CARE HOMES FOR OLDER PEOPLE
Lyndhurst Lodge 87 Burton Road Ashby de la Zouch Leicestershire LE65 2LG Lead Inspector
Helen Abel Unannounced 23 June 2005, 9:45am
rd 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 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 Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Lyndhurst Lodge Address 87 Burton Road Ashby de la Zouch Leicestershire LE65 2LG 01530 563007 01530 831779 None Mr Keith Halliwell Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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) Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 2nd November 2004 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 service users to sit and walk in. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced during a weekday morning over a four hour period. We spoke with residents, visitors, staff and the Registered Provider/Manager and the care manager. A full tour of the premises took place and some staff and care records were inspected as well as some home records policies and procedures. The home was receiving an announced inspection from the Community Pharmacist the morning of the Commission’s inspection. One of the residents was celebrating a special birthday celebration with a large party arranged for the afternoon. Staff were busy in the afternoon preparing the party area and the buffet. What the service does well: What has improved since the last inspection?
A photograph of each resident is now provided at the front of the resident’s care plan and meets the required legislation. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 6 A risk assessment has now been drawn up for a resident self- administering medication and is subject to review and monitoring by staff at the home. There are improved systems for the recording of controlled drugs. Protective clothing has now been obtained for staff to wear when working in the kitchen; this will reduce the potential spread of infection in the care home. Residents who receive care in their beds are now able to listen to music that reflects their choice and wishes. What they could do better:
Following on the last inspection in November 2004, five out of ten requirements and three out of the four recommendations were not met. Some of the requirements were outstanding from previous inspections. Three immediate requirements were made on the day of inspection. The Commissions will be undertaking an unannounced visit to check all these requirements and recommendations are in place within the set timescales. A range of information is still to be included in the home’s Statement of Purpose/Service User Guide. Residents care plans require more detail to provide guidance to staff and are to be reviewed more regularly. Risk assessments are to be produced for all residents; this is to ensure any aspects that could cause harm to residents have been removed or reduced, and to decide whether more action needs to be taken. An alarm system for external doors is to be fitted for the safety and wellbeing of residents. Work to be undertaken on unprotected radiators, pipes and water valves accessible to residents, and thus minimising risks from scalding. Required information is to be obtained and held when recruiting staff for the home and stored securely. The care manager must now make an application to register with the Commissions as a Registered Manager. Written risk assessments to be carried out for all safe working practice topics throughout the home. The care manager must attend accredited risk assessment training to aid her development and ensure the safety of residents. The Registered Provider/Manager must arrange to undertake a check for asbestos at the home and produce a report/risk assessment to this effect. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 7 Regulation 37 Notifications of death, illness and other events must be reported to the Commission without delay of the occurrence. The Missing Person’s policy and procedure to be updated and made accessible to staff. 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 Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 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 standard(s) 1,3 Information for new residents about the home does not meet the standard. The assessment systems for new residents are fully implemented. EVIDENCE: Information was missing from the Statement of Purpose/ Service Users Guide around the complaints procedure, the name, address and telephone number of the Commission for Social Care Inspection; and assurances must be given that complaints will be responded to within a maximum of 28 days; and results from surveys of residents to be included. These requirements were identified on the 7th of April 2004 inspection and have not been met. Assessments for new residents were in place and well presented. The care manager confirmed she is responsible for undertaking assessments and from this document will draw up a care plan for an individual resident. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 10 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 standard(s) 7, 8,9, There are shortfalls in ensuring all residents health, personal and social care needs are identified and met, which have the potential to place the resident’s care at risk. EVIDENCE: Individual plans of care are available but are insufficient to ensure that all aspects of health, personal and social care needs are identified and planned for. Risk assessments sampled were poor and lacked sufficient detail. This was made an immediate requirement on the day of inspection. Care plans sampled were not reviewed monthly and did not reflect the resident’s current condition. Daily entries are written for each resident and are detailed and informative and the staff are commended for this. Residents were not being weighed periodically; this was discussed with the Registered Provider/Manager. He confirmed he would not be able to purchase a sit down scale but would buy a stand-alone scale. Arrangements would be put in place to monitor other residents with mobility difficulties. This was made a requirement at the last inspection and has not been met.
Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 11 The Community Pharmacist was undertaking one of his quarterly year inspections during the morning of the Commissions inspection. He later confirmed records were well kept as were the storage of the medicines. It had been a good inspection. The home is commended for this aspect. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 12 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 standard(s) 12,13,14,15 Social, cultural, religious and recreational needs are met. Contact with relatives is supported and meals provide choice and variety; all of which assists residents in maintaining their independence and control over their lives. EVIDENCE: One of the residents was celebrating a special birthday; a party had been arranged with a buffet, a musician, and the local press attending later that afternoon. One resident told the Inspector, “I am happy in my room reading my newspaper and books and watching the television”. A monthly religious service is held in the communal areas for all religions. A visitor told the Inspector, “I am made welcome and when I come to visit on a Sunday I am invited to join my relative for Sunday lunch”. There is an activities book, which is laminated detailing the times and dates of activities. There is also a notice board in the hallway illustrating forthcoming events in the home. Residents are offered a menu for the day, where choices can be made for meals throughout the whole day. Staff confirmed any food alternatives could be provided. A resident said, “The food is beautiful here.” Plastic disposable cups were being used by residents for cold drinks and looked inappropriate. Glasses should be made available unless this is risk assessed unsafe for a resident. The Registered Provider/Manager confirmed he had ordered some new glasses on the day of inspection.
Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected. EVIDENCE: Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21,22,23,24,25 Some improvements to the décor have been made. There are a number of significant matters, which put people at risk of serious harm and do not provide safe surroundings in which to live. EVIDENCE: The outdoor garden areas were exceptionally well maintained. The main lounge has been decorated and some of the bedroom carpets have been replaced. All areas of the home look very clean, tidy and comfortable. Bedrooms were all individually personalised and resident’s confirmed they had brought items of furniture from their own homes into their rooms. All rooms had wash hand basins and the required furniture and fittings. One resident required additional support from staff because of her health needs, environmental adaptations were urgently required. An immediate requirement was made to meet this. The Registered Provider/Manager took prompt action to ensure this would be resolved over the following days.
Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 15 Discussions took place with the Registered Provider/Manager around the kitchen fire door being wedged open and the latch being removed. The Fire Officer was contacted following on this inspection and will be visiting the home and looking further at the kitchen fire door with the Registered Provider/Manager. Following on the last inspection a 1st October 2005 exisiting deadline is in place for the Registered Provider to complete works to ensure that the temperature of radiators and pipe work is controlled or guarded throughout the home. Risk assessments were not in place to show how the needs of individual residents had been risk assessed. This is to prevent any risks of scalding as they move around the home. An immediate requirement was made to meet this. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 Recruitment policies and practices do not protect residents. There is adequate training in place to support staff’s competent practice. EVIDENCE: One new staff member has been recruited since the last inspection. The required documentation for the recruitment of this person was not in place. This requirement was raised at the last inspection and has not been met. Increased security should be put in place for storing staff recruitment files, as the current system is still not secure. This aspect was also raised at the last inspection and has not been met. Staff confirmed attending a range of training such as National Vocational Qualfications in Care, Infection Control, Moving and Handling, Food Hygiene and Accrediated Medication Management. A staff member confirmed this helped develop her care practise. One senior staff member is learning about the management and office procedures one day a week as a development opportunity. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33,37,38 The current management structure of the home does not allow the care manager to discharge her duties. Record keeping is generally inadequate resulting in shortfalls for the health and safety of residents. EVIDENCE: The Registered Provider/Manager has been in the care sector for eighteen years. The care manager has day-to-day responsibility for Lyndhurst Lodge. She reports to regularly update and attend in house training. The care manager has confirmed over the past two years she will be resuming her National Vocational Qualification level 4 in Management and Care. This has not taken place. Advice and guidance has been given around training and development for the care manager. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 18 A training need for the care manager to attend accredited risk assessment training was identified at two previous inspections. (See also Standard 7 Service User Plan requirements around risk assessment processes). The care manager must now make an application to register with the Commissions as a Registered Manager. All six residents spoken with were very positive about the home, and felt confident they were being well looked after. The care manager confirmed a yearly quality assurance review was due in July 2005. The records held in the home were not kept up to date or in good order. Sampling resident’s records was difficult as some information was not complete or available. (See also Standard 7 Service User Plan). The Registered Provider/Manager and care manager were provided with information relating to Care Standards Act 2000 Regulation 37 to ensure the notification of death, illness and other events being reported as required to the Commission. The Missing Persons procedure should be updated and made available to staff. The Registered Provider/Manager confirmed a record would be made around no asbestos being present in the home and a report/risk assessment to this effect would be held in the home. Following on a recent fire inspection the care manager confirmed a new fire risk assessment is yet to be completed. Not all other health and safety checks were inspected and will be checked as appropriate at the next inspection of the home. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x 3 2 x x 2 x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x x x x x 2 2 Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 20 Yes 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 1 Regulation 4 Requirement Information was missing from the Statement of Purpose/ Service Users Guide and must be included: Results from surveys of service users views. Under the complaints procedure, the name, address and telephone number of the Commission for Social Care Inspection. An assurance must be given that complaints will be responded to within a maximum of 28 days. (Outstanding requirement since the inspection of the 7th April 2004) The Registered Provider shall ensure that any activities in which residents participate are so far as reasonably practicable, free from avoidable risks. 1) Risk assessments for all residents are to be produced. Residents plans must be in sufficient detail as to provide guidance to staff on the actions to be taken to meet their needs. The residents plans must be reviewed regularly.
C51 S1811 Lyndhurst Lodge V234689 230605.doc Timescale for action 29th July 2005 2. 7 13 29th July 2005 3. 7 15 29th July 2005 Lyndhurst Lodge Version 1.30 Page 21 4. 8 14 5. 22 16 The Registered Provider/Manager is required to undertake on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss, and appropriate action taken. The Registered Provider/Manager shall provide suitable environmental adaptations available to support residents. To provide a alarm system for external doors to safe guard residents. The Registered Provider/Manager shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated.The Registered Provider to ensure that the temperature of radiators and pipe work is controlled or guarded throughout the home. The Registered Provider/Manager shall ensure that any activities in which residents participate are so far as reasonably practicable, free from avoidable risks. 1)Risk assessments to be carried out for all safe working practices topics and that significant findings of the risk assessment are recorded. This includes unprotected radiators and water valves for minimising risks of scalding. The Registered Provider/Manager must gather Information and Documents in Respect of Persons Working at a Lyndhurst. Schedule 2. The care manager must now make an application to register with the CSCI as a Registered Manager
C51 S1811 Lyndhurst Lodge V234689 230605.doc Immediate As agreed on inspection 27th June 2005 6. 25 13 1st October 2005. Exisiting deadline from last inspection. 7. 25 13 29th July 2005 8. 29 7 Immediate 9. 31 9 Immediate Lyndhurst Lodge Version 1.30 Page 22 10. 31 9 The care manager must attend accrediated risk assessment training. 11. 38 12 12. 37 37 Via an Action Plan 7th July 2005 The Registered Provider/Manager 29th July is required to arrange a 2005 competent person to undertake a check for asbestos and produce a report/risk assessment to this effect. Regulation 37 Notification of Immediate death, illness and other events and must be reported to the ongoing. Commission without delay of the occurrence. 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. Refer to Standard 15 29 37 Good Practice Recommendations Glasses should be made available for cold drinks unless this is risk assessed unsafe for the individual. Increased security should be put in place for storing staff recruitment files. Outstanding since the last inspection. Update the Missing Persons Policy and Procedure including the referal to Commissions without delay and ensure the policy is accessible to staff. Lyndhurst Lodge C51 S1811 Lyndhurst Lodge V234689 230605.doc Version 1.30 Page 23 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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