Inspection on 18/08/06 for Lyndhurst Lodge

This inspection was carried out on 18th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Lodge 27/02/09

Lyndhurst Lodge 28/01/08

Lyndhurst Lodge 05/10/05

Lyndhurst Lodge 23/06/05

Lyndhurst Lodge 02/11/04

Lyndhurst Lodge 07/04/04

Similar services:

London Road Neurological and Specialist Care Unit

Carlton Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst Lodge 87 Burton Road Ashby De La Zouch Leicestershire LE65 2LG Lead Inspector Unannounced Inspection 18th August 2006 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 DS0000001811.V308113.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. DS0000001811.V308113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Lodge Address 87 Burton Road Ashby De La Zouch Leicestershire LE65 2LG 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) 01530 563007 01530 831779 Mr Keith Halliwell Mrs Irene Anita Keevins Mr Keith Halliwell Care Home 19 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (6), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (6), Old age, not falling within any other category (19) DS0000001811.V308113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No person falling within category MD (E) or DE (E) may be admitted to the home when 6 persons in total of these categories/combined categories are already accommodated within the home. 5th October 2005 Date of last inspection Brief Description of the Service: Lyndhurst Lodge is a 19-bedded residential home for older people, some of whom have a mental disorder or dementia. It is situated close to the centre of Ashby de la Zouch. The home was originally a large private house. The home has bedrooms on the ground and first floor. Access to the first floor is via the stairs or a shaft lift. The home has two large lounges, one of which is also used as a dining area, and an enclosed garden, which provides a safe place for residents to sit and walk in. The home is on a main bus route and has car parking available. DS0000001811.V308113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over 8.5 hours and commenced at 09.00 am on 16/08/06. The registered manager was present during the inspection. The focus of inspections is upon outcomes for residents living at the home and obtaining their views of the service provided. This process considers whether the home meets the National Minimum Standards and highlights areas, which might need further development or improvement. The method of inspection used is called “case tracking’ which involved selecting three residents and tracking the care they received this was achieved by discussion with them, their relatives and associated staff. Residents were selected randomly. During this inspection a tour of the rooms (occupied by those case tracked) and associated communal and external areas took place and the inspector viewed internal records, and care plans. Discussions were held after the inspection between the inspector and the Commission for Social Care Inspection pharmacy inspector and the Fire Officer connected to the home. Overall outcomes for residents appeared satisfactory however an immediate requirement notice was issued to the owner/ manager after the inspection in relation to the safety of residents (provision of radiator guards) and provision of suitable numbers of bathing facilities (un-repaired shower upstairs) and regarding the recruitment procedure (missing references). A response was received from the registered provider indicating that references had been found (these were supplied), the shower was going to be replaced within three weeks and that a number of radiators guards would be fitted shortly. Further discussion took place with the owner after the inspection in relation to the reasons why he did not intend to fit radiator guards in the dining room or the lounge, the owner stated that this was as staff were always in close proximity to these areas. It was agreed that although not a significant risk during summer months this must be addressed by robust risk assessment of the environment and risk’s associated with individuals who might be affected before radiators were again in use. Comments made by relatives/ residents (where possible) and staff about the home during this inspection was very positive. Typical residents/relatives/ staff /visitors comments included: DS0000001811.V308113.R01.S.doc Version 5.2 Page 6 “I was very lucky to get a room here, my doctor and a friend recommended it” “I prefer my own company but would attend activities if there were any” “We have not had any adult protection training other than NVQ” “Pictorial signs might be useful for some residents” “The food is nice” “We are notified if the care plan changes and have a regular handover of information each shift” “ We weigh people when we are told to” “ The home and its staff are super friendly” “ We have just completed the programme of fitting double glazed windows” “I have just finished a food an nutrition course” What the service does well: What has improved since the last inspection? What they could do better: Reviews of care plans are not routinely undertaken although weekly records summarised the care given, care plans should be reviewed more formally at least monthly. Allergies should be listed on medication records charts. The medicine policy should detail the use of bulk medication and appropriate use of medication. Medicines should be administered according to the label and for the person named on the label (using one bottle for all where a label identifies an individual by name, (this practise is strictly against the Royal Pharmaceutical Society of Great Britain guidelines and Care Homes Regulations) Personal risk assessments currently in place should detail all control measures to minimise risks. DS0000001811.V308113.R01.S.doc Version 5.2 Page 7 Funds raised through fund