Inspection on 04/12/07 for Lyndhurst

This inspection was carried out on 4th December 2007.

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 29/10/08

Lyndhurst 01/05/08

Lyndhurst 10/08/06

Lyndhurst 16/05/06

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 Ruth Burnham Unannounced Inspection 4th December 2007 09:30 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.V353562.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 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 Mrs Zehra Bibi 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.V353562.R01.S.doc Version 5.2 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 individual DE(E) Dementia - 0ver 65 to be added to the registration for the duration of their stay at the home. 10th August 2006 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. There is a kitchen and separate utility room. The manager stated fees range from £365 to £480 per week. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the Service was an unannounced “Key Inspection”. The Inspector arrived at the Service at 09.30 and was in the Service for seven and a half hours. It was a thorough look at how well the Service is doing. It took into account detailed information provided by the Service’s owner or manager and any information that CSCI has received about the Service since the last inspection. A high percentage of people who live in the home experience dementia, therefore information gathered for this report included a four-hour observation of the direct care provided to people who live in the home. Responses to surveys sent out to people as part of the inspection process were largely positive with little written comment. The manager completed an annual quality assurance review for the Commission; information from this has been used as part of the inspection. During the visit 3 residents, 2 members of staff and the manager were spoken to, a tour of the premises was undertaken and a number of records were examined. There are thirteen Required Developments and 3 recommendations at the end of this Report. What the service does well: People who are considering moving into the home are provided with information to help them decide if the home will be suitable. People who live in the home can be confident their physical and healthcare needs will be met and their privacy and dignity upheld. They are protected from harm through safe handling of medication. People who responded to the surveys sent out, as part of the inspection process had no complaints about the service. They are supported to attend appointments with health professionals when required. People who live in the home have opportunity to take part in a variety of group activities. They are free to offer comment or complaint and are given a complaints procedure. People are protected from abuse through clear safeguarding procedures. People who live in the home have sufficient space. They are protected through safe recruitment procedures. People can be confident the manager is qualified to run the home. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who are considering moving into the home are provided with information to help them decide if the home will be suitable. Failure to obtain information about people’s background, social history, interests and aspirations at the assessment stage may mean their social and emotional needs will not be met. EVIDENCE: People who are considering moving into the home are provided with information about what life is like there through the statement of purpose and service user guide. These documents contain sufficient information to help people decide if the home will be suitable for them. Copies of these documents have been provided to the CSCI and were seen at this visit. The home has an admissions policy that was forwarded to the CSCI Surrey Local Office following the last inspection. The manager was advised to review this policy, as it was not clear or easy to follow. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 9 People who have moved into the home since the last inspection were observed and spoken to during the visit. The manager confirmed that people who are considering moving in are invited to visit the home. The manager visits people before they are admitted to carry out a full assessment to ensure the home can meet their needs, copies of recent assessments were seen on personal files. Where a local authority care manager supports people, their assessments form part of the home’s admissions procedures, copies of these assessments were seen on the personal files of people who have recently moved to the home. The home uses the “Standex” care planning record system that includes a pre-admission section that details the specific needs of each service user, this information focuses on physical and healthcare needs. A lack of recorded information about people’s individual wishes, preferences, interests, backgrounds and social histories could mean that peoples’ social and emotional needs may not be met. The home does not admit service users for intermediate care. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 11 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident their healthcare needs will be met and their privacy and dignity upheld. Their social and emotional needs may not be met where care plans are not person centred and lack sufficient information or guidance for staff on how to meet individual needs. People may be at risk of harm where staff lack clear guidance on how to minimise risk. People are protected from harm through safe handling of medication. EVIDENCE: Personal files for four people were examined at the visit. Information was up to date and people can be confident their physical and healthcare needs will be met. However pre admission documentation and care plans are not person centred and focus primarily on the peoples’ physical needs, there is a lack of information about people’s individual wishes, preferences, interests, backgrounds and social histories within individual assessments and care plans to give clear guidance to staff on how to meet peoples’ social and emotional needs. There is some information about people’s religious and cultural needs. