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Inspection on 05/10/05 for Lyndhurst Lodge

Also see our care home review for Lyndhurst Lodge for more information

This inspection was carried out on 5th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Lyndhurst Lodge is set within a large comfortable Victorian property. There is a pretty garden area at the front and side of the home with trees, shrubbery and garden furniture. Residents spoken to gave comments such as: "Staff are good." "I am well looked after." A visitor commented about the provision "The most caring staff to people in their care." Assessments systems for new residents are in place, care plans and risk assessments are well documented and presented. Residents social, cultural, religious and recreational needs are met. Contact with residents relatives and visitors is encouraged and welcomed though regular social events held throughout the year.

What has improved since the last inspection?

A range of information is now included in the home`s Statement of Purpose/Service User Guide. Residents care plans and risk assessments have been reviewed are now in place; and identify any aspects that cause harm to residents have been removed or reduced. Required information is to being obtained and held when recruiting staff for the home and stored securely. An alarm system for external doors has been fitted for the safety and wellbeing of residents. Work is still at the final stages to protect radiators, pipes and water valves accessible to residents, and thus minimising risks from scalding. Written risk assessments are at the final stages of being carried out for all safe working practice topics throughout the home. The Registered Provider/Manager has completed a check for asbestos at the home and produced a report/risk assessment to this effect. Regulation 37 Notifications of death, illness and other events are now being reported to the Commission without delay of the occurrence.

What the care home could do better:

Devise a weight gain and loss chart to record resident weight and any action to be taken. Review and update a range of key policies and procedures taking into account current legislation, current guidance and good practice; and review and update the safe working practice risk assessment and fire risk assessment to ensure residents safety and well being. The Acting Manager must now make an application to register with the Commissions as a Registered Manager to demonstrate her fitness to manage Lyndhurst Lodge.

