Inspection on 07/02/07 for Lyndhurst

This inspection was carried out on 7th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 07/07/08

Lyndhurst 14/01/08

Lyndhurst 12/07/06

Lyndhurst 07/10/05

Lyndhurst 05/05/05

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 Helen Battle Key Unannounced Inspection 7th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lyndhurst DS0000026278.V330144.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 DS0000026278.V330144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Address 20 Oxford Road Dewsbury West Yorkshire WF13 4JT 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) 01924 459666 01924455223 Mr Annamalai Subramanian Mrs Meena Subramanian, Dr Mohammed Ismail Kardasha Mrs Jacqueline Cummins Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 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 formerly a private house that has been adapted for its current use. Many of the property’s 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 chair lift for service users who have mobility problems. The provider informed the Commission for Social Care Inspection, on 7 February 2007, that the fees range from £330 to £340 per week. There are additional charges for chiropody, optician, dentist, hairdressing and newspapers. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection a visit to the home took place. The inspector visited the home unannounced from 10.00 hrs to 14.15 hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and staff records were looked at, and so were some of the rooms and the garden. Three members of staff were spoken with, along with the manager. Six service users were spoken with. The manager had been asked to complete a pre-inspection questionnaire prior to the last key inspection in July 2006. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home and copies of the monthly management visit reports produced by the provider. Comment cards were not sent to service users or their relatives as there has been no change in the service users living at the home since the last key inspection. Feedback in previous surveys returned to the Commission were positive regarding the experience of living in the home. The purpose of this second key inspection was to measure the progress the home has made during the last six months and determine whether outcomes for service users have improved. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: The staff at the home evidently take pride in their work and put the needs of the service users first. This is confirmed by service users spoken to during this visit. Positive statements about the manager were also received from two service users who said that the manager “always comes to speak to me”. Service users are fully assessed prior to admission. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 6 Positive comments have been received from all responses to service user questionnaires about the quality and choice of food. Recruitment processes protect service users. 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 DS0000026278.V330144.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 DS0000026278.V330144.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed prior to admission into the care home. EVIDENCE: Pre-admission assessments were seen for three service users who live at the home. These were fairly detailed and evidently used to form the basis of the initial care plan. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health and personal care needs are set out in the individual plan of care, however social care needs are not included. Risk assessments are carried out but greater care is required in their monitoring. Generally, the service users are protected by the home’s medication policy and procedure. Service users are treated with dignity, respect and privacy. EVIDENCE: The care records of three service users were examined as part of this inspection. Generally, care plans were of a satisfactory standard with detail of how to meet the personal and health care needs of the individual. There was no evidence, however, of how the social care needs of service users are to be met. One care plan examined needed reviewing due to a deterioration in the general condition of the service user in the two days prior to this visit. The records of medical visits and daily records of this service user did reflect the Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 10 changes in their condition and detailed the care and support given. The manager agreed to review this care plan on the day of this visit. Other healthcare professionals in contact with the home include GPs, optician, speech therapist, tissue viability nurse, chiropodist and dentist. Checks were made on the medication of two service users during this visit. Generally, the medication systems in place are well managed. Records were found to be clear and appropriate codes and explanations for any dose omitted were well documented. All the tablets in the monitored dose system tallied with the records held as did one of the two boxed medications. There was a discrepancy with one amount of tablets. This was to be clarified by the member of staff responsible for checking the stock of medication. The medication fridge needed defrosting. Eye drops and insulin were stored correctly and labelled with the date of opening. During this visit, staff were observed to maintain the privacy and dignity of the service users and treat them with respect. This was confirmed by two of the service users who were spoken with as part of this inspection. Service users also stated that they were well cared for and staff are kind. It was evident that staff have built appropriate relationships with service users, and know their individual needs well. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, the service users’ cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. EVIDENCE: Activities are provided to meet the needs of the service users. These are often low key, with staff speaking to service users on a one to one basis about recent events in the news or reminiscence. Other activities include going out for walks, bingo, dominoes, reading newspapers and watching television. A member of staff was observed to be playing dominoes with two service users during this visit. Two other members of staff were observed to be having a lengthy chat with a service user later in the visit in order to reassure her when she was anxious. Other service users were seen to be reading, knitting and watching television. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 12 There was evidence of service users being able to maintain contact with families and friends. It was evident that service users are encouraged to make their own choices regarding their day to day life in the home. One service user stated that they can get up and go to bed when they want, that they choose where and how they spend their day and that there are good choices regarding meals. Comments about food were very positive and there was evidence that service users have input regarding the menus. The main meal served on the day of the visit was beef casserole, mashed potatoes, carrots and spring cabbage followed by homemade rice pudding. It was reported that the tea time meal was pork pie and beans, chicken soup, assorted sandwiches followed by home made lemon meringue. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users, their relatives and friends are confident in raising any concerns and complaints. The service users are protected from abuse. EVIDENCE: Complaints and compliments forms are available at all times in the signing-in area of the home. This is good practice. All service users spoken with stated that they found the manager approachable and are confident that they will be listened to and any issues resolved. There have been no complaints received by the home during the last twelve months. All staff have had adult protection training in June 2006. A member of staff spoken to was clear about the action to be taken should any adult protection issue arise. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users live in a safe environment that is adequately maintained and generally clean. EVIDENCE: There have been improvements to the maintenance to the environment of the home since the last visit. Two of the bedrooms have been redecorated and new carpets laid. There are still some bedrooms which require redecoration and plans are in place to continue the decorating programme. New curtains, bedding, towels and commodes have been purchased and these have improved the environment for service users. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 15 It is imperative that this improvement is continued throughout the service user bedrooms in the home. Communal areas of the home are satisfactorily maintained. The dining room has had a new carpet and curtains fitted since the last inspection. This has made the room feel more warm and friendly. It was reported that service users had requested sofas for the big lounge. Service users were involved in choosing the style and colour of these sofas. Service users were pleased with the result and were seen to use the sofas during the visit. There were no unpleasant odours noticed in the home. The gardens of the home, which are still poorly maintained, have been cleared of rubbish. The grounds are extensive but they are not accessible for service users to use safely. The gardens should be maintained and the possibility of a specific area which service users can safely access should be explored. It was observed that the clinical waste bins were overfull and not closed properly, bags were also placed on the ground. This was due to the company responsible for collecting the waste not collecting on the specified day. This was addressed by the manager at the time of the visit. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and receive induction and ongoing training. The recruitment process ensures the service users are sufficiently protected by the home’s recruitment policy. EVIDENCE: Rotas examined demonstrated that there are sufficient staff on duty to meet the needs of the service users living in the home. Generally, there are two care assistants on duty at all times, on some days there are three care assistants on duty in the morning. In addition to this, there are the domestic staff, cook and the manager. There has been a great deal of work carried out in the last nine months in relation to staff training. All staff have had training in fire safety, movement and handling, health and safety and the protection of vulnerable adults. The manager and the care officer have also completed the movement and handling facilitators’ course. Four members of staff have completed NVQ (National Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 17 Vocational Qualification) level 2 training and five others are working towards the award. It was reported by the manager that three members of staff have recently completed a first aid training course and are awaiting certification. The records of two members of staff were examined regarding recruitment practices at the home. All the required checks had been carried out. This is an improvement since the last visit. Induction records were seen for two members of staff. Staff spoken with confirmed that they had received induction training. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 18 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, 35, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a manager who is fit to be in charge. Generally, the home is run in the best interests of the service users. The financial interests of the service users are safeguarded. The health and welfare of service users and staff is promoted and protected. EVIDENCE: The manager has been in post at the home for the past two and a half years and positive feedback has been received about the manager from staff and Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 19 service users. The manager is currently working towards the Registered Managers Award and is hoping to complete the award by the end of 2007. Generally, the home is run in the best interests of the service users. However, the provider needs to ensure that the decoration of the home continues to improve and that the quality of the bedding and curtains are of an adequate standard throughout the home. Monthly management visits are now carried out in sufficient detail by the registered provider. It is imperative that these continue to ensure the improvements to the home continue. Quality monitoring systems at the home need to be implemented to ensure that the improvements made to the home in the last six months continue. Service users’ views should be sought as part of this process. During a tour of the premises there were no apparent health and safety issues. Issues regarding the hot water systems raised in the last inspection have been remedied, with new valves on order and tests of the hot water outlets carried out and recorded properly. Records of weekly tests of the fire alarm system and emergency lights were in place. The break glass points are now tested in rotation. Records of fire drills were also in place and these now detail the names of the staff members involved. The personal monies held by the home for two service users were checked as part of this inspection. These were found to tally with the records held. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 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 3 X 2 X 3 X X 3 Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation 23(2)(b)( d)(m)(o) 16(2)(c) Requirement Timescale for action 01/07/07 2. OP19 A programme of maintenance, decoration and refurbishment for the interior and exterior of the home should be continued. Adequate furniture, bedding and 01/07/07 other soft furnishings, including curtains and floor coverings must be provided in all rooms. 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 OP33 OP7 Good Practice Recommendations The views of the service users should be included in the home’s quality monitoring systems. The social needs of the service users should be included in their individual care plans. Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst DS0000026278.V330144.R01.S.doc Version 5.2 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. 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