Care Home: Lindhurst Lodge

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What the care home does well General comments about the home were, "My mother has been a resident here over six years. My mother is happy here. It is mainly a friendly, happy home. Usually well managed" and "To me I find everything very satisfactory" People living at the home were well cared for, and they were treated with respect. The home was well maintained, clean and hygienic, and there were no offensive odours. Bedrooms were well decorated with matching furnishings and had been personalised by their occupants. Staff recruitment procedures were robust and all staff undertook regular training. There was a quality assurance system to ensure that the home was run in the best interest of the people living there. When asked, "What do you feel the home does well?" one person answered "Everything". What has improved since the last inspection? All previous requirements had been met. All carers were either undertaking or had attained NVQ Level 2 in care and all senior carers were undertaking or had attained NVQ Level 3 in care. Mandatory health and safety training courses were ongoing and staff also undertook various training courses to improve their skills. Renovations and refurbishment within the home was ongoing. Work had also been carried out throughout the summer to improve the heating and hot water systems. CARE HOMES FOR OLDER PEOPLE Lindhurst Lodge Lindhurst Road Athersley Barnsley South Yorkshire S71 3DD Lead Inspector Mrs Christine Rolt Key Unannounced Inspection 12th February 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 DS0000018262.V355710.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. DS0000018262.V355710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindhurst Lodge Address Lindhurst Road Athersley Barnsley South Yorkshire S71 3DD 01226 282833 F/P 01226 282833 none NONE Mr Azad Choudhry 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) Post Vacant Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places DS0000018262.V355710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th December 2006 Brief Description of the Service: Lindhurst Lodge occupies a central position at Athersley North, and there are shops, pubs, a post office and other amenities within the vicinity. The home is approximately three miles from Barnsley town centre. The home is a purpose built, ex local authority, care home providing personal care and accommodation for 37 older people. It is a two-storey building with a passenger lift and has 33 single bedrooms and two double bedrooms. There is a small car park to the front, and large, private gardens to the rear. All areas of the home are accessible to people in wheelchairs. The weekly fee was £341.50 per week. Hairdressing, chiropody, toiletries, dry cleaning, private taxis and personal newspapers (extra to the ones supplied by the home) were not included in the weekly fee and were charged separately. The acting manager supplied this information during the site visit on 12th February 2008. The Service User Guide and the most recent inspection report were displayed in the foyer. Copies of the Service User Guide were available to people who came to view the home. All people living in the home had copies of the Service User Guide in their bedrooms. DS0000018262.V355710.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 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.30 am to 17:30 pm on 12th February 2008. The regulation inspector was assisted for part of the day by an ‘expert by experience’, Margaret Ferry. Margaret has the experience and knowledge of care for older persons. Her role during this inspection was to chat to people living in the home and observe the daily routines. This included people’s choices, activities, privacy and dignity, meals and the environment. Her feedback is included in this report. The acting manager had completed an Annual Quality Assurance Assessment before the site visit. This document gave her the opportunity to say what she thought they did well, what needed to improve and how they planned to do this. Various aspects of the service were then checked during the site visit. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the acting manager. The operations manager attended for feedback. Questionnaires were sent to six people living at the home, four relatives and three health professionals. Completed questionnaires were received from two persons living at the home and three relatives. There was no response from the health care professionals. Margaret and I wish to thank people living at the home, relatives, members of staff, the operations manager and the acting manager for their assistance and co-operation. What the service does well: General comments about the home were, “My mother has been a resident here over six years. My mother is happy here. It is mainly a friendly, happy home. Usually well managed” and “To me I find everything very satisfactory” People living at the home were well cared for, and they were treated with respect. The home was well maintained, clean and hygienic, and there were no offensive odours. Bedrooms were well decorated with matching furnishings and had been personalised by their occupants. DS0000018262.V355710.R01.S.doc Version 5.2 Page 6 Staff recruitment procedures were robust and all staff undertook regular training. There was a quality assurance system to ensure that the home was run in the best interest of the people living there. When asked, “What do you feel the home does well?” one person answered “Everything”. 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. DS0000018262.V355710.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 DS0000018262.V355710.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, 3 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People had the information they needed to make an informed choice. Assessments were carried out to ensure that the home could meet people’s needs. This home does not provide intermediate care. EVIDENCE: People considered that they had received sufficient information to make an informed choice about the home and that the home met their needs. People living at the home had copies of the service user guide in their bedrooms. The service user guide and latest inspection report were displayed. The acting manager assessed people who wished to come into the home to ensure that the home could meet their needs. Four assessments were checked. The assessments contained information of each person’s needs. Advice was given on how the forms could be updated to provide more individual information. DS0000018262.V355710.