Inspection on 20/12/05 for Lyndhurst Grove (1)

This inspection was carried out on 20th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyndhurst Grove (1) 04/02/09

Lyndhurst Grove (1) 09/01/07

Lyndhurst Grove (1) 30/03/05

Lyndhurst Grove (1) 20/07/04

Lyndhurst Grove (1) 03/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Lyndhurst Grove (1) Low Fell Gateshead Tyne & Wear NE9 6AU Lead Inspector Gillian McCabe Unannounced Inspection 20th December 2005 09:30 Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 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 Grove (1) DS0000007374.V260690.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 Adults 18-65. 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 Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lyndhurst Grove (1) Address Low Fell Gateshead Tyne & Wear NE9 6AU 0191 482 3104 0191 482 3104 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) Northgate & Prudhoe NHS Trust Mrs Christine Turnbull Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Lyndhurst Grove is care home, providing personal care for up to six people with a learning disability related need. Nursing care is not provided, but District, Learning Disability and Psychiatric Nursing services can be arranged where necessary. It is an adapted, detached house with accommodation provided over two floors. There is a bedroom on the ground floor, with en-suite bathroom that allows level access. Five other bedrooms and a bathroom and separate WC are situated on the first floor. Access is by stairs only, so accommodation on the first floor is unsuitable for people with a physical disability, or who cannot use the stairs for reasons of safety. There are enclosed garden areas to the rear of the home. The home is situated near to a range of local services, including local public transport links and a wide range of local facilities, including a doctors surgery, shops, pubs, a library and places of worship. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours and thirty minutes on one day in December 2005. As the inspection was unannounced the views of service users, their families and other professionals were not canvassed prior to the inspection. The inspector was able to chat to all six service users at Lyndhurst Grove. Two members of staff were asked about the running of the home and the support and training they receive to help them to do their jobs. As part of case tracking, two service users files were looked at along with records of service user meetings, staff training records, and staff supervision matrix. An audit of the home’s system for receiving, storing, administering and disposing of medication was carried out. A tour of the home was carried out looking at the standard of accommodation on offer, arrangements in place for maintaining safe living and working conditions. Three service users gave a tour of their rooms. The manager and two members of staff were asked about training and support they receive and the overall running of the home. What the service does well: What has improved since the last inspection? The manager and staff have worked hard to make improvements since the previous inspection. Consultation is now taking place on a weekly basis to plan activities, menus, weekly shopping list and any other things that may be going on in the home. There are a lot more planned activities; service users now Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 6 discuss and plan their preferred activities on a weekly basis with support from staff. The home has adopted a recruitment policy that involves service users and gives service users the opportunity to meet with new members of staff prior to formal interview. The kitchen has been temporarily repaired and a new kitchen has been chosen and ordered and is due to be fitted after the Christmas holidays. 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 Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 The home has a detailed service user guide and statement of purpose in place which provides current and prospective service users with details of the services the home provides. The home provides written contracts for some service users. EVIDENCE: Two Service users files were case tracked as part of the inspection. Both files had service user guides which included information about the home; what service users can expect with regards to the support they receive, details of members of staff who work in the home, facilities available in the home for individual use. The service user guide also has a summary of the home’s statement of purpose, thus enabling people to make an informed decision about where they live. Out of the two case tracked files, only one file held an individual written contract, All service users files need to have a contract giving details of provision of services, details of fees and what is payable. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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 Service Users are supported to remain as independent a possible, If independence is limited it is agreed with full involvement of service users and other agencies where needed to minimise any potential risks. Service users are given choices and promoted to make decisions about their daily lives. All service users are fully involved in the running of the home. EVIDENCE: Support plans were looked at and they clearly identified the decisions service users want to take as well as identifying the assistance that would be needed to help the person to reach their goal. Staff give service users the support they need to help them take as much control as possible over their lives. Staff support service users to chose their own daily activities, holiday destinations as well as contributing to the way the home is run, for example, service users have regular meetings to discuss and plan activities. Service users are encouraged to be independent in all areas of their daily life, such as making drinks and snacks, personal care tasks and taking part in Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 10 activities inside and outside the home. All of which can involve taking a degree of risk. The manager assesses any hazards that may be involved in carrying out certain tasks, as well as identifying any benefits and pitfalls. If hazards are too great, choices may be restricted to promote safety for that person. Any restrictions necessary will be with full involvement of service users and any other professional involved in the persons care. Information about risks are recorded in the format of a risk assessment; this allows staff to give the correct amount of support to the person as well as reducing any further chances of hazard. Examples of a risk assessment in place include using the kettle to make a hot drink, using the cooker and using the iron. As a result of a recommendation made in the previous inspection the home now holds meetings on a weekly basis for service users to discuss and consult on all aspects of life within the home. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 Service users are supported to take part in a wide range of activities both inside and outside the home. Service users are encouraged to maintain friendships and links with family members. A wide variety of nutritious and wholesome food is available and prepared with healthy eating in mind. Staff support service users with individual preferences and making their own choice of meals. EVIDENCE: At the time of the inspection five service users were out at daily activities and One service user was preparing to go out to Sunderland for the day with a carer. Reading records, talking to staff and service users, upon their return, confirmed that a wide range of activities are accessed both inside and outside the home, on a regular basis. One service user talked about how he likes to go to football matches, he said he goes to the games with staff support. Another service user goes to her local church every Sunday, a family member supports her to do this. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 12 Service users have the opportunity and support needed to go on a holiday of their choice. One person prefers an overnight stays rather than a long holiday; staff support her to do this. A couple of people prefer to go to Scotland for a week and other’s prefer to go the lakes, staff give support to help people to go on a holiday of their choice. Service users have recently made personalised Christmas cards to send to their friends and family members for. The menus and shopping lists are planned on a weekly basis with service user involvement. Service users and staff record details of meetings held in a ‘meetings book’, service users and staff sign the notes to confirm their attendance. Menu’s show that the meals provided are varied and some examples of the food on the menu were Quiche and new potatoes; Pork chops, potatoes and vegetables. One service user has special dietary requirements; staff monitors this persons food intake by using a ‘food monitoring record’. Staff share information on a daily basis with the person’s day care provider to make sure the person is supported with her dietary needs. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Systems are in place to ensure staff assist service users safely with medication, however they are not always followed. At present no one is able to keep or administer his or her own medication. EVIDENCE: Training records were looked at during the inspection and they showed that staff are trained in safe handling and administration of medication. Records also showed that staff members had recently completed a ‘safe handling of medicines’ refresher course. All medicines are stored correctly. Systems are in place for ordering medication, safe disposal of medication and administration of medicines. A medication audit found there recording errors with 2 service users medication records. The medication had not been signed to say that it had been given. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Arrangements are in place to protect service users from all types of abuse. EVIDENCE: The manager confirmed that staff had received training in relation to the local authority Protection of Vulnerable Adults Procedure’s (POVA). A copy of which is available within the home showing details of contact names, numbers as well as a guide for staff in the event of witnessing abuse or having any alleged abuse reported to them. Talking to one member of staff confirmed her awareness of types of abuse and what to do should there be a report of abuse. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 Lyndhurst Grove has a warm and friendly atmosphere. It is nicely decorated and has nice furniture that meets the need of the service users that live there. EVIDENCE: The standard of the home is good. Service users living at the home benefit from a home that is clean, hygienic and well maintained. All of the bedrooms are individually decorated to suit personal preference and lifestyle choice. One Service user had recently decorated her room with support from staff to put up seasonal decorations. She said she “loved her room” and “liked Christmas decorations”. One Service user gave a tour of his room and showed all his pictures that had been put up in his room. Another Service user gave a tour of his room and said that he had chosen the colours for his room. An immediate requirement from the previous inspection had resulted in kitchen being temporarily repaired. The manager said that the new kitchen had ordered and was due to be fitted in the very near future. The manager confirmed this by contacting head office to find out the fitting date. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35 The home has robust recruitment policies and practices in place to protect service users. Service users are involved in the recruitment process, which is good practise. Service users needs are met by well-trained team and which has a good skill mix of staff. EVIDENCE: Discussions took place with the manager about CRB guidance. The manager confirmed that no person would be appointed without completion of ‘POVA First Check’ or a full CRB check supervision is not received regularly for all staff. This should only be carried out in exceptional circumstances and with the knowledge and agreement of CSCI. Staff records are not held in the home therefore, it was not possible to look at staff records to determine whether or not proper recruitment procedures were being adhered to. Discussions have taken place with the Trust where we have agreed two inspectors will visit the head office to look at staff records. A well trained and experienced team support service users at Lyndhurst Grove. Regular training takes place and a system is in place for the provision of supervision, however Staff members are provided with regular training opportunities. All care staff are qualified up to level 2 in NVQ. A training plan for 2006 is in place, which identifies training courses for staff to go on. Any new members of staff receive Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 17 training in the form of an induction from the manager as well as mandatory training such as First Aid, Fire Training, Moving & Handling etc. Staff on duty confirmed they receive regular training and opportunities for refresher courses. The home has a low turnover of staff which means that service users can benefit from continuity of care. As a result of a requirement made in a previous inspection, Service users are now involved in the recruitment process of any new members of staff. Service users have the opportunity to meet new staff and be involved in the informal interview process. The manager said that some service users had recently been involved in an informal interview for a potential member of staff. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,39 The ‘acting’ manager strives to provide a service that is well run, and focussed on the interests of the service users. EVIDENCE: The home is currently being managed by an ‘acting’ team manager. Management arrangements in the home continue to be the same since the previous inspection. The registered manager continues to be on secondment to another post within Northgate and Prudhoe NHS Trust. The previous agreement where the registered manager works in the home in a supernumerary capacity is still going ahead, with the member of staff previously agreed carrying out the role of ‘acting up’. The ‘acting’ manager is competent and well experienced. She is due to complete NVQ 4 in Management & Care in January 2006. She continues to attend training courses that are relevant to her role. Observations and discussion with staff, service users and the manager confirmed that good relationships have developed with service users and the Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 19 staff team. Staff work effectively with the manger and said that morale within the team was high. Service users were observed approaching the manager with confidence. Discussions during the inspection highlighted there had been periods of unsettlement due to previous changes in management; however discussions suggested that service users and staff are settled at present. This would continue with the ‘acting’ manager ‘s post being made permanent. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X 3 Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lyndhurst Grove (1) Score X X 2 x Standard No 37 38 39 40 41 42 43 Score X 2 3 X X X X DS0000007374.V260690.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 YA20 Regulation 13 (2) Requirement The registered person must ensure that accurate recording is carried out to ensure that service users are protected from risk and that service users health needs are met. Timescale for action 20/12/05 2. YA5 5 (1) C ) The registered person must 31/03/06 ensure that all service users have a standard form or contract, in an accessible format, for the provision of services and facilities. 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 36 Good Practice Recommendations The Registered Person must ensure that members of staff receive the support and supervision they need, (at least six times annually), to enable them to carry out their jobs effectively. Lyndhurst Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Grove (1) DS0000007374.V260690.R01.S.doc Version 5.0 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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