Latest Inspection
This is the latest available inspection report for this service, carried out on 30th June 2009. CQC found this care home to be providing an Adequate service.
The inspector found no outstanding requirements from the previous inspection report,
but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.
For extracts, read the latest CQC inspection for Lyons Court.
What the care home does well People live in a home which is decorated, furnished and maintained to a good standard. Individual bedrooms are spacious, comfortable and personalised. The home is clean, tidy and odour free. Records and systems for ensuring that peoples` monies are safeguarded are in place. There is a clear audit trail demonstrating expenditure and monies received and these were seen to be of a good standard. The quality of food provided at the care home is good and peoples` comments were positive and are highlighted within the main text of the report. There is a formal assessment process in place to ensure that prospective people admitted to the care home are assessed prior to admission. People are assured that their needs can be met and that they will have sufficient information about the care home, so as to make an informed choice about where to live. There is a good range of activities so as to ensure that the social care needs of people who live at Lyons Court are met. Complaints management and referrals to the local Safeguarding Team are well managed and documented with a clear audit trail. People are confident that their complaints and/or concerns will be listened to and acted upon. People are supported and protected by the home`s recruitment policy and practices. The organisation are proactive in ensuring that staff are trained and competent to undertake their role. Visiting arrangements in the home ensure that people who live there, get to see their relatives and friends. Visitors to the home stated they are made to feel welcome and both the management team of the home and care staff are friendly and welcoming. Interactions between staff and people who live in the care home were observed to be positive. Staff have a good rapport with individual people. What has improved since the last inspection? Staff who administer medication sign the Medication Administration Record (MAR) after administering the medication to the individual person. Recruitment procedures within the care home are robust and all records as required by regulation are sought. A comprehensive quality assurance system is in place to seek the views of residents, relatives and other stakeholders as to the quality of the service and facilities provided at Lyons Court. What the care home could do better: Further improvements are required in relation to some aspects of medication practices and procedures so as to ensure peoples` health and wellbeing are maintained. Further development is required to ensure that care plans for individual people are fully reflective of their specific care needs and provide clear guidance for staff as to how care should be provided. This will ensure that staff have the information they need to deliver appropriate care and support to individual people. Ensure that risk assessments are devised for all areas of assessed risk and there is clear information as to how risks are to be minimised. Systems must also be put in place to ensure that other associated documentation e.g. nutritional records and turn charts are completed regularly and there is a clear audit trail depicting staff interventions. Inspecting for better lives Key inspection report
Care homes for older people
Name: Address: Lyons Court Canvey Walk Springfield Chelmsford Essex CM1 6LB The quality rating for this care home is:
one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Michelle Love
Date: 3 0 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area.
Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection.
This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 31 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home
Name of care home: Address: Lyons Court Canvey Walk Springfield Chelmsford Essex CM1 6LB 01245451254 01245451254 ch4can@sanctuary-housing.co.uk www.sanctuary-care.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sanctuary Care Ltd care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 26 The registered person may provide the following category of service only: Care Hpme only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Lyons Court consists of purpose built single accommodation, attached to a listed ancient barn that has been adapted to provide an attractive area for social activities. All bedrooms are furnished to a high standard, well maintained, and have en-suite facilities. There is a choice of two lounges and two dining rooms situated on two floors. A passenger lift is provided for access to the first floor. Lyons Court is situated close to Care Homes for Older People
Page 4 of 31 Over 65 26 0 Brief description of the care home a parade of shops and there is a bus stop nearby. Services provided include the provision of an en-suite room, personal care, meals, liaison with multi-disciplinary teams and also GPs. The home has regular activities and staff are trained to deliver a high standard of care in relation to service user needs. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees are charged at £563.00 and there are additional charges for toiletries, hairdressing, papers, magazines, private taxis, personal clothing and holidays. The garden area is attractively designed and set with shrubs and plants. Access to the garden area is suitable for wheelchair users. There is parking for up to six cars available to the front of the building. Care Homes for Older People Page 5 of 31 Summary
