Inspection on 05/05/05 for Lyndhurst

This inspection was carried out on 5th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lyndhurst 07/07/08

Lyndhurst 14/01/08

Lyndhurst 07/02/07

Lyndhurst 12/07/06

Lyndhurst 07/10/05

Lyndhurst 27/10/04

Lyndhurst 27/04/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst 20 Oxford Road Dewsbury West Yorkshire WF13 4JT Lead Inspector Bronwynn Bennett Unannounced 5 May 2005 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 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 J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address 20 Oxford Road Dewsbury WF13 4JT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 459666 01924 455433 Mr Annamalai Subramanian Mrs Jacqueline Cummins Care home 15 Category(ies) of Over 65 - 15 places registration, with number of places Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this service are listed on the registration certificate displayed at the service. Date of last inspection 27 October 2004 Brief Description of the Service: Lyndhurst is a care home registered to provide care and accommodation for up to fifteen older people. It is situated in a residential area of Dewsbury set in extensive grounds. The home was formally a private house that has been adapted for its current use. Many of the propertys original architectural features have been retained. The accommodation is on two floors, with the majority of bedrooms being on the first floor. The first floor is accessed by the stair lift for service users who have mobility problems. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a period of seven and three quarter hours with a full tour of the building. Fourteen service users were spoken to and six staff and records were examined. What the service does well: What has improved since the last inspection? The manager has met a requirement from the last inspection and all staff have now received the induction and foundation training. The manager has redeveloped the home’s application for employment, incorporating the required employment history for all staff that apply for employment. The home currently has three staff with the National Vocational Qualification at Level 2 and a further six staff are working towards this award; this training should continue. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 standard(s) 3 Service user’s needs are assessed prior to admission. EVIDENCE: A service user who had recently been admitted to the care home had a copy of the social services Community Care Assessment and care plan on their file, and the manager had completed the pre-admission assessment. There was detailed information seen in the service user’s daily records with examples of how the service user would like to be looked after. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 standard(s) 7,8,910, The staff are working well to meet the care needs of the services users. Risk assessments should be fully completed for all the risks identified. The procedures for medication administration were not followed consistently. EVIDENCE: The care records for four service users were looked at in detail, and all held a record of the homes completed pre-admission assessment. All care records were detailed; identifying each individuals care needs and how these needs should be met. The daily records were well written showing evidence of how the person had spent their day. Nutritional assessments and oral health care plans were also in place. One service user was identified as unable to use the home’s weighing scales; this was discussed with the home’s manager. The equipment required for pressure area care is obtained via the district nurse team. Pressure care for the individual service user is documented in the care records and in the district nurse notes. The home has contact with the local hospital’s incontinence advisor and the community mental health team. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 10 Risk assessments were in place for some identified risks, the staff team should take care to ensure that all identified risks are documented in the individual’s records so that staff have the information they require to work safely with service users. Service users spoken to said they were satisfied with the support they receive from staff. During this unannounced inspection staff were seen treating service users with respect and maintaining individuals privacy. Medication was checked for three service users. The inspector noted an irregularity for one medication that had been signed as given on the MAR sheet and had not been dispensed, this was discussed with the homes manager. All other medication tallied with medication records kept. During a tour of the building out of date medication was found stored in the fridge. This was discussed with the manager and removed immediately. Medication in the custody of the home should be handled in accordance with the home’s policy and procedure. The manager advised that all senior staff have received the supplying pharmacist’s medication training. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 standard(s) 12,13,14,15. Service users are supported to maintain links with the community; regular discussion with service users would meet individual recreational interests and needs. Service users are consulted about their choice of food. EVIDENCE: The manager said that the home provides activities for service users. The activity schedule is displayed on the notice board however, one service user spoken to said they were disappointed with the lack of activity within the home. Service users should be consulted about their choice of activity. Some service users were seen watching television and interacting with the staff. The home has links with local community; one service user is supported in visiting the local working men’s club and a religious service takes place in the home every two weeks. The manager explained that the care home has an open visiting policy and service users and their relatives are made aware of this. Service users are able to see whom they choose and in private. Service users are able to handle their own finances for as long as they wish or are able to do so. Personal possessions brought into the home were seen in service users rooms. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 12 The menus were looked at and advice was given that they had been developed with the approval of a dietician. Menus are displayed in large print on the homes information board. The cook consults service users on a daily basis for their choice of food. Interaction was seen between the cook and service users about their choice of food. All service users dietary intake is recorded on a daily basis. Service users spoken to said they enjoyed the food with a comment from one service user stating, “The food is beautiful.” Following a discussion with two members of staff regarding the support given to some service users at mealtimes, a recommendation is made about the staff approach to this activity. The kitchen was seen to be in need of redecorating and the kitchen floor is in need of repair. There are no fly screens fitted to the kitchen windows and an insectacuter has not been fitted as previously recommended. Flies were seen in the home during this visit. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. The home works well to ensure that service users are protected from abuse, however service users need to be supported to feel confident about raising a concern, or making a complaint. EVIDENCE: The home has a complaints policy in place. There have been no complaints received by the home since the last inspection, and the manager advised that a record of all complaints, investigation and any action taken is kept. The home has procedures in place for the protection of vulnerable adults. A discussion took place with some of the staff on duty who were knowledgeable about adult protection issues. Service users spoken to explained that they had been advised they could make a complaint. One service user advised that they were aware of how to complain, but would not feel comfortable in doing so. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 standard(s) 19,21,24,26. Greater attention needs to be taken with the general up keep of the home, and visual checks should be regularly undertaken to ensure the home is free from hazards. EVIDENCE: There is a lawned area to the front of the property and the grounds are tidy and maintained. On the day of this unannounced inspection the home looked clean, although the home appears to have a problem with flies. The dining room requires redecoration and a new carpet, this has previously been recommended to the manager. Contractor’s ladders were seen in the main entrance of the care home. This is a health and safety risk. Greater care should be taken to minimise the risk to service users, relatives and staff. The bathroom to the first floor requires repair or replacement of the bath panel. New boilers have recently been installed and a toilet has recently been replaced. Toilet facilities for service users are available close to lounge and dining areas, and toilet facilities are located near service users’ own rooms. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 15 Service users bedrooms looked at were personalised by the service users. Two rooms were noted to have an odour and this was discussed with the manager. Vanity units in some bedrooms require repair or replacement. The laundry facilities are located to the lower floor. Hand washing facilities are available but were in need of repair. The manager advised that all staff have recently completed a level 2 in infection control and that the home has a policy and procedure in place for clinical waste. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 There is a commitment to staff development and training. The staff provide care and support that is valued by the service users. There have been no improvements made for the sleep in arrangements for staff. EVIDENCE: The home has a four weekly rota system. There is one wakeful and one sleep in night staff. A discussion took place with the manager regarding the sleep-in arrangement for staff. The manager was advised that more suitable arrangements should be made for staff sleeping-in. The manager will provide additional staff at peak times or to provide for any service users changing needs. The home has three care staff with the NVQ level 2 and six staff are working towards this award. All the staff are currently working towards the TOPPS training. Staff who were spoken to discussed the homes ongoing training and the support they receive to complete this training. Evidence was seen of one member of staff having their course work marked. The service users made positive comments about the staff team and the care and support they provide. Three staff records were examined in detail. Where staff have been employed with only one reference a second reference should be obtained. The manager has responded to a previous recommendation, and has developed the employment application from to include information on the employees’ past employment. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36,37,38. The manager is committed to staff training and development; commencing formal supervision for all staff would further enhance this. Greater care needs to be taken to promote the health and safety of service users. EVIDENCE: Staff spoke highly of the manager commenting that training and development issues are identified and ongoing. The manager was seen as having a pleasant manner with service users and staff. The manager is working towards achieving NVQ level 4. Formal staff supervision needs to take place. The manager is committed to staff development; this development will be further enhanced through formal supervision with staff. There were no details of staff supervision held on staff records. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 18 Service users’ monies were checked and contained the written records for any transactions that had taken place complete with the relevant receipts. The monies were kept securely. Service users have access to their files and all records kept are stored securely within the home. The manager has recently completed a facilitators training course and is now able to train staff in safe movement and handling techniques. Senior staff have received first aid training. All care staff has completed training for infection control, and fire safety training has been completed as part of the health and safety level two training. The manager should review the present system for fire alarm testing and emergency lighting; these procedures should be carried out on a weekly basis and recorded. Checks for smoke detectors, heat detectors and call points for fire safety completed on 10-2-05 and a certificate was seen for gas safety. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x 2 x x 2 x 2 STAFFING Standard No Score 27 1 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 x x 3 2 3 2 Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 20 yes 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 27 Regulation 23(3)(b) Requirement the registered person shall provide for staff sleeping accommodation where the provision of such accommodation is needed by staff in connection with their work at the care home. Timescale for action 5/7/05 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. 3. 4. 5. 6. 7. Refer to Standard 7 9 12 12 15 16 19 Good Practice Recommendations All identified risks for service users should be documented in individual care records. Medication in the custody of the home should be handled in accordance with the homes policy and procedure. Service users should have further opportunity to express their choice in relation to activities and social interests. The manager may wish to discuss with staff how service users are supported at mealtimes. The kitchen should be repainted. An insectacutor should be fiited in the kitchen Service users should feel confident to make a complaint. The dining room should be redecorated and the carpet replaced. Health and safety issues should be considered in order to J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 21 Lyndhurst 8. 9. 10. 11. 28 29 36 38 provide a safe environment for service users, staff and visitors Staff should continue working towards the NVQ level 2 qualification. It is recommended that a second reference is sought for established members of staff. All staff should recieve supervision six times a year. Fire alarm testing and the recording of emergency lighting checks should be recorded on a weekly basis. Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse. HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst J01_s26278_Lyndhurst_v224489_040505.doc Version 1.30 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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