Inspection on 03/07/08 for Lyttleton House

This inspection was carried out on 3rd July 2008.

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

Lyttleton House 10/06/09

Lyttleton House 27/11/07

Lyttleton House 18/05/07

Lyttleton House 04/09/06

Lyttleton House 01/03/06

Lyttleton House 12/09/05

Lyttleton House 24/03/05

Lyttleton House 25/08/04

Lyttleton House 04/03/04

Lyttleton House 09/09/03

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Lyttleton House 1 Ormond Road Frankley Birmingham B45 0JD Lead Inspector Sara Gibson Unannounced Inspection 3rd July 2008 09:30 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 Lyttleton House DS0000033561.V363024.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. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lyttleton House Address 1 Ormond Road Frankley Birmingham B45 0JD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 460 1150 0121 457 7302 Not known Birmingham City Council (S) Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the home is registered to accommodate 30 people over 65 years who are in need of care for reasons of old age which may include mild dementia. Registration category will be 30 (OP) That minimum staffing levels are maintained at 4 care staff throughout the waking day of 14.5 hours. The home must adhere to a laundry policy which ensures that soiled laundry is not transported through dining areas when meals are served or consumed. That additional to above minimum staffing levels there must be two waking night care staff. 27th November 2007 Date of last inspection Brief Description of the Service: Lyttleton House is owned and managed by Birmingham City Council and is registered to provide care for 30 older adults who may have mild dementia. The building is a bungalow construction and divided into three separate units, each with their own dining area, kitchen and lounge. Facilities briefly include 30 single bedrooms, the majority of which are less than 10 square metres and therefore cannot contain all the items of furniture specified in the standards. Each bedroom has a call system. There are a number of communal areas equipped with televisions, video’s and music systems where people living at the home can socialise. The home is situated on a corner plot in a cul-de-sac. It has an open plan frontage with lawn, shrubs and flowers. There is level access to the front door and parking to the front and side of the property. Lyttleton House is located close to local shops and facilities, including public transport. Fees at the home are based on the financial assessment carried out by the social worker. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. The focus of our inspection is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. One inspector undertook the key fieldwork visit to the home, assisted by an “Expert by Experience” (the expert is a lay person who has experience of care homes), who spoke to the people living at the home and their relatives. The Pharmacy Inspector inspected the medication system on the same day. The home did not know we were visiting on that day. There were twenty-three people living at the home on the day of the visit. Information was gathered from speaking to people who lived at the home and observing the care they received. Three people were “case tracked”, and this involved discovering their experiences of living at the home by meeting and observing them, looking at medication and care files, and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. Random questionnaires were sent out to staff and people who live at the home in order to gain their views about the service, of which five had been returned with positive comments about living at the home. During our visit we spoke to nine people who live at the home and seven staff members. Comments received were generally positive. These will be included throughout the report. Prior to the inspection the manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements made, and plans for further improvements, which was taken into consideration. Regulation 37 reports about accidents and incidents in the home were reviewed in the planning of this visit. No immediate requirements were made on the day of our visit. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The majority of the requirements and recommendations made at the last inspection have been met. There is now a stable management team who provide clear leadership to the staff team enabling them to provide a high standard of care to the people living at the home. The home has improved the systems in place to ensure medication is given safely. People who raise concerns or make a complaint are confident that these will be dealt with effectively A homely and comfortable living environment has been achieved for the people who live there so that they feel safe and well cared for. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 7 The Manager is experienced and possesses the skills and knowledge to oversee the day-to-day management of the home. A quality assurance programme has been developed to evidence that continuous and sustained improvements are ongoing, and arrangements in respect of health & safety are robust and prevent the risk of injury occurring. 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. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 8 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 Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 9 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, 3, 4, 5 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The trial visits offered to prospective users of the service provide an opportunity for them to make an informed decision about coming to live at Lyttleton House. However, the lack of completed pre-admission assessments does not ensure the home can fully meet their individual needs. EVIDENCE: The local authority (Birmingham City Council) owns Lyttleton House Care Home. Information about the home is provided in a Statement of Purpose and a Service User Guide generated from the local authority. These documents should give prospective users of the service information about what they can expect and give an account of the services provided, the quality of the accommodation, the qualifications and experience of the staff team, how to make a complaint and recent CSCI findings. This enables them to make an informed decision about whether they would like to live at Lyttleton House. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 10 Both these documents require updating to reflect the changes in the home, for example, the change of manager, the changes in staffing and the new address and details for the Commission for Social Care Inspection, so that people have all the information they need to decide if they want to live at the home. The service user guide is on display in the reception area and is given to prospective residents. Copies of the guide were seen in the home in standard print but they can be made available in large print, other languages or Braille if required. The local authority complaints procedure is included in the service user guide. Residential contracts were seen during the inspection. The contract states the care and services provided by the home, what is included in the fee and what is not. Services such as hairdressing, chiropody and physiotherapy are not included, and will incur an extra cost. All the contracts seen had been signed and dated by the person using the service so that they know what they can expect from the service. The home offers trial visits to people thinking about coming to live at the home. During the trial visits pre-admission assessments should be carried out to ensure that the home can meet the specific needs of the individual person. Three care files were looked at; only one had a completed pre-admission assessment in place. The assessment was comprehensive and provided a good picture of the individual and their specific needs, which enables the staff to care for the person in the way they prefer. Intermediate care is not provided at Lyttleton House, but respite care is available for those people needing care for a short time. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Poor documentation regarding the individuals specific care needs may result in their needs not being fully met. Medications are administered at the prescribed time to promote peoples health. EVIDENCE: We talked to a number of people living at the home during the inspection, and they were all very satisfied with the care they received at Lyttleton House. To enable the staff to care for the individuals and their specific needs, a care plan or individual service statement is devised. Information is taken from the pre-admission assessment and from talking to the individual and their families to find out their specific needs, and a plan of care is formed to meet those needs. On the day of inspection individual service statements of the three people case tracked were looked at. The service statements did not contain information on Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 12 the individual’s medical conditions, for example, one individual is diabetic but how the diabetes is controlled is not noted in the service statement. The statements lacked detail and did not provide sufficient guidance for staff to enable them to fully meet the individual’s needs. For example, one person’s service statement says: “Assistance with washing and dressing”. There is no guidance in the service statement for staff on how they should assist with the personal hygiene needs or what the individual’s personal preferences are, this could lead to their needs not being fully met. The individual service statements seen had been dated and signed by staff each month to say they had been reviewed, but there was no evidence to show that changes had been made where needed, so that staff have the up to date information about how to support people. Risk assessments were in place for Manual Handling and Safe Working Systems; these assessments were detailed and provided guidance for staff to enable them to carry out the tasks safely. The risk assessments look at the issues identified, the impact this would have on the individual and the measures needed to minimise the risks. Risk assessments for tissue viability and nutrition need to be made more specific to the individual and their respective needs. A number of these risk assessments need reviewing to ensure any changes are identified and measures put in place to safeguard the individual at all times. People living at the home have their weight monitored monthly to ensure weight loss or gain is detected and appropriate actions taken. People living at the home have access to a range of health and social care professionals that visit the home, for example, social workers, district nurses, community psychiatric nurses, opticians and dentists. Their own GP can be retained on admission to the home if they wish. Annual care reviews involving each person living at the home, their families, social workers and key workers take place. These reviews allow everyone to express their views or concerns about living at the home, and they also identify where changes need to be made to improve the quality of life for the individual. One person’s review states: “Very happy with the care received at Lyttleton House, has no complaints”. The pharmacy inspection lasted two hours. Three residents medicines, medicine charts and care records were looked at. One Senior Care assistant who handled medicines was spoken with. Audits indicated that the majority of medicines had been administered as prescribed. All medicines that had been dispensed in the monitored dosage system had been administered correctly. The home had installed a quality assurance system involving counting the tablets left in the traditionally Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 13 dispensed bottles and boxes. This had reduced the number of errors previously found and the Senior Care assistant immediately followed up any errors to ensure that all staff administer medication as the doctor intended. All the prescriptions are seen before they are dispensed and the medicines and charts are checked against a copy of these for accuracy. For new residents who come to live in the home their medication is checked against any discharge letters, repeat prescription slips, or the doctor is contacted to ensure that the residents are administered their current drug regime only. All controlled drug balances were correct and matched the balance calculated on the medicine chart indicating good practice. They were all stored according to current regulations. The medication room was well organised and key security was good. The medicine refrigerator temperatures were read on a daily basis to ensure that the medicines