Inspection on 25/09/07 for Haslingden Hall and Lodge

This inspection was carried out on 25th September 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Haslingden Hall and Lodge 17/07/08

Haslingden Hall and Lodge 21/05/07

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 Haslingden Hall and Lodge Lancaster Avenue Haslingden Lancashire BB4 4HP Lead Inspector Mrs Janet Proctor Unannounced Inspection 25th September 2007 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haslingden Hall and Lodge Address Lancaster Avenue Haslingden Lancashire BB4 4HP 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) 01706 214403 0170 6219755 haslingdenlodge@orchardcarehomes.com www.orchardcarehomes.com Orchard Care Homes.Com Limited Catherine Elaine Connor Care Home 76 Category(ies) of Dementia (36), Old age, not falling within any registration, with number other category (40) of places Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC To people of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 40) Dementia - Code DE (Maximum number of places 36) The maximum number of people who can be accommodated is 76. Date of last inspection 21st May 2007 Brief Description of the Service: Haslingen Hall & Lodge home is a purpose built 76-bedded property in a residential area of Haslingden that was registered in 2006. The home is divided into two units: a 40 bedded unit for older people who need personal care and a 36 bedded unit for older people who suffer from dementia. There are local shops nearby and there is access to Haslingden town centre, which is about one and a half miles away. The registered persons are Orchard Care Homes Limited. The company have a number of other homes throughout the country, which are registered with the Commission for Social Care Inspection. All bedrooms are single with an en-suite toilet with shower. There is a lounge and dining area with a kitchen on each floor. There is access to a garden from the conservatory on the ground floor and a first floor terrace can be accessed from french doors on the landing. Information about the home is given to prospective residents and a copy also provided in their bedroom when they come in to the home to live. The fees were £320-00 per week if funded by a Local Authority. Residents who paid privately were charged £450-00 per week. The fee did not include hairdressing or private chiropody treatment. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Haslingden Hall & Lodge on the 25th September 2007. The inspection focused on the ‘Hall’, which is a 40-bedded unit for older people who need personal care. One additional visit had been made to the ‘Hall’ unit since the previous inspection. This was done by the Pharmacy Inspector to monitor the control of medications. On the day of the inspection there were 33 residents living on the ‘Hall’ unit. Prior to the visit the Registered Manager had submitted information in a preinspection questionnaire. This gave information that was used in the planning of the inspection. Surveys were sent out and were returned by three relatives. On the day of the inspection information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to residents, the Manager, staff members and visitors. A tour of the building took place. Wherever possible the views of residents were obtained about their life at the home and their comments are included in the report. What the service does well: All residents received a contract that made it very clear what they could expect for the fee paid and what was not covered by this. This prevented misunderstandings. All residents received a thorough assessment before they came to live at the home. This meant that their needs were known and arrangements could be made to meet these. All residents spoken to praised the staff that worked at the home. Some of the comments included, “It’s very nice here, they’re all very kind and friendly” and “The girls are very, very good with me”. This meant that there was a good relationship between staff and residents. Visitors were made welcome at the home and could see their relative in private. A resident said, “My visitors have just gone, they came here to my room to see me”. Residents were encouraged to and able to make choices. This gave them some control over how they lived their lives. Residents said, “I get up at 8.00am. My choice, I don’t have to get up if I don’t want to” and “I get up at all times. It was something to 11.00 am today. They let me stay in bed.” Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 6 Residents were happy with the environment of the home and found it a pleasant place to live. They said, “My room’s gorgeous – everything’s perfect. I’ve brought some of my own stuff here” and “The room’s nice and it’s kept clean”. One of the surveys returned said, “The décor & furnishings of the home are excellent.” Recruitment practices were through and proper background checks were carried out. This protected residents as they ensured that staff were suitable before they started work. All staff received training when they started work and throughout their employment. This meant that they had the skills and knowledge to do their work and knew how to meet residents’ needs. The management systems made sure that the views of residents, relatives and staff were obtained and used to identify any problems. There were systems to look at and improve the quality of care and services at the home. This meant the Manager could identify areas that needed attention and take action