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 11 People may be at risk of harm where risk assessments lack sufficient detail on the actions staff need to take to minimise risk. This was of particular concern where staff were seen to use unsafe moving and handling techniques when moving people around. Two carers did not use safe lifting procedures when they lifted a resident into a wheelchair, the resident was lifted by 2 carers who held her under her arms and by the waistband on the back of her trousers, it was noticed later that the elastic in the waistband was broken. One carer was seen to pull people up out of their chairs by their arms. These practices were drawn to the attention of the manager who ensured that the hoist was used throughout the rest of the visit. People who were spoken to during the visit commented that some staff handled them more roughly than others. Risk assessments do not contain clear instructions for staff to follow when moving people and not all new staff have had moving and handling training. There were no risk assessments relating to managing difficult behaviours although it was clear during the visit that this is an issue in the home where people are experiencing dementia or have mental health difficulties. Records seen showed periods of agitation and disturbed sleeping patterns. Lengthy discussion took place with the manager and deputy manager about care planning and risk management systems. It was noted at the previous inspection that plans continued to be reviewed on a monthly basis. It was also noted at the last inspection that the number of different “Standex” care plan sections previously used in individual files had been reduced, making the care plans easier to use. It is clear the manager works hard to keep people’s personal files in order and up to date, however the current system is complicated and not easy for staff to understand, particularly if their first language is not English. Advice was given that all these documents should be reviewed in consultation with staff and the individual resident to ensure they contain clear, easy to follow instructions on how to meet peoples’ health, personal and social care needs and minimise risk according to each person’s individual wishes and preferences. People can be confident their healthcare needs will be met. Nutritional screening is undertaken on admission and people are weighed regularly. The manager communicates well with the local GP surgery and arranges for GP visits where needed. These visits are recorded in individual files. Peoples’ health is promoted through regular access to a variety of health care professionals including dentists, chiropodists and opticians. People are protected from harm through safe handling of medication. Medication procedures were observed and records were examined during the visit. The home’s medication procedure is detailed and gives clear guidance to staff. The manager confirmed that only staff that have received appropriate training handle medication. The medication room and medication cupboard remains neat and orderly. Records were neat, and well maintained and at the time of the inspection no gaps or errors were observed in the records. The Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 12 home continues to hold a record of medication received into the home and returned to the Pharmacy. People can be confident their privacy and dignity will be upheld. Staff were observed to knock on bedroom doors before entering and provide discreet support with personal care needs. Details of Peoples’ wishes in the event of terminal illness or death continue to be recorded within their care plans. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home have opportunity to take part in a variety of group activities. Limited information about peoples’ backgrounds and social histories may mean their individual recreational needs and interests are not met. People enjoy the meals provided. EVIDENCE: People who were spoken to during the inspection stated they did not wish for more activities to be arranged. An activity list is displayed in the dining room/lounge area, which includes communal activities such as listening to music, time to read, activities such as keep fit and skittles and reminiscence sessions at the weekend. The daily diary showed entries on most days that residents enjoyed listening to music and watching the ATV in the morning. Throughout the morning of the visit Radio 2 was playing in the lounge where all the residents were sitting, there did not appear to be any choice offered to residents in this. Staff spoken to said there were CDs in the lounge but no one was asked if they would like to listen to anything else or watch TV. A high percentage of people who live in the home have some degree of dementia. Some staff had attended training in dementia care from an external Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 14 training organisation. However, it was not evident that activities had been specifically designed for service users with dementia. The home was advised at the last inspection that they must seek advice about current good practice and appropriate activities for service users with dementia, to ensure their needs are met sufficiently. An external activity organiser came to the home in the afternoon and conducted a music and exercise session, it was not clear if this was an activity all the people in the lounge had chosen to take part in although some people appeared to enjoy the session. Another external activity coordinator was visiting the home at the same time to observe the session with a view to providing activities in the future. Currently the activities are group activities and take little account of individual wishes and interests although it was noted that one person who had their own guitar was being encouraged to join in. It was noted at the last inspection that the home had undertaken to review the activities and consult people about activities they wished to take part in. Regular residents meetings do take place in the home. It is acknowledged that the manager has added to the opportunities on offer however, without sufficient information and understanding of peoples background and social histories, interests and preferences it is difficult to see how the home is meeting peoples individual needs in this area, particularly for those who have dementia. This is a requirement carried over from the key inspection of 15th May 2006 and subsequent inspections. Visitors are welcomed into the home at all reasonable times. A recent incident where a visitor had been removed with the involvement of the police had been documented and notified to the commission. However information available to staff about how to manage future visits was muddled and confusing, the manager was advised to ensure all staff have clear written guidance about this matter to protect themselves and people who live in the home from risk of harm. Staff confirmed that people can meet with visitors in private if they wish, either in conservatory area or in the person’s bedroom. Records show that visitors include community and church groups. People are encouraged to personalise their rooms, some people have brought items of furniture in with them. The manager confirmed the home does not hold responsibility for anyone’s personal finances and that they do not act as appointee for anyone. In most cases relatives take on this responsibility. The home pays for personal items, newspapers, chiropody and hairdressing, required on a day-to-day basis, it is agreed with relatives how often the home will produce an invoice for these items. Records and receipts were examined at the last inspection. People who responded to the survey confirmed they were happy with the food provided. There was a choice of meal at lunchtime. A daily menu board is now displayed each day. People who live in the home are involved in the Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 15 weekly planning of menus. The dining room is rather dark as the skylight has been damaged and partially obscured. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are free to offer comment or complaint. There is a clear complaints procedure although it is not clear how people with dementia are being supported to use this procedure. People are protected from abuse through clear safeguarding procedures. EVIDENCE: People are free to offer comment or complaint. People who responded to surveys said they knew who to complain to but did not have any complaints about their treatment in the home. The complaints procedure is clear, concise and meets the National Minimum Standards for Older People. Copies of the complaints procedure are displayed in service users bedrooms although it is not clear how people with dementia are supported to use the procedure. The complaints procedure details how complaints should be made to the home, and that the CSCI could be contacted at any time. The procedure also identifies external agencies for example the Local Government Ombudsman, if the complainant was dissatisfied with the outcome of the home’s investigation. The manager said no complaints had been received by the home since the last inspection. Clear inventories of peoples’ personal belongings are now recorded as a result of a complaint from a relative before the last inspection, this was investigated under Surrey’s Safeguarding Adults procedures. People are protected from abuse through clear safeguarding procedures. These are detailed and refer staff to the home’s other policies for example, Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 17 whistle blowing. Staff receive training in the protection of vulnerable adults. Two people who were spoken to during the visit commented that some staff are rough with them. This was passed on to the manager during the visit. An incident was observed during the visit where a resident who has mental health difficulties touched another resident in a way that caused some distress. The manager and deputy manager said they had not known this to happen before, they were advised to record the incident and update the person’s care plan and risk assessment to ensure staff are aware of any risk and provide adequate supervision. The manager said he was already reviewing the suitability of this person’s placement in consultation with relevant health and social care professionals. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 People who use the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home have sufficient space, however unpleasant odours and failure to maintain fixtures and fittings in a good state of repair and decoration detracts from their quality of life. Some people may be cold when in their bedrooms, others may be at risk where lighting levels are inadequate. EVIDENCE: People who live in the home have sufficient space, however unpleasant odours and failure to maintain fixtures and fittings in a good state of repair and decoration detracts from their quality of life. There are a number of areas where the environment needs improvement. A tour of the premises was made, it was disappointing to find that the decor in many areas needs upgrading where paintwork is damaged or stained. One bedroom on the first floor has no view, the window has heavily obscured glass. This was discussed with the manager who said there would be no problem in moving this resident to a room with a view and that no one had ever said it was a problem before this visit. It was agreed the room with the obscured window would no longer Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 19 be used as a resident’s bedroom following consultation with the current occupant. Several bedrooms had damaged furniture, one had a broken chair, others had mismatched furniture with worn veneers exposing rough areas underneath which could cause injury to residents. The manager said some new furniture has been purchased. A number of residents’ rooms were cold; one on the ground floor was very cold. The manager said some residents preferred their bedrooms cooler; advice was given that temperatures should be monitored. All beds seen were made up with plastic draw sheets. The manager was advised these were uncomfortable and where they have become creased they could compromise the skin integrity of people who were more frail. The manager agreed to replace plastic sheeting with more comfortable and appropriate continence aids where needed. The conservatory and garden are accessed by metal ramps, one of these had come unclipped and had moved out of position causing a trip hazard, this was drawn to the attention of the manager who immediately rectified the problem. The dining area has a skylight, this is the only source of direct natural light, the skylight is partially obscured as a result of damage that the manager said happened during repairs to the roof. A number of corridor areas are quite dark; the manager was advised to ensure there is always adequate lighting in all areas to avoid risk of falls. The overall appearance of the home is rather shabby and uninviting. The garden is pleasant and free from obvious hazards. There are sufficient bathrooms and toilets around the home. The owner was reminded to ensure these areas are kept free from risk of cross infection. Communal bars of soap and communal towels and bathmats were seen in bathrooms and toilets. There was a broken bin in the first floor toilet and the call bell pull was not easily visible. A commode was being cleaned in the ground floor bathroom. Discussion took place at the last inspection about the area allocated as a staff sleeping-in room. The inspector at that time observed this to be a small space that had a sink and was also used as the hairdresser’s room. This room also appeared to have a door to the outside, and may have previously been used as a fire escape route. A fold out bed is available to staff. It was noted at this visit that this room is also very cold. The manager said he had confirmed the room is no longer part of a fire evacuation route agreed with Surrey Fire and Rescue Service. On arrival at the home we noted that there was a strong, unpleasant odour. The deputy manager said this was where staff had used a spray whilst cleaning, an explanation we do not accept. Staff were cleaning the home throughout the visit. Laundry facilities are sited away from areas of the home where food is prepared. Policies are in place for the safe management of laundry. The manager confirmed that sluicing and high temperature cycles are available on the washing machines. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are protected through safe recruitment procedures although copies of work permits for overseas staff have not been obtained. People do not always have safe and appropriate support where some staff may not have an adequate understanding of the English language. There were insufficient numbers of suitably qualified care staff on duty during the visit to meet the needs of people who live in the home. EVIDENCE: People may not receive the individual attention they need due to inadequate staffing levels. There were 3 care staff on duty in addition to the manager and deputy manager. One experienced member of care staff was cleaning throughout the morning leaving 2 recently recruited care staff to meet the needs of the residents all of whom were congregated in the lounge. Another member of staff was cooking the lunchtime meal. The manager said they were short staffed that morning because of unexpected absence due to sickness. One member of waking night staff is available overnight with the support of one member of staff sleeping-in. Information provided in the manager’s annual quality assurance audit states 4 staff have achieved NVQ level 2 and 8 Staff are working towards achieving NVQ qualifications. There was one experienced member of staff on duty however she was doing the cleaning during the visit. The other 2 members of staff were recently recruited overseas staff with English not their first Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 21 language. The manager agreed this can be a problem for people who live in the home and English lessons are now arranged. People who live in the home are being placed at risk where staff are not adequately trained to meet their needs or handle them safely. Whilst records show staff have induction training, poor practice observed during the visit indicates that, either the training is not adequate or overseas staff are not understanding the training. Three staff files were examined including those of the overseas staff on duty. It was of concern that neither of these staff files contained work permits allowing them to work in the UK, the manager said he had phoned the Home Office to verify they could work in the home and will obtain copies of their work permits for the file. Staff files were otherwise in good order and contained all other required information. People are protected through recruitment procedures that include Criminal Records Bureau checks and references. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 – 36 & 38 People who use the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident the manager is qualified to run the home, however ineffective quality assurance systems fail to identify or take action in areas where improvements are needed. People are at risk where there are unsafe health and safety practices carried out by staff who are not adequately supervised. EVIDENCE: People who live in the home can be confident the manager, who is also the registered provider, has the relevant qualifications and experience to manage the home. However this visit and the findings of previous inspections indicate the management style is reactive rather than proactive. The majority of requirements from previous reports have been met but there does not appear to be an effective internal quality assurance system in place. A high percentage of people who live in the home experience dementia, therefore Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 23 information gathered for this report included a four-hour observation of the direct care provided to people who live in the home. Responses to surveys sent out to people as part of the inspection process were largely positive with little written comment. The manager completed the Annual Quality Assurance Audit for the commission as part of this inspection. This document details a number of improvements the manager intends to make including seeking the views of people who live in the home through questionnaires. Reasons given in this document for not having made further improvements in recruitment and the environment were lack of sufficient funding from the Local Authority. A copy of the home’s verified accounts were forwarded to the CSCI Surrey Local Office following the statutory notice issued in 2006, these met requirements at that time. People are not being protected from risk of infection. Poor practice and lack of clear written procedures for staff to follow to minimise risk of infection when they are carrying out their duties is placing residents at risk. This was of particular concern where staff were seen assisting people to the toilet during the visit. It was noted that staff wore gloves and aprons most of the time but failed to change them and continued carrying out other tasks in the lounge with other residents whilst wearing the same gloves and aprons. This was drawn to the attention of the manager who immediately moved supplies of gloves and aprons to a more easily accessible location. Staff have not received training in infection control. The fact that poor practice was observed in infection control and moving and handling during the visit rather than being picked up by the manager indicates a lack of adequate supervision even though one to one supervision sessions are being recorded for all staff. Only 2 staff have received infection control training. The home does not use current DOH guidance to assess infection control management. The manager said staff have had training in moving and handling however people are being put at risk through poor practice in this area. (See section on Health and Personal Care.) People’s health and safety are promoted through regular safety checks of equipment and installations. Fire safety systems are in place and are checked regularly. The manager said some work has been done to meet the recommendations made within the fire safety report produced by Paragon but there is some discrepancy between their recommendations and the recommendations of local fire safety authority who are currently satisfied with fire safety arrangements in the home. The hoist has been serviced recently. Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 24 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 3 x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 1 3 3 3 3 1 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 3 3 2 x 1 Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 12 & 15 Requirement (12)(3)The registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. In that a person centred approach should be taken to care planning to ensure that staff have clear guidance about how to meet individual social and emotional needs in line with peoples’ wishes and preferences (15) (2) (b) The registered person shall keep the service user’s plan under review; in that changes in peoples needs, including mobility should be reflected in updated guidance for staff on individual moving and handling needs. Timescale for action 31/01/08 Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 26 2 OP7 12 &13 12(1) The registered person shall 31/01/08 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users; in that personal care must be provided in a safe and appropriate manner. (13)(4)( c ) Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, in that individual risk assessments must cover all aspects of people’s lives. (13)(5)The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. In that all staff must be trained to move people safely using the appropriate equipment. (2) The registered person shall 31/01/08 having regard to the size of the care home and the number and needs of service users— consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. In that the home must seek advice about current good practice and appropriate activities for service users with dementia, to ensure that their needs are met sufficiently. This requirement from 10/08/06 has been partially met in that 3. OP12 16(2)(n) Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 27 4 OP18 12 (1) group activities are provided, however Peoples’ individual recreational needs and interests and choice about whether or not to take part in group activities must be taken account of. The registered person shall ensure that the care home is conducted so as (a) to promote and make proper provision for the health and welfare of service users; in that no person should experience rough handling by staff who have not received adequate training or supervision in moving and handling people. (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. In that residents who may behave in a way, which is inappropriate and upsetting to other residents, must be adequately supervised. 31/01/08 5 OP19 23(2) The registered person shall 28/02/08 having regard to the number and needs of the service users ensure that - (b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; (d) all parts of the care home are kept clean and reasonably decorated; The registered person shall having regard to the size of the care home and the number and needs of service users provide in DS0000013707.V353562.R01.S.doc 6 OP24 16(2) & 23(2) 31/01/08 Lyndhurst Version 5.2 Page 28 rooms occupied by service users adequate furniture, bedding and other furnishings, including curtains and floor coverings, and equipment suitable to the needs of service users and screens where necessary; in that all broken and damaged furniture should be replaced. Appropriate bedding should be used where incontinence is a problem. Peoples’ comfort and skin integrity must not be compromised by the use of plastic sheets directly under bed sheets. 7 OP25 23 (p) Ventilation, heating and lighting suitable for service users is provided in all parts of the care home which are used by service users. In that all residents’ bedrooms should have clear windows providing a view to the outside. All residents’ bedrooms should be adequately heated. Lighting in all areas of the home should be at a sufficient level to promote the comfort and safety of residents. The skylight in the dining room should be repaired. The registered person shall keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste; In that commodes should not be cleaned in bathrooms. Cleaning systems and schedules should eliminate unpleasant odours. The registered person shall, having regard to the size of the care home, the statement of DS0000013707.V353562.R01.S.doc 31/01/08 7 OP26 16(2) 31/01/08 8 OP27 18 (1) 31/01/08 Lyndhurst Version 5.2 Page 29 9 OP28 18(1) 10 OP30 18(1) 11 OP33 24 purpose and the number and needs of service users; (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Specifically care staff must have a sufficient grasp of the English language to understand their training, communicate effectively with residents and be able to follow safe procedures. (b) ensure that the persons 30/03/08 employed by the registered person to work at the care home receive - (i) training appropriate to the work they are to perform; in that a minimum of 50 of staff must be qualified to NVQ level 2 or equivalent. (c) ensure that the persons 31/01/08 employed by the registered person to work at the care home receive (i) training appropriate to the work they are to perform; in that staff who are moving and handling residents and assisting them with personal care must have appropriate training in moving and handling and infection control. (1) The registered person shall 31/01/08 establish and maintain a system for evaluating the quality of the services provided at the care home. In that there must be an annual development plan for the home based on a systematic cycle of planning- action- review based on seeking the views of residents. The registered person shall ensure that— (a) persons working at the care home are DS0000013707.V353562.R01.S.doc 12 OP36 18(2) 31/01/08 Lyndhurst Version 5.2 Page 30 appropriately supervised; in that less experienced staff should be supervised through observation of practice taking account of feedback from people who live in the home. 13 OP38 13(3) The registered person shall make 31/01/08 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. In that safe working practices must be ensured through adequate supervision and training in moving and handling and infection control. Protective clothing must be used in line with current good practice guidance. 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 OP3 Good Practice Recommendations The manager was advised to review the admissions policy as it was not clear or easy to follow. Pre admission assessments should include individual background and social histories, interests, wishes and preferences. People who are experiencing dementia must be supported to access the complaints procedure. The registered person must comply with immigration law when recruiting overseas staff. Copies of work permits should be kept on staff files. 2 3 OP16 OP29 Lyndhurst DS0000013707.V353562.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South East Regional Contact Team The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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. 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