Inspection on 05/11/07 for Lyndhurst Residential Care Home (Orrell Lane)

This inspection was carried out on 5th November 2007.

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... 16/06/06

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 Lyndhurst Residential Care Home (Orrell Lane) 51 Orrell Lane Walton Liverpool L9 8BX Lead Inspector Daniel Hamilton. Unannounced Inspection 09:30 5 November 2007 th 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 Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Residential Care Home (Orrell Lane) 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 Vacant post Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 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 28th December 2006 Date of last inspection Brief Description of the Service: Lyndhurst is a small privately run residential care home in the Orrell district of Liverpool. The service is operated by a company called Lyndhurst Limited, which is a family run business - registered to provide accommodation and care for a maximum of 20 older people. The home is set in a Victorian detached property and the residents’ rooms are situated 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 lounge and dining area is located on the ground floor. The home is fitted with a passenger lift and a call bell system is fitted throughout. Lyndhurst 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. Care Home Fees range from £315.00 to £340.00 per week. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were viewed and the Owner, Acting Manager, residents and staff were spoken with during the visit. Survey forms were also distributed to a number of staff, residents / or their relatives prior to the inspection, to obtain additional feedback about the home. All the key standards were assessed and progress / action taken in response to the previous requirements and recommendations from the last key inspection in June 2006 and the random inspection in December 2006 was reviewed. What the service does well: What has improved since the last inspection? Written records of staff supervision had been maintained and staff reported that they felt valued and supported by the acting manager. Medication Administration Records had been correctly completed and accounted for medication received and administered. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 6 The fire doors had been repaired to ensure they closed freely and fully onto their rebated frame. The owner had purchased some new furniture to improve the standard of furnishings in the communal areas of the home. What they could do better: The Statement of Purpose / Service User Guide and Complaints procedure for Lyndhurst made reference to the National Care Standards Commission and the correct contact details of the Commission for Social Care Inspection had not been included. The documentation should be updated to avoid confusion. An assessment and care planning system had been developed however records showed that residents had moved into the home before their needs have been fully assessed. Furthermore, some care plans and associated documentation did not identify how all the assessed needs of residents were to be met. These issues must be addressed to ensure the health, personal and social care needs of residents are identified and planned for. In order to ensure best practice and accountability with medication, a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain – ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ should be obtained for staff to reference. Furthermore, a record of staff responsible for administering medication, a resident identification system and a declaration of each resident’s wishes in regard to the administration of medication should be established / obtained. A copy of the Adult Protection procedures developed by the Local Authority and Lyndhurst could not be located on the day of the visit and some staff spoken with lacked awareness of how to recognise and respond to suspicion or evidence of abuse. All staff should complete training in the Protection of Vulnerable Adults from Abuse and have access to the relevant procedures so that they understand their duty of care. Despite a requirement at the last inspection, money belonging to a resident had been deposited in a bank account that was not in the name of the resident. This practice must cease immediately in order to safeguard the financial interests of the resident. Recruitment records highlighted that Staff had been confirmed in post before a Protection of Vulnerable Adult Check (POVA) check and two up-to-date satisfactory written references had been received. This practice is not safe and must stop to ensure the welfare of residents is protected. A policy on recruitment should be developed to ensure staff are recruited in accordance with best practice. The owner had appointed an acting manager to oversee the day-to-day management of the home. Arrangements should be made to ensure the Acting Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 7 Manager submits an application to the Commission, to register as the manager. Since the last visit, the owner had purchased a new Quality Assurance System. Action should be taken to fully implement the new system and the results of service user surveys should be published and made available for inspection. Training records showed that staff had not been inducted in accordance with the ‘Skills for Care’ – Common Induction Standards. Likewise, a number of staff had not completed training in the full range of Safe Working Practice topics and less than 50 of the care staff had a National Vocational Qualification in Care at level 2 or above. Staff must complete training appropriate to the work they perform to ensure they are competent in their roles. There was no service certificate in place for a bath hoist. This equipment must be serviced twice a year in accordance with the Lifting Operations and Lifting Equipment Regulations to protect the health and safety of the people using the service. Action should be taken to redecorate the communal areas of the home in need of attention and to remove the clutter in the patio area. This will ensure the environment is safe and more homely for residents. 