raising activities should be used to provide a more fulfilling and regular entertainment and activities programme. An activities organiser should be employed or alternatively a member of staff be identified each day to provide meaningful activities. Residents would benefit from enhanced care and protection if staff were to receive dementia training and if policies and procedures were put in place regarding adult protection, Staff should receive regular training relating to the needs of residents accommodated preferably each year. The upstairs bathroom sink hot tap and shower should be repaired and routine maintenance checks should be carried out and recorded. Water temperatures should be randomly checked and recorded. Employment of staff should not commence until all necessary checks and references have been obtained. Many rooms and communal areas such as the corridors and lounge/dining room still had not been fitted with guards; this is now a matter of urgency in view of the forthcoming autumn season and potential risks involved. Environmental risk assessments must be completed to ensure safety of residents and staff. Individual risk assessments must be completed to identify specific risks to individuals regarding radiators without guarding. Staff supervision and appraisals should be conducted regularly throughout the year 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. DS0000001811.V308113.R01.S.doc Version 5.2 Page 8 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 DS0000001811.V308113.R01.S.doc Version 5.2 Page 9 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): 1.3. Core standard 6 does not apply to this home. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Prospective residents are assessed before admission and receive the information they require to make a choice about where to live, a review of the present guide would ensure that they are fully informed. EVIDENCE: Terms and conditions of residency were seen in the care plan of a resident tracked; the resident guide (called a service user guide) had also been updated in July 2006. Inspection of the guide indicated that although informative did not cover the age range or sex of residents, criteria for admission or the arrangements for fire precautions, furthermore no information was included about visiting arrangements or how the home managed privacy and dignity. The service user guide (information about the home) detailed the complaints procedure but not its stages (Para: listening to your views) It was recommended that the guide be updated to include these areas. DS0000001811.V308113.R01.S.doc Version 5.2 Page 10 The manager said that where a resident was not capable of reading/understanding the guide it would be explained to the relatives. It was agreed that the current guide might not be in a font(size of writing) which was suitable to all residents’ accommodated and should be reviewed. Two out of three residents were unable to confirm they had read the guide, relatives spoken with indicated they had received adequate information about the home. A resident informed the inspector that the doctor had told them about the home and recommended it. They said they considered themselves “very lucky” to be here (at the home) All of the care plans tracked contained evidence of an assessment of needs; the manager had conducted this. DS0000001811.V308113.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are treated with dignity and respect and needs are met by the production of a care plan. Outcomes would be better if policies and procedures for administering medication were improved. EVIDENCE: All residents tracked were registered with a local General Practitioner and all had a care plan (information about how they would be cared for) in place. Community nurses provide nursing care. One care plan indicated that the resident used a medicinal spray and risk assessments were in place. The resident could not confirm their involvement in this risk assessment however and indicated they did not know about their care plan. One of the care plans tracked had been updated in March 2006 and previously in December 2005. The manager said they are updated every three months. Risk assessments had improved since the last inspection however consideration had not been given to more frequent reviews where risks had increased or where they were more difficult to control i.e. weight. Daily records seen indicated ongoing issues with DS0000001811.V308113.R01.S.doc Version 5.2 Page 12 managing a resident’s behaviour. Although staff demonstrated a good awareness of how to manage this, and care was being delivered according to the care plan no risk assessment was in place to address the increasing difficulties and risks presented. Daily records had been completed and summarised weekly. Medication records seen indicated medication were administered appropriately and records were in order. Allergies were not listed on medication record charts and this was recommended. Blister packs were inspected and were in order. Observation of stock and discussion with a member of staff indicated that a specific medicine was being given to a number of residents from one bottle (lactulose). The bottle was labelled with an individual’s name. The staff member said that this practise had been approved by the pharmacist however this practise is against the Royal Pharmaceutical Society guidelines (confirmed by Commission for Social Care Inspection pharmacist) and it was recommended that medicines are administered only to those persons whose name is on the label. The medicine policy was seen and manager said it had been updated recently. The policy was descriptive but did not include information about use of bulk prescribed medicines (administered to more than one resident and which can be bought over the counter). Staff discussion indicated that they were aware of