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): 35 and 38. The home has systems in place that are properly managed so that residents’ financial interests are safeguarded. The Manager ensures that residents and staff are protected by the systems and safe working practices used within the home. EVIDENCE: The records showed that money is kept by the home on behalf of the majority of residents, though a small number maintain control over their own finances with the help of their families or social worker. Money (known as cash control) is kept to pay for hairdressing, newspapers, bingo, trips, additional toiletries, etc. CLS is looking to introduce a system where residents will give the Home Services Manager permission to take from their individual cash control without the resident having to sign each time. The Home Services Manager explained that this is not a drive by CLS to take away any financial independence from a Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 18 resident; more a way to help reduce anxiety about money. Those residents who wish to pay for themselves as they do currently will be able to do so. No changes will be made without reference to the resident or their supporter. The cash control for three residents was checked. The records showed money coming in and going out of the residents cash control. Those individual funds checked during this inspection were found to be correct and up to date. Items handed over for safe-keeping are recorded in the receipt book and on an inventory. The Home Services Manager could demonstrate that, after a resident had left the home, what steps had been taken to return items handed over for safe-keeping. There was evidence to show that property had been returned. A new CLS health and safety manual is expected before the end of the year. In the period leading up to this, a number of initiatives have been or are in the process of being introduced in relation to health and safety. Staff awareness is being raised with the introduction of a notice board in the staff room specifically for health and safety matters, for example, control of substances hazardous to health (CoSHH) and the prevention of accidents. New notices are being displayed in the sluice rooms. The Home Services Manager has a meeting with domestic and catering staff each morning when health and safety matters are discussed. Staff awareness sessions have been scheduled for November 2005, and ways of ensuring that staff understand the principles of health and safety are being explored during individual supervision sessions. Staff are trained in safe working practices and, where appropriate, places will be offered to residents and their relatives. For example, 2 residents and 3 relatives attended an MRSA and scabies awareness session, and 3 relatives attended a moving and handling session. The manager feels that as residents do go out with families (and will be helped in and out of cars, up and down steps and stairs, etc.) and residents do contract MRSA, then it is only reasonable that they know how best to handle the situation. Equipment and systems used in the home are regularly audited and serviced, and repairs are carried out as necessary. For example, the lift had been serviced on 20th October and hoists on 3rd October 2005. A new system for maintenance and servicing has recently been introduced (IPOS) that identifies high, medium and low risks and, therefore, the timescale in which they must be remedied. For example, a member of staff identified that the brakes were broken on the bathroom scales – this was considered a high risk needing a speedy repair. The Home Services Manager said that a resident who identifies, for example, a bulb that as “gone” will come to report it to her. There is a set of risk assessments that has been developed by CLS, together with risk assessments that are applicable to – and developed for – Lyndhurst. For example, the smoke alarm failed recently in the kitchen. The Home Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 19 Services Manager was able to demonstrate what practical steps had been taken to ensure the safety of staff and residents. Additional staff were also brought on duty during the period until the alarm was repaired. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x 3 Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 Requirement A receiving signature must be obtained when medication is sent for destruction. Timescale for action 25/11/05 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 OP9 OP9 Good Practice Recommendations Photographs of residents should be included on dividers in the file containing the MAR sheet. Tablets should be kept in the boxes in which they are dispensed. Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst DS0000005747.V258325.R01.S.doc Version 5.0 Page 23 - 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. 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