to resolve these. What has improved since the last inspection? What they could do better: Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 7 The plan of care for each resident must be accurate about their problems and tell staff how to meet these. This is to ensure that staff know exactly what it is they have to do and to ensure that care is given in a consistent manner. The plan of care should be signed by the resident or their relative. This would allow them to know what care actions had been decided upon and show that they were in agreement with this. This may prevent relatives from thinking that care actions are “inconsistent.” The review of the plan of care should given an indication of what progress has been made over the month so that it can be seen that the care being given is right or not. Health assessments must be done for all residents no matter how long they are staying at the home. This is so that potential harm to residents’ health can be identified before a problem actually occurs. All medications in the Controlled Drug cupboard must remain there until the Community pharmacist comes to remove them. The record of drugs returned must be an accurate record of what has been put in the carton. This is to prevent them being misused. All handwritten medicines records should be double-checked and counter signed so that any errors are detected. Dates should not be altered on the Medication Administration Recording chart as this makes errors more likely. Medications should not be classed as Controlled Drugs unless there is a valid reason for this, for example concerns about misuse. The use of a dedicated person for activities should be explored as this would enable proper pre-planning to ensure that the programme met the recreational needs of as many residents as possible. It would also reduce any conflict for staff between delivering care or doing activities. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents were provided with information about the home and a contract. This meant they knew what they could expect from the home and this avoided misunderstandings. An assessment was done before they moved into the home. This meant that their needs were known and arrangements could be made to meet these. EVIDENCE: The Statement of Purpose and Service User’s Guide had been updated to show the change to the registration. There was a copy in the foyer of the home and copies seen in some bedrooms. All residents spoken to said they were happy at the home, A resident said, “I’ve been here about 6 months. It’s as good as it gets – nearly as good as home. I’m happy here.” All residents were issued with a contract on admission. The contract stated what was included in the fees and what was not and said what period of notice Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 10 was required. A pre-admission assessment was always done before the resident came to live at the home. Copies of these were seen in the files. Letters were sent to prospective residents telling them whether their needs could be met at the home or not. This gave them confidence that they would receive the right care. A relative spoken to said that an assessment had been done before her husband was admitted. Intermediate care was not given at Haslingden Hall and Lodge. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all of the care plans provided staff with the information they needed to satisfactorily meet residents’ personal and health care needs. Medication practices had improved and protected residents health. Residents were treated with privacy, dignity and respect. EVIDENCE: Each resident had an individual care plan. The information collected during the assessment was included in the plan of care. Some of the plans seen gave good directions to staff on what the resident could do so that independence was encouraged. Staff were using a plan of care that had been written in June 2007 for a resident who had recently been re-admitted for a period of respite. The plan had not been reviewed on her re-admission and said that she used continence aids. The resident was now catheterised. The fact that the care plan was not accurate meant that staff were not aware of what they had to do to manage this. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 12 Not all of the plans seen had been signed by the resident or their relative to show that they were in agreement with the care to be given. All three surveys said that they were always kept up to date with important issues affecting their friend or relative. Two of the surveys returned said that they felt that their friend or relative received the support or care they needed, one said that the care given was ‘inconsistent’. A daily record was made about the resident. This included details about their daily life. For example, diet taken, hygiene performed, any accidents or other incidents and their mood. The plans of care were reviewed monthly. Although a statement had been made in the review this sometimes just repeated the directions and did not indicate what progress had been made over the month. Although there were forms for assessing the health of the resident, these had not been completed for a resident who was on respite care. This meant that potential risks to health were not identified before a problem occurred. It also meant that there was no base line against which any improvement or deterioration could be measured. There were records to show involvement of GPs and other professionals. These