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Inspection on 07/12/05 for Lyndhurst Residential Home

Also see our care home review for Lyndhurst Residential Home for more information

This inspection was carried out on 7th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is able to offer care and accommodation in a homely environment.

What has improved since the last inspection?

Improvements have been made to the system of storage, recording and distribution of medication.

What the care home could do better:

Further improvements should be made to the information collected on staff files, especially for staff from overseas. Information required for the inspection was not available on file. The main kitchen would benefit from an upgrade to the kitchen units. The manager must be provided with appropriate office space, which must afford privacy and have access to outside ventilation and light.

CARE HOMES FOR OLDER PEOPLE Lyndhurst Residential Home Lyndhurst Road Goring On Thames Reading RG8 9BL Lead Inspector Andy McGuckin Unannounced Inspection 7th December 2005 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 Home DS0000013107.V270131.R01.S.doc Version 5.0 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.V270131.R01.S.doc Version 5.0 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 873397 Lyndhurst (Goring) Limited Kathleen Hayman Care Home 23 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (23) Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 23. 30th August 2005 Date of last inspection Brief Description of the Service: Lyndhurst Residential Home is a residential home registered for 23 older persons who require personal care and accommodation. 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. Staff are being provided in adequate numbers to enable care to be provided in a relaxed manner, taking account of service users’ privacy and dignity. The inspector was informed that the chef had been commended by the Environmental Health Officer for the standards maintained in the kitchen. She will be given a special merit award. This is despite the fact that the kitchen is in need of modernisation. The environmental improvements that had been planned for the home have been turned down by the planning department and the proprietor will be asked to forward a plan of proposed improvements to the Commission. The main requirement from the last inspection regarding medication has now been resolved to the inspector’s satisfaction. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on a mid-week morning. The inspector toured the building and had informal contact with the residents and staff. The inspector paid special attention to the medication of residents and examined the medication and recording for each resident in the home. No errors were found on this occasion. The inspector was informed that systems had been put in place to ensure that previous poor practice had been addressed. The inspector examined all residents’ care plans and associated documentation and found them to be satisfactory. The inspector has made two requirements and a recommendation. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 6 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.V270131.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The home provides residents with comprehensive information on which to make a decision. Standard 6 is not applicable to this home. EVIDENCE: The above standards have been assessed as met at the last inspection; no changes have been made to these policies. Standards 1-5 remain met. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 The health, social and personal care needs of residents are being met. EVIDENCE: The inspector looked at a random selection of service user care plans and found that information contained in the care plans was both informative and written in appropriate language. Evidence was found that where possible residents’ health care needs are being met. Records are kept of visits to health care professionals. Professional advice regarding residents’ health is being implemented. Previous problems with the recording and distribution of medication were found to be resolved at this inspection. The manager must ensure that this remains the same. Residents were observed being treated with respect. Information held on residents is kept in a confidential manner and shared on a need to know basis. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The home offers its residents a range of activities within and external to the home. EVIDENCE: Evidence was found at inspection that residents who were willing and able to participate in activities were given the opportunity to do so. Residents and their guests were invited to a buffet provided by the home last week. Fifty-two people attended and feedback deemed it a great success. The inspector was informed that a carol concert was to take place the following evening. The home should record activities taken on a month-by-month cycle as evidence for inspection. The chef takes great pride in the food provided and the inspector has been impressed on many occasions by the presentation and content of the meals provided within the home. On the day of the inspection Roast Beef with fresh vegetables was the main menu item with an alternative available. Despite the fact that the kitchen is showing signs of wear and tear a recent Environmental Health Inspection made very minor recommendations and has awarded the chef a Certificate of Merit. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has policies and procedures to enable residents or their representatives to complain. EVIDENCE: The inspector was shown a recent formal complaint made to the home. The complaint had been dealt with in a timely manner and to the satisfaction of the complainant. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The home is in the main well maintained and provides a comfortable environment for its residents. EVIDENCE: The home has been expecting to make significant structural changes to the building in order to improve its usage. Plans submitted have been turned down due in part to neighbours objecting. Therefore any major works required have been put on hold pending this approval. It is now important for the home to notify the Commission on its plans for future improvement especially in the light of the last inspection report with regard to office space. The inspector is of the opinion that this can be required of the home under Regulation 23 (3). As has been previously mentioned the kitchen is showing signs of wear and would have been upgraded if planning had been granted. The inspector requests that a plan of future works be forwarded to the Commission. A tour of the building did not highlight any significant health and safety issues. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. The home’s recruitment practice must be tightened up and include trackable information. EVIDENCE: Staff files inspected varied in content with many of the overseas staff having very limited information about past employment, education and training. This information is vital to the recruitment process and must contain sufficient information to check on an applicant’s past. Verbal references must be followed up by a written reference from the last employee and be presented on the company paper or stamped with the company name. Evidence was found at inspection that staff are trained, supervised and managed appropriately. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,38 The above standards have been assessed as met at the last inspection and remain the same with the exception of Standard 38. EVIDENCE: Standards 36 and 37 have been commented on in the previous section under Standard 29. During the inspection the fire alarm went off. Staff reacted in the way that they had been instructed. The inspector observed several of the residents being frightened and confused as the fire doors were automatically closing and the bell were ringing loudly. There were no staff available to provide reassurance till much later when the staff returned from doing their part in the fire drill. The manager was not on the premises at the time as she had left to collect a prescription. The inspector would recommend that the fire drill be reviewed to take account of residents’ anxieties. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 X X 3 Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 15 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 2 Standard OP19 OP29 Regulation 23 17 Requirement The proprietor must forward a plan of future works to the Commission. The manager must ensure that information held on staff files is sufficient to be checked for accuracy. Timescale for action 01/01/06 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The manager keeps a record of all social activities held. Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lyndhurst Residential Home DS0000013107.V270131.R01.S.doc Version 5.0 Page 17 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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