Inspection on 26/06/08 for Lyndhurst Residential Home

This inspection was carried out on 26th June 2008.

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

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 Home 15/12/08

Lyndhurst Residential Home 28/06/07

Lyndhurst Residential Home 19/06/06

Lyndhurst Residential Home 07/12/05

Lyndhurst Residential Home 30/08/05

Lyndhurst Residential Home 07/10/04

Lyndhurst Residential Home 27/08/04

Lyndhurst Residential Home 18/12/03

Lyndhurst Residential Home 24/06/03

Lyndhurst Residential Home 23/08/02

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Lyndhurst Residential Home Lyndhurst Road Goring On Thames Reading RG8 9BL Lead Inspector Marie Carvell Unannounced Inspection 10:50 26 and 27th June 2008 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 Home DS0000013107.V365430.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 Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndhurst Residential Home Address Lyndhurst Road Goring On Thames Reading RG8 9BL 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) 01491 871325 Lyndhurst (Goring) Limited Julia Anne Collyer Care Home 23 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Old age, not of places falling within any other category (0) Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia (DE) 2. Mental Disorder, excluding learning disability or dementia (ND) The maximum number of service users to be accommodated is 23. Date of last inspection 28th June 2007 Brief Description of the Service: Lyndhurst Residential Home is registered for 23 older persons who require personal care and accommodation. The home is not registered to admit service users who require full time nursing care. The home is privately owned and is set in the village of Goring. The accommodation is provided in a Victorian style house. The house has been altered and adapted for its purpose. Many rooms are large and bright with views of the countryside and the village green. The village offers shops, pubs and cafes with transport links to Reading and Oxford. Fees range from £450 per week to £560 per week. Items not covered within the fees include hairdressing, podiatry, newspapers and magazines, toiletries and contributions to some outings and activities. Continence aids are provided free of charge from the District Nursing Team, following an assessment of need. Lyndhurst Residential Home DS0000013107.V365430.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 0 stars. This means the people who use this service experience poor quality outcomes. This inspection of the service was an unannounced ‘Key Inspection’ carried out over two days. The inspector arrived at the service at 10:50 and was in the service until 12:50 on the first day and from 11:30 until 17:15 on the second day. The second day of the inspection the inspector was accompanied by a regulation manager. It was a thorough look at how well the service is doing. It took into account detailed information provided by the registered manager, in the form of the Annual Quality Assurance Assessment (AQAA) this is a self-assessment and summary of services questionaire that all registered services must submit to the Commission each year and any information that CSCI has received about the service since the last inspection. The AQAA was received by the Commission on the 9th May 2008. The inspectors asked the views of the people who use the service and other people seen during the inspection. No responses were received from surveys sent out by the Commission to the home, to distribute to service users, staff and health and social care professionals. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. Time was spent with service users, staff on duty, the manager and the home’s owner (responsible individual). A tour of the premises was carried out and a sample of records required to be kept in the home were examined, including case tracking of service user’s files and staff personnel records. In addition the inspector and regulation manager spent time observing how care was being delivered to service users. At the last inspection carried out in June 2007, four requirements and four good practice recommendations were made. Two requirements regarding safe recruitment procedures and staff training have not been complied with and the four good practice recommendations have not been addressed. These are referred to in the body of the report. Feedback was given to the manager during the two days and at the end of the inspection to the manager and the home’s owner, who was present during the second day of inspection. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Standards relating to choice of home, health and personal care, daily life and social activities, complaints and protection, staffing and management and administration need to be addressed and are subject to requirements. Requirements made at the last inspection, relating to safe recruitment practices, staff training and poor recording had been subject to requirement at previous inspections and have not been complied with. Failure to comply with these requirements will result in further action being taken by the Commission. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 7 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 Home DS0000013107.V365430.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 Home DS0000013107.V365430.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): Standard 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is poor. A person trained to carry out assessments for service users with needs associated with mental health, dementia or old age must undertake preadmission assessments. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated in the AQAA that fourteen of the service users have mental health care needs and three service users have care needs associated with dementia. Pre- admission assessments are carried out by the manager or the administrator of the owner’s second home in Goring. The manager was unaware of the experience, training or skills of the administrator. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 10 Two files of recently admitted service users were examined. Pre- admission assessments were basic. One service user had been admitted from a nursing home and the reason for admission was described as ‘depression, anxiety and memory problems’. The reason for the second service user’s admission was described as ‘unable to care for him/herself’. It was not recorded that the information and assessment was obtained prior to the service users being admitted to the home. An undated letter from a nursing home further supported this. There was no information recorded to suggest that consideration had been given to the specialist care the service users may require or the skills, ability or knowledge of the staff looking after them. Service users living in the home with specialist needs may receive a poor quality of care through lack of trained, knowledgeable or experienced staff. No information was recorded that the service user’s preferences in relation to how they receive their care had been sought or whether any assessment had been completed with the involvement of the service user or their representative. No information was recorded of whether the service users were able to visit the home before deciding to move in and although the manager said that the two service users were on a trial period, this was not stated in the admission records or that a review date had been planned. Lyndhurst Residential Home DS0000013107.V365430.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): Standards 7,8,9 and 10. Standard 7 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is poor. Care plans need to contain sufficient information to demonstrate that the care needs of the service users are being met. Staff must receive appropriate medication training before administering medication to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examination of five service user files, it was not recorded that the service user or representative had been involved in the care planning process. Care plans were not in sufficient detail to ensure that all staff are familiar with the care needs of each service user, when care is to be provided or how. Care Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 12 plans made no reference to service user choice or wishes. Information recorded was not in sufficient detail to demonstrate how the health, personal or social care needs can be met. This was subject to a good practice recommendation at the last inspection and has not been addressed. One care plan stated ‘ residents problem- memory problems, expected outcome-can become confused’. Another care plan stated ‘All personal care to be given and helped were needed’. Care plans are signed and dated as being reviewed monthly. Waterlow score documents, these are an assessment tool used to determine whether a service user is at risk of developing pressure sores were on file and despite being blank had been signed as having been reviewed monthly. Staff would need to receive training before being able to complete the documents competently and as this home does not provide nursing care, then the expectation would be for staff to notify the district nursing team of any service user at risk of developing pressure sores for preventive action to be put into place. Risk assessments for falls and manual handling were either blank or poorly completed, unsigned and undated, although recorded as being reviewed monthly. Information recorded for one service user, stated that over the last year weight had been lost, there was no record of the service users weight on admission and the nutritional assessment checklist was blank, again this was signed and dated as being reviewed each month. Daily records are maintained for each service user, however these record physical care provided and make no reference to emotional or social care needs being addressed. No reference is made to the two named key workers allocated to each service user. None of the service user files recorded that a care review had ever taken place. The manager confirmed that the care planning documentation does not met national minimum standards. Healthcare needs are provided by a local GP practice. The manager has regular meetings with the GP practice to discuss any concerns and new service users admitted to the home. District nurses attend to the nursing care needs of service users and visit the home as necessary, but no specialist care or advice from psychiatric community nurses is currently provided. Staff on duty administers medication. Training is provided to staff by the manager or in house trainer. Medication training must be provided by an creditable source, and must be at level 2 (basic), which is essential before any member of staff administers medicines. No evidence was recorded of how staff competency is evidenced. It was noted on the first day of the inspection that a service user was being given medication at times other than those prescribed by the GP. It is recommended that a staff signature list for staff who administer medication is maintained and a recent photograph of individual service users is kept together with the medication administration charts to assist with service user identification. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 13 Service users were seen to be well groomed and appropriately dressed. Feedback from service users able to express an opinion said that staff treat them well and were respectful. From discussion with the manager and service user records, the inspector considers that the home is not able to provide a service to meet the needs of individual service users of various religious, racial or cultural needs. Lyndhurst Residential Home DS0000013107.V365430.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): Standards 12,13,14 and 15. Standards 12 and 14 were subject to requirement at the last inspection. Quality in this outcome area is adequate. Service user records do not record that routines of daily living are flexible and varied to suite their expectations, diverse needs or preferences. Service users enjoy the meals provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection a requirement was made that a range of leisure and social activities must be on offer that provide service users with sufficient stimulation and suites their likes and capabilities, i.e. those service users with dementia. Care plans make not reference to how service users would like to spend their day, their daily routines or how their social and emotional needs can be met. The manager has introduced some activities on a daily basis, however it is not recorded if the activities provided suit the requests, Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 15 preferences and capabilities of the service users. A weekly activity schedule was displayed on the notice board and a record is kept of each days activities and the names of service users who take part. Activities are not able to be spontaneous as time is allocated each day. Staffing levels have a limiting effect on time staff are able to accompany service users to engage in 1-1 activities or activities away from the home. As in many homes there appears to be an over reliance on the television being a form of entertainment. On the first day of the inspection, the inspector arrives shortly after the Tai Chi session, which is provided twice a week. All service