requiring refrigeration were correctly stored. The Senior Care assistant on duty had a thorough understanding of the clinical needs of the residents and knew what most of the prescribed medicines were for. The individual service statements failed to record the residents clinical needs. This would hinder staff from looking after the residents as well as they could; as they do not have access to all information needed to fully support the residents. For example one resident suffered from diabetes but the service statement did not record any special diet she should have. There was no information about any further clinical conditions she had. No resident currently self-administered their own medicine but would be supported to do so if they wished. All staff had successfully completed the Safe Handling of Medicines course. Throughout the inspection staff were observed interacting well with the people living at the home, supporting them and talking to them in a friendly, relaxed manner. People living at the home appeared well cared for in appearance and were dressed appropriately for their age, gender and the time of year. People living at the home were addressed by their preferred name by the staff, and the care plans recorded the individual’s preferences regarding the gender of staff assisting them with personal care Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to lead independent and fulfilling lives. Meals are well balanced, and people have a choice of options so that individuals are provided with a healthy diet that meets their needs and expectations. EVIDENCE: At present there is no formal plan of activities for the residents to participate in, should they wish to. Activities on offer at present were Movement to Music, Arts & Crafts, and music therapy. A number of people living at the home attend a day centre. During the inspection we observed a staff member asking an individual if she wanted to take a walk to get some fresh air. The home has two resident cats that the residents really like. Various televisions and radio’s were on throughout the home, and people were seen sitting chatting in small groups and reading newspapers. Books and board games are available in the lounge. The “experts” report states: “The home has a very sociable atmosphere. The three units provide a space that feels homely and intimate. The residents I Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 15 spoke to felt comfortable within their unit and also liked having the option of going to the large lounge where activities such as bingo and gentle exercise take place. None of the residents I spoke to chose to spend much time during the day in their rooms, I thought this was a positive indication of their contentment. I was also encouraged to hear that all were issued with their own room keys. I had the opportunity to talk to one family who were visiting their mother and received positive comments about Lyttleton House. They all felt the quality of care was good, the staff were approachable and that the quality of their mother’s life had improved at the home”. Comments from the people living at the home reflected the fact that they are not concerned over the lack of planned activities. A number of people living at the home frequently go out with their friends and families, maintaining contact, which is important to them. One person said: “My daughter visits me every week and sometimes we go out if it’s a nice day”. The atmosphere within the home was very relaxed and informal, good interaction was observed between the staff and the people living at the home. The daily menu was displayed in the dining rooms. We observed lunch taking place in the dining room and it was a very relaxed affair. Tables were nicely laid and everything was within reach of the people at the tables. Music was playing in the background and it was a very pleasant environment in which to eat. People were chatting with each other, and staff were on hand to assist where needed. Two choices were available at lunchtime and individuals were given the option of which to choose. On the day of inspection beef stew or chicken & mushroom pie with vegetables and potatoes was available. Rhubarb fool or apple crumble & custard were offered for dessert. Drinks and snacks are offered throughout the day, and a late supper of sandwiches and milky drinks is on offer. The people living at the home were very satisfied with the food and comments included: “The food is very nice, plain cooking none of that fancy stuff” “ I have to have a special diet as I am diabetic but I get a choice of what I want” “ The food is very nice, always lots of it, very tasty” “ The food is always good, well cooked and what I like”. Different dietary needs can be met by the home such as vegetarian, gluten free, or Caribbean. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The way the home manages complaints ensures people living at the home are confident their views are listened to, and issues raised are dealt with appropriately. The lack of training in safeguarding people does not ensure that people will be protected from harm. EVIDENCE: Since the last inspection the home had not received any complaints about the service provided, and CSCI had received one complaint, which is currently being investigated. The notice board in the dining room has the local authority complaints procedure displayed on it and explains how to complain and who to contact. There are no details of how to complain to the Commission for Social Care Inspection. People spoken to during the inspection said if they had a complaint they would speak to a member of staff or the Manager but added: “I’ve got no complaints, very happy here” “ I’ve got no complaints at all”. The “experts” report said: “The inspector asked me to get a general feel for the home and to observe the staff and resident interaction. I was asked to talk to the residents about their personal safety, for example did they know who to talk to if they felt unsafe? Did they know how to make a complaint? If a complaint had been made, how had it been dealt with? Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 17 When asked about personal safety, all residents stated that they felt safe within the home. I asked if they felt worried about anything could they speak to the staff and all stated that they could. One woman commented that staff were always helpful and approachable. She said she had no problem reporting any worries to staff or going to see the manager if necessary. Another resident stated that she had no complaints but if she did she would talk to staff and they would help. She stated that the new manager had made noticeable improvements and I believe this has given the residents confidence. None of the residents I spoke to disclosed that they had made a formal complaint at any time so I was unable to establish if concerns voiced were appropriately dealt with”. Numerous compliment letters had been received. In June four compliment letters were received: “Family very happy with the care that is being given to their father who is a resident and is very poorly at this time” “Compliments on the food, mother enjoys it, and she is looking really well”. “Mother came to stay for respite for 3 weeks, very pleased with care and premises”. There have been no issues regarding Adult Protection at the home, and the Manager stated they would refer to the Birmingham Multi Agency Guidelines for the Protection of Vulnerable Adults should an issue arise to ensure all the relevant authorities are notified. Not all staff spoken with had had training on protection of vulnerable adults, although they did all have an understanding of the types of abuse that could occur and they would refer any concerns to the Manager immediately. Staff recruitment procedures are robust and the appropriate checks are carried out prior to the person commencing employment, safeguarding the people living at the home. People living at the home have access to their personal monies, and there is a system in place to monitor and record financial transactions for each resident, thereby ensuring an accurate account is kept and enabling an audit trail to be maintained. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 18 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A homely and comfortable living environment has been achieved for the people who live there so that they feel safe and well cared for. EVIDENCE: People living at the home were happy with their environment and said they were very comfortable. During a partial tour of the home all the areas seen were clean and smelt fresh. Toilets and assisted bathrooms were clean and odour free, with wash hand basins complete with paper towels and liquid soap to safely manage infection control. The bedrooms seen during the inspection were comfortable and had been personalised with the individuals own photos and ornaments, and in some cases items of their own furniture to reflect their personal taste, gender and culture. There are no en-suite facilities available but wash hand basins are Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 19 present in each bedroom, and bathroom and toilet facilities are close to the bedrooms. Comments from people living at the home included: “I’ve been here two years. Its very good, couldn’t ask for better” “ My room is very comfortable; I’ve got what I need here” “ My room is lovely; I brought some of my bits and pieces with me from home”. Various communal lounge and dining areas are spaced around the home, allowing people living at the home to socialise with each other, or have some quiet time if they prefer. The communal area’s are very comfortable and homely, and are decorated and furnished to a good standard. The home has a well-tended garden area with disabled access, and is regularly used by the people living at the home. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are maintained to ensure people living at the home receive care from the right number of appropriately recruited staff. Refresher training is required in some areas to ensure that staff provide support in a competent and safe manner EVIDENCE: Staffing levels at the home are adequately maintained to meet the needs of the people living at the home. The rota was seen for the next month and shows that four care staff plus a member of the management team are on duty during the day. There are two care staff vacancies, which are being covered by agency staff. A new rota system has been introduced by the Manager that ensures there is a full complement of skilled staff on duty to meet the individual needs of the people living at the home. New roles and responsibilities have been introduced for the members of the Senior Management team. Each member has designated roles; Senior Carers are in charge of a unit and the staff on that unit. They are responsible for care files, resident meetings, staff meetings and supervisions, medication management for that unit, supervision of care practices, and care staff support. The Assistant Manager has overall responsibility for two of the units, Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 21 plus financial management, time sheets, risk assessments, residents meetings, information and quality management, managing attendance and return to work interviews. The Manager has overall responsibility for Lyttleton House, plus financial management, supervision of senior staff, staffing rota’s and annual leave planning, health & safety, quality audits, and co-ordination of staff training. This ensures that the well being of the people living at the home is safeguarded by the clear lines of staff accountability Robust recruitment procedures safeguard the people living at the home. Three recruitment files were sampled and all the relevant checks had been carried out prior to the staff member starting work at the home. New staff undergo an induction programme and work with a more experienced staff member until they feel confident to work on their own. The culture and gender mix of the staff team reflected the culture and gender mix of the people living at the home so that care is provided in an understanding way. From talking to staff and observing them during the day it was evident that staff morale was good, and the interaction with the people living at the home was excellent. Staff spoken to said that there was a good staff team at the home and they all worked well together to achieve the best outcomes for the people living at the home. Comments included: “Its brilliant here, a really friendly homely atmosphere, not at all clinical” “The interaction with the residents is what I really enjoy” “The staff team work really well together” “It doesn’t seem like a job, I love it” “There’s nothing I would change here. We aren’t rushed, the residents might want to talk or need a hug” “ The management support is really good, very helpful, able to approach and talk to them. I genuinely love it here”. “It’s a very good home, nice environment, very clean. The staff have a great rapport with the residents and their families” Staff meetings have been held monthly since April this year. All issues of care practice and the running of the home are discussed, and the Manager gives open and responsive answers. The staff training plan required updating as it was difficult to see how many staff required refresher training in mandatory areas, although staff did say they had had some mandatory training in the last year. However it was identified from talking to staff that training on Adult Protection is needed, as not all of the staff spoken to had had training in that area. This could potentially place people living at the home at risk due to a lack of staff awareness. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 22 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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is experienced and possesses the skills and knowledge to oversee the day-to-day management of the home. A quality assurance programme has been developed to evidence that continuous and sustained improvements are ongoing. Arrangements in respect of health & safety are robust and prevent the risk of injury occurring. EVIDENCE: The Manager has been in post for three months and has made a number of improvements to the home. The Manager is clear about further changes she would like to implement in order to ensure that the home is run in the best interests of the people who live there. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 23 The Manager has a number of years experience in health care and has substantial management experience. The Manager is ably supported by the Senior Carers, and it was evident from talking to them that they know the people living at the home very well, and have good knowledge of the individual care needs for each person, ensuring that a good standard of care is delivered. Staff told us: “The management support is really good, very helpful, able to approach and talk to them” “The home has really improved since the new Manager started” “The Manager has made a lot of changes, all for the better, even the residents have noticed”. Residents and staff meetings are held so that people have the opportunity to voice their concerns, and make suggestions for improvement. Senior Managers visit the home and complete Regulation 26 visit reports which report on the quality of the service being offered at the home, and identifies any shortfalls, which the staff team then act on to improve the service provided. A Quality Management System developed twelve months ago is based on CSCI standards. Auditors from outside the home annually complete various audits within the home and identify any issues that need improvement. Satisfaction surveys for residents and staff are sent out to gain feedback on the service being provided. A report is produced to show the overall responses, the last report showed that people living at the home were satisfied with the service delivered. People living at the home have access to their personal monies, and there is a system in place to monitor and record financial transactions for each resident, thereby ensuring an accurate account is kept and enabling an audit trail to be maintained. Supervision of staff is very good. There is an annual plan for each staff member, and sessions take place monthly. Staff have the chance to discuss care issues, air any concerns they may have, gain feedback from their mentor and residents, and identify any training needs they may have. This further safeguards the people living at the home by ensuring that staff have the skills, knowledge and support they need to meet people’s needs. General arrangements for health and safety are good. Maintenance checks are carried out on schedule to ensure equipment is safe to use. Weekly tests of the fire alarm take place, and staff had recently undertaken a fire drill and were familiar with the procedure to follow in the event of a fire. Reports of accidents involving residents are completed, and appropriate actions are taken following accidents to ensure good outcomes for the individual. A falls report and accident audit are undertaken each month in order to reduce the risk of similar accidents occurring again. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 24 Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 25 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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 12 Requirement Timescale for action 03/09/08 2. OP18 13(6) Each person must have a care plan that identifies the specific support required by staff in order to meet their care needs. These should be reviewed regularly with the involvement of residents so that their current care needs are identified. Arrangements must be made for 03/09/08 staff to have training about the protection of vulnerable adults so that they should have the appropriate knowledge in order to protect residents from harm. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The statement of purpose and service user guide should reflect the current services provided at the home to ensure people have the right information to enable them to make a decision about coming to live at the home. DS0000033561.V363024.R01.S.doc Version 5.2 Page 27 Lyttleton House 2. 3. OP7 OP8 4. OP12 5. OP30 6. OP38 Daily recording needs improvement. Daily records when well written, help ensure a consistent approach and good quality of care for the people living at the home. Risk assessments for nutrition and tissue viability need to be made more specific to the individual person. This will ensure that the people living in the home receive a service specific to their individual needs. People living at the home should be offered the opportunity to take part in activities of their choice to enable people to lead a more interesting and stimulating lifestyle. The training matrix should be updated to ensure the staff have received the training they require to meet the individual and collective needs of people living in the home. Regulation 37 forms should be completed for all accidents and incidents occurring within the home and forwarded to CSCI. Lyttleton House DS0000033561.V363024.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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