Inspection on 09/09/08 for Lyndhurst Residential Care Home (Orrell Lane)

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Adequate service.

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 Residential Care Home... 05/11/07

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 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Lyndhurst Residential Care Home (Orrell Lane) 51 Orrell Lane Walton Liverpool L9 8BX Lead Inspector Daniel Hamilton Key Unannounced Inspection 9th September 2008 09:30 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.V365012.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.V365012.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 lyndhurstltd@hotmail.com Lyndhurst Limited Manager post vacant 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.V365012.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 5th November 2007 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 £322.00 to £350.00 Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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 sample of care records were examined as part of a case tracking process and a selection of staff and service records were viewed. The Owner, Acting Manager, eleven residents and three staff were spoken with during the visit. Prior to the inspection, survey forms were distributed to a number of staff, residents / or their relatives, to obtain additional feedback about the home. The Acting Manager also completed an Annual Quality Assurance Assessment to provide general information on the service. All the key standards were assessed and progress/action taken in response to the previous requirements and recommendations from the last key inspection in November 2007 was reviewed. What the service does well: What has improved since the last inspection? Since the last visit, staff had been provided with training in Safe Working Practice topics including Moving and Handling, Fire Safety, Food Hygiene, Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 6 Infection Control and First Aid, to raise awareness of Health and Safety matters. Signed copies of contracts had been returned to Lyndhurst and were available for inspection. Health Care Summary records had been updated to provide evidence that residents were being supported to access routine health care appointments when required. A copy of guidance issued by the Royal Pharmaceutical Society of Great Britain had been obtained for staff to reference. Furthermore, a record of staff responsible for administering medication together with a resident identification system had been developed to ensure best practice. A copy of the local authority adult protection procedures had been obtained for staff to reference to ensure an appropriate response to suspicion or evidence of abuse. Copies of induction material from Skills for Care had been obtained to ensure new staff were inducted in accordance with the Common Induction Standards. The Acting Manager had submitted an application to the Commission for Social Care Inspection to apply for registration as the Manager of the service. The temperature of hot water outlets had been tested on a monthly basis to confirm the temperature was correctly regulated to 43°C. New wardrobes, chairs and chest of drawers had been purchased for three bedrooms; new perimeter walls had been fitted around the rear garden and a fishpond and planting areas had been built. Furthermore, the side of the premises had been re-concreted to improve access and a new front entrance gate had been fitted. The owner also reported that all of the communal areas and bedrooms were in the process of being redecorated to improve the environment. What they could do better: The Statement of Purpose / Service User Guide should be updated to remove all reference to the National Care Standards Commission and include the correct contact details of the Commission for Social Care Inspection. Furthermore, the documentation should be developed in other formats, for example large print. This will ensure that service users and / or their representatives have up-to-date information on the service and help to avoid confusion. Contracts should also be updated to include the room number allocated to each resident and the details of the person / organisation responsible for fees. This will help to clarify the rights and responsibilities of prospective and current residents. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 7 In order to improve assessment practice, a comprehensive assessment of need should be undertaken by suitably trained staff, which is dated and includes information on past medical history and equality and diversity information. Furthermore, care plans should be reviewed and updated to ensure they are more person-centred and individualised. In order to ensure best practice, the Medication policy / procedure should be developed to ensure staff have access to comprehensive in-house procedures covering the ordering, recording, handling, safekeeping, administration and disposal of medicines received into the care home. Furthermore, a declaration of each resident’s wishes in regard to the administration of medication should be obtained (where practicable). Although a programme of activities had been developed since the last inspection, some residents reported that they did not know the full range of activities on offer and expressed an interest in community-based trips. The programme should be displayed in communal parts of the home for residents to view and extended to include community-based activities. This will help to meet the ongoing recreational needs, wishes and expectations of the people using the service. Feedback received from residents via surveys and / or discussion highlighted that some residents did not understand the procedure for making a