CARE HOMES FOR OLDER PEOPLE
Lyndhurst Care 120 Manchester Old Road Middleton Manchester Greater Manchester M24 4DY Lead Inspector
Tracey Devine Unannounced Inspection 15th December 2005 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 Care DS0000025481.V272870.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 Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Lyndhurst Care Address 120 Manchester Old Road Middleton Manchester Greater Manchester M24 4DY 0161 643 9222 0161 653 8060 enquiries@lyndhurstcare.co.uk 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) Lyndhurst Care Limited Mrs Beverley Eagleton Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Within the maximum registered number 33 there can be up to :33 Older People (OP) The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 10th July 2005 Date of last inspection Brief Description of the Service: Lyndhurst Care provides care and accommodation for 33 older persons. The home is situated near to the centre of Middleton, and is close to shops, the bus terminus, pubs and leisure facilities. The home was opened in 1990 and has been extended to include purpose built rooms to the rear of the house. The home is two storey and has the provision of a passenger lift. Accommodation is provided in 29 single rooms and 2 double bedrooms. Ten of the bedrooms have the provision of en-suite toilet facilities. Three lounge areas (including a designated smoking area) are provided, plus a separate dining room. The home is well maintained both internally and externally. The gardens are attractively landscaped and accessible to service users. Ramped access is provided to one of the patio doors. Car parking is available to the rear and side of the home. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on 15th December 2005 by 1 Inspector. The inspection started at 9.30am and finished at 12.30pm – a period of 3.00 hours. The inspector arrived at the home without informing them of the visit – this is called an unannounced inspection. Time was spent time talking with the Provider, the Manager, and 3 residents. Staff were spoken with on an informal basis as the Inspector looked around the home and watched how the staff worked. This is the second inspection the home has had this year. On this occasion, the inspector looked at the (key) standards which were not looked at on the first inspection, and she also looked to see if the things the provider and manager were asked to do at the last inspection had been done. What the service does well: What has improved since the last inspection?
At the last inspection, the Provider and Manager were asked to do 2 things. The 1st related to the manager making sure that a record is completed for each resident when they come into the home (called a care plan) which records how the home is to look after the resident. This makes sure that staff understand what they need to do for each person. This has been done, but there is still room for improvement. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 6 The 2nd matter the Provider and Manager had to do was make sure that the staff record all the activities which take place, so that a more accurate judgement can be made on the activities provided. Staff are now recording activities better. 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 Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standard 3 was assessed at the inspection of 10th July 2005. For comments on this section please refer to the report of the 10th July 2005. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The care planning system in place does not provide staff with all the information they need to satisfactorily meet residents needs. Personal support is offered in such a way as to promote privacy, dignity, and respect. EVIDENCE: Each resident has a record in place (care plan) which should detail their personal care needs, their emotional needs and social needs and how the staff are to meet these needs. On looking at 4 care plans, some were more complete than others. The manager has introduced a new care plan format and staff were in the process of transferring the information from the old format onto the new format. This was said to be the reason why some of the plans looked at by the inspector were largely incomplete. However, at least two of the care plans related to new residents and their care plans (new format) were largely incomplete. The manager must ensure that each resident has a complete and up to date care plan in place. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 10 The care plan format introduced does make provision for details on personal care, continence, pressure relief, social and emotional needs, personal history, risk assessments, visits from GP’s etc. Full completion of these plans would ensure that residents needs are fully documented and known to staff. 3 residents were spoken with, and the inspector spent some time observing the interactions of residents and staff with each other. Residents spoken with said they felt to “live as they wished” at the home and could “do as they pleased”. Residents said they felt respected by staff and treated with “patience and understanding”. 1 resident said she felt able to “have a lie in, go to bed early if she wanted, read in the lounge, watch TV, or have a doze”, she went on to say the staff are “smashing”, “lovely” and that “there are enough of them”. Observations of staff showed that they were respectful to residents, conversations were chatty and friendly, residents were assisted/lifted appropriately, and doors to toilets closed properly when in use. Medications systems in place were satisfactory. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 12, 13, 14, 15 were assessed at the inspection of 10th July 2005. For comments on this section, please refer to the report of 10th July 2005. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a satisfactory complaints system in place with some evidence that residents feel their views are listened to and acted upon. Arrangements in place ensure that the manager and staff are knowledgeable about adult protection issues which promotes the safe keeping of residents. EVIDENCE: The complaints procedure was on display and is included in documentation given to residents and/or their relatives when they first move into the home. None of the residents had any complaints, but of the 3 spoken with all felt if they did they would speak to the staff and it would be resolved. The provider and manager are proactive in addressing complaints, and like to resolve any issues before they become a complaint. The home has a quality assurance system in place which supports this. The manager informed the inspector of a recent complaint which was addressed through the use of a staff meeting (minutes seen), however no formal documentation relating to the complaint and its outcome had been made. The manager must ensure that all complaints are recorded. The manager has the Inter Agency Guidelines on the Protection Of Vulnerable Adults and was conversant with the procedure. Staff receive training on the Protection Of Vulnerable Adults. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 13 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 standard of the environment within this home is good providing residents with an attractive, clean and homely place to live. EVIDENCE: The home is well maintained, warm, clean and comfortable. The provider has good contacts with relevant maintenance firms ensuring that the home is decorated, bedrooms redecorated, re-carpeted and refurbished when vacant thereby ensuring that the all parts of the home are furnished and decorated to a good standard. The Provider is giving consideration to replacing the dining carpet. Facilities for the laundering of residents clothes are satisfactory, and the housekeeper explained her routine in the laundry of clothes, and the use of different colour coded bags to reduce infection from soiled linen. In the main residents clothes are washed and ironed within 24 hours of entering the
Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 14 laundry. The Housekeeper and her assistant are also responsible for cleaning all parts of the home, and the routine they adopt to ensure they clean all partws regularly and effectively was outlined. The home was seen to be clean and odour free on the day of this inspection. Residents spoken with said they felt the home “to be clean”, and their clothes were cleaned to their satisfaction and they “got their own back”. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29, 30 The vetting procedure in place ensures that staff who commence work at the home are suitable to work with vulnerable adults. Training in place is good and provides staff with knowledge and understanding enabling them to provide a good quality of care to residents. EVIDENCE: Standard 27 was assessed at the inspection of 10th July 2005, for comments please refer to that report. The staff recruitment procedures in place showed that staff are employed following receipt of 2 references and CRB’s. The manager said that if they are short staffed they do start new staff following receipt of references and a POVA 1st check pending arrival of the full CRB (police check). Such staff work until close supervision until the CRB arrives. The Manager needs to be mindful that guidance from the Commission is that generally staff should not start until the full CRB has arrived at the home. Staff do receive training at the home relevant to their jobs (moving and handling, infection control, adult protection, fire safety, food hygiene, first aid), and records kept for each member of staff support this. However the manager does not compile the records into an overall training programme which would allow her to see exactly how many of the staff have received training and in
Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 16 what. The provision of a matrix would enable her to evidence the training undertaken and determine what needs to be ongoing. This should be introduced. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The home regularly reviews aspects of its performance through a good programme of self review and consultations, which include seeking the views of residents, staff and visitors to the home. The management of the health and safety arrangements in the home ensures that the home is a safe place to live and work. EVIDENCE: The registered manager has many years experience in managing the home, and is a qualified nurse. She holds her Registered Managers Award. The manager runs the home in an open and inclusive manner and spends time working alongside staff on the floor. Systems are in place for regular staff meetings, residents meetings, and the provider canvasses opinions on how the home is run on an 6 monthly basis through sending out questionnaires to residents and visitors. Feedback from these questionnaires was generally
Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 18 very positive with just a small number of minor issues raised which have been addressed by the provider. The home encourages residents and families to retain control of monies, but for those who wish the home to hold the money this service is available. A record is kept of all transactions, and receipts are held corresponding with purchases. A number of records were verified against the monies held and corresponded. Servicing records of equipment and facilities were in place and up to date. Staff receive training in health and safety, fire safety, moving and handling, food hygiene, and infection control. Other health and safety matters were satisfactory such as the display of appropriate notices, testing of hot water, valves fitted to regulate the temperature of the hot water, accident recording etc. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 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 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 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement Each resident must have a fully completed care plan in place which identifies personal, social, emotional and health care needs and how these are to be met. Complaints made must be formally recorded identifying the investigation and its outcome. Timescale for action 31/01/06 2 OP16 22 31/01/06 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 OP30 Good Practice Recommendations The manager should have an overall training matrix in place which shows all members of staff and the training they have undertaken which would support the individual training records held. Lyndhurst Care DS0000025481.V272870.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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