users were either in the dining room or conservatory. No service users were seen to use the lounge at the front of the home. Several ministers of religion visit the home on a regular basis. Visitors are able to visit the home at any time. Several service users enjoy reading a daily newspaper and copies of the local magazine are provided to the service users. At the last inspection a requirement was made that risk assessments must be undertaken on service users who smoke to determine whether or not it is safe to allow them to keep their cigarettes and matches. Risk assessments are in place, stating that with the service users agreement, cigarettes and matches will be kept by staff and provided to the service users on request. Service users able to express an opinion were complimentary about the food provided. A choice is always offered and service users described the cook as ‘a very good cook’. From discussion it was clear that the cook is familiar with the food preferences of all service users. None of the current service users require a special diet. On the second day of the inspection, it was observed by inspectors that the days menu was displayed on each table and the midday meal service, looked nutritious and well cooked. Service users said that they had enjoyed their lunch. Lyndhurst Residential Home DS0000013107.V365430.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. There is a complaints procedure in place. However, it is not demonstrated that complaints are taken seriously and acted upon. Staff receive in house training in the protection of vulnerable adults from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA completed by the manager states that no complaints have been received in the last year. This has been the case since the inspection undertaken in 2005. Service users able to express an opinion said that they would speak to their family or the staff if they had a complaint or concern. The manager was advised to record all complaints received, whether verbal or written, detailing action taken and outcome. The manager agreed to this. Since the last inspection in June 2007, the Commission has not received any information about complaints. The majority of staff have received in-house training in ‘Abuse in the care Home’. The policies and procedures in relation to safeguarding adults and making a referral to the Safeguarding Adults team need to be updated. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 17 No safeguarding adult referrals or safeguarding adult investigations have taken place since the last inspection. No referrals have been made for inclusion on the POVA (Protection of Vulnerable Adults) list. Lyndhurst Residential Home DS0000013107.V365430.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): Standards 19 and 26. Quality in this outcome area is good. The home is maintained to a good standard and is kept clean, hygienic and pleasant to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is comfortable, homely and well maintained. Since the last inspection the home has received an Enforcement Order issued by the Fire Authority, identifying twelve areas needing attention. A timescale of 30/04/08 was given for compliance. The manager confirmed that all the work required had been completed. No documentation was available to confirm that the Fire Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 19 Authority have yet issued a notice of compliance certificate. The manager is to contact the fire authority to request the necessary document. One bedroom smelled strongly of stale cigarettes, the manager insisted that the service user was not smoking in the bedroom. Service users able to express an opinion said that they were satisfied with the premises and facilities available. Several bedrooms were seen at the invitation of service users, each one had been personalised by service users, with items of furniture, family photos and pictures. One service user was delighted that his/her ground floor room had an outside area to sit. The manager was advised to consider, with service users agreement, to put their names on bedroom doors, as currently all bedroom doors look identical and as many of the service users have difficulties associated with memory loss, reduces the risk of service users entering the wrong bedrooms. The manager agreed to consider this. Lyndhurst Residential Home DS0000013107.V365430.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): Standards 27,28, 29 and 30. Standards 29 and 30 were subject to requirement at the lat inspection. Quality in this outcome area is poor. Recruitment procedures are putting service users at risk of harm. Staff are not provided with the necessary training to enable them to carry out their care duties with the necessary skills and knowledge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA completed by the manager states that ten care assistants have left the home in the last year. Since April 2008 ten care assistants have started work in the home, eight care assistants have started work since 16/06/08. The manager advised the inspector at the start of the inspection that none of the care assistants employed since 16/06/08 have had any Criminal Records Bureau (CRB) or Protection of Vulnerable Adult (POVA) checks undertaken. The manager confirmed on the second day of the inspection that none of the applications had been received by the CRB and unfortunately no copies of the applications had been kept by the home. Safe recruitment procedures have been subject to requirement at the last two inspections. Following the last inspection, an improvement plan was issued requesting details of how the Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 21 requirement will be met; non compliance of a request for an improvement notice is an offence, and could result in enforcement action being taken. An improvement plan was received by the Commission giving an undertaking that the requirement would be met. This has not been complied with. On the first day of inspection the manager decided to send staff employed without the appropriate checks in place home and to use agency staff and existing staff to cover the shifts. On the second day of the inspection, the manager confirmed that eight care assistants had been asked not to attend for duty until the appropriate employment checks were in place. Agency staff and staff from the owner’s second home were covering shifts. Thirteen staff personnel files were examined. The manager described the recruitment process, as staff completing an application form in the home at the same time an interview would take place, then a start date would be agreed. Records seen demonstrated that application forms were incomplete, no formal interview took place, references