Inspection on 11/05/05 for Cardinal Heenan House

This inspection was carried out on 11th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cardinal Heenan House 25/08/09

Cardinal Heenan House 02/05/07

Cardinal Heenan House 01/02/06

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 WN8 0QR Lead Inspector Helen Lindsey Announced 11 May 2005 10:00am 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 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 F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 Telephone number Fax number Email 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 31 Category(ies) of OP Old Age registration, with number of places Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Up to a maximum of 31 service users requiring personal care may be accommodated in the home, in the category of OP (old age 65 and over). 2) The registered provider should, at all times, employ a suitably qualified and experienced manger who is registered with the National Care Standards Commission. 3) Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the National Care Standards Commission regarding staffing levels in care homes. Date of last inspection 11/10/2004 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. In the village there is a public house. 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 mainly bedrooms, two bathrooms, and a smoking room. There is also bedroom accommodation on the lower ground floor. In total there are 32 single rooms. All rooms except for three contain en-suite facilities. The registration is for 31 persons of old age. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 10.00am. It took place over 6 ½ hours. The pharmacy inspector also attended the inspection. The inspector spoke to 15 service users, 4 members of staff, the administrator, registered manager and responsible individual. Comment cards were received from 20 service users, 5 relatives and 2 General Practitioner’s. Staff and care records were examined, and a full tour of the premises was undertaken. One additional visits had been made to the home since the previous inspection, to ensure action had been taken in response to an immediate requirement had been made. What the service does well: What has improved since the last inspection? The home was following a maintenance programme to improve the overall presentation of the home. The car park had been re-surfaced, removing the risk of people tripping in potholes. The dinning room floor had also been replaced, which had improved the appearance of the area, and also reduced Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 6 the echo in the large area, which was better for service users with a hearing impairment. Risk assessments had been reviewed and updated by the manager, and covered all the areas in the home, to ensure the environment remained safe for residents, staff and visitors. An internal audit had also been developed and was completed monthly to ensure the home continued to provide good quality care at a consistent standard. 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 F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 standard(s) 3 The admission and assessment process was clear, and ensured the residents needs were fully assessed. EVIDENCE: The home had developed a detailed admission assessment, which identified needs of individuals and enabled the manager to ensure their needs could be met by the home. Records showed that residents and their representatives had been consulted, and care management assessments had been received to ensure a comprehensive assessment was completed, ensuring the service users needs were fully assessed. Residents confirmed that they had seen the manger, and been involved in the assessment, and were told about the home and given written information, which meant that they knew what to expect when they moved in. Staff members spoken to were fully aware of the admission process, and were made aware of new residents needs prior to them moving to the home. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 standard(s) 7,8, 9 and 11 The health and social care needs of residents were assessed, and then reviewed on a regular basis, ensuring needs continued to be met. Procedures were in place to facilitate the safe handling of medicines through the home but some medication records could be clearer. EVIDENCE: Individual records were kept for each resident with a plan of care setting out the actions that needed to be taken by the staff. A full social assessment had also been carried out with the resident and their families where appropriate, and this affected the activities in the home, trips out of the home, and meals served at the home. Residents confirmed that they were asked every month how everything was, and their records were updated where their needs had changed. A resident said ‘they have got used to my ways now’. Residents also confirmed they were visited by the district nurse when needed, and if they asked to see the GP, it was arranged for them. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 10 Staff confirmed that they reviewed the care plans monthly but continued to monitor individuals on a daily basis, and knew what action to take if they had concerns about anyone’s health. Feedback forms about the home mainly confirmed that the home provided suitable activities, however a small percentage said this was only ‘sometimes’. Positive feedback was received from GP’s about the home, one stating ‘If I ever need care I would not hesitate in becoming a resident there, the care given is excellent’. The self-administration of medication had been assessed in accordance with the homes self-administration policy for one but not both self-administering residents. Trained carers administer all other medication. The Medication Administration Records (MAR) examined were generally up-todate but there was on occasion lack of clarity for example, where entries indicated ‘not supplied this month’ or where self-administration was not indicated. Dividers and photographs were not included within the MAR file, this is recommended to clearly segregate individual records and to assist in positive identification. Medication was securely stored within the medication room; the storage was orderly with no evidence of overstocking. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 standard(s) 14 and 15 Daily life at the home offered choice to residents and met a range of social and religious interests and needs. EVIDENCE: Residents spoken to confirmed the meals served were of a good standard, and offered a variety. An alternative was also available at every meal. A resident said ‘I had minced beef pie today, with chips, it was good’. Another resident had the alternative meal and also said ‘it was really good’. Staff felt the meal was always well cooked and well presented, and that there was enough for everyone. Staff were seen to take meals to residents in their rooms if they did not wish to eat in the dinning area. Snacks and drinks were also seen to be served at intervals through the day. Nearly all the residents in the home chose to join in the afternoon bingo session, and clearly enjoyed the experience. Trips out of the home had included a recent visit to the Cathedral in Liverpool, including lunch out. Other residents explained how they liked being able to go out of the home into the village to visit the pub, or just go out for fresh air and to stretch their legs. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 12 Visitors were seen to be made welcome. Feedback provided to the inspector confirmed that they felt their relatives/friends needs were well met at the home. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 standard(s) Standards not assessed EVIDENCE: These standards were not assessed during this inspection, however they had been met on previous inspections, and will be looked at in future inspections. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 standard(s) 19, 21 and 22 The home provided a comfortable environment, and an ongoing maintenance programme was ensuring the presentation of the home was being improved. EVIDENCE: Since the previous inspection the car park had been re-surfaced and the outside areas tidied up. Inside the home bedrooms had been re-decorated, the dinning area had been re-carpeted. Bathrooms had been worked on to ensure they provided a pleasant environment and storage areas had been sorted out. This had improved the general presentation of the home. Service users felt the home was kept clean and tidy, and that their rooms were comfortable. A resident said the new maintenance person ‘did what needed to be done when it needed to be done’. Another showed the inspector their personal possessions that they had brought to the home with them, and explained how this made them feel more settled. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 15 The manager had completed a risk assessment for all areas of the home, and did regular checks to ensure a safe environment was maintained, and records were seen to provide a record of this. Aids and adaptations were provided throughout the home, and where individuals had specific needs, equipment had been provided such as pressure care cushions. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards not assessed. EVIDENCE: These standards were not assessed during this inspection, however they had been met on previous inspections, and will be looked at in future inspections. However, during the inspection residents were very positive about the staff at the home, saying they were ‘excellent’ and a relative feedback that ‘staff are always helpful and friendly’. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The home was managed and run efficiently. The manager and staff team worked hard to ensure the home was run in the best interests of the service users, and the accounting and financial procedures in place at the home safeguarded the residents interests. EVIDENCE: The manager had worked at the home for a number of years, and had been manager for nearly 3 years. Staff spoken to felt the home was ‘getting better and better’ because of how it was being run. Residents thought the manager was approachable and did their job well. Residents meetings were held to gain the residents views on the home and this had been effective in deciding what trips to take, and the menu. Consultation should be extended to relatives, and stakeholders and results should be Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 18 published, so those moving to the home can have an idea of what the residents at the home think of the service they receive. Residents spoken to felt they knew what was going on in the home, and felt involved in the meetings. Written feedback from residents answering the question ‘do you wish to be more involved in the decision making within the home’ mainly answered ‘no’ with a small number answering ‘sometimes’. An audit system had been developed to ensure the home continued to provide a quality service, and this had supported the manager to identify areas of practice that needed attention, such as ensuring Medication Administration Record (MAR) sheets were fully completed, to make sure medication administration was safe for the residents. Health and safety records were seen to be clear and up to date, though some development was needed in the policies to ensure safe working practice in the home. Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 3 x x x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x x x x 3 Cardinal Heenan House F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? 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 op9 Regulation 13(4)(c) Requirement The provider must ensure that all self-administration of medication is assessed and reviewed. Timescale for action 20/06/200 5 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. Refer to Standard op26 op33 op9 Good Practice Recommendations The registered provider should demonstrate that the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. The registered provider should ensure service users, relative and stakeholder surveys are completed and results should be made available in the service user guide. The policies and procedures should be expanded to include the management of ‘leave‘ medication and should household remedies be used, a policy describing their safe handling. Details of the current Warfarin dose should be held with the MAR and clearly recorded. Handwritten MAR entries should be signed, checked and countersigned. Verbal changes should be fully referenced. Consideration should be given to the inclusion of dividers and photographs within the MAR file F57 F08 S5890 Cardinal Heenan House V218960 110505 Stage 4.doc Version 1.30 Page 21 4. 5. 6. op9 op9 op9 Cardinal Heenan House Commission for Social Care Inspection 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. 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