Inspection on 11/07/06 for Lyndon Croft Care Centre

This inspection was carried out on 11th July 2006.

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

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

Other inspections for this house

Lyndon Croft Care Centre 21/01/08

Lyndon Croft Care Centre 28/02/06

Lyndon Croft Care Centre 26/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lyndon Croft Care Centre Ulleries Road Solihull West Midlands B92 8ED Lead Inspector Lisa Evitts Unannounced Inspection 11th July 2006 09:20 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 Lyndon Croft Care Centre DS0000063159.V301006.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. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyndon Croft Care Centre Address Ulleries Road Solihull West Midlands B92 8ED 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) 0121 742 3562 0121 742 3562 lyndoncroft@prime-life.co.uk Prime Life Ltd Vacant Care Home 52 Category(ies) of Dementia - over 65 years of age (52) registration, with number of places Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered to provide care for up to 52 older people for reasons of dementia 52DE/E For full occupancy, 7 care workers are to be on duty throughout waking hours, including one of whom is designated as a senior member of staff. For full occupancy, 3 care workers are to be on waking duty throughout night time hours, including one of whom is designated as a senior member of staff That the home may accommodate 1 named service user who is in need of care for reasons of old age. Registration Category 1(OP). 28th February 2006 4. Date of last inspection Brief Description of the Service: Lyndon Croft first opened in January 2005 and is a custom built facility owned by Prime Life Ltd providing residential care for 52 older people over the age of 65 years with dementia care needs. The home is spacious and accommodation is provided over two floors. All bedrooms are for single occupancy with an en suite facility that includes a walk in shower. The home has assisted bathing facilities and toilets throughout which meet the needs of the residents living at the home. Hoisting equipment is available for residents who are assessed as requiring this assistance. Corridors are wide and spacious and allow residents to move around the home freely and safely. All rooms offer an excellent standard of accommodation and include all of the furnishings and fittings as required by the National Minimum Standards. The ground floor rooms have an adjoining patio and there is an attractive enclosed garden for all residents to enjoy, which is easily accessed. There are numerous lounge and dining areas in the home and these have all been furnished and equipped to a high standard. Meals are cooked on site and the home offers a full laundry service for people living there. The home has one passenger lift and one service lift. In the reception area of the home there is a TV, which gives information about staff on duty and menus for the day. Copies of the previous reports written for the home are available from the manager upon request, should anyone wish to read them and discuss the findings. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 5 There is ample car parking space to the front and side of the building. The home is located in a residential area of Solihull and is close to shops and public transport links. Residents are permitted to smoke at the home following individual assessments. All beds are contracted with Solihull Metropolitan Borough Council and the current charges for living at the home are £400 per week. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was undertaken by two inspectors over one full day and was assisted throughout by the Manager. There were 45 residents living at the home on the day of the visit and three residents were receiving hospital treatment. It was not possible to gain direct feedback about the home from residents spoken to and information was gathered from observing residents and from observing care staff perform their duties. Care and health and safety records were reviewed along with medication procedures. Staff files were sampled and a partial tour of the building and garden was undertaken. Prior to the inspection the compliance officer had completed a pre inspection questionnaire and returned it to CSCI, and this gave some information about the home, staff and residents that was also taken into consideration. Since the last fieldwork visit to the home, there had been a brief suspension of placements on the home by Social Care and Health, following an adult protection concern. The organisation had worked hard to implement changes to prevent further concerns being raised and the home was able to accept admissions again. One healthcare professional stated at a recent meeting “the home was the best it had ever been” One immediate requirement was made on the day of the fieldwork and the manager sent confirmation the following day that remedial work had been completed to meet this requirement. What the service does well: Resident’s general health and personal care needs are well met by the care staff and they are supported in a respectful manner. Residents are enabled to make choices about their daily routine, activities they wish to participate in and whether they wish for their bedroom doors to be locked and this promotes their independence. There are a variety of activities on offer for resident to participate in if they choose and outings are arranged fortnightly to encourage links with the community. The home has an open visiting policy and this means that residents can see their visitors at anytime. The home is spacious and enables residents to walk around the home freely in a safe environment. Equipment is available to assist residents with decreased mobility to move safely around the home. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 7 The systems for managing resident’s personal finances are robust and ensure that resident’s monies are safeguarded. What has improved since the last inspection? What they could do better: The home must send letters of confirmation following assessment, so that residents and their representatives know that the home can meet their needs. Care plans for short term problems and specific medical needs must be written to ensure that staff are provided with instructions to follow. Auditing and administration of boxed medicines needs to be improved to ensure that residents receive their medication as prescribed. Laundry staff must be aware of infection control procedures in order to safeguard themselves from harm. They must have training in use of equipment to prevent any cross infection occurring within the home. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 8 Full recruitment checks had not been carried out on all members of staff and this lapse in following procedures could potentially pose a risk to resident’s safety. The home must ensure that all staff receive mandatory moving and handling training annually, to ensure they are competent to perform safely within their role. The home must develop a formal quality assurance system to ensure that the opinions of residents, staff, representatives and external stakeholders are sought in order to provide a continuing improving 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. Lyndon Croft Care Centre DS0000063159.V301006.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 Lyndon Croft Care Centre DS0000063159.V301006.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 The quality outcome of this area is poor. This judgement has been made using available evidence including a visit to the service. The assessment process is comprehensive and ensures that the home can meet the needs of the residents prior to admission, with the exception of a recent admission into the home. Residents are not informed in writing that the home can meet their assessed needs. EVIDENCE: Two recently admitted resident’s files were sampled and one was found to contain a very comprehensive pre admission assessment. The second file did not have a pre admission assessment, as the documentation was not taken to record the information. Some notes were made on the referral form to the home but this does not ensure that a complete assessment of needs is recorded and does not ensure that staff know they can meet the needs of the residents prior to admission. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 11 The manager does not confirm in writing to prospective residents that the home can meet their assessed needs and this needs to be implemented as per the regulations. The home does not offer intermediate care services. Lyndon Croft Care Centre DS0000063159.V301006.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s health and personal care needs are generally well met by the care staff. The new care planning system in the home was good and needed to be put in place for all residents detailing how their individual needs are to be met. Medicine management requires some improvements to ensure it is safely administered to residents. EVIDENCE: Each resident has a care plan written. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the resident to maintain their needs. At the time of the last fieldwork visit the manager had introduced a new set of documentation to the home, and it is pleasing to see the progress made with the use of these. Two recent admissions into the home had very detailed plans of care and evidence of reviews being sought from external healthcare professionals. Mobility risk assessments were written and gave good details of care needs for staff to follow. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 13 Mental health care plans gave good details of challenging behaviour and gave details of triggers, which may start this behaviour, for staff to look out for. For example one care plan stated “behaviour is affected by being hurried, ensure time is given when completing personal care tasks” and this minimises the potential of challenging behaviour occurring. Individual risk assessments were seen for residents who chose to smoke and these minimised any risks to the residents and the home while enabling residents the choice to continue to smoke. A care plan around eating and drinking identified that a soft diet was required while waiting for new dentures and the evaluation of this was good as provided an outcome that the resident had received the new dentures and was now eating a normal diet. Nutritional risk assessments were completed every three months and this ensures monitoring of residents weight is taking place. Food charts and fluid balance charts were in place for residents who were assessed as requiring close monitoring for poor appetite. There is evidence of visits from external healthcare professionals such as G.P, Community Psychiatric Nurses, Opticians and District nurses. The GP was seen to visit the home during the fieldwork inspection and was called back to the home later in the day to review a resident and this shows that staff are seeking the advice of other professionals. The GP reviews two or three residents each week in addition to those residents he has been asked to see and this ensures that residents who do not require the GP do not get overlooked and ensures that their medication is also reviewed. Two longstanding resident files were reviewed and these were in the process of being changed over to the new documents, and did not contain all the relevant information as the two recent admissions had, however it is recognised that progress is being made. The manager must ensure that previous care plans are available for staff to follow until the new plans are written to ensure that staff have some guidance to follow in order to meet the assessed needs of the residents. Risk assessments for manual handling, nutrition and skin sores must also be available so that staff have information to follow to meet the needs of individual residents. The district nurses see residents who are diabetic and require their blood sugars monitoring. Staff at the home will test blood sugars if they require monitoring more than once a day and they take their instructions from the nurses. There is evidence of follow up from the nurses when blood sugars have been fluctuating. Care plans around the monitoring of blood sugars and details of what action staff are to take are required in order to ensure that staff have the knowledge to deal with an unstable blood sugar appropriately, this was available on one plan of care but was not consistent on other files, where residents had diabetes. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 14 One resident had been commenced on antibiotics but there was no care plan written for the short-term problem and this does not ensure that all staff receive the information about a change in care. Daily records were very detailed with behaviours, how the residents had spent their day, visitors received and any changes in condition recorded. There was evidence on files that residents are asked if they wish to have their bedroom doors left open and this enables the residents to make their own choices. Residents were well presented and were appropriately dressed for the time of year. Staff were seen to interact well with the residents. The management of medication was reviewed. Fridge temperatures are recorded twice daily and were within acceptable ranges to ensure that drugs were stored within their product licences. The supplying pharmacist had recently undertaken a six-month audit and had requested that room temperatures are also recorded and the manager had yet to implement this. Controlled drug storage was good and audits were correct. There were a number of identity photographs missing from the Medication Administration Records (MAR) and this does not ensure that residents can be safely identified prior to medication administration, particularly as the residents have dementia and are not always able to confirm their names. Six residents medications were reviewed. One resident’s drugs had not been signed in on receipt and therefore there was no audit trail to follow. Variable dose mediactions must clearly identify how many are being administered in order to provide an audit trail and to monitor their effectiveness. Medications administered from blister packs were good however medications in boxes found some discrepancies on auditing, where residents had not received some doses of their prescribed medication. Boxes of paracetamol found discrepancies and this is most likely due to staff using any box and not the one prescribed for the resident. Staff must ensure they use the medication issued to each resident and carry over any tablets to provide accurate audit trails. The manager has not completed any recent staff drug audits to ensure the competence of staff in drug administration and this now requires attention, as has been an ongoing requirement since August 2005. Lyndon Croft Care Centre DS0000063159.V301006.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,12,14 & 15 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their individuality. Residents receive a wholesome and varied diet, which meets any special dietary needs. EVIDENCE: There are a variety of activities on offer and this includes painting, sing a longs, board games, baking, nail care, quizzes, music and exercises. A volunteer was due to start at the home and would be working with residents to do flower arranging. The hairdresser visits every week and the local church visits the home. There is no dedicated activities co coordinator and the staff assist residents with their interests. The organisation has its own bus and this comes to the home once a fortnight and takes a group of residents out in the morning and a different group in the afternoon, this ensures that residents who are able still maintain a contact with the local community. In the main entrance area of the home there were a number of photographs on display of trips to the park, pub lunches, pancake shopping and Valentines Day, which the residents had participated in. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 16 During the tour it was pleasing to see drawings and paintings that residents had made on display on the walls. One resident was sitting in the lounge in the afternoon with a large pack of felt tip pens and was enjoying colouring. Other residents were out in the garden enjoying the sun and staff were monitoring how long residents were sitting outside in the direct heat of the day to prevent them becoming dehydrated or suffering from heat exhaustion. The manager stated that one of the residents enjoyed gardening and watered the garden each morning with the hosepipe, therefore continuing previous interests. Residents are able to go out with their friends and family as they wish and the home has an open visiting policy, which means that residents can see their visitors as they choose. One resident attends a Dementia Care day centre twice a week and this promotes their independence and maintains links made previously with the community. The activities folder was reviewed and staff had recorded group and individual activities, however staff must ensure that they record all activities that residents participate in as there was a gap of five days where no entries had been recorded and this does not show what activities residents had taken part in. Menus are different each week and offer some choices for residents. Breakfast is a choice of cereals, toast, porridge and fruit, cooked breakfasts are not on the menu but this would be arranged if requested. Four weeks menus were reviewed and these did not always offer two choices of meal, the manager stated that alternatives of sandwiches or salads were available if preferred but this was not identified on the menu and residents may not be aware of this. The home is able to cater for special diets to meet any medical or cultural needs, including soft and pureed foods for residents who have swallowing difficulties. Food records were kept for residents who required specific monitoring but not for each resident as required by the Regulations and the home must implement this in order to provide an audit trail of what the residents have eaten. Lyndon Croft Care Centre DS0000063159.V301006.