complaint. The Complaints Procedure should therefore be updated to include the contact details of the Commission for Social Care Inspection and displayed in communal parts of the home so that people understand how to make a complaint and to contact the Commission. Although the home had received ongoing investment in the past twelve months, a number of rooms / areas viewed during the inspection remained in need of maintenance, redecoration and / or refurbishment. Action should be taken to address these issues to ensure the environment is more homely, attractive and comfortable for residents and a copy of the redecoration and refurbishment plan should be available for reference. Some staff spoken with during the visit lacked knowledge and understanding of equality and diversity issues. A staff training and development programme should be developed for the service to provide staff with opportunities for continuous professional development and training in equality and diversity should also be provided for staff, to raise awareness of the diverse needs of people accessing social care services. Documentary evidence should also be obtained to provide evidence that 50 of the care staff team have successfully completed a National Vocational Qualification in Care at level 2 or equivalent. The Owner reported that he had stopped acting as an appointee for a person using the service and that he had returned money that had been held in a company bank account on behalf of a resident since the last visit. Records pertaining to the transaction were not available in the home for inspection at Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 8 the time of the visit. Furthermore, receipts for expenditure had not been retained on file for a resident’s personal money. These issues must be addressed to confirm the financial interests of the people using the service are safeguarded. Examination of recruitment records highlighted that new staff had been confirmed in post without two up-to-date satisfactory written references. This practice is mot safe and must stop to ensure the welfare of residents is protected. Furthermore, the application form for Lyndhurst should be revised to provide more space for prospective employees to record their full employment history. At the time of the visit there was no up-to-date service certificate in place to confirm the portable fire extinguishers had received an annual inspection and maintenance. This equipment must be serviced annually, to safeguard the health and safety of the people using the service. A service record /certificate should also be obtained to verify that the fire alarm, nurse call and emergency lighting system has been serviced as detailed in the fire log-book. Action should be taken to fully implement the Quality Assurance system and for the results of service user surveys to be published and made available for inspection. Furthermore, the annual development plan for the home should be available for reference, to demonstrate that the service is run in the best interests of the people using the service. 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.V365012.R01.S.doc Version 5.2 Page 9 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.V365012.R01.S.doc Version 5.2 Page 10 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. Information on the service and the needs of prospective service users is in need of ongoing development, to ensure the service is able to meet the diverse needs of people who are considering moving into the home. 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 reported that the service was able to produce the document in alternative languages and large print upon request. No other formats were available for reference at the time of the visit. The Acting Manager was advised to update the document to remove reference to the National Care Standards Commission and to include the correct contact details of the regional office of the Commission for Social Care Inspection. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 11 Feedback received via Care Home Surveys and discussion with residents highlighted that the people using the service had generally received information on the service prior to being admitted to the home. 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. Since the last visit, the owner had made arrangements to ensure copies of signed contracts were available on the premises for reference. Examination of the contracts / terms and conditions revealed that some room numbers had been allocated twice to residents. Furthermore, the details of the person / organisation responsible for the payment of fees had not been recorded. The management team was recommended to address these issues and to clarify the rights and obligations of residents in more detail. The Annual Quality Assurance Assessment for the service detailed that policies were in place for referral and admission. The personal records of three residents were viewed during the visit. Each file contained a copy of pre-admission (functional / dependency) assessment. One of the assessments was not dated, another had been dated six days after the resident had been admitted to the home and the third had been completed on the day of admission. Copies of assessments completed by social workers had also been obtained for two of the residents and these provided additional information for staff to reference. Each of the assessments undertaken by staff at Lyndhurst had not been completed in full and some key information was missing. The Acting Manager was advised to ensure the assessment document was updated to include all the criteria identified in Standard 3 of the National Minimum standards. Furthermore, the Acting Manager was recommended to also include information on past medical history and equality and diversity issues, to ensure a holistic assessment of needs. The Statement of Purpose for the service detailed that prospective residents were offered a trial visit of 4 to 6 weeks prior to admission. At the time of the visit Lyndhurst did not offer intermediate care. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning processes remain in need of review in order to ensure a person centred approach to meeting the health and personal care needs of the people using the service. EVIDENCE: The Annual Quality Assurance Assessment for the service detailed that the service had policies and procedures in place for ‘Individual Planning and Review’, the ‘Control, Storage, Disposal, Recording and Administration of Medicines’ and the ‘Values of Privacy, Dignity, Choice, Fulfilment, Rights and Independence.’ Three resident’s care plan files were viewed as part of the inspection process. Each file contained a number of functional assessments covering: physical health; mental health; nutrition; dependency; physical ability and personal care; emotional and behaviour and sensory and communication needs. Risk assessments had also been completed to address hazards / risks including; falls; personal risks; transfers and pressure areas etc. Advice was given on how to further develop the risk assessment process as some risk Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 13 assessments viewed were vague and did not adequately address potential / actual risks as previously noted. Each file also contained a plan of care, which was based upon a nursing model of care. Care plans outlined individual needs, outcomes and action required by staff and covered a range of areas including: ‘Personal Care and Dressing’; Personal Hygiene; ‘Sleeping’; ‘Eating and Drinking’; ‘Maintaining Comfort and Safety’; ‘Mobility’ and ‘Elimination’. It was difficult to determine whether the care plans viewed addressed all the necessary needs necessary to deliver appropriate levels of care, as significant gaps were noted in the assessment process operated by the home. Furthermore, some care plans viewed lacked a person centred approach. These issues were discussed with the Acting Manager during the inspection. Records confirmed that Care Plan documentation had been kept under monthly review and daily, weight and health care records were also in place. The Acting Manager was advised to record the actual weight of residents as some records viewed had been rounded up to the nearest stone. 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 and chiropodist appointments. The Annual Quality Assurance Assessment for the service detailed that the Provider had developed a Medication Policy. The Acting Manager was advised to develop a more comprehensive policy / in-house procedures, as the guidance available to staff was limited. Since the last visit a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain had been obtained for staff to reference. Furthermore, a record of staff responsible for administering medication together with a resident identification system had been developed. Previous inspection records confirmed 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 again confirmed by Acting Manager. Competency ‘Safe Handling of Medication Assessments’ could not be located on the day of the visit. The Acting Manager reported that none of the residents self-administered their own medication. Personal files viewed did not contain any evidence that the wishes / consent of residents had been obtained in relation to the administration of medication as noted at the last visit. This should be addressed. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 14 A monitored dosage system was used at Lyndhurst which was dispensed by a local pharmacist. Medication Administration Records viewed had been completed to a satisfactory standard and accounted for medication received and administered. On the day of the visit medication was correctly stored and 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. Advice was given regarding the need to ensure the Controlled Drugs Cabinet was fixed to the wall using the correct method of fixing to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 2001. Staff spoken with during the visit demonstrated a satisfactory awareness of the value base of social care and were observed to offer appropriate support to the people using the service during the day. Likewise, feedback received from the people using the service confirmed their privacy was respected and that they were valued and treated with respect and dignity. Comments received from residents included; “The staff are very nice. They are good natured and very kind”; “I can’t fault the care provided” and “The care staff are all good to us.” Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 15 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced in the home is flexible and varied to enable the people using the service to have choice and control over their lives. EVIDENCE: Since the last visit the Acting Manager had produced a weekly activity programme in a standard format, which was displayed in the office. A record of activities had also been developed which provided evidence that the people using the service had participated in a limited range of activities. The Acting Manager was advised to display the programme around the home as some residents spoken with reported that they did not know the full range of activities available. Activities were provided in the main lounge from 10.00 am to 12.00 mid day. The activity programme detailed that the following activities were on offer each week. Monday – Bingo, Cards or Quiz; Tuesday – Sing-a-long or Snakes and Ladders; Wednesday – Ludo, Puzzles or Gentle Exercise; Thursday – Bingo, Sing-a-long or Movie; Friday – Sing-a-long or Movie; Saturday – Ludo and Walk in the back garden and Sunday – Bingo or Snakes and Ladders. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 16 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 however some residents reported that they would like the opportunity to go out on day trips. For example, one resident reported; “I’m not particularly interested in the activities however I would like the opportunity to go out more.” The Acting Manager reported that a trip had recently been organised to visit ‘The Mill’ in Kirkdale, however this was cancelled due to poor weather. The Statement of Purpose for the home detailed that a local vicar and priest visited the home on a regular basis and 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 remained warm and friendly. Staff were observed to communicate and engage with the residents in a positive manner and were seen to offer appropriate care and support to people when required. Residents spoken with confirmed they were able to follow their preferred routines, exercise choice and control over their lives and receive visits from family and friends at any reasonable time during the day. Examination of the menus for the home revealed that the home had a twoweek rolling menu, which offered a choice of meals for residents. Despite a recommendation at the last visit, the menu had not been expanded to provide more variation and some repetition in menu planning was noted as identified at the last visit. A record of meals provided was available for tea-time meals only. The Acting Manager reported that the menu had been revised in consultation with the people using the service to reflect the residents’ needs and expectations and that the service would cater for different health, cultural and / or dietary needs upon request. Evidence of consultation with residents regarding the meals had been recorded in the minutes of resident meetings. Meals were served in the home’s dining room at set times however the acting manager confirmed that alternative arrangements would be made to accommodate individual needs as required. Staff were observed to be available to provide support and assistance to residents during meal times and feedback received from residents regarding the meals was generally positive. Comments included; “The food is absolutely wonderful”; “Food very good” and “The meals are nice but more variation would be welcome.” Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 17 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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures remain in need of review to ensure people understand how to complain and to safeguard the welfare of vulnerable adults. EVIDENCE: A Complaints Procedure had been developed in a standard format to provide residents and / or their representatives with information on the procedure for making a complaint. The acting manager reported that the service was able to produce the complaints procedure in alternative languages and large print upon request. No other formats were available for reference at the time of the visit. Information on the complaints procedure was included in the Statement of Purpose however the timescales for investigating complaints had not been recorded. Furthermore, the complaints procedure and Statement of Purpose remained in need of review as the correct name and contact details of the regulator (Commission for Social Care Inspection) had not been included. A separate leaflet had been developed for people to record any complaints, comments and / or suggestions and copies were available in the reception area for reference. 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. Some people reported that they did not understand the procedure for making a complaint and the Acting Manager was Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 18 advised to review this matter and to ensure that the Complaints Procedure was visible and displayed around the home for people to view. The Annual Quality Assurance Assessment (AQAA) for the service detailed that no complaints had been received by the management team at Lyndhurst in the last twelve months. The Commission for Social Care Inspection had been notified of one concern, raised a relative of a service user which had been reported directly to the local social services department. The issue concerned the staffing levels in the home and the length of time taken to respond to a resident who had fallen. The concern was investigated by social services and was not substantiated. Recommendations were made regarding assessment and care planning processes and risk assessments. Records showed that there had been one safeguarding referral and investigation since the last visit, which concerned an allegation of abuse. The incident was investigated by the Police and Social Services and the allegation was not substantiated. Concerns regarding recording practices and the absence of key information in care plans was noted by the investigating officer. Since the last visit, the Acting Manager had obtained a copy of the City of Liverpool and Borough of Sefton – Safeguarding Adults policy for staff to reference and training records detailed that all staff had completed training in Adult Protection. A whistle blowing procedure was also available for staff to reference, however a robust internal policy on the Protection of Vulnerable Adults had not been developed. Staff spoken with during the visit demonstrated a satisfactory awareness of how to recognise and respond to suspicion or evidence of abuse. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 19 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): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some parts of the home remain in need of redecoration, refurbishment 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 management team reported that since the last visit new wardrobes, chairs and chest of drawers had been purchased for three bedrooms; new perimeter walls had been fitted around the rear garden and a fish pond and planting areas had been built; the side of the premises had been re-concreted to improve access and a new front entrance gate had been fitted. The owner reported that all of the communal areas and bedrooms were in the process of being redecorated. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 20 Overall, areas viewed during the visit appeared safe however concern was brought to the attention of the Owner and Acting Manager regarding some maintenance issues and clutter in a shower room, the cracked floor seams on the kitchen floor covering and the arrangements for residents who wished to smoke. Furthermore, some communal areas and a number of bedrooms viewed were in need of redecoration and / or refurbishment as the fabric / furnishings were in need of renewal. The management team reported that the premises would continue to receive maintenance and investment as required and that the rear garden area had required priority attention due to health and safety issues. The Acting Manager had developed a checklist that was used to identify hazards and to monitor the ongoing condition of the environment. The owner advised that a maintenance and refurbishment plan had also been developed since the last inspection, however this was not available on the premises to view. The location and layout of the home remained 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. Rooms viewed had been personalised by residents and contained photographs, ornaments and other memorabilia. The home did not employ domestic or laundry staff. A member of the care staff team was designated with the responsibility of keeping the home clean and hygienic. On the day of the unannounced inspection, the home was generally clean and did not have any malodours. Two areas were noted to be in need of cleaning and the acting manager made arrangements to address the issues during the visit. The Annual Quality Assurance for the service detailed that a policy on communicable diseases and infection control was available for reference. Training records showed that all of the staff team had completed training in infection control. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 21 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): 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. Recruitment practice is not completely robust and requires further improvement to safeguard the welfare of the people using the service. EVIDENCE: At the time of the inspection, fifteen residents were living in the home. Examination of the rotas and discussion with the Acting Manager and staff confirmed the staffing levels in the home remained largely the same as at the last inspection. No progress had been made in developing a tool to monitor the dependency and staffing levels as previously recommended. Three carers were generally on duty from 8.00 am until 2.00 pm and from 2.00 pm until 8.00 pm there were two carers on duty. Two waking night staff were on duty through the night. One of the carers on duty in the morning was designated with responsibility for cleaning the home. Residents spoken with during the visit were generally complimentary of the staff team and confirmed staff were available when needed and that they received the care and support they required. The Annual Quality Assurance Assessment for the Service detailed that a policy on recruitment and employment had been developed since the last visit. The Acting Manager reported that two staff had commenced employment in the home since the last inspection. The recruitment records for the two staff were viewed during the visit. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 22 Each file contained the necessary records required under the Care Home Regulations 2001 however the following issues were noted. One employee had commenced employment prior to receipt of two satisfactory references and the other employee had only one reference on file. Similar issues were also noted at the last inspection. Examination of records revealed that the Acting Manager had made arrangements to obtain health declarations from new employees, to confirm they were physically and mentally fit for their roles. The Acting Manager was advised to review the application form, as there was insufficient space for prospective employees to record their full employment history. At the time of the inspection, the home employed 12 care staff (excluding the Owner, Acting Manager and Cook). Documentary evidence was available to confirm that 4 (33.33 ) of the care staff had a National Vocational Qualification (NVQ) in Care at level 2 or above. The acting manager reported that a further five staff members had completed the award and were waiting to receive certificates and two staff were working towards a NVQ 3 at the time of the visit. Once all the staff have completed their qualifications and received documentary evidence, 11 (91.66 ) of the 12 care staff will be qualified to NVQ level 2 or above in Care. A training and development programme had not been developed however a training matrix was available for reference which detailed that staff had access to Safe Working Practice, Adult Protection and other training that was relevant to their role. Records showed that the two new staff had also completed induction training that was compliant with the Skills for Care Common Induction Standards. Staff spoken with confirmed they had received training that was relevant to their role. The acting manager was advised to continue to increase the range of training offered to staff and to include equality and diversity training as staff spoken with lacked knowledge and understanding in this key area. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of service information is in need of ongoing development and review in order to demonstrate that the service is run in the best interests of the people using the service. EVIDENCE: Lyndhurst did not have a manager who was registered with the Commission for Social Care Inspection. The Owner had appointed Mr kavish Mahadeo as the Acting Manager of the service and a senior care assistant remained responsible for personal care issues. Since the last inspection, the Acting Manager had submitted an application to the Commission for Social Care Inspection to apply for registration as the manager of Lyndhurst. Furthermore, the Acting Manager reported that he had completed the National Vocational Qualification (NVQ) level 4 Registered Managers Award (certificate awaited from training provider) and had enrolled Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 24 to also undertake the NVQ 4 in Health and Social Care and an MSc (Masters degree) in Healthcare Management. Examination of training records / certificates confirmed the Acting Manager had completed a number of academic qualifications. Certificates were available to confirm the acting manager had completed; First Aid at Work, ASET introduction to advanced Medicines Management; Advanced Dementia Care; Dealing with Challenging Behaviour and Mental Capacity Act Awareness training since the last inspection. The Acting Manager also reported that he had completed: Abuse; Infection Control; Food and Hygiene; Health and Safety; Moving and Handling and Fire Safety however some certificates were not available in the home for reference. Feedback received from staff confirmed the Acting Manager was supportive and approachable and records confirmed the Owner had continued to undertake monthly visits in accordance with Regulation 26 of the Care Home Regulations 2001. Minutes were also available to confirm that monthly staff and resident meetings had been coordinated and records highlighted that staff had access to regular supervision. A compliments, suggestions and complaints book had also been placed in reception for people to provide feedback. Prior to the inspection, the Acting Manager completed an Annual Quality Assurance Assessment for the service. All sections of the document were completed however there were areas were more supporting evidence would have been useful to illustrate what the service has done in the last year and how it is planning to improve. Previous inspection records detail that the owner had purchased a quality assurance system from an external organisation. The acting manager reported that a ‘Resident questionnaire’ had been distributed to the people using the service and / or their relatives since the last visit however copies of the questionnaires could not be located on the day of the visit and a summary report of the findings had not been produced. The acting manager also advised that the service had produced an annual development plan for the service however this was not available in the home for reference. 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. The owner reported that he no longer acted as an appointee or held money in a bank account in his name for any of the people living in the home. The owner advised that since the last visit he had transferred money held in his company bank account on behalf of a resident and made arrangements for the resident to receive support to manage his financial affairs independently with assistance from an external advocate. It was not possible to check the records pertaining Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 25 to the resident on the day of the inspection, as the owner had transferred his bank statements and cheque book records to his registered office address. The acting manager reported that relatives supported the people using the service to look after their personal finances. At the time of the visit the acting manager looked after the personal spending money of only one resident. A written record of financial transactions was maintained which detailed the date, details of the transactions, money in, money out, balance and signature. Receipts had not been adequately maintained to account for expenditure. The Annual Quality Assurance Assessment for the service detailed that Health and Safety policies and procedures were in place and that test and maintenance checks were undertaken periodically. Fire records were checked during the inspection. Records had been developed to provide evidence that the fire alarm system and extinguishers had been tested / visually inspected on a weekly basis. A separate record had been established to record the testing of the emergency lights and the call bell system. The acting manager was advised to record all the tests / checks associated with the fire alarm system and fire fighting equipment in one central record. Service / maintenance records were also checked for the fire alarm system, extinguishers, nurse call system, electrical wiring, gas safety, portable appliance, lift and hoisting equipment. An up-to-date service certificate could not be located to provide evidence that the fire alarm, nurse call and emergency lighting had been serviced during May 2008 (as detailed in the fire log book) and the last service certificate for the fire extinguishers was dated 30/07/07. All other records were found to be up-to-date. Since the last visit records had also been established to record and monitor the temperature of hot water outlets accessed by the people using the service. The acting manager was recommended to ensure that night staff receive fire instruction training at least every three months and day staff every six months as fire drill attendance records viewed did not provide evidence that all staff had received training in accordance with the recommended intervals. Good progress had been made in supporting staff to complete training in all safe working practice topics since the last visit. Advice was given to the acting manager regarding the development of risk assessments for fire and safe working practice topics. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 26 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 28 2 29 2 30 3 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.V365012.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Requirement Staff must only be confirmed in post if two up-to-date satisfactory written references have been received. This will ensure recruitment practice is safe and the welfare of residents is protected. A record of all money deposited by a service user for safekeeping including the written acknowledgement of the return of the money must at all times be available for inspection in the care home, to confirm the financial interests of the people using the service are safeguarded. The portable fire extinguishers must be periodically maintained, to safeguard the health and safety of the people using the service. Timescale for action 09/10/08 2. OP35 17 (3) (b) 09/10/08 3. OP38 23 (4) (c) 09/10/08 Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 28 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 available in other formats and updated to remove reference to the National Care Standards Commission and 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. Contracts should be updated to include the room number allocated to each resident and the details of the person / organisation responsible for fees. This will help to clarify rights and responsibilities. Comprehensive assessments of need should be undertaken by trained staff, which are dated and include information on past medical history and equality and diversity information. This will ensure a more holistic assessment of needs is undertaken. Care plans should be based upon a comprehensive assessment of needs and reflect a person-centred approach to care planning, to confirm the needs of the people using the service are appropriately planned for. The actual weight of each resident should be recorded to ensure staff have accurate records of weight loss / gain. The Medication policy / procedure should be developed to ensure staff have access to comprehensive in-house procedures covering the ordering, recording, handling, safekeeping, administration and disposal of medicines received into the care home. 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. The programme of activities should be kept under review and displayed in communal parts of the home for residents to view. Furthermore, the programme of activities should be extended to include community-based activities. This will help to meet the ongoing recreational needs, wishes and expectations of the people using the service. The two-week rolling menu plan should be expanded over a four-week period in consultation with residents, to provide more variation and less repetition. DS0000062401.V365012.R01.S.doc Version 5.2 Page 29 2. OP2 3. OP3 4. OP7 5. 6. OP7 OP9 7. 8. OP9 OP12 9. OP15 Lyndhurst Residential Care Home (Orrell Lane) 10. OP16 11. 12. OP18 OP19 13. 14. OP29 OP28 15. OP30 16. OP33 17. OP35 18 18 OP38 OP38 The Complaints Procedure should be updated to include the contact details of the Commission for Social Care Inspection and displayed in communal parts of the home so that people understand how to make a complaint and to contact the Commission. An internal policy on the Protection of Vulnerable Adults from Abuse should be developed and available for staff to reference. A copy of the redecoration and refurbishment plan should be retained in the home and action should be taken to maintain, redecorate and / or refurbish the rooms identified to the Acting Manager during the inspection. This will ensure the environment is more homely, pleasant and comfortable for residents. The application form for Lyndhurst should be revised to provide space for prospective employees to record their full employment history. Documentary evidence should be obtained to provide evidence that 50 of the care staff team have successfully completed a National Vocational Qualification in Care at level 2 or equivalent to verify that Training Targets have been met. A staff training and development programme should be developed for the service to provide staff with opportunities for continuous professional development. Training in equality and diversity should also be provided for staff to raise awareness of the diverse needs of people accessing social care services. Action should be taken to fully implement the Quality Assurance system and for the results of service user surveys to be published and made available for inspection. Furthermore, the annual development plan for the home should be available for reference, to demonstrate that the service is run in the best interests of the people using the service. Records pertaining to the management of all residents’ monies should be available for inspection in the home and receipts for expenditure should be maintained, to account for all expenditure. A copy of a service certificate should be obtained to verify that the fire alarm, nurse call and emergency lighting system has been serviced as detailed in the fire log book. Risk assessments should be developed for all Safe Working Practice topics, to ensure potential risks and hazards are controlled. Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection N W Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst Residential Care Home (Orrell Lane) DS0000062401.V365012.R01.S.doc Version 5.2 Page 31 - 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. 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