Inspection on 01/02/06 for Cardinal Heenan House

This inspection was carried out on 1st February 2006.

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

The inspector 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

Cardinal Heenan House 25/08/09

Cardinal Heenan House 02/05/07

Cardinal Heenan House 11/05/05

Cardinal Heenan House 11/10/04

Cardinal Heenan House 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cardinal Heenan House Don Orione Centre School Lane Roby Mill, Upholland Lancashire WN8 0QR Lead Inspector Phil McConnell Unannounced Inspection 9:30am 1 February 2006 st 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 Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cardinal Heenan House Address Don Orione Centre School Lane Roby Mill, Upholland Lancashire WN8 0QR 01695 622885 01695 627609 upholland@hotmail.com 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) Sons of Divine Providence Mr Gerard Stewart Hilton Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 32 service user in the category of OP (old age, not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines that may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. Bedroom 6 may be used as a shared bedroom by two named service users who have expressed the wish to share. This room will revert back to single occupancy use when one or both of the named service users no longer reside at the home. 11th May 2005 4. Date of last inspection Brief Description of the Service: Cardinal Heenan House is owned by the Sons of Divine Providence, and their head office is based in London. Cardinal Heenan House is set in a rural area of Roby Mill, which is approximately one mile from the village of Upholland where a number of local community facilities can be accessed. Within the home there is a large entrance hall, with seating. The home also consists of a chapel, a large open plan dinning room, with access to ground floor bedrooms and the first floor. There are two lounges on the ground floor, and access to the outside seating area. There are two toilets and a bathroom with an assisted bath also on the ground floor. The first floor consists of bedrooms, two bathrooms, and a smoking room. There is also bedroom accommodation on the lower ground floor. In total there are 32 single rooms with en-suite facilities. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 7.5 hours. This meant that the provider was unaware that the inspection was to take place. The inspector spoke to a number of service users, the home manager, staff members and a visitor. As part of the inspection process ‘case tracking’ was used to assess some of the National Care Standards. This process focused on a small group of people who live at Cardinal Heenan House. All records relating to these individuals were examined and people were spoken to individually and invited to discuss their experiences of the care and support received. Comments from service users were generally positive, including: “This is the best place I have ever lived in”, “This place is brilliant, it’s everything you could want” and “I don’t think you could find a fault with this home”. What the service does well: What has improved since the last inspection? The previous inspection requirement regarding the self-administration of medication has been appropriately addressed. The recommendations raised at the last inspection have also been addressed, including compliance with the Water Supply Regulations (standard 26). Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 6 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. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 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 Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10. Service users are cared for in a sensitive and courteous manner. Individuals are treated with respect and dignity. Service users’ files are generally disorganised. EVIDENCE: Four service users’ care plans were examined and were found to be up to date, containing relevant information with clear guidance on how to provide individual personal care and how to meet a person’s specific health care needs. However, service users’ files were a little disorganised with loose pages in files, which could potentially cause some confusion. Service users have their own en-suite bedrooms, providing privacy and dignity. The inspection coincided with a visit from a service user’s G P, with the consultation taking place in the person’s bedroom. District nurses visit on a daily basis and after speaking to staff and service users, it was apparent that people are treated in their own rooms in order to ensure privacy and dignity. The staff are trained in the ‘five principles of care’, which promote: privacy, dignity, independence, fulfilment and choice for the service users. Some staff Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 10 members were observed speaking to service users in a polite, courteous and respectful manner. One person said, “When I came to live here I was asked what would I like to be called?” Indicating that people are addressed in the name they prefer. A portable public phone was available for use by service users, although it was stated by the manager and confirmed by some service users, that most people prefer to use the office phone, demonstrating the confidence that people have and the relaxed atmosphere within the home. There is a loop system in the home to assist people who have hearing impairments and some individuals have their own mobile phones. This helps to maintain and promote independence, choice and privacy for individuals. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. Service users were encouraged to be involved in a range of stimulating individual and group activities, which promoted motivation and participation. Service users were enabled to see their chosen visitors in a safe and private environment. Contact with relatives and friends is both promoted and encouraged. EVIDENCE: Service users’ files contained care plans with a ‘personal profiles’ section, identifying any dietary needs, religious beliefs, cultural needs and any leisure or activity interests. There was a choice of menus available, which were seen to be nutritious, varied and appetising. There was the opportunity to have lunch with the service users, who were observed expressing their own choices about what to eat. Staff were observed supporting less able service users in a calm, relaxed atmosphere, with sensitivity and gentleness, thereby reducing any embarrassment that service users may feel. There is the opportunity for people to attend the chapel on the premises or to be supported (where necessary) to attend their choice of alternative places of Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 12 worship. This indicates that people’s religious