correct ordering procedure and were able to describe the use and side effects of some drugs administered. Staff said they had received medicines training. Comments received from residents’ and their relatives indicated that all staff in the home are respectful and tolerant and respect individual privacy and dignity. The inspector witnessed good examples of this. The home had attempted to maintain the cultural needs of two residents accommodated; this was well evidenced by the manager and relatives. It was recommended that cultural and diverse needs relating to privacy and dignity be detailed in the care plan (if the resident agreed) End of life decisions are covered in the residents care plan. DS0000001811.V308113.R01.S.doc Version 5.2 Page 13 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): 12.13.14.15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The lifestyle experienced by some residents does not satisfy all social or recreational needs. Residents are supported to maintain important links and control over their lives and enjoy a wholesome diet. EVIDENCE: On the day of this inspection three residents were case tracked. Discussion with two was not possible and therefore views were obtained through relatives and staff. Two residents were able to express views about lifestyle and one said that they took an interest in most things but preferred to stay in their own room due to the lack of ability for communication with other residents. This resident enjoyed going out with family most weekends. Another resident said, “ I might be interested if there was any activities” There were no activities on the day of inspection, and no daily or weekly plan was in place. No activities organiser is employed and activities are based on occasional music evenings and three formal activities per year including fetes and Christmas activities, these activities are documented. The home manager said that she had not considered taking advice from other professionals such as the Alzheimer’s society about meaningful DS0000001811.V308113.R01.S.doc Version 5.2 Page 14 activities, which are viewed as important when caring for people with Dementia. One resident in the home who is younger than most other residents was observed during this inspection. It was evident from their behaviour they were somewhat institutionalised. A different resident who wandered constantly was observed staff managed this by offering of cups of tea. Staff said they had not received any specific dementia care training other than during their NVQ programme (recognised training programme in care) Church services were offered each month and discussion with the manager indicated that none of the residents accommodated had expressed any interest in any alternative denomination church services. It is recommended that was stated that where this was required this would be addressed during assessment. Two residents came from minority ethnic backgrounds and good evidence was found by discussion with relatives to confirm that all reasonable attempts had been made to address cultural and spiritual needs. The service user guide (brochure) says that money raised through fund raising activities provides equipment. The inspector spoke with staff who said that this year the funds have provided the home with a CD player, DVD, and a shower chair and recliner chair. It was recommended that funds raised are spent on providing daily meaningful activities and outings and that an activities person be put in place or a member of staff allocated each day to provide activities. A resident informed the inspector that they visit their relatives every weekend and that visitors are welcomed to the home anytime. A hairdresser visits the home each week; residents said they looked forward to this. Residents who were able indicated that the routines and schedules in place were appropriate and met their needs. One resident indicated that they had one bath a week and had fitted into the homes schedule; they informed the inspector that this was appropriate. The inspector was informed that staff responded quickly to requests for help and that they respected choice. It was further stated that residents’were assisted to maintain independence where possible. Two staff spoken with said that they were aware of the special diets of two residents’ tracked. Residents spoken with indicated the food was “nice”. A menu was seen in the dining room and most residents were aware of this and could read it. They were also aware of alternative choices available. Several staff and the manager were observed assisting residents with their food at lunchtime, they spent time talking to them and encouraging them to eat, most residents took a long time to eat and this was undertaken patiently, good reasons were given for these people not sitting with others DS0000001811.V308113.R01.S.doc Version 5.2 Page 15 in the dining room and it was recommended that this information be included in care plans. Senior staff or the registered manager are responsible for the cooking of meals, both have appropriate qualifications. The senior carer cooking said that four residents’ had requested alternatives ranging from sandwiches to soup. Evidence was seen in a staff file (mgr) of recent nutritional care training, other staff files indicated this training had been undertaken. The manager said that eight staff had taken the nutritional course within the last three years. The manager and staff when questioned were aware that a resident tracked had a soft diet and could not eat normal consistency food, it was indicated that the homes’ staff and not a dietician had reached this decision. The Care plan did not include any evidence of rationale (reason) and the risk assessment in place did not fully detail control measures to minimise risk relating to eating difficulties.It was recommended that the current risk assessment be reviewed to ensure it is robust enough and that where considered necessary that appropriate discussion takes place with a General Practitioner or dietician. The service user guide details the arrangements for snacks and drinks. One resident tracked was able to read this document. Two care assistants said that they were given instructions when to weigh someone and it was written in the care plan. Appropriate equipment is in place to weigh people. DS0000001811.V308113.