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. The summary of this inspection report can be made available in other formats on request. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service and assessment information was available however some information was out-of-date or missing. Unless a full assessment of needs is undertaken prior to admission there is no assurance that the care needs of residents will be met. EVIDENCE: A Statement of Purpose / Service User Guide had been developed in a standard format to provide information for prospective residents and / or their relatives on the service and facilities provided at Lyndhurst. The Acting Manager was advised to update the document to remove reference to the National Care Standards Commission and to update the contact details of the local office of the Commission for Social Care Inspection. The Owner reported that all residents were issued with a Contract / Statement of terms and conditions upon admission. A copy of the Contract was included in the Statement of Purpose, which outlined the responsibilities of all parties and what was included in the fees, etc. Signed copies of each resident’s contract were not available for inspection on the day of the visit, as the Owner had temporarily removed them from the home. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 10 Feedback received via Care Home Surveys and discussion with residents confirmed that people had received information on the service. The personal records of three residents were viewed during the visit. Each file contained a copy of Pre-Admission Assessment. Records showed that each of the three assessments had been completed following admission to the home and only one file had a copy of an assessment completed by a Social Worker. Assessments viewed had generally been completed to a satisfactory standard however some sections were missing from one assessment and there was no information on personal hygiene, special service and general health care needs. Likewise, another assessment did not include information on past medical history, ethnicity and / or gender. Previous inspection records detail that trial visits were offered to all prospective residents prior to admission – this was re-iterated in the Statement of Purpose / Service User Guide. It was recommended to the Acting Manager that all trial visits be clearly documented in appropriate care files as and when they take place. Lyndhurst currently did not offer intermediate care. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning processes are in need of review to ensure all the health and personal care needs of residents are identified and fully planned for. EVIDENCE: A random sample of three resident’s files was undertaken as part of a casetracking process. Each file viewed contained a Care Plan, which was loosely based upon the Roper, Logan and Tierney model of care. Care plans had been designed to identify the needs, outcomes and action required by staff and covered a range of areas including: ‘Personal Care and Dressing’; ‘Sleeping’; ‘Eating and Drinking’; ‘Maintaining Comfort and Safety’; ‘Mobility’ and ‘Elimination’. Some care plans viewed had not been signed by residents and / or their representatives and lacked information on how all the assessed needs of residents were to be met. For example, one resident’s assessment detailed that the person had dementia and poor mobility, however the care plan did not identify how these needs were to be met. Likewise, care plans did not identify how the health care needs of residents were to be addressed. Other examples were discussed with the Acting Manager during the visit. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 12 Additional documentation had been completed as part of the care planning process. This included a range of person-centred risk assessments to address falling, bathing and the use of bedside rails etc. Advice was given to the Assistant Manager on how to further develop risk assessment practice, as some risk assessments viewed were vague and did not adequately address potential / actual risks. Care plans had generally been kept under monthly review however some gaps were noted. Daily, weight and health care records were also in place. Discussion with residents and examination of health care records provided evidence that residents had accessed a range of medical practitioners including; doctor, hospital, district nurse, optician and chiropodist appointments. Some health care summary records had not been updated following appointments i.e. Chiropody and dentist appointments and this issue was brought to the attention of the Acting Manager. The Annual Quality Assurance Assessment for the service detailed that the Provider had developed a Medication Policy. The Acting Manager was advised to also obtain a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain for staff to reference. The Owner reported that staff responsible for the administration of medication had completed both in-house and external training prior to being