This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection. The visit took place over one day by one inspector and lasted a total of 8.5 hours, with all key standards inspected. Progress against previous requirements and recommendations from the last key inspection (2007) were also inspected. Prior to this inspection the manager had submitted an Annual Quality Assurrance Assessment (AQAA). This is a self assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. A partial tour of the premises was undertaken, residents, peoples representatives and members of staff were spoken
Care Homes for Older People Page 6 of 31 with and their comments are used throughout the main text of the report. Prior to the site visit, surveys for residents, staff and healthcare professionals were forwarded to the home for distribution and for people to complete and return to us. We received 5 resident, 1 healthcare professional and 3 staff surveys and where comments have been recorded, these have been incorporated into the main text of the report. At the time of the site visit the manager was on annual leave. Feedback of the inspection findings, were given as a summary to the homes regional manager. The opportunity for discussion and/or clarification was given. What the care home does well: What has improved since the last inspection? What they could do better: Further improvements are required in relation to some aspects of medication practices and procedures so as to ensure peoples health and wellbeing are maintained. Care Homes for Older People
Page 8 of 31 Further development is required to ensure that care plans for individual people are fully reflective of their specific care needs and provide clear guidance for staff as to how care should be provided. This will ensure that staff have the information they need to deliver appropriate care and support to individual people. Ensure that risk assessments are devised for all areas of assessed risk and there is clear information as to how risks are to be minimised. Systems must also be put in place to ensure that other associated documentation e.g. nutritional records and turn charts are completed regularly and there is a clear audit trail depicting staff interventions. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their needs will be assessed and that they will have sufficient information about the service to make an informed choice about where to live. Evidence: There is a Statement of Purpose and Service Users Guide readily available within the care home. Both documents provide good information about the aims and objectives of the home, details of the services and facilities provided and is specific to the individual home and the client group they care for. The Service Users Guide is written in larger print and provides a useful most frequently asked questions section. Resident surveys returned to us confirmed that people had been given sufficient information about the care home prior to moving in. There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective persons needs.
Care Homes for Older People Page 11 of 31 Evidence: Admissions are not made to the home until a full assessment has been undertaken. Records showed that in addition to the formal assessment procedure, supplementary information is provided from individuals placing authority and/or hospital. As part of this inspection, the care files for the 2 newest people admitted to the care home were examined. Records showed that a pre admission assessment had been completed for both people, prior to their admission to Lyons Court, however the assessment for one person was observed to be incomplete. In general terms the information recorded within both pre admission assessments was seen to be informative and included the rationale for the admission to the care home. Records showed that the prospective person and/or their representative were given the opportunity to visit the care home prior to admission. One person spoken with confirmed that their member of family had visited the care home on their behalf and that the admission process had been smooth. Lyons Court does not provide intermediate care. Care Homes for Older People Page 12 of 31 Health and personal care
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care needs of people are identified however these are not always recorded. Evidence: There is a formal care planning system in place to help staff identify the care needs of individual people and to specify how these are to be met by staff who work in the care home. In addition formal assessments relating to moving and handling, falls, continence and nutrition are completed for individual people, providing useful information as to the person being at high, medium or low risk. As part of this site visit, the care records for 4 people were examined (2 in full and 2 were partially examined in relation to specific healthcare areas). Records showed that each person case tracked had a plan of care, however further development of the care planning and risk assessment process is required to ensure positive outcomes for people and to ensure there is consistency in recording. While shortfalls and deficits have been highlighted within all care files examined, some elements of the care plan were completed well. For example the care file for one person recorded detailed and comprehensive information relating to their personal care. This included information