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are protected from abuse and supported to make complaints, outcomes might be further improved if policies were developed and training provided regarding protecting adults from abuse. EVIDENCE: The complaint procedure is documented in the service user guide under Para: listening to your views. The information does not detail the stages of the procedure and it was recommended that this is updated to be reflective of the homes actual procedure. Relatives spoken with were not aware of the procedure but said they would speak with the manager or senior care staff if they needed to complain. Two people said their relatives had been in the home for over two years and that they had never had to complain. The manager said there had not been any complaints since the last inspection. A resident tracked said that they were not aware of how to make a complaint but said they would speak with the manager or their relative. The relative spoken with said she was aware but had not read the policy. Policies and procedures were not in place regarding adult protection, this featured as a requirement at the last inspection. The missing persons policy had been updated. Most staff had completed NVQ training @level 2/3 so had a reasonable awareness of adult protection, it was however stated by staff that they had not had any formal adult protection training. Staff were unfamiliar with the whistle DS0000001811.V308113.R01.S.doc Version 5.2 Page 17 blowing policy but were clear about their responsibility when reporting suspected abuse. Staff had received copies of the code of conduct (accepted good practise for healthcare workers) It was recommended that adult protection training be provided for staff. A discussion with the manager and a tour of premises demonstrated that residents’ were safe in the home, as keypads had been fitted to external doors, which could be freely accessed by staff but required a security number. Garden areas toured were sufficiently safe and secure to protect resident’s safety and the manager said that service users did not go outside unattended, usually being accompanied by staff or a relative. Good evidence was found to support night monitoring of residents who wandered and who were at risk of falls. DS0000001811.V308113.R01.S.doc Version 5.2 Page 18 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): 19.21.23.24.25.26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Facilities provided suit resident’s needs. More frequent maintenance monitoring, risk assessment and replacement of fixtures would ensure the home remains safe and homely for residents. EVIDENCE: During this inspection two residents were case tracked with specific issues relating to the environment. A tour of the bedrooms and communal areas associated with these residents took place. The inspector was also invited to look at additional bedrooms and external areas of the home. External doors had been fitted with keypad locks as required at last inspection. The rooms of residents tracked were noted to be homely and well equipped most containing items of a personal nature. One resident said that they were particularly happy as the bathroom/toilet was opposite their bedroom and easy to access. DS0000001811.V308113.R01.S.doc Version 5.2 Page 19 A resident tracked who was at risk of falls was discussed with the manager it was confirmed that the person usually spent the day in a recliner chair for safety and comfort this had not been fully detailed in the care plan. The risk assessment of a resident who wandered was seen. No specialised equipment was in place (i.e. pressure mat) the manager said the person would be at too much risk if one were used, this was not evidenced on the assessment however the care plan and corresponding night records did detail night checks and actions taken by staff. A shower in the upstairs bathroom was still not operational (as identified at the last inspection) this resulted in no useable bathing/ showering facilities for residents living on the top floor. Although the home have other facilities on the ground floor residents choices cannot be considered if they do not wish to go downstairs or use the lift. An immediate requirement notice was issued to secure a date for replacement or repair of the shower. The owner has replied to this notice and a date given for replacement of the shower. Upon inspection the upstairs bathroom sink hot tap was poorly fitted and spun around when touched. The water was difficult to turn on and off and would not be possible by a resident. The inspector was unable to turn on /off the tap. Decoration of one bedroom visited was in progress and new windows had been fitted to the old part of the building, The majority of the home was reasonably well maintained. The manager said that most general maintenance is done by a person who also does the gardening and decoration. The lounge carpet looked very worn and the manager said it was over twenty years old although no obvious health and safety hazards to residents were noted. It was agreed that the carpet would need replacement as soon as reasonably possible. Some residents in the home have dementia/ confusion and a resident who was tracked had evidence of a significant number of falls, observation of the resident indicated that they wandered most of the time. It was suggested that the resident might be