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedure is comprehensive and is accessible to residents and their representatives should they wish to make a complaint. To ensure the safety of residents the adult protection procedure needs to be further developed so that staff have guidelines to follow in the event of an allegation of abuse. EVIDENCE: The home has a comprehensive complaints procedure in place, which is accessible to residents and their representatives if they should wish to make a complaint. Since the last fieldwork visit, the home had received one complaint regarding missing laundry. Documentation of complaints had improved and now records actions taken to resolve the complaint. The complaint was still being investigated at the time of the fieldwork however the manager stated that the home would reimburse the resident if the clothing could not be found. The home had obtained a copy of the Solihull Multi Agency guidelines, which gives details for staff to follow in the event of an allegation of abuse. Staff have received training in the Protection of Vulnerable Adults and this ensures that staff have the appropriate knowledge and skills to act upon any allegations of abuse. The homes adult protection policy incorporated the Department of Health’s publication “No secrets” however required amendments Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 18 to include contact details of social services and CSCI, to ensure that staff have relevant information available. Social Care and Health had recently placed a suspension on placements at the home following an adult protection concern in which staff had failed to seek the appropriate medical treatment for a resident. The managers had worked hard to address the problems and the suspension had been lifted, allowing new residents into the home. Lyndon Croft Care Centre DS0000063159.V301006.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 & 26 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Lyndon Croft provides a homely, comfortable and clean environment to live in where residents appeared relaxed. The procedure practised by staff for the laundering of soiled items was not always safe and may pose a risk to staffs’ health. EVIDENCE: Since the last fieldwork visit the manager has moved into the office just off the reception area and this allows her to be more accessible to visitors to the home and to any family who may wish to see her. Corridors are wide and spacious and allow residents to move throughout the home as they wish, in a safe environment. Handrails are available throughout the corridors to assist those with limited mobility. It was pleasing to see that a number of new pictures had been put upon the walls as this gives something of interest for residents to stop and look at. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 20 The home has five assisted bathrooms and each en suite includes a walk in shower facility that is appropriate to the needs of the residents. Assisted bathrooms have raised toilet seats and handrails around the toilet to help residents use the facilities safely. One of the bathrooms did not have a paper towel dispenser and therefore did not provide hygienic hand washing facilities in order to minimise the risk of infection. The nurse call facility was positioned too far away from the toilet for residents to reach and this did not ensure that residents could call for assistance as required. Both of these points were brought to the attention of the manager and she confirmed after the fieldwork visit that these had been rectified and this will be reviewed at the next fieldwork visit to the home. The bath was soiled and this was brought to the attention of the manager who arranged for it to be cleaned appropriately. Two of the bathrooms were being used for storage, one of them was observed to be left open by a member of staff whilst attending to a resident, then the staff member returned to lock the door. COSHH products were stored in this room and staff must ensure that the door is locked at all times to prevent any accidents occurring with hazardous items. The home has an attractive accessible garden area and residents were walking around the garden freely. There was a trailing hosepipe and this was a potential trip hazard for residents and staff must ensure that the hosepipe is rewound after use to minimise the risk of anyone tripping over it. The manager has further developed the garden risk assessment and this shows the home to be proactive in preventing harm occurring to residents. Two windows for one of the ground floor bedrooms had broken and missing window restrictors and an immediate requirement was made for them to be repaired to ensure the safety of the residents. The manager informed CSCI the following day that the repairs had been undertaken and this will be reviewed at the next fieldwork visit. The home has many seating areas, which the residents can choose to use and a range of seating is available. Fabric on some of the seating had become soiled and the manager must ensure that the seating is cleaned or replaced to ensure a clean environment for residents to live in. The manager stated that more chairs had been ordered for the home to provide clean and adequate seating facilities. Bedrooms seen were personalised and the doors have doorknockers for use on entering rooms. Some rooms had photographs on the door of the occupants to assist them to find their rooms but this was not evident for all residents and it was not clear how the residents would identify their rooms. The manager stated that memorabilia boxes have been ordered for resident’s doors, which will assist residents to identify their own rooms. Residents are able to keep their doors unlocked if they choose so that they can access their rooms as they choose to. It is recommended that the door handles are reviewed for suitability of the residents needs. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 21 A recent Environmental Health Inspection report stated that “Standards were high at the time of inspection” and this ensures that the residents are living in a safe environment where potential for infection is minimised. Improvements had been made to the overall cleanliness of the home since the last fieldwork visit and the home was odour free providing residents a clean and homely environment in which to live. The home had two washing machines, which included sluice cycles, but laundry staff were manually sluicing soiled items of residents’ personal items. The staff member was recently appointed and was not aware of the use of alginate bags in line with good infection control procedures and the staff must have training in this to protect themselves from harm. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 The quality outcome of this area is poor. This judgement has been made using available evidence including a visit to the service. The home had adequate numbers of staff on duty to meet the assessed needs of the residents. The recruitment process fails to ensure that all appropriate checks are in place prior to staff commencing work and this does not ensure that residents are adequately protected from harm. EVIDENCE: At the time of the fieldwork the home was fully staffed, and rotas reviewed were found to indicate adequate numbers of staff were on duty to meet the assessed needs of the residents. Sickness was clearly identified on the rotas. The staffing rotas do not identify the surnames of staff working at the home and the manager stated that she had devised a new rota to be able to record this information but the new rota style was not accepted by the head office and had to return to the original system. The person in charge of the night shift is now identified on the rota on each floor and this ensures that staff and residents know who has overall responsibility for the shift. Laundry staff work over seven days and this ensures that laundry is kept up to date and assists with a more timely return of clothing back to the residents. Domestic staff support the home and the amount of hours allocated for domestics must continue to be reviewed in order to ensure that the home is Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 23 kept clean and comfortable for residents to live. There are currently no allocated domestic hours over the weekend and night staff have cleaning duties to assist in the cleanliness of the home. The home currently has fourteen members of staff who have completed NVQ Level 2 and a further two staff are awaiting their certificates of completion, this ensures that the home has at least 50 of staff who hold this qualification in order to ensure that residents receive care from well-trained and competent staff. Recruitment practice was poor and does not ensure that residents are safeguarded from harm. Four staff files were reviewed. One file did not have a reference returned from the last employer until after they had commenced work at the home and the PoVA first check was confusing as was dated before the application form was filled in. A second file reviewed did not have a new application form or recent references for the member of staff who had worked at the home previously, left and now returned to the home. Another file reviewed only had two verbal references, with one written one received after commencing employment at the home. A PoVA first check had not been received until three weeks after commencing employment and this does not afford protection to residents living at the home. It is required that PoVA first checks and two written references are received for all staff prior to them commencing employment at the home in order to ensure the safety of the residents. The manager was not fully responsible for employing staff at the home and she is informed by head office when someone can start employment at the home, after they have collated the information. The manager must be sure that all the appropriate checks are in place before giving new employees a start date, to ensure safety of the residents. The organisation had sent a copy of a recent staff file audit and this had highlighted a number of missing recruitment documents from files, this was prior to the current manager being employed. The home had sent for missing references and Criminal Records Bureau checks in order to ensure the files contained all the information as required by the Regulations. The staff-training matrix was reviewed and showed that staff had received recent training in fire, food hygiene, moving and handling, COSHH and first aid. Sixteen staff had completed a distance-learning course on Dementia Care and the home were trying to source further courses for staff, to ensure they had the training to meet the care needs of residents with Dementia. The training matrix identified that six members of staff had not received manual handling training since December 2004 and the manager must ensure that staff receive yearly updates to ensure that their knowledge is up to date in order to protect both staff and residents from harm. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 24 Medical questionnaires were available however there was no evidence that these had been queried, were required, in order to ensure that the staff were fit for the purpose of the role they were applying to undertake and would be able to meet the requirements of the residents. One file had evidence of induction training however only some of the information had been completed and the book had not been signed off as completed. This does not ensure that staff have been given appropriate guidance and training to ensure they have the basic knowledge to perform well within their roles. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 25 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): 31,33,35, & 38 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. There is a robust system in place for the management of personal finances. While the home has mechanisms in place for feedback from residents and representatives the home must develop a quality assurance system to ensure a consistent improving standard. There is a robust system in place for the management of resident’s personal finances. EVIDENCE: The manager has been in post for eight months and has submitted her application form to CSCI to become the Registered Manager of the home. She has previous experience of managing homes and has been the Registered Manager of other establishments. She has the Registered Managers Award and is working towards her NVQ Level 4 in Care. The manager has recently achieved a certificate in ‘Positive Dementia Care’ and this shows she is keen to Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 26 continue to learn and develop new skills in order to care for residents at the home. Following the suspension on placements by Social Care and Health, the management structure has been reviewed and a Hotel Services Manager role has been implemented. This manager takes care of all non-clinical areas such as kitchen, domestic and laundry, which allows the home manager more time to spend on clinical care and enables her to work alongside staff “on the floor”. Both managers take part in an on call rota and work weekends to ensure that there is always a manager available for staff to refer to. The home manager has also started to work some night shifts in order to ensure that the nighttime care delivery is of the same standard as during the day and to provide support to the night carers. There is currently no formal quality assurance system in place. The company send out questionnaires twice yearly and speak with residents, the responses are collated into a report each year, however no audit has taken place at Lyndon Croft, as a previously arranged date had been postponed. The home must address this as it must demonstrate that views of residents, representatives and external stakeholders are taken into account and action plans drawn up to ensure a consistent improving service. External Managers support the Registered Manager by visiting the home and also complete Regulation 26 visit reports regarding the service provided by the home, this ensures that staff and residents views are listened to and acted upon, and that the home continues to make improvements. Copies of these reports were available at the home for review. Senior carer meetings are now being held once a month and a recent staff meeting had been held at the home. This gives staff the opportunity to discuss any concerns and managers to discuss any areas for improvement to ensure resident’s needs are met. Minutes of the meetings were available for review. A relatives and friends meeting was planned for the near future and this will enable residents and representatives the opportunity to express any opinions, concerns or ideas on how the service is performing. The home currently manages the personal monies of ten residents. The system was found to be robust with two signatures for debits and credits and receipts available. Balances checked were correct. The head office audits personal finances and this had last been completed in February, this ensures that resident’s money is safe and secure and that any discrepancies would be highlighted. Maintenance records were reviewed and servicing had taken place for hoists, legionella, fire alarms, emergency lights, nurse call system, five yearly wiring, passenger lift, and gas safety and this ensures that equipment is safe for staff Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 27 and residents to use. It is recommended that Portable Appliance Testing is completed yearly to ensure the equipments safety. Water temperature checks were completed and recorded monthly and this ensures that the water is at a safe temperature to prevent residents from scalding. Fire alarms are tested on a weekly basis and fire doors are examined each month along with emergency lighting checks. A recent fire drill had been undertaken at the home and this had been documented along with staff that had attended. It is required that night staff also take part in at least two fire drills per year and the manager must arrange this, in order to ensure that staff know the procedure to follow in the event of a fire and protect the residents. On the ground floor there is a coded lock to the fire escape but the fire door itself is not alarmed to alert staff should a resident manage to gain access to this area. It is required that the manager liaise with the fire officer for advice on alarming the door to ensure that staff would be aware of a resident leaving the building through this door in order to ensure their safety. The garden risk assessment required further development to include other identified hazards around the garden such as the gravel paths and trailing hosepipes, which could be a potential trip hazard. The manager sent a copy of the revised risk assessment to CSCI the day following the fieldwork visit. The accident reporting procedure had been reviewed and staff now write an incident report, which is passed, to the manager who then records into the accident book. This ensures that the manager reviews all accidents/incidents. There was good evidence of reviews and comments were recorded such as ‘had an infection at the time of fall’. This is good practice as shows evidence that review of accidents is undertaken to try and identify any trends and reduce the risk. It is recommended that a monthly audit is documented to clearly identify any trends without having to go through the accident book. It is recommended that an alternative accident book is sought for recording of accidents as the current book contains five separate incidents on one page and this does not ensure that resident’s information is kept confidential. Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 28 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 4 2 4 X 3 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 29 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. 2. Standard OP3 OP4 Regulation 14(1)(a) 14(1)(d) Requirement Pre admission assessments must be completed for all residents prior to admission. The manager must confirm in writing that the home can meet the assessed needs of the resident. The care planning system must be further developed to include the following: Evidence of involvement of residents or their representatives in agreeing the care plans. Previous timescale of 01/10/05 & 23/05/06 partially met. Care plans, falls risk assessments, Moving & Handling assessments, Tissue Viability assessments must be available for staff whilst new care plans are being written. Specific instructions for residents with diabetes must be documented. Staff must ensure that any new DS0000063159.V301006.R01.S.doc Timescale for action 15/08/06 19/09/06 3. OP7 15 06/10/06 4. OP8 15(2)(b) 22/08/06 Page 30 Lyndon Croft Care Centre Version 5.2 5. OP9 13(2) 6. OP9 13(2) 7. 8. OP9 OP9 13(2) 13(2) 9. 10. OP12 OP15 15 16(2)(n) 17(2)Sch 4 11. OP18 13(6) 37 12. OP19 13(4)(c) identified problems are recorded on a plan of care to ensure that progress is monitored and an outcome recorded. (Previous timescale of 21/04/06 not met) The quantity of medicines received (or balance carried over from previous cycles) must be recorded on the Medicine Administration Record (MAR) chart to enable accurate audits to be undertaken. (Previous timescales of 28/07/05 & 24/04/06 not met) Regular staff drug audits must be undertaken before and after a medicine round to confirm staff competence in the administration and recording of medicines. (Previous timescale of 02/08/05 & 30/04/06 not met) Variable dose mediactions must have the actual amount administered recorded. All residents must have an identity photograph to assist with the safe administration of medicines. All activities residents participate in must be recorded. A daily record of food provided for residents must be kept in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual residents. (Partly met) The adult protection policy must include contact details of the local authorities and CSCI. (Previous timescale of 31/03/06 not met) The identified bathroom must DS0000063159.V301006.R01.S.doc 19/09/06 09/10/06 08/09/06 31/07/06 25/09/06 15/09/06 22/09/06 28/07/06 Page 31 Lyndon Croft Care Centre Version 5.2 13. 14. OP19 OP25 15. OP26 16. OP29 17. OP29 18. OP30 19. OP30 20. OP33 have: A paper towel dispenser A call facility within reach (The manager informed CSCI that these had been actioned) 16(2)(j) Fabric on seating must be reviewed to ensure it is clean or replaced. 23(2)(b)(c Window restrictors on an ) identified room must be repaired to ensure the safety of the residents. (The manager received this as an immediate requirement) (Informed CSCI that remedial work has been completed) 16(2)(j) Laundry staff must have training 18(1)(i) relevant to their role and must have training in infection control procedures. 13(6) Staff must not commence 19(1) employment at the home without satisfactory POVA first checks being received. (Previous immediate requirement timescale of 28/02/06 not met) 19(1) The Registered Person must obtain two appropriate satisfactory written references for all staff prior to them commencing employment at the Home. (Previous immediate requirement timescales of 26/07/05 & 28/02/06 not met) 18(1)(c) The manager must ensure that (i) all staff have received mandatory training, for moving and Handling. (Previous timescale of 30/04/06 not met) 18(1)(c)(i The manager must ensure that ) induction booklets are signed once completed to ensure that all aspects of induction training have been completed. 24 A quality assurance audit must DS0000063159.V301006.R01.S.doc 16(2)(j) 18/09/06 13/07/06 15/09/06 31/07/06 31/07/06 29/09/06 09/10/06 31/10/06 Page 32 Lyndon Croft Care Centre Version 5.2 21. 22. 23. OP36 OP38 OP38 18(2) 22(4)(e) 22(4) be undertaken and a report must be available. (Previous timescale of 02/06/06 not met) A written record of formal staff 01/10/06 supervision must be kept. (Not assessed on this occasion) Night staff must participate in 29/09/06 fire drills. The manager must liaise with the 23/10/06 fire officer regarding the ground floor fire door being linked into the alarm system. 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 OP9 Good Practice Recommendations Staff should install a facing page for each service users Medicine Administration Record (MAR) chart and all page numbers must be written for each MAR chart. E.g. 1 of 2, 2 of 2 and the photocopied prescription kept alongside the MAR chart for future reference. (Not assessed on this occasion) Room temperatures were medications are stored should be recorded. Menus should detail alternatives available to ensure that residents are informed of choices available. It is recommended that bedroom door handles are reviewed and meet the resident’s needs. The home should continue to work towards achieving 50 of care staff that have NVQ Level 2. It is recommended that interview notes are kept in order to evidence the information that is given and received in respect of prospective employees during their interviews. It is recommended that Portable Appliance Testing is completed annually. The Manager should audit all accidents monthly. It is recommended that an alternative accident book is sought to record any accidents. (Previous recommendation) DS0000063159.V301006.R01.S.doc Version 5.2 Page 33 2. 3. 4. 5. 6. 7. 8. OP9 OP15 OP19 OP28 OP29 OP38 OP38 Lyndon Croft Care Centre Lyndon Croft Care Centre DS0000063159.V301006.R01.S.doc Version 5.2 Page 34 - 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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