Care Homes for Older People Page 13 of 31 Evidence: relating to their strengths and abilities, areas where they require specific staff support, frequency of personal care to be provided and evidence that the persons preferences, likes and dislikes had been taken into account. We were advised that since the last key inspection, all care files have been reviewed, a new care planning document has been introduced and historic information archived. The care file for one person showed that not all areas of need were recorded and it was unclear as to the rationale for several elements of the care plan to be completed 14, 51 and 60 days after they were first admitted to the care home. Senior staff spoken with at the time of the inspection were unable to clarify why this had happened. The persons pre admission assessment made reference to the person having Parkinsons Disease and being at risk of falls, however no care plan was devised in relation to either area. There was no evidence to show how this impacted on the persons daily life and their ability to undertake activities of daily living. The care file for another person recorded them as having lost over a 6 month period, over 6KG in weight. No plan of care or risk assessment was devised detailing how this was to be proactively managed. There was insufficient evidence to show how this was being monitored, including prompt referral to an appropriate healthcare professional. Nutritional records examined showed that recording by staff was inconsistent and it was not always possible to determine whether or not the nutritional intake on any given day was satisfactory. The latter was not an isolated case and other nutritional records examined showed that these too were inconsistently completed with gaps. Care must be taken to ensure that associated healthcare records are completed so as to evidence staff interventions and to reflect the care being delivered. For example we looked at the care file for one person who has developed a pressure sore. A plan of care was available, however this made reference to the person requiring to have their body repositioned every 2 hours as a result of being at high risk of developing pressure sores. A senior member of staff spoken with confirmed that the person required 2 hourly repositioning, however records to evidence this being undertaken regularly by staff were not consistently completed. Records also showed that not all areas of assessed risk were recorded within each care file. The care file for one person who is insulin dependent showed that a plan of care pertaining to their diabetes was in place and that appropriate healthcare professionals were regularly involved, however no risk assessment had been formulated. Records showed that people living at Lyons Court have access to a range of healthcare professionals and services as and when required, both at the care home and within the local community. These include, District Nurse Services, GP, attendance at hospital appointments, Optician etc. Care Homes for Older People Page 14 of 31 Evidence: Staff interactions with people living at the care home were observed to be positive and staff were noted to have a good rapport with individual people. Where support and assistance was provided by staff, this was conducted with respect and sensitivity. Residents spoken with were complimentary regarding the care and support provided at Lyons Court. Resident surveys returned to us confirmed that people are happy with the care and support provided by staff. One recorded, the care staff are excellent. Medication records and storage facilities were examined as part of this site visit. Medication is stored securely however on inspection of medication storage temperatures (room) these were regularly recorded above recommended guidelines. A guidance sheet for staff that was pinned to the wall, stated that the temperature has to be between 16 and 28 degrees centigrade. This is incorrect and not within recommended guidelines and could potentially place people at risk of having medication that is ineffective. We looked at storage facilities for medication that requires cold storage. Records were maintained, however it was difficult to assess whether or not the temperatures were accurately recorded. Neither senior member of staff spoken with was able to advise us as to how the minimum and maximum temperatures recorded had been attained. One member of senior staff confirmed to us that they had copied the previous temperature recordings provided by other staff, as they did not fully understand the systems in place. The Annual Service Quality Audit of April 2009 was not completed in relation to medicines and food supplements being stored at the relevant temperatures. We looked at medication and a random sample of medication records for several people and in general terms these are of a reasonable standard, however some shortfalls were identified. We found that where a variable dose of medication can be administered, the specific quantity given is not always recorded. This means that there is not a clear record of medication administered and this could potentially place people at risk of receiving too much or too little medication. Where people are prescribed once weekly medication (Alendronic Acid), records showed that this medication is administered at the same time as other medications. We discussed the issue with both senior members of staff on duty on the day of the site visit and only one senior was able to demonstrate an understanding and/or awareness relating to the specific instructions associated with this particular medication e.g. to be given at least 30 minutes before food and other medications. One team leader confirmed they had administered this medication to people at the same time as their other medications and were unaware of the potential side effects. Records also showed that in some cases the quantity of medication available had not been carried forward to the new medication administration record (MAR) and the new MAR record did not always Care Homes for Older People Page 15 of 31 Evidence: include the date or amount of medication received. On inspection of the staff training matrix, records showed that all staff who administer medication have got up to date training. However the training matrix details that this training is renewed every 3 years and there was no evidence to show that staff receive regular assessment as to their continued competence to administer medication. Care Homes for Older People Page 16 of 31 Daily life and social activities