looking for the bathroom but staff indicated they were aware of the person routines and habits. No obvious signs other than health and safety signs were seen in the home, Discussion took place around the use of signs and symbols and their value in homes with confused or dementing people. This resident appeared to know where the toilet was despite no signs being in place. Discussion with the manager indicated that all residents were taken to the toilet and had a toileting programme so didn’t feel that signs would be beneficial. Discussion with staff indicated that some residents had sensory impairment and felt that in some case signs may be beneficial. It was recommended that consideration be given to some signs in the home to ensure residents with confusion are able to find their way around the home. DS0000001811.V308113.R01.S.doc Version 5.2 Page 20 One room visited belonging to another resident was very cluttered and contained a large amount of personal furniture and fixtures also a wheelchair, commode and hoist. Whilst enabling residents to take risks and to offer the choice of personal possessions, the room must be accessible to those working in there with equipment and therefore it was agreed that a risk assessment would be put in place to protect both resident and staff safety. There is limited extra space for storage of hoists in the home. A current legionella test certificate was seen on display. It was confirmed by the manager that maintenance records kept do not include random water temperature monitoring. The owner and manager stated that most water outlets are fitted with thermostatic valves, and did not consider this necessary. DS0000001811.V308113.R01.S.doc Version 5.2 Page 21 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): 27.28.29.30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ needs are met by adequate numbers of competent staff, more frequent training would enhance the care received. EVIDENCE: Staff rosters were seen and a calculation of hours undertaken, the home are meeting the Department of health’s recommended numbers of care hours but are inclusive of manager hours. The manager provides hands on care and no separate supernumerary time is allocated. The manager and staff said that no agency staff are used and all shifts are covered internally by permanent staff. Senior care staff are responsible for cooking of meals, again this time is included in care hours. An extra member of staff was on duty on the day of inspection to cover cleaning duties in the absence of the cleaner. The home was reasonably clean. Rosters seen indicated that two waking night staff are on duty every night. Records seen of overnight monitoring by staff indicate that staff are awake at night. One service user spoken with but not tracked said that staff come promptly when the call bell is used and also at night. Relatives spoken with say always adequate staff and lounges are never unattended. DS0000001811.V308113.R01.S.doc Version 5.2 Page 22 The service user guide (information about the home) states that a key worker scheme is in operation however staff said that the home was too small for this to operate and that staff look after everyone. The manager insisted that there is a scheme, which staff were aware of and which ensures staff provide assistance for particular individuals such as letter writing etc. One resident tracked was new and wasn’t aware of the key worker system others were unable to clarify. The manager stated she was undertaking the registered managers award (a course for managers) and has completed dementia training (seen in staff file) Staff spoken with said that the manager would assist them when required and provide hands on care; this was witnessed during the inspection. Some staff spoken with informed the inspector that they had not had any training this year. The manager stated that the home can only do so many free courses each year and that last year moving and handling and safety compliance and safe handling of medications was completed. fire training had been undertaken by manager and had been approved by a fire officer. Staff files inspected indicated that staff had received training but not this year. Information received from the manager and in the service user guide indicated that 70 of staff had achieved their NVQ level2/3. (Recognised care qualification) No evidence of a training plan was provided and. staff said, there was “nothing planned” The registered provider must consider the client group and current legislation and provide appropriate training each year to ensure staff are equipped with the correct knowledge and good practise requirements. The manager stated that she conducted face-to-face interviews. One staff file inspected did not have any references in place, which had been sent for in March 2006.An immediate requirement notice was issued. The owner faxed over copies of references within 48 hours. All other staff files contained essential information as required in the Regulations. Staff application forms include an equal opportunities monitoring statement. DS0000001811.V308113.R01.S.doc Version 5.2 Page 23 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): 31.33.36.37.38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and staff benefit from the leadership of the manager. The health, safety and welfare of residents would be improved by provision of appropriate risk assessments and regular supervision of staff. EVIDENCE: The person in charge of the home is an experienced and established manager who is registered with the Commission for Social Care Inspection. Discussion with the manager indicated that she had completed the registered manager award and undertook training to ensure she remained competent. Staff and relatives spoken with spoke highly of the manager and the support given by her. Although no formal supervision of staff is