authorised to administer medication and this was confirmed by a senior member of staff on duty. A checklist had also been developed to assess the competency of staff responsible for administering medication. None of the residents selfadministered their own medication at the time of the visit. A record of the staff responsible for medication and / or their sample signatures was not in place. Personal files viewed did not contain any evidence that the wishes / consent of residents had been obtained in relation to the administration of medication. These issues were discussed with the Owner and Acting Manager. Lyndhurst used a monitored dosage system that was dispensed by a local pharmacist. Medication Administration Records viewed had generally been completed to a satisfactory standard and accounted for medication received and administered. Medication was correctly stored. Records were in place to account for medication returned to the pharmacist and to monitor the room and fridge temperature. There were no controlled drugs in the home at the time of the visit. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 13 Advice was given on how to correctly count and handle medication to ensure best practice. Staff were observed to offer appropriate support to the people using the service during the day and residents spoken with were complimentary of the staff team and confirmed they were valued and treated with respect and dignity. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, daily life and social activities were flexible and varied to enable the people using the service to have choice and control over their lives. Menu planning would benefit from a review to provide a greater selection of meals and less repetition. EVIDENCE: The Acting Manager confirmed that residents were asked on admission to the home about their wishes and preferences in relation to lifestyle, diet, and social activities. The home did not have a programme of activities for residents to view. Likewise, there was no central record of the activities provided on a daily basis and / or the participants. The Acting Manager reported that individual records of activities had been maintained on daily record notes however records viewed were difficult to case track and contained limited information. Feedback received from residents and/ or their representatives via surveys and / or discussion confirmed the people using the service were generally satisfied with the range of activities provided. Comments included; “Activities are organised most days”; “I like the sing-a-longs” and “We have a number of activities including quizzes, sing-a-longs and board games.” One resident reported that he would like to go out more on day trips. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 15 The Statement of Purpose for the home detailed that a local vicar and priest visited the home on a regular basis. The Acting Manager confirmed that arrangements would be made to assist the people living in the home to follow the religious practice of their faith. The general atmosphere of the home was warm and friendly. Residents spoken with confirmed they were able to exercise choice and control over their lives, follow their preferred routines and receive visits from family and friends at any reasonable time during the day. Residents reported that they were able to entertain their visitors in the communal lounges or in their own rooms. One resident reported; “Visitors are welcome at any time. My niece visits once per week.” Staff spoken with demonstrated a good awareness of the rights and diverse needs of the people using the service and rooms viewed had been personalised by residents and contained photographs, ornaments and other memorabilia. Records showed that the home had a two-week rolling menu, which offered a choice of meals for residents. Some repetition in menu planning was noted and this was discussed with the Owner and Acting Manager. Mealtimes were considered to be a social occasion and food was served in the dining room at set times. The Acting Manager reported that alternative arrangements would be made to accommodate individual needs and confirmed the service would cater for different health, cultural and / or dietary needs upon request. Residents complimented the food provided. Comments included; “The food is good and they give you an alternative choice if you don’t like something”; “The food is great and you always get plenty to eat” and “I am well fed and I am putting on weight.” Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies, procedures and training are in need of review to ensure an appropriate response to complaints and / or suspicion or evidence of abuse. EVIDENCE: The Owner had produced a Complaints Procedure to enable residents and / or their representatives to understand the process to follow when making a complaint. A copy of the process was included in the Statement of Purpose and a separate leaflet had been produced for people to record any complaints, comments and suggestions. Some parts of the documentation were in need of review as reference had been made to the National Care Standards Commission and the up-to-date contact details of the Commission for Social Care Inspection had not been included. Records detailed that no complaints had been received by the management team at Lyndhurst since the last visit. The Commission for Social Care Inspection had received concerns from one person alleging poor levels of communication and practice in relation to the movement of a former resident to different rooms within the home. The issue was discussed in detail with the Owner and Acting Manager during the visit. Feedback received from residents confirmed they had no complaints about the service and were confident that the manager and / or senior staff would listen and act upon any issues of concern. One resident stated; “I have lived in the home for about three years. I am happy and content and have no complaints whatsoever.” Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 17 At the time of the visit the Owner and Acting Manager could not locate a copy of the local authority’s adult protection procedures. A whistle blowing procedure was available for staff to reference however a policy on abuse could not be found. Training records detailed that a number of staff had not completed Adult Protection training and staff spoken with demonstrated different levels of understanding regarding the different types of abuse and reporting procedures. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 personalised. Some areas of the home are in need of redecoration and / or maintenance to ensure the environment is homely, safe and attractive for residents. EVIDENCE: Lyndhurst did not have a handyperson who was responsible for general maintenance and repair. The owner undertook minor maintenance work and contractors were hired for major and specialised work as and when required. The owner reported that a maintenance and refurbishment plan had not been developed as the home received ongoing maintenance and refurbishment as required. Since the last visit, new double-glazing units had been fitted, a new front wall had been built and the trees had been trimmed. On the day of the visit the owner was observed to be delivering new furniture for the lounge areas. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 19 The location and layout of the home was suitable for its stated purpose (please refer to the ‘Brief Description of the Service’ section for more information on the premises) and residents had access to personal mobility aids, subject to their individual needs. The Acting Manager had developed a checklist that was used to identify hazards and to monitor the ongoing condition of the environment. Overall, areas viewed during the visit appeared safe. Concern was brought to the attention of the Owner and Acting Manager regarding the clutter in the outside patio area and some floorboards were noted to be uneven. Likewise, some communal parts of the home were in need of redecoration. The owner reported that the home did not employ domestic or laundry staff. Care staff were designated with the responsibility of keeping the home clean and hygienic. On the day of the unannounced inspection, the home was clean and did not have any malodours. The Annual Quality Assurance for the service detailed that a policy on communicable diseases and infection control was available for reference. Records showed that six staff had not completed training in infection control. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are not correctly recruited or trained. This has the potential to place the welfare of vulnerable adults at risk. EVIDENCE: Discussion with the acting manager and staff confirmed there had been no changes to the staffing levels in the home since the last inspection. Rotas were checked for the period 22/10/07 to 4/11/07. Records revealed that three carers were generally on duty from 9.00 am until 2.00 pm and from 2.00 pm until 9.00 pm there were two carers on duty. The home’s Cook worked from 9.00 am to 6.00 pm and generally undertook care duties from 2.00 pm to 4.00 pm. Two waking night staff were on duty through the night. Records detailed that only one member of staff had been on duty on the 28/10/07 from 9.00 am until 9.00 pm. The acting manager reported that he had also been on duty however this was not detailed on the rota. The acting manager agreed to address this matter. Residents spoken with during the visit confirmed staff were available when needed and that they received the care and support they required. Comments received from residents included; “The staff are all very nice”; “The staff are warm and kind people” and “I like the home. I am very settled and the girls are lovely and care for us well.” Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 21 To ensure best practice, the acting manager was recommended to undertake a dependency assessment, to provide evidence that the staffing levels in the home were monitored and sufficient to meet the needs of the residents at all times of the day and night. The Annual Quality Assurance Assessment for the Service detailed that a policy on recruitment and employment had been developed. This could not be located at the time of the visit. The acting manager reported that 5 staff had commenced employment in the home since the last inspection. The recruitment records for the five staff were viewed. Each file contained the necessary records required under the Care Home Regulations 2001 however the following issues were noted. One staff member had commenced employment before two satisfactory written references had been received and another was addressed ‘to whom it may concern’ and was not dated. Likewise, three of the staff had commenced employment prior to receiving a Protection of Vulnerable Adult (POVA) and / or Criminal Record Bureau check and an additional file did not have any record of a POVA check being undertaken. None of the files contained evidence that the staff were physically and / or mentally fit for their work. The home did not have a training and development programme. Records showed that new staff had been supported to undertake an induction booklet for the Training Organisation for Personal Social Services (TOPSS) foundation standards. Records viewed were incomplete and / or had not been signed off. Advice was given to the Acting Manager on the current ‘Skills for Care’ Common Induction Standards and where to access information. The home’s training matrix showed that a number of staff had not completed training in all safe working practice topics and / or additional training that was relevant to their roles. The acting manager reported that the home employed 13 care staff. Documentary evidence was available to confirm that 3 staff (23.07 ) of the staff had a National Vocational Qualification (NVQ) in Care at level 2 or above. A further two staff members were working towards a NVQ 2 at the time of the visit and one employee had enrolled to commence the training. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the administration of the service are in need of attention, to ensure the health, safety and welfare of the people using the service is fully promoted and protected. EVIDENCE: Lyndhurst did not have a manager who is registered with the Commission for Social Care Inspection. This issue has also been noted on previous inspections. The Owner had appointed an acting manager who was in day-to-day charge of the home. A senior care assistant was responsible for personal care issues. The acting manager reported that he was in the process of applying to register with the Commission and was working towards the National Vocational Qualification level 4 Registered Managers Award. The acting manager was advised to also complete a National Vocational Qualification in Care at level 4. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 23 Since the last visit the acting manager had completed diabetes, first aid and medication training. The owner reported that he undertook monthly visits in accordance with Regulation 26 of the Care Home Regulations. Examination of records revealed that the report resembled a health and safety checklist. Advice was given on how the format of the report could be improved. Minutes were also available to confirm that monthly staff and resident meetings were coordinated. Records also showed that staff had access to regular supervision. Since the last visit, the owner had purchased two quality assurance manuals from an external organisation. Limited progress had been made in the implementation of the system. The acting manager reported that questionnaires were sent out to residents and their relatives during September 2007 and that only two relatives had responded. No responses were available for inspection at the time of the visit and a summary of the outcome of the quality assurance process had not been produced. The management team were planning to organise a meeting with relatives. The Annual Quality Assurance for the service detailed that a policy had been developed on the management of service users’ money, valuables and financial affairs. This could not be located during the visit. The owner reported that he acted as an appointee for one of the residents and that since the last visit the service had ceased to look after the personal allowances of residents. Arrangements had been made for relatives to look after the personal money of residents. Records of financial transactions were viewed for the resident who required an appointee. The balance could not be checked as money was held in a Barclays account in the owner’s name. Likewise, statements for the account were not stored on the premises. This practice was also noted at the last inspection and must stop. Personal money belong to a resident should be transferred into a separate account bearing the name of the resident – this was discussed in depth with the owner and acting manager during this inspection. The Annual Quality Assurance Assessment for the service detailed that Health and Safety policies and procedures were in place and that test, maintenance and / or associated records were up-to-date for all key areas except hoisting equipment. Public Liability Insurance was also up-to-date. Examination of service records revealed that the home had a service certificate for a portable hoist but not for the bath hoist. Fire records were checked during the inspection and these were found to be in good order. A fire risk assessment had been completed and certificates were in place to confirm the fire alarm system and extinguishers had been serviced. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 24 The acting manager was advised to undertake monthly visual inspections of the fire extinguishers and to monitor and record the temperature of all hot water outlets to ensure they were correctly regulated. Some staff had not completed training in all Safe Working Practice topics. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 25 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (a) Requirement Residents must not move into the home before their needs have been fully assessed. This will ensure best practice and safeguard the welfare of people who wish to access the service. Care plans must outline how all the assessed needs of residents are to be met. This will ensure the welfare of residents is safeguarded and that appropriate action is taken to ensure health, personal and social care needs are met. Staff must only be confirmed in post if full and satisfactory information has been obtained via a Protection of Vulnerable Adult Check (POVA) check and two up-to-date satisfactory written references and evidence that the staff are physically and mentally fit has been received. This will ensure recruitment practice is safe and the welfare of residents is protected. Money belonging to a resident(s) must not be