Inspection on 07/10/05 for Lyndhurst

This inspection was carried out on 7th October 2005.

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

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

Other inspections for this house

Lyndhurst 07/07/08

Lyndhurst 14/01/08

Lyndhurst 07/02/07

Lyndhurst 12/07/06

Lyndhurst 05/05/05

Lyndhurst 27/10/04

Lyndhurst 27/04/04

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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 Inspection 7th October 2005 09:15 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.V251133.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 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 01924 455433 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.V251133.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th May 2005 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 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. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors. The service users and staff were spoken to and a sample of written records kept by the home was looked at. What the service does well: 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. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 6 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.V251133.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9. The staff are working well to met the care needs of the service users. In general, risks are assessed to ensure the health care needs of the service users are met. Generally, the service users are protected by the home’s practice regarding medication. EVIDENCE: The service users spoken with said that the staff are helpful and supportive. The care records were looked at for four service users and contained some detailed information that identified the care needs for the individual and how those needs should be met. The documentation used for the service users daily records is good and gives clear information of how the individual has spent their day. There were risk assessments in place for some identified risks. Care should be taken to ensure that all identified risks are documented in the individual’s records so that the staff have the information required to work safely with the service users. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 9 Nutritional assessments were in place. The home does not have suitable scales so that all service users weight gain/ loss cannot be monitored. The medication for three service users was checked. All the medication could be reconciled with the records kept with the exception of one signature omission. A discussion took place with the senior carer on duty regarding the safe storage of some medication in the refrigerator. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15. The service users are supported to exercise choice and preferences in their lives. EVIDENCE: The senior care on duty advised that there is activities held on a daily basis. There was some evidence in the care records of the individual’s preferences and interests. The service users spoken with said that there are regular activities in the home. Service users are supported to exercise their choice of social activity and religious observance. A programme of activity is displayed on the homes notice board. All the service users were consulted on the day of this inspection as to their choice of meals. The service users spoken with said that there is a choice of food and the food is good. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The service users are confident to express their concerns or make a complaint. EVIDENCE: The home has a complaints policy in place, however this policy is in need of updating to include the information of how to contact the Commission for Social care inspection. The service users spoken with said that they would feel comfortable to speak with staff if they had a complaint of any concerns. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. The fire safety and maintenance issues means that the service users are not fully provided with a safe environment. The home is generally clean, however the lack of infection control measures in the bathroom has the potential to put the service users at risk. EVIDENCE: The dining room has been redecorated and an “insectacutor” has been fitted following a recommendation at the last inspection. A number of bedroom doors were not closing into the rebate and would not prevent smoke seepage in the event of a fire. This needs to be addressed in order to meet fire safety standards. There are some fire works outstanding and these should be completed as soon as possible. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 13 The home was generally clean and tidy, however, a bath hoist was in need of a thorough clean and the removal of communal soap and body cloths. The use of communal soap should be discontinued in order to promote good hygiene and infection control. A bathroom is in need of general maintenance and repair. This had been identified in the home’s maintenance log and was discussed during the inspection. There was an unpleasant odour to one of the bedrooms and this was discussed with the senior carer. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The home has taken action since the last inspection and provides two waking night staff. EVIDENCE: The home no longer has a sleeping in rota and there is now two staff who work waking nights. The requirement from the last inspection is now met. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38. The service users should be involved in the quality monitoring of services, to ensure that the home is run in the service users best interests. The health and welfare of the service users is generally promoted and protected. EVIDENCE: The home has a quality monitoring system in place but this is aimed at friends and relatives and not the service user. The staff should aim to include the service users in the homes quality monitoring with the results published and made available to all interested parties and the service users. The fire alarm testing and emergency lighting is tested on a weekly basis. Health and safety information was displayed in the home and the staff have received training in fire safety. A record of accidents is maintained by the home. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 16 The bath water temperatures were checked and were below the recommended temperature of 43°C. Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 18 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(4)(c) Requirement The registered person shall after consultation with the fire authority provide adequate arrangements for containing fires, and for the evacuation in the event of a fire. The fire safety works as requested by the fire authority should be completed. The identified doors to the service users bedrooms should be repaired. The registered person shall ensure that unnecessary risks to the health or safety of the service users are identified and so far as possible eliminated. To promote good hygiene and prevent the spread of infection, communal bars of soap and body cloths should not be used. The bath hoist must be kept clean to prevent a potential health risk to the service users Timescale for action 21/10/05 2 OP26 13(4)(c) 21/10/05 Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 19 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 OP8 Good Practice Recommendations The identified risks for the service user should be documented in the individual’s care records. Suitable sit on weighing scales should be purchased to ensure that the weights of all the service users can be monitored. The home should consider the purchase of a medication refrigerator or a suitable lockable container to store in the kitchen refrigerator. The complaints procedure needs updating to include the information for the Commission for Social Care Inspection. The views of the service users should be included in the homes quality monitoring systems. The bath water temperatures should be delivered at a temperature of close to 43 degrees centigrade. 2 3 4 5 OP9 OP16 OP33 OP38 Lyndhurst DS0000026278.V251133.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office 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 DS0000026278.V251133.R01.S.doc Version 5.0 Page 21 - 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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