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were treated with respect. Medication procedures needed improvement. Care and health needs were met but care planning could improve. EVIDENCE: The information received showed that people’s needs were always met and that staff listened to people and treated them with respect and dignity. Comments were, “They tend to residents’ needs in a friendly atmosphere” and “Always keeps me well informed about my father’s care and needs”. One person commented, “Doctor visits home infrequently, often gives out prescriptions based on symptoms described on phone.” DS0000018262.V355710.R01.S.doc Version 5.2 Page 10 This was discussed with the acting manager. She said that this had been the case in the past, but since she had been in post, she insisted that GPs visit their patients and this had largely been resolved. People living in the home looked well cared for, clean and appropriately dressed. They said they were happy living in the home. Staff were observed treating people with respect and kindness, and interactions were good. The ‘expert by experience’ observed that staff were “caring and friendly without being patronising”. The files for three people were checked. The files were well organised and information was easy to find. The care plans provided information of people’s needs but more detailed information would show how people’s particular needs were to be met. Daily records contained some information of the physical, health and emotional needs that had been met, based on the care plan information. In some files there was good recording of how staff had dealt with particular incidents, particularly on the night shift. However, there was very little information of social needs and how people spent their day although some files contained information of visitors. Person centred care (covering physical, health, social and emotional needs) was discussed with the acting manager and the operations manager. Files contained risk assessments, monitoring charts and weight charts. Information of visits by health care professionals e.g. GPs, district nurses was recorded. Accidents forms were completed and placed on people’s files. The manager said that monthly analyses of accidents were carried out to determine any patterns to falls. The home used 72-hour monitoring sheets for persons who’d had accidents but the recording of this information was not consistent. This was discussed with the acting manager All senior care staff had undertaken accredited medication training. A medication round was observed. The member of staff did not follow the correct procedure for administering medication. This was discussed with her at the time. Medication was stored securely and the room was clean and tidy. The medication for three people was checked. There were no gaps in the Medication Administration Record sheets. Medication was signed and dated on receipt and quantities were recorded. Records contained the name and a photograph of the person. Handwritten entries were signed by two people, which is good practice; however some relevant information had not been included and this was brought to the acting manager’s attention. The acting manager carried out random checks of medication as part of her quality assurance system and records of this were seen. DS0000018262.V355710.R01.S.doc Version 5.2 Page 11 Medication that needed to be kept cool was kept in the medication refrigerator. The temperature was recorded daily and this showed that the temperature was within the prescribed limits, which was also shown on this sheet. Controlled drugs were stored in a controlled drugs cupboard. The controlled drug register was checked. Medication was recorded properly with two signatures and a reducing total. DS0000018262.V355710.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 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received nutritious and appetising meals and choices were offered. The lifestyle did not always match people’s expectations and preferences. EVIDENCE: There were several comments about the lack of outings. People who were physically able said that they had the independence to go out to the local pub or the shops when they wanted. The acting manager said that escorts were always available for people who wished to go out for walks into the community. The acting manager said that an outside entertainer had visited the home the previous evening. Several people spoke about the weekly bingo sessions where families were invited. There was an activities chart on the notice board but this was three months out of date. No activities were observed during the site visit. Daily records provided very little information of how people spent their days. Records need to show people’s daily routines and how they have been encouraged in DS0000018262.V355710.R01.S.doc Version 5.2 Page 13 activities, hobbies and discussions. The necessity for stimulation that is ‘needs led’ was discussed with the acting manager. Visitors were made welcome and were offered drinks but could also make themselves a cup of tea in the kitchenette. Information in people’s files showed that people’s preferences were listed and staff were observed offering choices. The majority of people said that the meals were good. The dining room was pleasant with tablecloths, place mats and condiments on each table. People had the choice of a cooked breakfast every day. The menu board did not show an alternative to the meal on offer for lunch. The ‘expert by experience’ said that she had discussed this with people living in the home and they said that an alternative would be supplied. There was only one negative comment about the meals, “Not enough food. Also bacon sandwiches and scrambled egg served for tea as well as breakfast. Not enough variety.” This was discussed with the acting manager who said that choices were available at all meals. She said that there was no restriction on food and that people could have as much as they wanted. She also said that as part of her quality assurance, she had introduced ‘taster sessions’ of different foods to increase variety. These were normally served at the evening meal and were in addition to the meals on offer. They were small portions for people to try so that the home could decide whether to incorporate them into the menus. ‘Tasters’ had included scampi, pizza, pasta and curry. Also as part of her quality assurance, she had given out questionnaires and discussed meals with people to ensure that their preferences were included in menus. DS0000018262.V355710.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 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and their visitors knew how to complain and were confident that any complaint would be dealt with effectively. People were protected from abuse EVIDENCE: The home had a complaints procedure. The CSCI details needed amendment to bring the procedure up to date. People said that they knew how to complain and considered that complaints would always be dealt with appropriately. A comment received was, “My mother ….has made many friends…we have never had cause to complaint. The home is run in a friendly atmosphere. No complaints.” The complaints book was checked. There was only one complaint and this had been dealt with to the satisfaction of the complainant. There were no allegations of abuse. The acting manager said that all staff undertook adult safeguarding training and this was currently being arranged for new employees. The acting manager and the operations manager had recently attended a familiarisation session on the new South Yorkshire safeguarding procedures. DS0000018262.V355710.