CARE HOMES FOR OLDER PEOPLE Lyndhurst Lodge 87 Burton Road Ashby De La Zouch Leicestershire LE65 2LG Lead Inspector Helen Abel Unannounced Inspection 5th October 2005 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 Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 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 Mr Keith Halliwell 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 DS0000001811.V252641.R01.S.doc Version 5.0 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. 23rd June 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. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during a weekday morning over a 4-hour period. A full tour of the building took place with care records, policies and procedures inspected. There was the opportunity to talk with two residents. Visitors and staff were also interviewed. The Registered Provider/Manager and Acting Manager were present at the inspection. What the service does well: What has improved since the last inspection? What they could do better: Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 6 Devise a weight gain and loss chart to record resident weight and any action to be taken. Review and update a range of key policies and procedures taking into account current legislation, current guidance and good practice; and review and update the safe working practice risk assessment and fire risk assessment to ensure residents safety and well being. The Acting Manager must now make an application to register with the Commissions as a Registered Manager to demonstrate her fitness to manage Lyndhurst Lodge. 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 DS0000001811.V252641.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 The assessment systems for new residents are fully implemented. EVIDENCE: A Statement of Purpose/Service User Guide is available on display near the entrance and contains a brief description of the accommodation and services provided. Assessments for new residents were in place and well presented. The Acting Manager confirmed she is responsible for undertaking assessments and from this document will draw up a care plan for each individual resident. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10,11 Residents health, personal and social care needs are identified and met. EVIDENCE: Individual care plans with risk assessments were in place, safeguarding resident’s care. Care plans sampled were reviewed weekly and reflect the resident’s current condition. Daily entries are written for each resident and are detailed and informative and staff are commended for this. Residents are regularly weighed. Suggestions were given around recording residents weight gain and loss. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Residents social, cultural, religious and recreational interests and needs are met. EVIDENCE: On the morning of the inspection the residents were enjoying a Harvest Festival with relatives and visitors and friends and a group of children from a local school. This is one of the social highlights at the home and was well attended. Some visitors told the Inspector how good the home was and how caring the staff were. There is an activities book, which is laminated detailing past and forthcoming events in the home. Photographs were displayed of past parties, musician, and singers who had visited and entertained the residents. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 There is a shortfall for producing robust policies and procedures around adult abuse, which has the potential to put residents and staff at risk. EVIDENCE: Complaints procedures are displayed around the home and in the Statement and Purpose/Service User Guide. The Acting Manager confirmed not receiving any complaints but confirmed working hard to resolve any difficulties that may occur for residents. The Whistle Blowing, Adult Protection, Missing Persons Policy and Procedure were in place but must be reviewed and updated. All these improvements will further safe guard residents care and welfare. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-25 The premises are well maintained clean, hygienic, and comfortable throughout. EVIDENCE: The outdoor garden areas are 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. The Registered Provider confirmed radiator covers were at the final stages of being fitted, and all the top floor windows will be replaced with UPVC within twelve months. Water valves are in the final stages process of being fitted. This is to prevent any risks of scalding as they move around the home. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 13 The Registered Provider /Manager should review the fire risk assessment and ensure the kitchen fire resistant door is kept closed when not in use. This aspect has been referred to the Fire Officer to follow through with the home. It was agreed with the Registered Provider /Manager the upstairs shower will be upgraded and adapted to be accessible to residents within six months. The Registered Provider/Manager confirmed the home’s risk assessment is still to be completed. Discussions took place around risks to health and for these to be included in the written risk assessment. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 The staff group are effective and able to meet the individual needs of residents. EVIDENCE: Staff confirmed attending a range of training such as National Vocational Qualfications in Care, Moving and Handling, Food Hygiene and Accrediated Medication Management. Staff interviewed spoke about regular meetings with the Acting Manager and exchanging information when going on and off duty. A health professional commented “ I visit regularly for various things. Staff are always helpful and take a keen interest in any care that I provide.” Completed relatives and visitor questionnaires gave comments as follows: “Wonderful here, can’t do enough for residents and visitors” “Doesn’t smell here. It is spotless” “Very homely and comfortable.” Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35 There are shortfalls around resident’s finances being safeguarded; however residents and staffs health, safety and welfare, is promoted. EVIDENCE: The Acting Manager has day-to-day responsibility for Lyndhurst Lodge. She regularly attends in house training with the care staff. She has just started her National Vocational Qualification level 4 in Management and Care. The Acting Manager is due to submit an application to register with the Commissions as a Registered Manager. Resident’s finances records were checked and found to be disorganized. Ensure better holding and recording systems to be developed, including two staff signatures for all transactions (including the resident where possible). In addition written policies and procedures should be drawn up to further safe guard residents financial interests. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 16 The Registered Provider/Manager confirmed the home’s risk assessment around safe working practices is still being completed. Discussions took place around risks to health and what information should be included in the risk assessment. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 3 3 3 3 2 x STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x 3 2 x x x Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 18 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 OP18 Regulation 12 Requirement The Registered Person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of residents: Review and update the Adult Protection and Whistle Blowing procedures taking into account current legislation, guidance and good practice. Complete the Missing Persons procedure with appropriate contact numbers. The Registered Person shall after consultation with the fire authority- take adequate precautions against the risk of fire: Review the fire risk assessment and ensure the kitchen fire resistant door is kept closed when not in use. (This aspect has been referred to the Fire Officer to follow through with the home). The Registered Person shall make suitable arrangements to ensure that the care home is conducted in manner, which DS0000001811.V252641.R01.S.doc Timescale for action 05/11/05 2 OP19 13 05/10/05 3 OP35 12 05/11/05 Lyndhurst Lodge Version 5.0 Page 19 respects the privacy and dignity of residents: Improve holding and recording systems for residents finances. This should include two staff signatures for all transactions, where possible one of these should be the resident. In addition produce written policies and procedures – Management of Residents Money, to further safe guard residents financial interests. A person shall not manage a 14/10/05 care home unless fit to do so. The Acting Manager must now make an application to register with the CSCI as a Registered Manager. Outstanding Requirement from the 23rd June 2005 inspection. The Registered Provider/Manager 30/11/05 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 protected radiators and water valves for minimising risks of scalding, window restrictors, beverage glasses, risk of Legionella, asbestos and fire safety.Outstanding requirement from the 23rd June 2005 inspection. The agreed timescale of 29th July 2005 has expired. 4 OP31 9 6 OP25 13 Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations Ensure residents weight gain and loss is recorded on their plan of care. Lyndhurst Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Lodge DS0000001811.V252641.R01.S.doc Version 5.0 Page 22 - 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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