Inspection on 18/01/06 for Lynfords

This inspection was carried out on 18th January 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lynfords 06/02/09

Lynfords 14/02/08

Lynfords 05/01/07

Lynfords 23/08/05

Lynfords 24/01/05

Lynfords 09/09/04

Similar services:

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Lyncol House

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

CARE HOME ADULTS 18-65 Lynfords 3b Nursery Close Hailsham East Sussex BN27 2PX Lead Inspector Lucy Green Unannounced Inspection 18th January 2006 11:00 Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 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 Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 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 Adults 18-65. 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. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lynfords Address 3b Nursery Close Hailsham East Sussex BN27 2PX 01323 440843 EX22 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) The Regard Partnership Limited Miss Teresa Kate Murphy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is six (6). Service users will be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 23rd August 2005 Brief Description of the Service: Lynfords is a purpose built bungalow, situated in a quiet residential area of Hailsham. The home shares the same site as The Marshes. Shops and public transport links are a short walk away. Resident accommodation provides six single bedrooms and a communal lounge. The bathrooms are fitted with the necessary adaptations. The grounds are secure and provide a well-maintained garden and ample parking. The home is registered to accommodate six younger adults with learning disabilities. Lynfords is owned by The Regard Partnership, an organisation that owns a large number of homes across England and Wales. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Lynfords are referred to as ‘residents’. This unannounced inspection took place over three hours on 18 January 2006. This is the second inspection of this year and therefore this report should be read in conjunction with the report from the announced inspection carried out on 23 August 2005. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. A tour of the premises took place, care, medication and recruitment records were inspected. The Inspector met with five of the six residents and spoke individually with two of them. Three staff members were also spoken with during the inspection. What the service does well: What has improved since the last inspection? What they could do better: There is an outstanding requirement from previous inspections that the home update its adult protection policy. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 6 At that inspection it was identified that the home needs to ensure all staff undertake role specific and mandatory training that is relevant to their role. The monthly monitoring visits which are carried out on behalf of the organisation need to be undertaken on an unannounced basis. 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. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents are protected by an admission process which assesses ability to meet needs and compatibility with other residents. EVIDENCE: The home has not had any new admissions in the last twelve months. There was however documentary evidence that thorough assessment processes had been undertaken prior to the existing residents moving into Lynfords. The historical information available in the care plans identified that various professionals and representatives were involved at the pre-admission stage. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 Residents influence and make choices about all aspects of their lives. The care planning process enables residents to retain and develop independence. Residents would benefit if care plans included clear guidelines that detail how specific behaviours should be managed and therefore ensuring staff responses are consistent. EVIDENCE: The Inspector viewed the care plans for two residents, both were found to contain detailed information about how care should be delivered. There was evidence that residents had been consulted about how they receive support and individual likes and dislikes were recorded. There are currently some specific behavioural issues that are not fully reflected in the care plan. From discussion with the staff on duty it was clear that staff were responding appropriately, but this needs to be documented in a guideline format to ensure all staff respond to known behaviours consistently. It was evident that residents have much control over their lives and the way they spend their time. Residents are able to get up, go to bed and have their meals at times which suit them. One resident showed the Inspector her Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 10 bedroom which she confirmed had been decorated in a colour chosen by her. Another resident was offered a range of activities, but their decision to sit quietly was also respected. Throughout the inspection process, residents were observed requesting drinks and being offered choice as a matter of routine. At lunchtime, residents were given a choice of food available and the opportunity to prepare it for themselves. Some residents at Lynfords, have limited verbal communication and therefore staff have to use other ways of ascertaining residents’ likes and dislikes. There was information in the care plan about individual’s communication methods and how individuals express their feelings. Throughout the inspection, staff were observed communicating effectively with the residents. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 Residents benefit from support that reflects both their rights and responsibilities. EVIDENCE: It was evident throughout the inspection that staff at Lynfords treat the residents as individuals and respect their rights as people. As such residents are given choice and control over their lives. During the inspection, one resident was visited by the District Nurse, it was pleasing to note that the resident was given the chance to have a private consultation. Care plans identify skills and targets to work towards to help residents increase their life skills. It was observed that residents are given the opportunity and time to make drinks and snacks for themselves and wherever possible are encouraged to maintain and develop their independence. Discussion with staff also demonstrated that staff promote the concept of responsibility. As such residents are aware of the necessary boundaries in place to ensure their lives are healthy and that their actions do not impinge upon the lives of other living at Lynfords. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents are protected by the systems in place to manage medication safely. EVIDENCE: Medication is stored, dispensed and administered appropriately. Staff confirmed that only those who had received relevant training and supervision were permitted to administer medication. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Adequate systems are in place to protect residents from abuse. EVIDENCE: Various systems are in place to protect clients from abuse. The two recruitment files inspected showed that new staff are employed subject to the required references and checks by the Criminal Records Bureau. It was identified during the inspection that an incident between residents had not been reported in line with local multi-agency protocols. Whilst this incident appears to have been fairly minor and isolated, staff must get into the habit of reporting any potentially abuse of a vulnerable adult to the appropriate agencies. It is an outstanding requirement that the adult protection policy is updated to include details of the Protection of Vulnerable Adults register which was introduced on 26 July 2004. Employment and disciplinary policies should also be updated to reflect the correct procedures to be followed in the event of an adult protection allegation being made against a staff member Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Residents benefit from a clean, comfortable and well maintained home. The physical adaptations enable residents to move safely and independently around their home. EVIDENCE: Lynfords is a large purpose built bungalow which is situated in a quiet residential area of Hailsham. The home is well maintained and provides residents with sufficient private and communal space to meet their needs. Level access is provided both internally and externally. At the time of the inspection, the home was found to be clean and tidy throughout. Resident accommodation is provided in six single bedrooms which have been decorated and furnished to reflect the individual. Communal space comprises of a large lounge and a kitchen / dining area. The external grounds offer a garden and patio area. The home has two assisted bathroom facilities and a separate toilet. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Residents benefit from a dedicated and competent team of staff to support them and are protected by the recruitment processes in place. Residents would be further protected if staff had the opportunity to undertake all mandatory training and attend regular update sessions. EVIDENCE: The recruitment files for two new members of staff were inspected. It was noted that whilst all required information was in place, one of these staff members had not included specific dates of employment. It is not possible to check out any gaps in employment without this information and therefore it is required that a full employment history is in place for all staff. Staff reported that The Regard Partnership has recently changed the way in which training is accessed. Internal trainers have now been appointed and staff confirmed that they had received some recent training. It was however identified that not all staff were up to date with their mandatory training. It is therefore required that staff have access to all required training and attend regular refresher courses to keep their skills and learning updated. The Inspector met with three staff members on the day of inspection, one of whom has recently started work at Lynfords and was able to describe the induction process he had undertaken. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 16 There was evidence that new staff undertake a thorough induction, followed by training in line with Learning Disability Award Framework (LDAF). It was however, not possible to evidence that the current induction package meets the Skills for Care specification. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 Residents benefit from an inclusive and well-managed home. EVIDENCE: The home has a number of systems in place to gain feedback about the service and to include residents in the running of the home. One-to-one resident and key-worker meetings are held on monthly basis which gives residents the opportunity to talk to someone they trust about issues important to them. Monthly monitoring visits are also carried out on behalf of the Registered Provider, however at the current time these are not unannounced and this needs to be addressed. Various systems are in place to ensure the safety of the home is maintained. Several safety audits were viewed and found to be accurately recorded. A senior member of staff is responsible for training the staff team in fire safety. Whilst this person has undertaken appropriate training in this area, it was identified that they had not attended an update session in the last twelve months and therefore this needs to be addressed. Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X 2 X X 2 X Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 19 YES 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. 2. Standard YA6 YA23 Regulation 13(4) & 15 14 & 13(6) Requirement Care plans to include guidance for how staff should manage identified difficult behaviours. Policies and Procedures to reflect current guidance on the Protection of Vulnerable Adults. (Previous timescale of 01 December 2004 and 01 October 2005 not met) Any incident of potential abuse to be referred to the appropriate agencies without delay. All new staff to supply a full employment history. All new staff undertake induction training which is in line with Skills for Care specification. (Previous timescale of 01 October not met) Staff to receive mandatory and role specific training, including regular updates. That the monthly monitoring visits are conducted unannounced, in accordance with Regulation 26. All staff to receive the appropriate level of fire training. This is to include the appointed DS0000047635.V276541.R01.S.doc Timescale for action 01/03/06 10/02/06 3. 4. 5. YA23 YA34 YA35 37 19(1) & Sch 2 as amd 18(1)(c) 18/01/06 18/01/06 01/04/06 6. 7. YA35 YA39 18(1)(c) 26 01/04/06 01/02/06 8. YA42 23(4) 01/03/06 Lynfords Version 5.1 Page 20 fire officer undertaking update training to ensure they are still qualified to provide this training. (Previous timescale of 01/10/05 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Lynfords DS0000047635.V276541.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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