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was pleasant, hygienic, well maintained and safe. EVIDENCE: The home created a good first impression for any new visitor. It was pleasant and clean with a calming atmosphere and there were no offensive odours. All rooms were warm, well decorated and well lit. redecoration and refurbishment was ongoing. A rolling programme of The home had a new walk in shower room and a new adapted bath. Throughout the summer, work had been carried out on the boiler system to improve the hot water and heating systems. DS0000018262.V355710.R01.S.doc Version 5.2 Page 16 Bedrooms were clean and well decorated with matching furnishings and bedding. They looked comfortable and were personalised. Bathroom and toilets were clean. Aids and adaptations were in place. The acting manager said that when work on the bedrooms was complete, communal areas were to be refurbished. Work had been carried out in the enclosed rear garden to make it more accessible to people living in the home. This included raised flower beds and better paths and seating areas. DS0000018262.V355710.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were protected by the home’s recruitment procedures and staff were trained and competent to do their jobs. The numbers of staff on duty met people’s needs. EVIDENCE: At the time of this site visit there were sufficient care staff on duty. Ancillary staff were seen throughout the day. People considered that care staff always or usually had the skills and experience to do their jobs and were always or usually available. The acting manager said that staff received training. Staff training was displayed on a training matrix that showed the dates that courses had been undertaken. It also highlighted staff’s training needs. Almost 70 of care staff had attained NVQ Level 2 in care and the remaining 30 were undertaking this training. All senior carers had either attained or were undertaking NVQ Level 3 in care. The manager said that ancillary staff also undertook training relevant to their jobs e.g. Catering staff had undertaken NVQ Level 2 in catering. Information on future training courses was displayed in the staff room. The acting manager said that training was DS0000018262.V355710.R01.S.doc Version 5.2 Page 18 planned for palliative care, bereavement and nutrition. The acting manager was advised to also consider sensory awareness training. The recruitment files for four members of staff were checked. All contained the relevant checks and information. Advice was given on the organisation of information to ensure it could be found easily. DS0000018262.V355710.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was run and managed in the best interests of people living at the home. Their health, safety and welfare were promoted and their financial interests were safeguarded. EVIDENCE: The acting manager was qualified and experienced. She had attained the Registered Managers Award. She was in the process of applying for registration with the CSCI. The home had a quality assurance system that included audits of systems within the home, meetings and questionnaires. The manager said that she DS0000018262.V355710.R01.S.doc Version 5.2 Page 20 sent out a number of themed questionnaires to ensure that the home was run in the best interest of people living in the home. The operations manager carried out monthly visits and produced detailed reports of her findings. The reports showed that her inspections were thorough and areas for improvement were clearly identified. The reports also included information of the actions to be taken and the persons responsible. Money held on behalf of people who lived at the home was stored safely. Records were kept and a sample of these was checked against the money and these tallied. Receipts were available for purchases made on behalf of people living at the home. The acting manager was advised to number the receipts and provide a column in the records to enable easy reference. The operations manager carried out audits of personal allowances. Mandatory health and safety training (i.e. moving and handling, infection control, basic food hygiene, emergency first aid and fire awareness) was ongoing and information of each member of staff’s level of training was recorded. The acting manager said that all care staff had regular updates of moving and handling training and she was currently trying to arrange food hygiene training. Certificates were available to verify that systems and equipment within the home had been serviced and maintained within the required timescales. DS0000018262.V355710.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 DS0000018262.V355710.R01.S.doc Version 5.2 Page 22 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 15 Requirement Provide more detailed information to show how people’s needs are to be met and ensure that daily records verify that these needs have been met. Ensure that staff provide consistent records following accidents (e.g. 72 hour monitoring sheets) Staff who deal with medication must follow the correct procedure by administering the medication before completing the MAR sheet. Consult people about their interests and provide a programme of activities suited to their needs. Daily records need to include information of each person’s daily routine and how they spent their day (group activities, hobbies, one-to-one sessions etc). Update the complaints procedure to include the Commission for Social Care Inspection’s current details. The acting manager must apply for registration with the DS0000018262.V355710.R01.S.doc Timescale for action 08/04/08 2 OP7 15 11/03/08 3 OP9 13 12/02/08 4 OP12 16 m & n 08/04/08 5 OP16 22 18/02/08 6 OP31 8, 9 18/02/08 Version 5.2 Page 23 Commission for Social Care Inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP3 OP9 OP29 OP30 OP35 Good Practice Recommendations Consider updating the home’s assessment forms. Handwritten entries on medication administration records should include all relevant information that is provided with the medication. The reorganisation of information in staff recruitment files would ensure it was easy to find. Consider sensory awareness training to enhance staff’s skills in meeting people’s needs The numbering of receipts and the provision of a receipts column in people’s finance records would ensure that there was easy reference to financial information for auditing purposes. DS0000018262.V355710.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000018262.V355710.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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