conducted staff stated, “The manager is supportive, has an open door policy and is a good leader”. DS0000001811.V308113.R01.S.doc Version 5.2 Page 24 Annual appraisals of staff are conducted however none had taken place up to the time of this inspection. Observation of the manager during the inspection indicated that she was a team member and provided a level of hands on care. Staff and residents were familiar with the staff structure in the home. Quality assurance was not fully explored on this occasion however the manager said that an annual satisfaction survey is completed by the home each year, this had not been completed this year. The service user guide did not include any details about how views are obtained Concerns were raised at the last inspection about a number of health and safety matters including fitting of radiator guards and risk assessments. The inspector looked at rooms belonging to residents tracked and the manager showed the inspector other resident’s rooms (with consent). It was evident that many rooms and communal areas such as the corridors and the lounge/ dining room still had not been fitted with radiator guards as required at the previous inspection. Discussion took place with the owner over this matter. Risk assessments had not been undertaken to address the safety issues regarding radiators and particularly in relation to residents who have dementia. An immediate requirement notice was left to address. Discussion with the owner after the inspection indicated that some action had been put in place to reduce the hazards associated with radiators, however risk assessments were not supplied. The owner stated his intention not to replace all radiator guards. Discussion with the manager indicated that the fire officer had visited the home recently. Discussion with the fire safety officer after the inspection indicated that the home were working with the department on their fire and evacuation plan. The fire risk assessment was seen this had recently been updated. Discussion took place with a resident, relative and the manager about the suitability of locks fitted to bedroom doors. It was demonstrated that although locks are able to be overridden (unlocked by staff) from the outside they may not be suitable for all residents accommodated and the manager agreed to audit all doors with this type of lock to ensure they were suitable for the resident accommodated to use. A Health and safety policy was in place but had not been updated recently it was recommended that this document be updated. Accident records were inspected and residents with issues around falls management had been fully documented. Monitoring of residents concerned was also well evidenced. DS0000001811.V308113.R01.S.doc Version 5.2 Page 25 Staff training records seen included a large number of staff trained in First aid including night staff (2004) this training expires in 2007). Generic risk assessments still had not been completed for safe working practise and the environment. One bedroom seen had a number of environmental hazards and staff also said it was difficult to work safely with all furniture and fixtures in place. DS0000001811.V308113.R01.S.doc Version 5.2 Page 26 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 3 2 DS0000001811.V308113.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Timescale for action The Registered Provider/Manager 18/08/06 shall ensure that any activities in which residents participate are so far as reasonably practicable, free from avoidable risks. Risk assessments to be carried out for all safe working practices topics and that significant findings of the risk assessment are recorded. This includes protected radiators and water valves for minimising risks of scalding, The agreed timescale of 29th July 2005 had expired. Arrangements for the safe administration of medication must be made. This is in relation to use of liquid medicines administered from one bottle. Appropriate numbers of baths/showers fitted with a hot and cold water supply must be provided. Requirement 2. OP9 13 (2) 18/08/06 3. OP21 23(2)J 18/08/06 DS0000001811.V308113.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Refer to Standard OP16 OP18 OP7 OP9 OP12 OP15 OP18 OP19 OP24 OP19 OP30 OP36 OP33 OP38 OP38 OP29 Good Practice Recommendations An adult protection policy should be developed and staff made aware of it. Adult protection training should be provided for staff. Behaviour management should be addressed within a written care plan Allergies should be recorded on medication record sheets. Meaningful daily activities should be provided which are suitable to the type of residents accommodated Risk assessments related to eating and food should fully describe measures to be taken to reduce risk. The care plan should fully describe seating used and why this is required. Attention should be given to the lounge carpet as soon as is reasonably practicable. Risk assessments should be completed where residents wish to store excessive amounts of furniture or equipment in their room. Random water temperature monitoring and recording is recommended. Training should be provided giving consideration to the client group and any new legislation Staff should receive more formal supervision and appraisal. The views of resident should be sought on a regular basis and records kept of any surveys undertaken. An audit should be undertaken to ensure the suitability of bedroom door locks and should consider individual persons abilities/disabilities. The heath and safety policy should be updated. The recruitment procedure should be strengthened to ensure all documentation is in place before an employee starts work. DS0000001811.V308113.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 DS0000001811.V308113.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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