Inspection on 19/09/05 for Lyons Gardens

This inspection was carried out on 19th September 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 found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyons Gardens 12/10/07

Lyons Gardens 07/12/06

Lyons Gardens 06/04/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Lyons Gardens 36 Lincoln Road Glinton Peterborough PE6 7JS Lead Inspector Nicky Hone Unannounced Inspection 19th September 2005 17:10 Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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 Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lyons Gardens Address 36 Lincoln Road Glinton Peterborough PE6 7JS 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) Hereward Care Services Ltd Roslyn Sadie Stone Care Home 11 Category(ies) of Learning disability (11), Mental disorder, registration, with number excluding learning disability or dementia (11), of places Physical disability (11) Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection Brief Description of the Service: Lyons Gardens is a purpose built care home on the outskirts of the village of Glinton, about six miles north of the centre of Peterborough. Set back from the main road through the village, the home consists of two bungalows. Each bungalow has a lounge, dining room, kitchen, toilets, bathroom and shower room as well as a laundry, office and staff facilities. One of the bungalows has five single bedrooms with ensuite toilet and washbasin; the other has six. There is parking space at the front of the bungalows and each has its own closed garden area. The bungalows were commissioned by the Greater Peterborough Primary Care Partnership, to replace an outdated home, and the places are all used for respite care. One bungalow offers accommodation to people who have a greater need for support with their physical care needs. The home has its own minibus, but is also on a bus route. Peterborough, with its range of facilities such as restaurants, pubs, shops and leisure facilities is within a short drive. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Lyons Gardens was registered by the Commission for Social Care Inspection on 01 June 2005. This report refers to the first inspection of the service, which was unannounced and carried out on 19 September 2005. It also includes information requested from the home in documentation which was received by the CSCI on 01 November 2005, and from comment cards which the home sent to service users and their relatives on behalf of the CSCI. One comment card was received from a service user; six from relatives/carers on behalf of service users; and ten from relatives/carers. The inspection was carried out during the evening. The inspector briefly met all six service users who were in residence at the time of the inspection, walked around both bungalows and spoke to three staff and one relative, as well as checking some records. The inspector decided to finish the inspection when a member of night staff telephoned the home to say she would be unable to work her shift that night due to illness, so that the carer in charge could concentrate on finding staff cover. What the service does well: What has improved since the last inspection? What they could do better: Records were not available to show whether service users are offered a range of activities, and staff say they do not receive formal supervision sessions. A fire door to a laundry was held open by a reel of cable, and records of tests of Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 6 the fire alarm and emergency lighting systems were not available. An immediate requirement was left at the home regarding the fire door. It was disappointing to observe a staff member poking a service user’s meal with her finger: further staff training is needed. 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. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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 Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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, 4 Assessments received prior to the service user’s admission are detailed so that staff know the care needs of each individual. EVIDENCE: Files of three service users were checked and all contained detailed assessment information which forms the basis of each person’s care plan. Before the home opened, an open day was held and service users and their carers were encouraged to visit and look round. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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, 8, 10 Care plans contain sufficient information for staff to be able to meet each service user’s individual needs. EVIDENCE: Care plans of three service users were checked. These contained detailed information about each person’s needs. Participation in all aspects of the life of the home is encouraged where possible, but this is more difficult for people who perhaps only stay overnight. Confidentiality was discussed with a staff member who said the issue had been covered during her induction training. She demonstrated a good understanding of the need to only share confidences when by not doing so would put the service user or others at risk. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 10 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): 12, 14, 17 Records of activities undertaken are not in sufficient detail to judge whether service users are given enough opportunities to take part in activities of their choice. A varied menu with alternative choices means that service users’ tastes are met. EVIDENCE: The majority of service users continue to take part in their usual day-time activities while they are staying at Lyons Gardens. Some activities take place during the evenings at weekends, depending on what service users want to do. Records of activities were not kept well enough to give a clear picture of exactly what is offered. Staff described weekends as being busy times, with a lot of activity taking place in the house, including cooker, as well as service users going out if they want to. The meal on the day of the inspection was sausages, chips beans and garlic bread. Vegetarian sausages had been cooked for those who preferred them. Menus seen show that a varied diet is offered, with alternative choices available if people do not like what is on the main menu. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 11 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): 18, 19 Support with personal care and healthcare is offered in the way service users prefer. EVIDENCE: Care plans indicate that service users and their families are involved in deciding on the personal support needed by each person. Healthcare needs can be met when required, but generally appointments with healthcare specialists such as doctors, nurses, chiropodist, optician and so on remain the responsibility of the service user’s main carer. Service users are expected to bring sufficient medications with them for their stay. These are checked in by the senior staff on duty and kept in a locked cupboard in each bungalow. Senior staff administer the medications. Records, and policies on the administration of medications were not assessed in full. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 12 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): 22, 23 The home must ensure that information about how to complain is available to all service users and their relatives, and staff receive training in the protection of vulnerable adults, so that service users are kept safe. EVIDENCE: Although these standards were not assessed in full, there is some evidence that neither is fully met. Of the seventeen respondents to the questionnaires sent out by the Commission for Social Care Inspection, twelve indicated they are aware of the home’s complaints procedure, and five said they are not. One staff member spoken to had not attended a specific training session on protection of vulnerable adults, although this had been “touched on” during induction. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 13 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): A well-decorated, comfortably furnished and clean home provides service users with a pleasant place to stay. EVIDENCE: The home is brand new and had only been operating for about ten weeks when the inspection took place. It is purpose-built and all rooms are suitably decorated and furnished. All bedrooms are larger than the size required by the National Minimum Standards and are light and airy. Each room has an ensuite toilet and washbasin. Each bungalow has its own closed garden and although these are still to mature, they offer outdoor space for service users to enjoy games and activities such as barbeques. Bedrooms in the bungalow used by people with greater physical needs have hospital-style beds which can be easily raised and lowered, and there is some overhead tracking available for hoisting people. Mobile hoists, grab rails and other equipment needed by people with disabilities is provided. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 14 Both bungalows were clean and smelled fresh throughout: staff were keen that the high standards of decoration and cleanliness due to the newness of the buildings should be maintained. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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): 32, 35, 36 Sufficient numbers of staff, who are receiving training in a range of topics, are able to meet service users’ needs. Individual, formal supervision sessions do not take place. EVIDENCE: Some staff had transferred from the service that closed, and some were new when the home opened. Two staff spoken to had been able to have a week’s induction before any service users were accommodated. This included all the mandatory training topics and touched on topics relevant to the service such as epilepsy, challenging behaviour and communication. One staff member felt training on specific conditions such as autism would be helpful. Training records were not seen. It was disappointing to observe a staff member poking a service user’s meal with her finger. On the evening of the inspection there were sufficient staff on duty to meet the needs of the service users. The senior carer said that staff numbers are increased depending on which service users would be staying at the home at any particular time, and depending on what they wanted to do. Staff meetings are held every six weeks. Both staff spoken to said they had not yet received any formal supervision. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 16 One relative wrote: “the staff are warm and trustworthy. I feel my relative (very precious to me) is in safe hands”. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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): 41, 42 Health and safety procedures are not sufficiently robust to ensure that service users are kept safe. EVIDENCE: Records of tests of the fire alarm and emergency lighting systems were not available, but the senior carer on duty said these are tested weekly. The temperature of the hot water to the washbasin in one bedroom was checked and was found to be within safe limits. The door to the laundry in one of the bungalows was held open by a reel of cable. An immediate requirement notice was left at the home regarding this. Both laundries were very cluttered with items such as mops and buckets, and the doors to the laundry rooms were not locked. Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lyons Gardens Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X X X 2 2 X DS0000063991.V252135.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? N/A 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 YA14 Regulation 16(2)(n) Requirement Records must be available to show that appropriate and sufficient activities are arranged for service users. The registered person must ensure that service users and their relatives are aware of the complaints procedure. The registered person must ensure that staff are fully trained in the protection of vulnerable adults. All staff must receive training appropriate to their work. Staff must be appropriately supervised. All staff must receive one formal, recorded supervision session within the timescale, and at least six times a year thereafter. Timescale for action 31/12/05 2 YA22 22 31/12/05 3 YA23 13(6) 31/03/06 4 5 YA35 YA36 18(1) 18(2) 31/03/06 31/12/05 6 YA41 23(4)(c) & Tests of fire alarm and 17, sch 4 emergency lighting systems must be carried out as required and the record must be available for inspection. DS0000063991.V252135.R01.S.doc 05/12/05 Lyons Gardens Version 5.0 Page 20 7 YA42 23(4)(c) Fire doors must not be held in the open position except by a means approved by the fire authority. An immediate requirement notice was left at the home regarding this. 19/09/05 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 Gardens DS0000063991.V252135.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Lyons Gardens DS0000063991.V252135.R01.S.doc Version 5.0 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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