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to have their social care needs met and to receive a varied diet. Evidence: An activities co-ordinator is employed at Lyons Court for 16 hours per week, Monday to Friday. People who live at the care home are actively encouraged to take part in a range of activities and leisure interests. Lyons Court offers a range of activities that includes, armchair exercises, sing-a-long, religious observance, sensory sessions, regular monthly visits by external entertainers, board games, arts and crafts, bingo, quizzes and trips out within the local community. The activities co-ordinator advised that the increase in activity hours at Lyons Court from 10 to 16 hours per week, has proved invaluable and enables her to spend more quality time with residents, as previously she was spending a significant proportion of her time writing up notes. The activities co-ordinator has undertaken 2 days training specifically centred around the provision of activities and this is accredited by NAPA (National Association of Providers of Activities for Older People). In addition she has also completed an Activities Training Assessment course which covered 5 modules (Distance Learning). The organisation are registered with NAPA. Care Homes for Older People Page 17 of 31 Evidence: There is an open visiting policy whereby visitors to the home can visit at any reasonable time. People spoken with confirmed that they can have visits from family members and/or friends and are enabled and encouraged to maintain friendships and contact with family members. One visitors spoken confirmed that they are always made welcome when they visit Lyons Court. The dining experience for people living at Lyons Court was observed at this visit during the lunchtime period. Dining tables were attractively laid and a menu depicting the choices available was evident on each table. A choice of drinks was available and people were offered more, as and when required. Meals provided to people were observed to be plentiful and attractively presented. Where people required assistance to eat their meal, this was provided with due care and was not rushed. Comments from people regarding meals provided were positive and these included, the food is very nice and Oh I have no complaints. Care Homes for Older People Page 18 of 31 Complaints and protection
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the care home can expect their concerns to be listened to and dealt with appropriately. Evidence: A booklet entitled A Guide on How to Complain was readily available in the reception area of the home. It provides information on the various stages of the complaints procedure and the timescales that people will receive responses, so that complainants know what to expect. It does not provide information on the option of taking the complaint to Social Care (Social Services) and this is recommended to be included. The AQAA details that complaints received are seen as an opportunity to develop or adjust services and to listen to constructive criticism from people who live at the care home and/or their representatives. Resident surveys returned to us confirmed that people who live at the care home know how to make a complaint and know who to speak to if they are unhappy and/or concerned. On inspection of the complaints folder, records showed that over the past 12 months, the management team of the home have received 5 complaints relating to environmental issues, difficulties with laundry and alleged poor care practices. Information recorded included the specific nature of complaint, details of investigation and any action taken. Records showed that these had been addressed promptly and each complaint resolved satisfactorily. Care Homes for Older People Page 19 of 31 Evidence: Records of compliments were readily available and included comments such as [name of resident] has been at Lyons Court and I would just like to say a big thank you to you and all your staff for making them so welcome. Since staying at Lyons Court they have improved in so many ways. Everyone has been so kind and helpful and we were most grateful for the way you cared for [name of resident] while they were at Lyons Court. There is a safeguarding policy and procedure in place. The AQAA details that within the last 12 months there has been 1 safeguarding referral at the care home pertaining to alleged poor care practices. Records relating to this were unavailable at the time of the site visit, however we spoke with the manager upon her return from annual leave and were advised that this has been fully investigated by external agencies and no further action is to be taken. The staff training matrix confirms that all but 7 people who work at Lyons Court have received up to date training on safeguarding. Staff spoken with confirmed that they had received the above training and were able to advise of appropriate reporting procedures. The training matrix also details that staff are waiting for challenging behaviour training and this will be provided from a DVD. It is recommended that the manager needs to ensure that such specialist training provided from a DVD is provided too a sufficient level which ensures staff are competent. Care Homes for Older People Page 20 of 31 Environment