beliefs and practises are catered for and supported. The home has it’s own mini-bus with regular day trips and outings occurring. Some of the day trips included visits to: the Albert Dock, Martin Mere, Southport Theatre and Blackpool. One service user commented on how much they “like going on trips out”. There is also the opportunity for service users to have one to one support on outdoor excursions. Regular shopping trips were also arranged and one service user daily and independently visits the local shops. This helps to promote community awareness and social inclusion. The notice boards in the home advertised various appropriate activities that are available along with any forthcoming events. There were bi-monthly service users’ meetings, where places of interest to visit are discussed, demonstrating that service users are consulted, involved and included in decision making. Regarding relatives and friends visiting the home, there is an ‘open house’ ethos in place. The manager said, “the home has a common sense visitors’ policy”, whereby people can visit the individual service user at any appropriate and reasonable time. One visitor said, “when I visit, the staff always treat me with respect and are always courteous”. An information pack, containing a policy referring to ‘maintaining contact with relatives and friends’ is given to service users and relatives, before admission to Cardinal Heenan House, helping to promote the importance of maintaining existing relationships. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. A satisfactory complaints procedure is in place, helping to ensure that any concerns or complaints are heard and addressed. Appropriate procedures and training were in place in order to safeguard and protect service users from harm or abuse. EVIDENCE: The home had a comprehensive complaints policy and procedure in place, which were found to meet requirements. There were no recorded complaints documented, however, the manager and staff were aware of the process, in the event of a complaint being made and whom to contact in the event of a serious complaint being made. This demonstrated that staff have received correct and appropriate training in order to help to protect service users. In discussion with some service users, there was an awareness and understanding of what to do if they had a complaint. There was a robust policy and procedure in place for responding to an allegation or suspicion of abuse, with training being provided for staff in the protection of vulnerable adults. The training includes ‘how to identify signs and symptoms of abuse’ and ‘what to do if there is a suspicion / or alleged abuse’. The manager and staff members were fully aware of the procedures to be followed in the event of any abuse or suspicion of abuse towards a service user. This highlights that staff are appropriately trained in order to help protect and safeguard service users. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26. The home was well maintained, with a pleasant and safe environment. EVIDENCE: A tour of the home was carried out and it was found to be clean and well maintained. The laundry and washing facilities were appropriately sited, with correct procedures in place to help ensure that the control of infection is eliminated. Laundry staffing levels were seen to be sufficient to meet the required needs of the home. A policy and thorough procedures were in place for the control of infection, with staff being trained in infection control. The staff were provided with protective clothing, in order to reduce the risk of cross infection. During the inspection, an engineer attended the home in order to carry out work in relation to the water system. The engineer said that he is “contracted to inspect and maintain the water system to help prevent water contamination and ensure a safe water supply.” Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. Staffing levels and skills represented were sufficient to meet the needs of the service users. The recruitment process was seen to be robust and comprehensive. The training provided has benefited both service users and staff. EVIDENCE: Staff files, rotas and training records that were examined, highlighted that there was a mixture of suitably skilled staff with sufficient staffing levels employed in the home. In observation and discussion with staff members, there was a clear indication that staff work together to meet the needs of the service users. There was a comprehensive recruitment procedure in operation with staff files showing that correct procedures had been followed for individuals, including: two written references and Criminal Records Bureau (CRB) checks being taken up prior to commencing employment, ensuring the protection of service users wherever possible. Training records showed that staff had received mandatory training in moving and handling, fire safety, first aid, food hygiene, and the administration of medication. There was documented evidence that staff had also received other appropriate training; for example: abuse awareness, mental health awareness, dementia and alzheimer’s awareness. Staff are positively encouraged to attend training courses, with overtime payment for attendance during off duty hours. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 16 A member of staff said “the training is really good and has helped me in my work”. The training plan for 2006 – 2007 includes a course for staff in the development of Person Centred Planning (PCP) This shows that the management is proactive in the training of staff in order to provide the best quality service to the people living at Cardinal Heenan House. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 An appropriate and adequate system is maintained to help ensure that service users’ finances and valuables are securely protected. EVIDENCE: There were procedures in place, regarding service users’ finances, with appropriate and adequate records being kept. A number of service users were able to manage their own finances. Other people who need assistance with finances are supported, and empowered as much as possible to maintain and promote independence. There is a safe on the premises offering security for the safe-keeping of service users’ money and any valuables, with records being maintained. Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action 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 OP37 Good Practice Recommendations Individual records and home records are secure, up to date and in good order; and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. (See standard 10 in the report) Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cardinal Heenan House DS0000005890.V264374.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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