paid into any bank account unless it is in the name DS0000062401.V346811.R01.S.doc Timescale for action 05/01/08 2 OP7 15 (1) 05/01/08 3 OP29 19 05/01/08 4. OP35 20 05/01/08 Lyndhurst Residential Care Home (Orrell Lane) Version 5.2 Page 27 5 OP38 23 (2) (c) 6 OP38 18 (1) of the service user. This will safeguard the financial interests of the resident (s). A certificate must be obtained to 05/01/08 confirm lifting equipment used by the people in the home is safe and has been serviced in accordance with the Lifting Operations and Lifting Equipment Regulations. All care staff must complete 05/03/08 training appropriate to the work they perform including the full range of Safe Working Practice topics i.e. Moving and Handling, Fire Safety, Food Hygiene, Infection Control and First Aid. This will ensure staff are trained and competent in care and health and safety matters. 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 OP1 Good Practice Recommendations The Statement of Purpose / Service User Guide should be updated to remove reference to the National Care Standards Commission and to include the correct contact details of the Commission for Social Care Inspection. This will ensure that service users and / or their representatives have up-to-date information on the service. Signed copies of Contracts should be available for inspection in Lyndhurst to provide evidence that residents and / or their representatives are aware of their rights and obligations. Assessment information should include information on past medical history and equality and diversity information. This will ensure a more holistic assessment of needs is DS0000062401.V346811.R01.S.doc Version 5.2 Page 28 2 OP2 3 OP3 Lyndhurst Residential Care Home (Orrell Lane) 4 OP7 5 OP7 6 OP9 7 OP9 8 9 10 OP12 OP15 OP16 12 OP18 13 OP19 14 OP27 undertaken. Reference should be made to the Medical Devices Agency website to enable the service to further develop risk assessments for residents who have bed rails. This will help to ensure all potential / actual risks are identified and controlled. Health Care Summary records should be kept up-to-date to detail the outcome of all health care appointments. This will help to provide evidence that the health care needs of residents are being met. The home should obtain a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain – ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ for staff to reference. A record of staff responsible for administering medication together with sample signatures should be developed. Furthermore, a resident identification system should be established and a declaration of each resident’s wishes in regard to the administration of medication should be obtained (where practicable), to ensure best practice and accountability. A programme and up-to-date record of activities should be available to provide supporting evidence that the recreational needs and wishes of residents are met. The two-week rolling menu plan should be developed / expanded in consultation with residents to provide more variation and less repetition. The Complaints Procedure should be updated to include the contact details of the Commission for Social Care Inspection. This will assist people to understand how to contact the Commission. A copy of the Adult Protection procedures developed by the Local Authority and Lyndhurst should be available in the home and all staff should complete training in the Protection of Vulnerable Adults. This will help to ensure that all staff understand how to recognise and respond to suspicion or evidence of abuse. Action should be taken to repair the communal areas in need of redecoration / maintenance (as identified to the Owner and Acting Manager during the inspection) and to remove the clutter in the patio area. This will ensure the environment is more pleasant and comfortable for residents. A dependency assessment should be undertaken to provide supporting evidence that the staffing levels in the home are monitored and adequate to meet the needs of residents during the day and night. Furthermore, all shifts undertaken by the management team should be recorded DS0000062401.V346811.R01.S.doc Version 5.2 Page 29 Lyndhurst Residential Care Home (Orrell Lane) 15 OP28 16 OP29 17 OP30 18 OP31 19 20 OP33 OP38 on the rota to ensure accountability. 50 of the care staff team should have obtained a National Vocational Qualification in Care at level 2 by 31st December 2005. This matter should receive priority attention to ensure compliance with National Training Targets. A policy on recruitment should be developed / available for inspection as detailed in the Annual Quality Assurance Assessment. This will help to ensure staff are recruited in accordance with best practice. Arrangements should be made to ensure staff are inducted in accordance with the ‘Skills for Care’ – Common Induction Standards. This will provide evidence that staff are inducted in accordance with National Occupational Standards and are “safe to leave”. Arrangements should be made to ensure the Acting Manager submits an application to the Commission to Register as the manager, to ensure the best interests of the people using the service. Action should be taken to fully implement the new Quality Assurance system and the results of service user surveys should be published and made available for inspection. The temperature of hot water outlets should be tested and recorded on a monthly basis to confirm they are correctly regulated to 43°C. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V346811.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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