Inspection on 16/06/06 for Lyndhurst Residential Care Home (Orrell Lane)

This inspection was carried out on 16th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lyndhurst Residential Care Home... 09/09/08

Lyndhurst Residential Care Home... 05/11/07

Lyndhurst Residential Care Home... 12/01/06

Lyndhurst Residential Care Home... 28/04/05

Lyndhurst Residential Care Home... 28/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Havenview Care Home 51 Orrell Lane Walton Liverpool L9 8BX Lead Inspector Miss Julie E King Key Unannounced Inspection 09:30 16th June 2006 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 Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 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. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Havenview Care Home Address 51 Orrell Lane Walton Liverpool L9 8BX 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) 0151 525 2242 Lyndhurst Limited Anne Waldock Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named Adult under the age of 65 years in an overall total of 20 12th January 2006 Date of last inspection Brief Description of the Service: Havenview is a small privately run home in the Orrell district of Liverpool. The home has recently been taken over by a company called Lyndhurst Limited which is a family run business with a home in Wales. The home is set in a Victorian detached property and the rooms are on two floors. The rooms are either double or single and there are enough bathrooms and toilets on both floors to meet the residents needs. The home is staffed twenty four hours a day. The double rooms are used as single at present. However the home can accommodate residents who wish to share. The home is well served by local shops and public transport and there are pubs and restaurants close by. Newspapers are delivered to the home and arrangements can be made for hairdressing and chiropody services for residents as required. Fees for this service are local authority rate with agreed variations in some cases. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours during which a full tour of the premises took place, and staff and care records were inspected. The inspector spoke to the staff on duty plus some residents. Since the previous inspection this care home has improved in many aspects, and a considerable amount of effort has been made to upgrade the premises, both internally and externally. The registered provider has applied to CSCI change the name of this care home from Havenview to Lyndhurst – this is currently in process. What the service does well: What has improved since the last inspection? There have been ongoing improvements at Lyndhurst / Havenview since the last inspection. The information available for residents has improved, as have the following; care planning, multidisciplinary healthcare team involvement, record keeping, and the environment. The overall management of the home also evidences ongoing improvement and development, and staff morale and attitude was noticeably better. Residents spoken to told the inspector that “things are nice here” and they “am happy”. Staff also confirmed this. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 6 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. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 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 Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 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): 1,2,3,4,5,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide now provides enough information for prospective service users so they can be clear about the services the home provides to meet their care needs. EVIDENCE: The provider has now updated the Statement of Purpose and Service User Guide to reflect the actual home, rather than another home in the group. The home’s brochure has also been updated. This now gives prospective residents an accurate reflection of the services and facilities provided at Lyndhurst (Havenview). All service users are issued with a contract / statement of terms and conditions on admission, which sets out responsibilities of all parties and what is included in fees, etc. Pre admission assessments have improved since the previous inspection, but the tool is still not being utilised properly and the inadequate recording is not compliant with the expected standard. If this document was being used to it’s full potential and the recording was accurate, it would provide a holistic Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 9 assessment of actual and potential needs of each prospective resident; thus allowing a comprehensive care plan to be developed. This was discussed with the acting manager during the previous inspection, and some improvement has been noted, but further improvement is still required. Multidisciplinary healthcare team (MDT) input is evident in resident’s care files, and include reference to NHS out-patient’s appointments, opticians, dentistry, and district nurse input at the home when needed. Currently there are no residents with pressure sores. Trial visits are offered to all prospective residents prior to admission – this is re-iterated in the Statement of Purpose and Service User Guides. It was suggested to the provider’s representative that all trail visits are clearly documented in appropriate care files as and when they take place. Lyndhurst currently does not offer intermediate care. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10,11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place for most residents. This provides staff with the information they need to generally meet most resident’s needs. Medication management was not compliant with current good practice requirements and guidelines, potentially placing residents at risk. EVIDENCE: Some improvements have been made to most of the residents care documentation since the last inspection. This has resulted in the resident’s daily health records being more informative and relevant to the care needs of the resident. The care plans are loosely based on the Roper, Logan & Tierney model of care, and generally reflect the resident’s needs as identified. The care files still need further improvement regarding the content and quality of recording, and the staff must pay regard to the Data Protection Act 1998 with what they write. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 11 Personal support in the home is offered in such a way as to promote and protect the residents’ privacy, dignity and independence. Care plans contained some information as regards to the residents care needs, though more should be documented regarding the actual care delivered, and whether the resident has had any family / friend involvement. Risk assessments were in place for falls, continence, mental health, bathing, smoking and a night care plan had been further developed since the previous inspection. All residents in the home can access their NHS entitlements; and care staff escorts the residents to their hospital appointments if family members cannot attend. Medication management and administration was also examined in detail, and it was found that this area is the only area of the home that has deteriorated since the previous inspection. The main findings were as follows• Out of date stock • Incomplete course of antibiotics in medication cupboard • Some missing signatures on medication administration records (MARs) • Room temperature records not being recorded Residents spoken to confirmed that they had choices over their daily routines, meals, who they would like to visit, etc. Policies and procedures were in place to guide staff in conjunction with district nurses to deliver end of life care as needed. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 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 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 this service. Links with the local community are good, and support and enrich the resident’s lives. Meals in Lyndhurst are good, offering choice and variety, and cater for resident’s special dietary needs. EVIDENCE: Residents in the home are asked on admission about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident with help from a family member completes an initial care plan, which includes a social history as well as referring to hobbies, food likes and dislikes information, etc. This information is used to plan organised activities for the resident. Visitors are allowed in the home at any reasonable time for day, residents may entertain their visitors, in the communal lounges, or in their own bedroom. The gardens have been tidied and are an ideal setting for residents to sit with their relatives, especially in the summer months. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 13 Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 14 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaint and adult protection policy and procedure was in place that helps ensure the safety and welfare of residents. EVIDENCE: Lyndhurst has a complaints and adult protection policy and procedure in place which helps ensure the safety and welfare of residents. The residents, relatives and staff can access these when necessary. The procedures includes information on ‘whistle-blowing’, in accordance with the Department of Health ‘No Secrets’ guidelines. The CSCI has not received any complaints about this service since the previous inspection. Most of the staff have, or are in the process of completing training in adult protection, with the remaining having training planned for the near future. However all staff do receive basic training in the protection of vulnerable adults during induction. Residents are enabled to exercise their right to vote, either via post or in person; and there is no religious or political persuasion in the home. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 15 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): 19,20,21,22,23,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall fabric of the building is of an adequate standard, with most resident’s rooms being personalized, providing residents with an attractive and homely place to live. EVIDENCE: Both the exterior and interior of the building were inspected, and were seen to have significantly improved since the previous inspection. All the bedrooms identified on the previous inspection as needing upgrading have been decorated, some with new floor coverings and new soft furnishings. New carpets in communal areas have been laid, and the gardens to the front, side and rear have been tidied and cleared. There is an ongoing programme of redecoration and refurbishment, with communal areas and resident’s bedrooms being done as needed. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 16 All communal bathrooms and toilets now have a soap and towel dispenser, and no communal toiletries were seen. Mobile hoists and bath hoists now have a safety certificate and are compliant with Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). On the day of this unannounced inspection the home was clean and did not have any malodour. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. There is now a consistency of care within the home provided by permanent staff, which helps to offer safety and stability for the residents. Further work is still necessary to fully comply with staff training and development. EVIDENCE: All staff personnel files were examined as part of the case-tracking process. Most files now contain all the required documents and records, but some are still lacking or are in process of completion. CRB and POVA evidence was available, as were references, some training information, NVQ training, proof of ID and basic inductions. The provider’s representative was able to evidence that most of the staff have now completed mandatory training, and some service user (resident) specific training had taken place, with more planned. It was strongly recommenced that the provider considers a more comprehensive induction programme that would be fully compliant with the Health & Safety at Work Act 1974, as well as the Care Homes Regulations 2001. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 18 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): 31,32,33,34,35,36,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some quality assurance is in place, thus helping to improve the quality of care given to residents. EVIDENCE: Lyndhurst still has no registered manager – this is an ongoing requirement from the previous inspection. The provider’s representative is in day-to-day charge of the home, with a senior care assistant being responsible for personal care issues. The home has commenced staff and resident’s meetings, with minutes of these meetings kept. A suggestions book has also been commenced, and a ‘comments box’ is planned for the reception area. Service user (resident’s) questionnaires are also in process of being collated. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 19 Some of the resident’s personal allowances are currently being looked after by the provider’s representative and held in a bank account that is not registered in the resident’s names. This practice must cease immediately, and all monies should be transferred into separate accounts bearing the names of the residents – this was discussed in depth with the provider’s representative during this inspection. Most of the required documents and records are now available in the home, the majority of which have been, or are in the process of being updated at present. Health & Safety certificates are up to date and valid, including Gas Safety, NICEIC Electrical safety, and lifting equipment. Public Liability is also up to date and displayed in the main reception. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 20 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 2 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 2 X 1 2 2 2 Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 8 Requirement The registered person must appoint a suitably qualified and competent manager to manage the care home. Previous timescale of 30.05.05 not met. The registered person must ensure that documented supervisions for staff are held six times per year. Previous time scale of 28.02.05 & 30.05.05 not met. The registered person must make suitable arrangements for persons working at the care home to recieve suitable training in fire prevention, and the procedure to be followed in case of fire, including the procedure for evacuation and saving life. Previous timescale of 30.05.05 not met. The registered person must manage all service users monies in accordance with this regulation - refer to incorrect management and recording of service user’s monies Previous timescale of DS0000062401.V289439.R01.S.doc Timescale for action 31/07/06 2 OP36 18 31/07/06 3 OP38 23 (4) 31/07/06 4 OP35 20 31/07/06 Havenview Care Home Version 5.1 Page 22 30.05.05 not met. 5 OP3 14 Finding – inadequate pre admission assessments Requirement The registered person shall not provide accommodation at the care home to a service user unless the needs of the service user have been assessed by a suitably qualified or suitably trained person, there has been appropriate consultation regarding the assessment with the service user or a representative of the service user, and the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the needs of the service user in respect of their health and welfare. 6 OP7 15 Finding – inadequate service user care plans RequirementThe registered person is required to, after consultation with the service user or a representative of his, prepare a written plan (the service user’s care plan) as to how the service user’s needs in respect of his health and welfare are to be met. The registered person shall • • • • Make the plan available to the service user Keep the service users plan under review Where appropriate revise the care plan Notify the service user of any such revision Version 5.1 Page 23 31/07/06 31/07/06 Havenview Care Home DS0000062401.V289439.R01.S.doc 7 OP9 13 (2) Findings – medications not been managed or administered in accordance with good practice guidelines RequirementThe registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home, and ensure that all records pertaining to the service users are kept up to date and accurate. 31/07/06 8 OP19 16 & 23 The registered person is required to ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair externally and internally; all parts of the home are kept clean and reasonably decorated. Findings- Incomplete staff training and development, supervision and appraisals RequirementThe registered person is required to ensure that at all times suitably qualified, competent and experienced staff are working at the care home in such numbers as are appropriate to the health and welfare of service users; and ensure that all persons working at the care home receive training appropriate to the work that they perform; and the registered person is also required to ensure that all staff are appropriately supervised 31/07/06 9 OP30 18 31/07/06 10 OP33 24 The registered person shall establish and maintain a system DS0000062401.V289439.R01.S.doc 31/07/06 Havenview Care Home Version 5.1 Page 24 for reviewing at appropriate intervals and improving the quality of care provided at the care home. 11 OP37 17 The registered person must ensure that all records at the care home are kept up to date and valid at all times. 31/07/06 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 OP38 Good Practice Recommendations It is strongly recommenced that the provider considers a more comprehensive induction programme that would be fully compliant with the Health & Safety at Work Act 1974, as well as the Care Homes Regulations 2001. Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Havenview Care Home DS0000062401.V289439.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!