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to live in a comfortable and safe environment which meets their needs. Evidence: As part of this site visit a partial tour of the premises was undertaken by us. All areas of the care home were observed to be clean, tidy and odour free. The home is maintained, decorated and furnished to a good standard and provides people with a homely and comfortable living environment. Each person has their own room and bedrooms are located within 2 floors, which can be accessed by a passenger lift. Each floor has its own communal lounge area, dining room, bathroom and toilets. A garden and paved patio area is available for people to access and enjoy. A random sample of residents bedrooms were inspected and all were seen to be personalised and individualised. People confirmed they are encouraged to bring small items of furniture and as many personal possessions as they wish to personalise their own room. Evidence confirmed that many people have done this. Residents spoken with confirmed they were satisfied with their own bedroom and found them comfortable. The AQAA details there is a maintenance and refurbishment programme in place for Lyons Court. The AQAA also details that in the last 12 months a new entertainment
Care Homes for Older People Page 21 of 31 Evidence: system including large flat screen televisions and sensory equipment have been purchased, kitchenettes within each of the dining areas has been replaced and new flooring and curtains purchased, new furniture and curtains have been replaced within the 1st floor lounge area and bedroom carpets are being replaced over a period of time. A random sample of safety and maintenance certificates showed that equipment in the home has been serviced and remains in date until their next examination. Records of fire drills were examined and these showed that these are regularly undertaken with records kept. Records showed that the Essex County Fire and Rescue Service undertook a visit to the service in February 2009 and a satisfactory standard of fire safety was attained. A fire risk assessment was also in place and this was reviewed in 2008 and 2009. Care Homes for Older People Page 22 of 31 Staffing
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be assured that there will always be sufficient staff on duty to meet their needs. However, people can be assured that staff are trained in core areas and can expect appropriate recruitment checks to be undertaken. Evidence: At the time of the site visit we were advised that 23 people were living at Lyons Court. We were advised by the team leader that staffing levels are currently, 1 team leader and 3 care staff between 07.00 a.m. and 21.30 p.m. and 1 sleeping in person and 2 waking night staff between 21.30 p.m. and 08.00 a.m. each day. We were advised that the managers hours are supernumerary to the above and additional ancillary staff are employed and these include a chef, kitchen assistant and housekeepers. The home also employs an administrator, Monday to Friday between 09.00 a.m. and 14.00 p.m. On inspection of 4 weeks staff rosters these evidence that staffing levels as detailed above have not always been maintained. We have not received Regulation 37 notifications, advising us of the staffing shortfall and measures undertaken to deploy staff to the home. The rota available reflected accurately the team leader and care staff on duty on the day of the site visit, however it was inaccurate pertaining to the managers hours. The rota detailed that the manager was schedule to work 07.30 a.m. to 15.30 p.m., yet we had been advised by both the team leader and
Care Homes for Older People Page 23 of 31 Evidence: administrator that the manager was on annual leave. We were advised that no agency staff are utilised at the care home, however where there is staff sickness and annual leave to cover, this is undertaken by the homes regular bank staff. The AQAA confirms this and records, the home has bank staff to maintain continuity of care. The staff files for 4 people were examined and included the employment files for 3 people who had been newly employed. Files were well managed and organised. Records showed that the majority of records as required by regulation had been sought with the exception of a POVA 1st for one person. The recruitment file showed that confirmation of a satisfactory CRB (Criminal Record Bureau check) had been received by the organisation, however the person commenced employment 2 days prior and there was no evidence of a POVA 1st check on the file. The administrator was unable to clarify as to its whereabouts. A record of induction was evident for 2 out of 3 files examined for those people newly employed at Lyons Court. The team leader was unable to locate the third induction record at the time of the site visit. Inductions records were seen to be comprehensive and staff surveys returned to us confirmed that individuals induction covered everything. The training matrix provided to us by the team leader/administrator of the home showed that staff have up to date training in core subject areas such as food hygiene, COSHH (Control of Substances Hazardous to Health), fire safety, first aid, mental capacity act, moving and handling and safeguarding. Records also showed that several people have received training relating to dementia awareness, communication, person centred care and the principles of care. There was limited evidence of training pertaining to those conditions specifically associated with the needs of older people, however staff surveys returned to us recorded that staff felt they were given sufficient training by the organisation and this was relevant to their role. Following the inspection we were provided with NVQ training statistics for staff. We were advised that 9 staff have attained NVQ Level 2, 3 staff have attained NVQ Level 3, 1 member of staff has attained NVQ Level 4, 3 staff are currently undertaking NVQ Level 2 and 4 people are to commence NVQ training in the future. Care Homes for Older People Page 24 of 31 Management and administration
