Inspection on 26/07/05 for Lyndon Croft Care Centre

This inspection was carried out on 26th July 2005.

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

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

Other inspections for this house

Lyndon Croft Care Centre 21/01/08

Lyndon Croft Care Centre 11/07/06

Lyndon Croft Care Centre 28/02/06

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 Lead Inspector Amanda Lyndon Announced 26 July 2005 th 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 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 E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lyndon Croft Care Centre Address Ulleries Road Solihull West Midlands Telephone number Fax number Email 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 Prime Life Ltd Sheila Naisbitt Care Home 52 Category(ies) of Dementia- over 65 years of age (DE(E) registration, with number of places Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered to provide care for up to 52 older people for reasons of dementia 52DE/E. 2. 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. 3. 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. 4. That the home may accommodate 1 named service user who is in need of care for reasons of old age. Registration Category 1(OP). Date of last inspection This is the homes first 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. All beds are contracted with Solihull Metropolitan Borough Council. The home is located in a residential area of Solihull and is close to shops and public transport links. 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. 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. 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. There is ample car parking space to the front and side of the building. Residents are permitted to smoke at the home following individual assessments. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the first statutory inspection undertaken at the home by CSCI and the inspection was undertaken by two Regulation Inspectors and the Pharmacist Inspector over one day and were assisted throughout by the Registered Manager and the new Home Manager. Information was gathered from speaking to residents, staff, observing residents throughout the day, observing care staff perform their duties, examining care, medication and health and safety records and a full tour of the premises was undertaken. There were 42 residents living at the home on the day of the inspection and 7 of these people were currently in hospital. CSCI did not receive any completed comment cards about the service provided at Lyndon Croft. It was pleasing to note that although the home had only been in operation for a short period of time, the atmosphere within the home on the day of the inspection was one that instilled confidence in anyone visiting there that the staff were working competently within their job roles and the vast majority of residents appeared to be settled within their home environment. What the service does well: Lyndon Croft has quickly established itself as providing a good quality of care for older people with dementia care needs and all of the residents and staff met during the inspection expressed their satisfaction in respect of the service provided at the home. Residents’ general health and personal care needs are well met by the care staff and they are supported in a respectful manner. There is a range of activities for residents to participate in and a recent trip to the safari park had been successful. Visitors are welcomed to the home. One resident said “ My family are always made to feel welcome by the staff when they visit me here”. Residents can exercise choice over their daily lives and can personalise their bedrooms to reflect their individual tastes. One resident said, “ I chose my own room here and I’m very happy with it”. Residents receive a wholesome and nutritious diet, which meets any dietary needs, and mealtimes are relaxed and unhurried to allow residents the time to enjoy their meals. One resident said “ I’m always served a snack at bedtime”. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 6 Lyndon Croft is a spacious, secure and clean home to live in and residents are free to walk around as they wish. The use of different colours has been used to assist residents in identifying their location within the home. An appropriately trained and competent work force is being established at the home to ensure that a good standard of care is being provided. The home generally maintains adequate staffing levels and do not use agency staff and this ensures continuity of care. One resident said, “ The staff are very nice here”. Another resident said, “ If I need the staff I press my buzzer and the staff come and answer it to help me”. 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. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 8 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 standard(s) 1, 2 & 3 Prospective residents and their families have enough information to enable them to make a choice about whether or not they may wish to live in the home and normally know before admission that the home can meet their care needs. EVIDENCE: The Organisation had produced a comprehensive statement of purpose and this included all information as required by Regulations and was accessible to all interested people. Residents were issued with statements of terms and conditions of residency and these included the room number to be occupied. One resident said, “ I chose my own room here and I’m very happy with it ”. Pre admission assessments were undertaken using a comprehensive assessment document for prospective residents coming to live at the home, however it was not always identified on the assessment whether these had been undertaken prior to or actually on admission as the date of assessment was often the same date as that of the admission and the location that the assessment was undertaken was not documented. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9 & 10 Residents’ health and personal care needs are well met by the care staff and the care planning system was generally good as a baseline and now requires further development in order to ensure that staff know the individual needs of the residents and how these are to be met. Residents and visitors are at risk because appropriate advice from Social and Healthcare Professionals was not sought for one resident. Medicines are generally safely managed within the home. More attention to detail is sometimes needed to ensure the systems and records necessary to demonstrate the correct use of medicines are available. Residents are cared for in a respectful manner to ensure that their dignity is maintained. EVIDENCE: The care planning system was being developed and this evidence is based on a sampling of four residents’ care plans and the information available on the day of the inspection. Comprehensive assessments had been completed in respect of residents’ care needs on admission and these included information about the life history of residents. Care plans and personal risk assessments had been derived from the Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 10 assessments undertaken and a number of these identified residents’ personal preferences in respect of their daily routines. In particular care plans for agitation and verbal aggression included good detail of the actions to be taken to reduce this type of behaviour. Personal risk assessments undertaken included managing the risk of falls and nutrition, however the risk of developing pressure sores had not always been identified. Care plans in respect of oral hygiene needs and some specific care needs of residents had not been written. Care plans evaluations were recorded in good detail, however, not all care plans had been evaluated each month, a number of these had not been signed by staff and there was no evidence of resident and/or their relatives’ involvement in the agreeing or reviewing of these. Residents’ assessments and daily reports identified a wide variety of personal interests and hobbies, however this information had not been developed into personalised activity care plans and these did not include the full name of the staff member completing them. Residents have the option of retaining their own General Practitioner on admission to the home (if the GP is in agreement) and have access to other Social and Health Care professionals, for example, Social Workers, Opticians, Chiropodists and District Nurses. There was evidence that the care staff refer to the resident’s General Practitioner as required for medical advice and to ensure that residents’ health care needs are met, however residents had not been weighed each month in keeping with good practice for those residents deemed to be nutritionally at risk. The staff appeared to be meeting the needs of residents with the exception of one resident who was exhibiting physically aggressive behaviour on a regular basis and this had posed a risk to other residents’ and visitors’ safety. Inadequate systems had been installed to check the prescribed and dispensed medication received into the home. The majority of medicines had been recorded as received but carry over balances had not been routinely recorded so audits were difficult to perform in these instances. It could not be demonstrated that the medicines had been administered as prescribed in all instances. A few gaps were found where the medicines had been administered but not recorded. One medicine was found in the refrigerator but not recorded on the Medicines Administration Record (MAR) chart. The home had a dedicated medicines room and locked refrigerator. A Controlled Drug cabinet was on order at the time of the inspection. A number of incomplete entries were found in the Controlled Drug register but all balances were correct. The new manager was keen to implement practices to improve the medicine management. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 11 Two members of staff including the Registered Manager are responsible for the administration of medication at the home. Remedial action must be undertaken to ensure that appropriately trained staff are on duty during the nighttime hours to administer medication to residents as required and this includes regular and as required medication. Residents appeared to be well supported by the care staff to meet their personal hygiene needs and to choose clothing appropriate for the time of year and staff were interacting respectfully with residents during the inspection. Relatives are encouraged to participate in meeting residents’ care needs as appropriate. One resident said, “ I am very happy living here”. Residents have the option of retaining the key for their bedroom door. One resident said “ I can lock my door whenever I want to”. Risk assessments in respect of bedroom door locks were not available on all residents’ files. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14 & 15 The activities on offer meet the needs of some of the residents. 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 was a range of activities available for residents to participate in including creative mobility, short trips out, karaoke, entertainers and board games. The home does not employ an activities organiser however a care assistant has taken an interest in this and it is recommended that consideration is given to staff training in respect of activities specific to the needs of people with dementia. A hairdresser visits regularly. Daily reports stated that residents had enjoyed a trip to the safari park recently. The Organisation has an open visiting policy and one resident met during the inspection said “ My family are always made to feel welcome by the staff when they visit me here”. A relatives meeting is scheduled for the near future. Residents have choice over their daily routines and the times that they get out of and go to bed. Breakfast is served at whatever time the resident chooses to have it. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 13 The main meal on the day of the inspection was homemade beef casserole and an alternative of smoked haddock was available and these were both nutritious and well presented. A snack meal is available before bedtime. One resident said “ I’m always served a snack at bedtime as it’s too long to go through the night until the following morning without food”. The lunchtime meal was relaxed and residents were interacting well together and staff were assisting residents with their meals in a respectful manner as required. A daily record of food provided for each resident was not kept as required by Regulations. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 14 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 standard(s) 16 & 18 The complaints procedure is comprehensive and is accessible to the residents and complaints are dealt with in an appropriate and timely manner. Despite a generally comprehensive procedure being in place, not all staff are familiar with the correct adult protection procedure and as a consequence this has not been followed on occasion, which has put other residents and visitors at risk. EVIDENCE: The Organisation had produced a comprehensive complaints procedure and this was accessible to residents and their visitors. This included the contact details of CSCI. One resident said, “ If I wasn’t happy about anything, I would go straight to the Manager ”. The complaints log identified that one complaint had been received since opening and this had been investigated and resolved in a timely manner by the Registered Manager to the satisfaction of the complainant. The Organisation had produced whistle blowing and adult protection policies that incorporated the Department of Health’s publication, “No Secrets”, however these did not include the contact details of the local lead agencies in respect of adult protection procedures. The accident book identified that there had been a number of incidents of a possible adult protection nature involving residents and CSCI and appropriate authorities had not been informed of these. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 Lyndon Croft provides a homely, comfortable and clean environment to live in where residents feel safe and staff have most of the equipment that they require to work safely within their job roles. The procedure practised by staff for the laundering of soiled items was not always safe and may pose a risk to staffs’ health. EVIDENCE: All furniture, fittings and floor coverings are new and of a good quality. Despite the large size of the building, the home has been arranged into smaller zones with seating areas to promote a homely feel to the environment in order for residents to feel secure in their surroundings. The use of different colours painted on the doors and walls had been used to assist residents in identifying their location within the home. The home has an enclosed garden and this was landscaped and well maintained. A number of bedrooms on the ground floor lead into the garden. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 16 There was a number of lounge and dining areas throughout the home and some of these could be used as a quiet facility if residents had visitors that they wanted to entertain in private instead of going into their bedroom. The home has five assisted bathing facilities and were decorated in a homely style. In addition each en suite included walk in shower facilities that are appropriate to the needs of the residents. The home had one transfer hoist, however staff stated that further moving and handling equipment was required and the Registered Manager stated that this additional equipment had been ordered. Handrails were available in all corridors and near to all communal toilets. All bedrooms are spacious; meet the size required by Regulations and contained residents personal items to reflect their personal tastes. Each bedroom had a lockable storage facility and nurse call system. The temperature within the internal environment of the home was comfortable on the day of the inspection. During the inspection, the Inspectors received a comment that the temperature within the internal environment on the first floor of the home was too warm at times. Restrictors had been fitted to windows and radiators were of a low surface type in keeping with health and safety guidelines. Thermostatic valves had been fitted to hot water outlets and these were checked regularly to ensure that they did not exceed safe limits. A Legionella risk assessment had been undertaken. The lighting in the home was attractive and domestic in style. The home was found to be clean and fresh on the day of the inspection and hygienic hand washing facilities were appropriately located with the exception of a downstairs communal toilet. Despite having two washing machines which included sluice cycles being available, the Inspector was informed by the laundress that the laundry staff were manually soaking soiled items of residents’ personal items and bed linen in a bucket prior to them being transferred into the washing machine and this is considered to be an unsafe practice. Appropriate alginate linen bags were on order in line with good infection control guidelines and following the inspection, CSCI have been informed that the practice of manually soaking soiled items has now ceased. One resident said, “ My bedroom is cleaned very regularly, it’s always clean”. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Adequate staffing levels are maintained for the majority of the time to meet the needs of residents. There is a generally robust system for staff recruitment in place, but a lapse in this on occasions may fail to afford full protection to residents. Staff receive training and are competent to do their jobs. EVIDENCE: The staffing levels identified that for the majority of the time the home were working within approved levels and the home had not used agency staff. The staffing rotas did not identify the surnames of staff employed at the home and it is recommended that the format of the rotas are revised for ease of calculating actual staff hours worked. The management team provide on call support for the person in charge of the shift and it is recommended that the detail of this be recorded on the staffing rotas. One resident said, “ The staff are very nice here”. Another resident said, “ If I need the staff I press my buzzer and the staff come and answer it to help me”. Housekeeping, laundry and kitchen staff provide ancillary support each day of the week, however the care staff undertake kitchen duties during afternoons and evenings and housekeeping staff are not on duty on Sundays. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 18 Two staff files were sampled and these contained the majority of information as required by Regulations with the exception that one staff member had commenced employment without satisfactory criminal records clearance and a second reference was not available for another staff member on the day of the inspection. One staff file did not include detail of the person’s five year employment history as requested on the application form and interview notes were not available to identify whether the interviewer had sought this missing information. Health declarations were available and Working Time Disclaimers had been signed for staff working in excess of their contracted hours per week. Staff are issued with terms and conditions of employment and job descriptions. New staff have informative employee handbooks and were working towards comprehensive induction programmes at the time of this inspection. A number of staff had undertaken training in caring for people with dementia and challenging behaviour and continence promotion and a training needs analysis had been undertaken for each staff member. Despite this being covered during induction, a member of staff met during the inspection could not recall undertaking training in the protection of vulnerable adults and it is recommended that staff receive refresher training regarding this. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 36 & 38 This is a well-managed home run for the benefit of residents. Maintenance checks of equipment used at the home are undertaken and staff are trained in respect of health and safety issues to ensure that residents’ safety and welfare are protected. Residents’ health and safety is at risk until some health and safety issues are addressed. EVIDENCE: The Manager had been in post since the day before this inspection and it was pleasing to note that there would be a full handover period between the Registered Manager and new Home Manager. Regulation 26 visits by external managers are undertaken regularly. A residents meeting had not been undertaken and a staff meeting had not been undertaken recently. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 20 The financial plan for Lyndon Croft was available for inspection. The home do not manage the personal finances, including personal allowances of residents and the residents are supported in this area by their families. The staff had received informal supervision from the Registered Manager since commencing employment at the home but a written record of this was not available. The Registered Provider had produced a range of comprehensive policies and procedures relevant to the service provided at the home and these were available in a clear and concise format. Staff had received training in safe working practices including moving and handling, COSHH, food hygiene, fire safety awareness and a fire drill had been undertaken recently. A number of staff had undertaken training in first aid. All equipment used at the home was new and still under the manufacturer’s warranty and health and safety checks of the lifts, emergency lighting, nurse call and fire alarm systems used at the home were maintained as required. An Environmental Health inspection had been undertaken recently and no requirements were made following this. Risk assessments had been undertaken in respect of the premises and grounds and a general fire risk assessment was available. Plans were in place for a risk assessment relevant to the fire safety needs of Lyndon Croft to be undertaken. A number of bedroom doors had been wedged open and this may be a risk to residents’ safety in the event of a fire. Denture cleaning tablets were not stored securely and were found within the linen room despite the fact that a resident’s care plans had identified that they had previously mistaken these for sweets. The staff maintain a record of all accidents involving residents, however there was not always evidence that these had been audited and any action taken following an accident was not always documented on the accident records for ease of auditing. There was an attractive water feature in the garden area and it was identified that the large stones lining the edge of this may be a trip hazard for residents. In addition, in parts, the water was deep enough for residents to drown if they fell into this. Residents had access to the water feature from their bedroom patio areas. A risk assessment in respect of this was undertaken on the day of the inspection, however following this, remedial action must be taken to further explore ways to make this attractive feature safer for residents to enjoy. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 4 4 4 3 4 4 3 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 2 x 4 x 2 x 2 Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 22 NA Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15 Requirement The care planning system must be further developed to include the following: Physical health care needs Activities Oral hygiene needs Evidence of monthly reviews Evidence of involvement of residents or their representatives in agreeing the care plans. The Registered Manager must ensure that the home can meet the holistic needs of all residents and the appropriate authorities must be informed and reassessments are arranged for residents who are deemed to be at risk of affecting other residents staff and visitors safety The Registered Manager received this in the form of an immediate requirement All new procedures installed within the home must be reflected in the medicine policy and staff trained to adhere to the policy. The Registered person must install a Controlled Drug Cabinet that complies with the Timescale for action 01 October 2005 2. OP8 14(2) 27 July 2005 3. OP9 13(2) 26th August 2005 Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 23 4. OP9 13(2) 5. OP9.4 13(2) 6. 7. OP9.7 OP9 13(2) 18(1) 13(2) 18(1) 8. OP15 17(2) Schedule 4 Misuse of Drugs Act (Safe Custody)1973 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. All mediaction available for administration must be recorded on the MAR chart. Staff must refer to the MAR chart before administration and sign directly after the transaction or record the reasons for nonadministration at all times. All Controlled Drugs transactions must be witnessed and signed by a second designated member of staff at the time of the administration. Regular staff drug audits must be undertaken before and after a medicine round to confirm staff competence in the administration and recording of medicines All staff that handle medicine must receive accredited training in the safe handling of medicines Remedial action must be undertaken to ensure that appropriately trained staff are on duty during the night time hours to administer medication to residents as required and this includes regular and as required medication. 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. 28th. July 2005 2nd August 2005 30th October 2005 30 September 2005 15 September 2005 Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 24 9. OP18 13(6) 10. OP26 13(3) 11. OP29 13(6) 19(1) The adult protection policy must include detail of the contact details of the local authorities to be informed in the event of alleged or actual abuse. All communal hand washing facilities must contain liquid hans wash and disposable towels to prevent cross infection. Staff must not commence employment at the home without satisfactory criminal records clearance. 30 September 2005 31 August 2005 27 July 2005 12. OP29 19(1) The Registered Manager received this in the form of an immediate requirement The Registered Person must 26 July obtain two satisfactory 2005 references for all staff prior to them commencing employment at the Home. The Registered Manager received this in the form of an immediate requirement A written record of formal staff supervision must be kept Fire doors must not be wedged or held open except by suitable means. If doors need to be held open then they must be fitted with devices that are linked into the fire alarm system. Risk assessments must be written in respect of this in the interim. 13. 14. OP36 OP38 18(2) 23(4) 01 October 2005 07 July 2005 15. OP38 13(4) The Registered Manager received this in the form of an immediate requirement. All products that may cause 26 July harm to residents health must 2005 be stored securely at all times. The Registered Manager received this in the form of an immediate requirement Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 25 16. OP18 13(6) 37 The Registered Manager must 26 July ensure that arrangements are in 2005 place to ensure that the appropriate procedure is followed and authorities are informed with regards to adult protection. The Registered Manager received this in the form of an immediate requirement Remedial action must be taken 15 to ensure that residents safety September is maintained in respect of the 2005 garden water feature. 17. OP38 13(4) 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. 2. 3. Refer to Standard OP3 OP8 OP9.3 Good Practice Recommendations The location of where the pre admission assessment took place should be documented on the assessment record. It is recommended that residents are weighed each month in keeping with good practice 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. Risk assessments in respect of bedroom door locks should be available on all residents’ files. It is recommended that the temperature within the internal environment on the first floor of the home be monitored to ensure that it is of a comfortable temperature. It is recommended that the staffing rotas identify the surnames of staff employed at the home and the format of the rotas be revised for ease of calculating actual staff hours worked. Detail of the on call arrangements for the home should be identified on the staffing rotas. 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. A residents meeting should be arranged E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 26 4. 5. OP10 OP25 6. OP27 7. 8. OP29 OP32 Lyndon Croft Care Centre 9. 10. 11. 12. OP32 OP12 OP30 OP38 Staff meetings should be held regularly It is recommended that consideration is given to staff training in respect of activities specific to the needs of people with dementia. It is recommended that staff receive refresher training about the protection of vulnerable adults The Registered Manager should audit all accidents involving residents living at the home and maintain a written record of any follow up action taken on the accident record for ease of auditing. Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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 Lyndon Croft Care Centre E54_S63159_LyndonCroft_V233290_260705 Stage 2 - draftQR draft2 2nd.doc Version 1.30 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!