Inspection on 24/10/05 for Lyndhurst Park Nursing & Residential Care Home

This inspection was carried out on 24th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Park Nursing &... 18/12/06

Lyndhurst Park Nursing &... 13/02/06

Lyndhurst Park Nursing &... 24/03/05

Lyndhurst Park Nursing &... 26/07/04

Lyndhurst Park Nursing &... 04/03/04

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

CARE HOMES FOR OLDER PEOPLE Lyndhurst Park Nursing & Residential Care Home 33-35 Severn Road Weston-Super-Mare North Somerset BS23 1DW Lead Inspector Patricia Hellier Announced 24 & 25 October 2005 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 Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lyndhurst Park Nursing & Residential Care Home Address 33-35 Severn Road Weston-Super-Mare North Somerset BS23 1DW 01934 627471 01934 627518 lyndhurst park@aol.com Mrs Margaret Ann Butcher 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) Mrs Margaret Ann Butcher Care Home with Nursing 27 Category(ies) of Old Age (27) registration, with number of places Physical Disability (1) Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) May accommodate up to 27 persons aged 65 years and over who require nursing care 2) Manager must be a registered nurse on part 1 or 12 of the register 3) May accommodate one person between 50 and 64 years of age with a physical disability who may require nursing care Date of last inspection 24 March 2005 Brief Description of the Service: Lyndhurst Park Nursing and Residential Care home situated in a quiet residential area of Weston-Super-Mare to the south of the town. The sea front is only a short walking distance away with a park and bowling green nearby. It is within close to proximity to some local shops and amenities. The building and décor is of a high standard providing a comfortable and homely environment. Accommodation is provided over two floors with a passenger lift giving easy access to all floors. There are twenty six single rooms, and one which may be shared. Some of these have en-suite facilities and all have a call bell system. Communal space is provided in 2 lounges and a dining room in the main building, and a recently built conservatory. This includes a water feature and pond and is much appreciated by the residents. Provision is made within the home for a variety of activities and outings which also enable close links with the local commumity to be maintained. All local facilities are within easy walking distance but some are closed in winter. Mr and Mrs Butcher are the proprietors of this family run home and are very involved in the day-to-day running of the home. Mrs Butcher is also the Registered Manager Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the first statutory inspection of the current year and took place over seven and a half hours on two days. Before the inspection the information about the home was received from the pre inspection questionnaire and comment cards from relatives and residents. All 4 of the residents who returned cards were happy with the home and care provided. Saying “very happy here”, “the food is excellent”, “caring staff”. Of the 7 relatives cards returned all felt very welcomed in the home and that there relatives were receiving very good care. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “my relatives care needs are well met”. The inspector toured the premises; spoke to 4 members of staff, 14 residents 3 relatives and inspected a number of records. What the service does well: This is a family run home that has a group of staff who work well as a team, are resident focused and provide continuity for residents. During the inspection a good rapport was seen between staff residents and their relatives. Occupancy levels are consistently high. The staff team is well established, motivated, and enthusiastic about their work, and resident’s personal and health care needs are well met. They ensure the well being and comfort of the residents’ and treat them with great respect and kindness. Residents spoke of the “lively atmosphere” and “happy home.” The home have good links with the local GP, and nurse specialists in the hospital whom they involve appropriately to ensure all care needs are well met Meals are varied, well balanced and nicely presented offering choice and variety. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One relative said ‘the home is excellent Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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 standard(s) 1,3,4,5 The Statement of Purpose and Service Users Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they or their relatives have access to the relevant information at all times. Care needs are well met through a full assessment process and the completion of a care plan from this information. The assessment includes all the elements listed in the standard. A comprehensive assessment was seen for a recently admitted resident. The resident when spoken to said ‘I am well looked after, they know what I need’ Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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 standard(s) 7,8,10 Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. . Personal and environmental risks are well managed. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Four care plans were inspected and all reflected clearly current identified health and social care needs with actions to meet those needs. . Daily records were up to date and written in a respectful manner. Due to the introduction of new style care plans and assessment documentation, which had just been rewritten prior to the inspection; it was not possible to assess regular reviews, and resident, relative involvement with the care plans. These will be assessed at the next inspection. Residents’ specific choices relating to care issues were well recorded. However spiritual wishes of residents had not been recorded in any of the files inspected. . All care plans contained well-formulated risk assessments for Manual Handling and falls. Other personal and environmental risk Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 10 assessments were present to ensure the safety of the resident while promoting independence as able All residents spoken with felt that kind and caring staff respected their dignity and privacy. During the inspection staff were seen to be polite; knocking on doors before entering and assisting residents in a cheerful and understanding manner. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents right to choice and control over their lives is well respected, and encouraged. EVIDENCE: An excellent range of activities is provided with posters displaying information of forthcoming events throughout the home. Residents spoken with said, “we have plenty of choice and variety, there are quizzes and things to help keep your mind active, also regular outings.” “The staff are always willing to accommodate what we want”. “ There is a music and movement session one afternoon and on another we have a time for reminiscence”. The aromatherapist visits weekly and was present for part of the inspection. . During the inspection a number of residents spoke enthusiastically about the forthcoming outings to the theatre and the local garden centre for Christmas. A programme of outings is displayed on the hall notice board Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt that their relatives were well looked after by friendly staff. There was evidence of a good rapport between residents and staff, with lots of laughter and encouragement. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 12 All the residents said that the ‘food is good’ and that they liked the daily choices offered. For example one resident said ’if you don’t like something they’ll change it’. Menus showed a varied, balanced and nutritious diet. The meal on the day of inspection reflected this. The dining room is homely and tables well presented. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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) 16,18 Residents are confident that they are listened to and their requests acted upon. Staff were not fully aware of the homes adult protection policy and procedures and this potentially places residents at risk. EVIDENCE: The home has a complaints procedure and all residents have a copy contained in their residents pack received on admission. It does not contain any timescales for complainants to measure response against. This is recommended. There have been no complaints and residents stated that if they were not happy about anything they would speak to the manager. Staff and residents spoken to, say the manager is very approachable and understanding. One service user said ‘I’ve nothing to complain about, it’s the best home I’ve been in”. A record of complaints received with actions taken and outcomes need to be kept when complaints are received. During the inspection a complaint was received regarding the manner in which a resident had been spoken to. The manager was taking appropriate actions to deal with the complaint. A comprehensive policy and procedure for responding to allegations of abuse is available, together with the Local Adult Protection guidelines. The home also has a Whislteblowing policy and staff said they would report any concerns to the manager. Staff were not able to tell the inspector who outside of the establishment they could contact. Staff said they had never seen any signs of abuse in the home and demonstrated understanding of what abuse is. Four staff interviewed were not conversant with the homes Adult Protection policy and the appropriate ways of handling an abusive situation. Training is therefore required. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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) 19,22,26 Residents are provided with safe, comfortable surroundings. The home has suitable equipment to maximise resident independence. Robust Infection control practices are followed. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. The living accommodation is well decorated and homely. Residents’ rooms are personalised and comfortable. A forward looking maintenance plan is not available, however records of daily maintenance requests are kept. It is recommended that these are dated on completion to provide evidence of good practice and appropriate response times. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility and aid independence within the home. Pressure relief equipment was seen in use as well as profiling beds for the patients who had very limited mobility. All resident rooms are provided with locks that are accessible to staff in an emergency. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 15 The home was clean and free from offensive odours throughout. The laundry facilities were well organised. The laundry floor did not have an impermeable surface thus providing potential opportunity for the spread of infection. The provider has agreed to replace this in the near future. Staff interviewed and observed demonstrated good understanding of Infection control procedures and practices and maintained a clean and hygienic environment. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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) 27,29 The home’s staffing levels are sufficient to manage the current care needs of residents. The procedures for the recruitment of staff are inconsistent and do not always provide the safeguards for the protection of people living in the home. EVIDENCE: All residents spoke of caring and helpful staff who meet their needs and with whom they could have a good rapport. Copies of two weeks staffing rosters were inspected. Staffing levels rostered are mostly in accordance with CSCI requirements. Comments received from 2 relatives, 3 residents and one member of staff reflected that the evening routine is not always flexible in regard to bedtime routines for individual residents due to staffing levels. Two residents said they “cannot always chose their bedtime its when the staff are available.” This highlights the area where staffing levels are one member less that those stated in the requirements and should be reviewed. A sufficient team of ancillary workers supports care and nursing staff to ensure the smooth running of the service. Staff interviewed said that they were kept busy, but still had time to chat with the residents. Call bells were answered promptly during the inspection. A number of the staff team have worked at the home for a long time and provide good continuity for residents. Recruitment practices for new staff employed are satisfactory, however some staff have not been subjected to the same recruitment procedures. Of the five personnel files inspected 2 did not have a current Criminal Records Bureau check, and one had no documents available except a contract of employment. The above practices leave residents potentially at risk. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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) 32,35,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. The management of resident’s monies in the home is subject to regular and robust auditing by the home to ensure that resident’s monies are handled safely by the home. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager has experience of caring for the elderly and has recently obtained her NVQ 4 / Registered Managers Award. She gives clear leadership, guidance and direction to staff. Residents feel the manager is approachable, available and seeks to ensure all their needs are met. Staff interviewed stated that they felt well supported by an approachable manager Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 18 The management of resident monies by the home were inspected. Monies inspected tallied. Audit trails of residents’ monies in and out were not totally clear however all had been signed for. The practice of two signatures for the protection of resident was recommended. The manager stated that 3 monthly audits of resident finances have been implemented. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. A number of staff have received First Aid training. A record of accidents is kept which complies with Data Protection to maintain staff and resident confidentiality. However it is not the recommended format and the home are advised to obtain the recommend format to maintain best practice. Hot water outlets to baths and showers are thermostatically controlled to reduce risk of burns and scalds. Hot water outlets in resident’s rooms are not thermostatically controlled and this is recommended for the protection of resident from potential harm. Records were inspected of weekly temperature checks and were seen to be satisfactory. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 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 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x 3 x x 3 x x 3 Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 20 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. 2. Standard 16 29 Regulation 22 19.4 (b) Requirement The complaints policy must include timescales. The provider to ensure that all required documents and checks,as detailed in Schedule 2, are obtained prior to the commencment of employment of staff. Timescale for action 30/11/05 30/11/05 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. Refer to Standard 18 19 26 35 38 Good Practice Recommendations Staff to have further training to ensure they have a good understanding of what forms abuse can take and how to deal appropriately with an abusive situation. The signing of all maintainence works completed To replace the current laundry flooring with an impermeable and wahsable surface to minimise the risk of spreading infection. The development of a clear aidut trail for all residents monies The fitting of theromsotatic valves to all hot water outlets to which reidents have access. Lyndhurst Park Nursing & Residential Care Home D53_D02 S20359 Lyndhust Park V248521 241005 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL 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. 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