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the care home can expect a well managed home. Evidence: At the time of the site visit the manager was on annual leave, however upon her return to work we spoke with the manager. The manager has been employed at Lyons Court since 2004. She has many years experience of working in a care field setting and previous to managing Lyons Court, had managerial experience in other residential establishments. The manager has attained NVQ Levels 3 and 4 and achieved the Registered Managers Award in 2005. In addition the manager has completed the Management Development and Leadership course. We were advised by the manager, that the ethos of the service is to ensure that people who live at the care home are happy and that Lyons Court provides the best possible care. Both staff and people who live in the care home stated that the manager is approachable. The manager advised that staff morale within the home is
Care Homes for Older People Page 25 of 31 Evidence: good and several members of staff have been employed at the care home for some considerable time. While all 3 statutory requirements highlighted at the last key inspection in 2007 have been addressed, further development is required in relation to improving the homes care planning and risk assessment documentation and ensuring that medication practices and procedures meet regulatory requirements. All sections of the AQAA were completed and the document returned to us when requested. The AQAA contains clear information about the service. It lets us know about the changes they have made and where they still need to make improvements. The administrator manages residents personal money held on their behalf. The records of 4 peoples monies held by the home were examined and seen to be satisfactory with a clear audit depicting expenditure and monies received. The AQAA details that an effective quality control programme with regular and routine internal audits is conducted at Lyons Court. An annual quality audit is completed by the organisations Quality Assurance Team and this was noted to be comprehensive covering Choice of Home, Health and Personal Care (Care Planning), Health and Personal Care (Medication), Daily Life and Social Activities, Complaints and Protection, Environment, Staffing (Human Resources), Staffing (Training and Development) and Management and Administration. Records showed that the last annual audit was completed in April 2009, with an overall audit rating scored as good. The guidance notes detail that where shortfalls are identified an action plan needs to be formulated and this is checked against monthly Regulation 26 visits by a representative of the organisation. No shortfalls were identified as part of the audit in April 2009. The results of a service user survey conducted since the last key inspection in 2007 were forwarded to us. The results show that out of 26 surveys forwarded to people living at Lyons Court, 14 were returned. In general terms the results are positive and evidence that people living at Lyons Court are happy with the care, services and facilities provided. Comments were mixed and included, I have nothing to worry about and feel safe and secure. I know the staff would be there for me if I needed help. It is better than living at home alone, I am generally happy and am not lonely here, the manager is always approachable and available. When she is on duty the staff are much more on hand than when she is off-then the staff seem to have hugely extended tea and smoking breaks and I have no complaints about anything. One resident survey returned to us recorded, I am very happy and settled at Lyons Court and consider myself lucky that I have found such a pleasant home. I like the fact that it is a small home and I can recognise faces and dont lose my way. Care Homes for Older People Page 26 of 31 Evidence: In addition to the above annual audit, the organisation monitor the quality of the service through regular monthly visits by the Regional Manager. Records were noted to be comprehensive and show that residents, relatives and staff are spoken with at random and a number of care records and other records are examined. Records also showed that regular resident, relatives and staff meetings are held at the care home. On inspection of a random sample of staff supervision records, evidence showed that staff are receiving regular formal supervision in line with National Minimum Standards recommendations. Care Homes for Older People Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 31 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 7 14 There is a plan of care, 30/09/2009 clearly identifying all aspects of the persons care needs and how these are to be met by staff. This will ensure that staff have the information they need so as to provide appropriate care to meet the individuals care needs. 2 9 13 Ensure that staff who administer medication receive regular assessment as to their continued competence to undertake this task. So as to ensure peoples safety and wellbeing. Ensure there are sufficient staff on duty at all times. So as to ensure the needs of people living at the care home are met according to 31/08/2009 3 27 18 31/08/2009 Care Homes for Older People Page 29 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action their specific needs and dependency levels. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 9 The quantity of medication received, amount of medication carried forward and the date when received should be recorded on the MAR record. Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 31 of 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!