Inspection on 30/05/07 for Lyons Court

This inspection was carried out on 30th May 2007.

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

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

Other inspections for this house

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lyons Court Canvey Walk Springfield Chelmsford Essex CM1 6LB Lead Inspector Pauline Marshall Unannounced Inspection 30th May 2007 09:40 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 Lyons Court DS0000067460.V341705.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. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyons Court Address Canvey Walk Springfield Chelmsford Essex CM1 6LB 01245 451254 01245 451254 ch4can@sanctuary-housing.co.uk www.sanctuary-care.co.uk Sanctuary Care Ltd 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) Mrs Bridget Bernadette McDonnell Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provider personal care to 26 older people. Date of last inspection 6th June 2006 Brief Description of the Service: Lyons Court consists of purpose built single accommodation, attached to a listed ancient barn that has been adapted to provide an attractive area for social activities. All bedrooms are furnished to a high standard, well maintained, and have en-suite facilities. There is a choice of two lounges and two dining rooms situated on two floors. A passenger lift is provided for access to the first floor. Lyons Court is situated close to a parade of shops and there is a bus stop nearby. Services provided include the provision of an en-suite room, personal care, meals, liaison with multi-disciplinary teams and also GPs. The home has regular activities and staff are trained to deliver a high standard of care in relation to service user needs. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees are charged at £563.00 and there are additional charges for toiletries, hairdressing, papers, magazines, private taxis, personal clothing and holidays. The garden area is attractively designed and set with shrubs and plants. Access to the garden area is suitable for wheelchair users. There is parking for up to six cars available to the front of the building. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for five hours and thirtyfive minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, a visiting district nurse, the manager and the homes staff. As part of this inspection surveys were sent to eight residents, six relatives, six health and social care professionals and eight care staff to obtain their views on the service the home provides. Five residents surveys were returned and all were positive in their response, one survey stated that the “meals are excellent”. Two relatives surveys were returned and included comments that “staff are friendly and helpful and that they trust them to care for their relative”. One relatives survey made comments on the level of staffing and said, “more staff would improve the home”. Two of the eight staff surveys were returned and one had concerns over the home not always having enough staff and that they sometimes did not feel appreciated. The other staff survey stated that they were “happy in their working environment”. No other surveys were returned at the time of writing this report. Twenty-six of the thirty-eight standards were inspected. What the service does well: The home offers prospective residents good clear up to date information on the services it provides. Lyons Court is decorated to a good standard and each room is maintained to each individual residents taste. The home has a stable staff group that are well trained and supervised. Entertainment is organised by the staff team and residents have the opportunity to participate in both indoor and outdoor activities. The home is very responsive to changes in residents’ health care needs and ensures that residents are referred to other professionals at the earliest opportunity. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 6 Lyons Court has a good communication system within the home. 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. The summary of this inspection report can be made available in other formats on request. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have the information that they require to make an informed choice and they receive a written contract on admission to the home. The home ensures that it can meet the needs of prospective residents and offers them opportunities to make trial visits. EVIDENCE: The homes Statement of Purpose and Service User Guide were last reviewed in April 2007. Both documents give good information and the Service User Guide is printed in a style that is suitable for those with poor vision. Relatives stated on their survey forms that on visiting the home with their relative they were made very welcome and all questions were answered fully. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 9 There was a written contract on all of the care files examined. Contracts contained the contact details of the Commission. The home carries out a thorough pre-admission assessment that includes wherever possible the input of prospective residents, their families and friends. The manager said that the pre-admission assessment is generally carried out in the prospective residents home but has on occassions has been completed at Lyons Court. Residents spoken with said that they had the opportunity to make trial visits before deciding to move into Lyons Court. Lyons Court does not provide intermediate care. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are set out in the individual plan of care and their health care needs are fully met. The homes medication practice does not always follow its policies and guidelines. Residents are well treated and their right to privacy is upheld. EVIDENCE: Four care plans were examined and three contained clear detailed information on the level of staff intervention required. The fourth is a new format that is being piloted and is not yet fully completed for the most recent admission to Lyons Court. The manager said that the provider Sanctury Care have asked her for feedback on the use of this new format. The new format of care plan was discussed and issues around the repetitiveness of the document were raised. The manager said that the resident would be very involved in writing Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 11 up the care plan and that this particular resident was not eager to do so and wanted to wait until they had settled in. There was a record of medical appointments and the outcomes on each of the individual care files examined. The district nurse spoken with during the inspection said that staff were helpful and identified issues as soon as they arose and contacted the district nursing services, they said that they felt the home was a good home. One relatives survey form commented on how well the home helps residents with short term memory problems. Sanctuary Care are in the process of reviewing all of the homes policies and procedures and intend to replace the existing ones that were prepared by the previous owners Ashley Homes. The medication policy is being reviewed; the home is working to an existing policy that works within the Royal Pharmaceutical Society of Great Britain guidelines; staff are encouraged to read these documents. A monitored dosage system of medication administration is used and the use of a colour coded highlighter pen to identify the entry on the MAR (medication administration record) sheet with the bubble pack of medication is a good idea and enables recognition at a glance. An observation of the lunchtime medication round was undertaken and it highlighted some concerns with regard to the way the medication was administered. The staff administering pushed the medication from the blister pack into their hand before placing it in the medicine cup and signed the MAR sheet before the medication was given. Staff must follow safe procedures for the administration and recording of medication. Residents spoken with said that they felt well treated and that staff was nice and respectful and that they were able to have privacy when receiving their visitors. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents experience a lifestyle in the home that matches their requirements and they are encouraged to maintain contact with their families and friends. Residents are supported to exercise control over their lives. The home offers its residents a wholesome appealing, well balanced diet in pleasant surroundings. EVIDENCE: Lyons Court offers a good range of activities that includes, sing-a-longs, armchair excercise sessions, quizzes, local shopping and regular visits by entertainers. One of the residents spoken with commented on the large range of activities offered at the home and said that they did not have the opportunity to get bored as there was always something going on. A resident spoken with said I still enjoy playing the piano and am happy that I can do so in private as I am not as confident in my performance as I used to Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 13 be. The visiting district nurse confirmed that the home offers plenty of activites. Residents spoken with said that Lyons Court encourage visits from their family and friends and that they can visit whenever they want but for security reasons are asked to advise staff if they wish to visit between the hours of 10pm and 8am. The home holds regular residents meetings and keeps a record of the issues discussed. In addition to residents meetings the manager regularly surveys residents to ensure that the home is providing the service that they require. The home currently uses Caterplus for their domestic and catering needs; this will change as Sanctuary Care will be employing the domestic and catering staff direct from 18th June 2007. The manager said that she feels that this will enable her to have more control over the menus. The current menu rotates over a four week period and offers residents two alternatives each mealtime. The menus showed one dessert option only and the manager said that icecream or yoghurt is always available as an alternative; residents spoken with confirmed this. One residents survey forms returned decribed the food at Lyons Court as excellent. The home has a dining area on each floor and the manager said that a request for funding has been made to replace the cabinets and install dishwashers in both dining areas and that she is hopefull it will be sucessful. The food provided was homecooked and looked and smelled appertizing. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that their complaints will be listened to and acted upon and residents are protected from abuse. EVIDENCE: The complaints policy clearly explains the procedure and includes timescales. Concerns and complaints have all been dealt with appropriately and residents spoken with confirmed that they felt able to raise any concerns with the staff team and that they were always resolved. Survey forms returned confirmed that residents and their relatives were aware of the homes complaints procedure and how to use it, however one relative was unsure of the process but stated that they “assummed through the manager”. The Protection of Vulnerable Adults policy was reviewed in January 2006 and includes reference to the local authority procedure that is to be used for any suspected abuse. All staff have had training in the Protection of Vulnerable Adults, the most recent training was provided in January 2007. Staff spoken Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 15 with were fully aware of the actions to take if they ever suspected abuse was taking place. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Lyons Court provides a safe, well-maintained environment where residents have comfortable bedrooms with their own possessions around them and the home is clean, pleasant and hygienic. EVIDENCE: The furniture and fittings were of good quality and are well maintained; the home is well decorated and residents spoken with said that they had chosen the colour scheme for their bedrooms. All bedrooms were very individual and included many small personal items. Residents spoken with said that they were encouraged to bring small items of Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 17 furniture and as many personal possessions as they wished. The home has two floors and one domestic staff works on each of them. The home was clean, pleasant and hygienic. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff and are in safe hands at all times. The home’s recruitment policies and practice supports and protects residents and staff are well trained and confident in their work. EVIDENCE: The care staff duty rota corresponded with the care staff on duty but the caterplus rota for catering and domestic staff showed both the chef manager and the second chef on duty at the same time. The manager said that due to a recent change the chef manager was working two weekdays instead of the weekend and that the second chef should have been crossed off the rota. All staff duty rosters must reflect the staff working at all times and any changes must be recorded immediately. The home employs sixteen care staff ten of whom are qualified to NVQ level 2. All of the homes team leaders are NVQ qualified. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 19 Three staff files were examined and all contained copies of staff application forms, references, proof of identity, and documentry evidence of qualifications. Criminal Records Bureau checks are held at Sanctuary Cares head office; there was evidence on each file that checks have been carried out. The company carries out a pre-employment health check but there was no evidence on the staff files examined to confirm that employees were physically and mentally fit as required under 2 of the regulations. The home must provide evidence that staff are physically and mentally fit as required under Schedule 2 of the Care Home Regulations. The home provides staff with a range of training included moving and handling, first aid food hygiene and POVA in addition to more service specific subjects that are relevant to the needs of the homes current residents. Staff files examined contained copies of training certificates to confirm that regular training takes place. Staff spoken with confirmed that training at Lyons Court is good and had included dementia and person centred care. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of its residents. The homes quality assurance policy and practice needs to include other stakeholders’ views. Residents’ financial interests are safeguarded and the home promotes and protects the health, safety and welfare of residents and staff. EVIDENCE: The manager has worked in the care environment for more than ten years and is NVQ 3 trained and is nearing completion of her NVQ4 Registered Managers Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 21 Award. Staff spoken with said that the manager is approachable and that they are involved in all aspects of running the home. Team leader and staff meetings take place regularly where staff are able to air their views and make suggestions for any improvements they feel need to be made. The homes quality assurance system needs further development as it does not currently obtain the views of others when undertaking quality audits. The homes quality assurance policy is dated June 2004 and is an Ashley Homes policy and states that the quality assurance system will include obtaining the views of other relevant stakeholders, the manager said that this is soon to be replaced by a Sanctuary Care policy. A good quality assurance system must include the views of others to ensure that the home gets a balanced response to their review of the quality of care that they provide. Sanctuary Care undertook its own Quality Assurance and Development audit on 10/1/07 which looked at the homes care documentation, individual risk assessments, continence, medication and pressure sore management. Each area was evaluated and any concerns discussed with the manager and suggested remedial actions devised. The home has provided the CSCI with a copy of this audit. Four residents cash records were examined and the entries were made appropriately and the cash counted corresponded with the final balance. Regular fire drills have taken place and all safety checks and certificates were in place and up to date. Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Timescale for action The registered person shall make 30/07/07 arrangements for the safe handling and administration of medicines. This refers to the medication that was transferred into the staffs hand and signed for prior to administration. The registered person shall not employ a person to work at the care home unless he holds all of the information and documents as required in Schedule 2 of the regulations. This refers to the need to provide evidence that staff are physically and mentally fit. The registered person shall ensure that their quality review system includes the views of all stakeholders. Requirement 2. OP29 19 (1) (i) 30/08/07 2. OP33 24 (3) 30/09/07 Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 24 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 Lyons Court DS0000067460.V341705.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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