were not requested, some had photocopies of letters ‘ to whom it may concern’, most recently recruited staff had not provided evidence of identification, had little or no previous care experience and started working in the home within days of making contact with the home. None of the most recently recruited staff have received any induction, despite having little or no previous care experience. More worryingly, three care assistants commenced work on the 16/06/08. Two were on the 2pm until 8pm shift with a care assistant, who had only been in post since April 2008 and the third care assistant worked night duty, despite having had no interview, no induction, no references and no CRB or POVA check having been undertaken. Two care assistants have a student visa, which only allows them to work for 20 hours per week during term time, duty rosters showed one is working 42 hours per week and the second 24 hours per week. One member of staff is aged fifteen and has been in post for two years. No evidence was seen that a work permit has been obtained from the Local Authority, as legislation states that any employer who wants to employ a young person under school leaving age must obtain a permit before they start work. In addition this young person is employed at weekends from 9am until 2pm, but should not be working for more than two hours on a Sunday. He/she has no job description or appropriate risk assessments in place. The manager stated that duties include serving drinks, folding laundry and setting tables. However the duty roster for a weekend in June, demonstrated that due to staffing shortages, this member of staff was roster to work from 7.30am until 2pm. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 22 Day duty rosters show that 4 or 5 care assistants are on duty from 7.30am until 8pm. The manager confirmed that two waking care assistants are on duty each night from 8pm until 8am the following morning. Night duty rosters were not accurately maintained. The home also employs a full time cook, housekeeper and handy person. One part time care assistant has recently been promoted to care assistant/in house trainer. Duty rosters do not record who is the senior member of staff on shift and able to make decisions in the absence of the manager or that a hand over period between staff going off duty and staff coming on duty. The manager said that either she or the cook provide on call cover to staff when the manager is not in the home. The on call arrangements are clearly unacceptable and puts pressure on the staff on duty to make decisions about service user care, beyond their level of knowledge, skills or experience. The home currently has care assistant posts vacant for 84 hours per week. One care assistant and the care assistant/trainer have completed National Vocational Qualification (NVQ) training to level II or III. The remaining fifteen care assistants will commence the training in due course. At the last inspection a requirement was made that all staff are suitably trained to undertake their duties safely and competently and that training profiles for each member of staff are maintained. Following the last inspection, an improvement plan was issued requesting details of how the requirement will be met; non compliance of a request for an improvement notice is an offence, and could result in enforcement action being taken. An improvement plan was received by the Commission giving an undertaking that the requirement would be met. This has not been complied with. None of the ten care assistants employed since April 2008 have, yet commence an induction training programme which complies with the standards and content of the national training organisation Skills for Care. The home does not have a staff training and development plan in place. Some in house training using video training materials have been provided to staff since February 2008, in first aid, health and safety, fire safety, abuse in the care home, moving and handling and food hygiene. Three care assistants have undertaken in house medication training. In house certificates have been issued to staff that have attended these training sessions. Some staff appear to have received in house training before applying to work in the home. It was unclear as to the contents of the training, the knowledge or skills of the trainer or how the competence of the care assistant’s understanding is evidenced. It is a requirement that a care home has a qualified first aider on duty and the expectation would be that moving and handling training is provided by an appropriately trained trainer. Medication training should be provided by an accredited source, such as a pharmacist or registered nurse as described under standard 10 of this report. None of the staff have received training in infection control, care planning, risk assessment, equality and Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 23 diversity, mental health or dementia. None of the staff have a training profile in place. The training file needs to be updated, as training records of staff that have resigned have not been removed. At the feedback to the manager and home’s owner, the owner acknowledged that he had not complied with the requirement to follow safe recruitment procedures, but said that he did not agree that he had not provided staff with sufficient training to carry out their roles safely and competently. The home’s owner was issued with documentation advising him that the Commission believes that two offences may have been committed. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 24 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): Standards 31,33,35,36, 37 and 38. Standards 33 and 37 were subject to good practice recommendations at the last inspection. Quality in this outcome area is poor. The home is not being effectively run. Systems for measuring the quality of the service need to be improved, so that the service users, staff and other interested parties have access to published quality survey results. Record keeping is poorly maintained, not up to date or in good order. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 25 The manager has worked in the home since 2002; working as a housekeeper, care assistant then manager until her current appointment. She completed the Registered Managers Award last year and has been managing the home since 2006, In March 2008; she was registered with the Commission as the registered manager. Inspectors did not see any evidence to demonstrate that the home is being effectively run; the manager said that this is due to staffing shortages and difficulties in recruiting and retaining staff. The manager is frequently expected to provide direct care to service users and therefore neglects her management responsibilities. It is a recommendation that the manager records her hours worked on the duty roster. Quality assurance procedures in the home are poor. Surveys were sent to the home by the Commission to distribute to service users, staff, GP, health and social care professionals. None were returned to the Commission and it is understood that some surveys were not passed on to the appropriate individuals as requested. Two good practice recommendations were made at the last inspection, that a summary of the service users survey is produced and made available to interested parties to read and that an annual development plan for the home is produced in order that the progress of key objectives can be monitored. The manager had sent out eighteen of the in house surveys to service users and families, only three were returned. A report is planned to be written for July 2008. An annual development plan has not been produced. The homes business and financial plan was not available for examination by inspectors. The home does not manage any money on behalf of residents. A good practice recommendation was made at the last inspection that a record is kept of personal possessions brought into the home by service users. This has not been actioned. No evidence was available to demonstrate that the home is being run in the best interests of the service users. The home is owned by a company Lyndhurst (Goring) Limited. This requires the responsible individual (home owner) to visit the home at least once a month, unannounced and to write a report on the conduct of the home. The report must be available in the home for examination by inspectors. The manager said that the owner visits the home and chats to service users at least once a week and she speaks to him by telephone daily. Staff meetings take place infrequently the last one being held in January 2008 and the manager confirmed that service user meeting do not take place. Care staff do not receive formal one to one supervision or an annual appraisal. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 26 The AQAA stated that during the last twelve months, seven service users have passed away either in the home or in hospital. In addition two service users have died since the AQAA was completed. The manager is required by regulation to notify the Commission of all deaths. The Commission has not been notified of any deaths since 2005. Record keeping in the home is poorly maintained and the manager confirmed that some records relating to the business is kept off site. There is a fire risk assessment in place, undertaken by an external contractor. The home has recently recruited an external health and safety consultant, who has supplied templates and risk assessment guidance for all aspects of health and safety in the home. These have not been completed yet. The handy person carries out weekly checks on the fire alarms, fire extinguishers and door guards. The manager confirmed that water temperatures are not checked as valves are in place, but has agreed to undertake regular hot water checks. Service records were in place for the passenger lift, gas boiler and electrical equipment. The kitchens cleaning schedule is well maintained as is fridge and freezer temperature records. A call bell was activated by the inspector and staff attended promptly. Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 27 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 x x 1 x N/A x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x N/A 1 1 3 Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 28 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 Requirement Timescale for action 15/08/08 2. OP7 13 A suitably qualified or trained member of staff must assess the care needs of the service users before admission to the care home. Care plans must be in sufficient 15/08/08 detail to ensure that all staff are familiar with the specific care needs of each service user, when care is to be provided and how. Care plans must be completed with the service user or representative, agreed, signed and dated. Service user’s psychological health needs and nutritional screening must be monitored on a regular basis to ensure that the care needs of the service user are being met. Appropriate risk assessments must be in place, so that all staff have a clear understanding of the purpose and benefits to service users. 3. OP9 13(2) Medication administered to DS0000013107.V365430.R01.S.doc 15/08/08 Version 5.2 Page 29 Lyndhurst Residential Home service users must be given as prescribed by the prescribing GP 4. OP30 18 There must be at all times 15/08/08 suitably qualified, competent and experienced staff working in the care home who can meet the assessed needs of service users. A staff training and development programme must be completed and include an individual training profile and assessment. In addition all staff must complete a formal induction programme, which meets Skills for Care guidelines, mandatory training and appropriate, specialist training to meet the specific care needs of the service users admitted to the home, with care needs associated with mental health, dementia and old age. Staff who administer medication, must complete training to level 2 (basic) from a creditable source. 5 OP29 19 Staff recruitment processes must 15/08/08 be more robust to protect service users from potential harm. Full and satisfactory checks including, CRB/POVA 1st and satisfactory references must be available on file for each member of staff before they start work in the home. A method of continual 15/08/08 monitoring, reviewing and improving the service must be implemented to ensure that the care provided to service users and the home is monitored effectively. Effective quality assurance systems must be put in to place Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 30 6 OP33 24 based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose. A copy of the home’s business and financial plan must be sent to the Commission, to demonstrate the effective and efficient management of the business. 7 OP37 37 The Commission is to be notified retrospectively, in writing of the nine service users who have died since the inspection in 2007. A copy of the written report prepared by the responsible individual on the conduct of the home completed following an unannounced visit to the home must be sent to the Commission, each month until January 2009. 15/08/08 8 OP32 26 15/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 31 Lyndhurst Residential Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Home DS0000013107.V365430.R01.S.doc Version 5.2 Page 33 - 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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