included District Nurses, chiropodists and opticians. There was some good practice seen for the control of medications on the ‘Hall’ unit. The storage of medications was appropriate and safe. Suitable lockable fridges were used to store medicines that required cold storage. Prescriptions were seen and carefully checked before the pharmacist dispensed them to ensure medicines were correctly ordered and prescribed. Records were kept of medications received at the home. Patient information leaflets were on file. Any specific issues had been highlighted so that they were immediately apparent to staff. There were records of medications administered to residents. Not all of the handwritten entries were signed and witnessed, which meant there was the potential for errors to occur. One resident had been admitted after the start of the month. The dates on the Medication Administration Recording chart had been altered. The 23rd September had been written in twice and signed for on each day. This made it look like 14 tablets had been given when in fact only 13 had been given. Controlled Drugs were stored in an appropriate cupboard and there was a register for recording how many there were and when they had been given and to whom. The Controlled Drugs were checked and there were some discrepancies between the register and what was in the cupboard. These related to a recently deceased resident’s medication. The register stated that he had 50 Temazepam tablets. There were 43 in the cupboard and a pack of seven tablets dispensed from the hospital were also found in the drug returns carton. The returns book recorded that 50 had been put for destruction. Another five lots of medications entered in the Controlled Drug register were Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 13 also found in the returns carton when they should have been kept in the cupboard until the Community Pharmacist came to sign them out. Some medications for ‘the end of life pathway’ were being unnecessarily recorded in the Controlled Drug book and stored in the cupboard. Staff were told how to promote privacy and dignity when they received their Induction training. A telephone was available for residents to use and they could do this in the privacy of their own room. Some residents had their own telephone line. A resident said, “I’ve my own phone so I can make and receive calls when I want.” The problems with the laundry had been resolved through a new tagging system for clothes. Residents were seen to be approached in a discrete and respectful manner. A resident confirmed that staff always used his preferred term of address. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some of the residents’ social and recreational needs were met by activities being available and contact with visitors. The daily routines for residents matched their preferences and choices. Residents received a balanced diet and enjoyed their meals. EVIDENCE: The interests and hobbies of the resident were noted in the plan of care. There was a social activity record in the care plans that said what had been done with the resident. Some of the records also noted whether they had been asked if they wanted to do this and refused. There was a programme of planned activities and these were done by the care staff. There was no one person who took overall responsibility for the activities and ensured that these matched the recorded interests of the residents. Some of the residents spoken to felt that there was little going on during the day as the planned programme was not to their liking. One of the surveys returned said, “Activities – weeks can go by when no activities have been offered.” Holy Communion was held each month and the dates of this were displayed in the foyer. Communion was taken on the day of inspection. Residents were seen to be asked individually whether they would like to attend or not. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 15 The Service User’s Guide stated that regular contact through visits, letters or phone was encouraged and staff would assist residents with this. Visitors could attend at all reasonable times and the resident had the right to refuse to see any visitor and this would be respected. Daily notes seen recorded when visitors came. Residents spoken to said they could receive their visitors in their bedroom if they wished. Only one of the surveys answered the question about contact. This survey from said that their relative was usually helped to stay in contact with them. Both residents and staff spoken to said that routines were flexible and that the residents could make choices about when they got up and went to bed. Residents could use their rooms whenever they wanted to. A number of residents spoken to said that they had some meals in their bedrooms. There was a purpose built kitchen on the second floor. In addition to this each floor had a kitchen area in the dining room where drinks and snacks could be prepared for residents. The Cook said that the seniors on night duty also had access to her store so that there was no need for anyone to go hungry during the night. Staff were seen to prepare drinks for residents at regular intervals and also on request. The majority of residents spoken to said that they enjoyed the food at the home. There was a four-week cycle of menus with a choice of meals for lunch and tea. This menu was on display in the foyer and the days menu was also advertised on the notice board. Alternatives to the menu were also available. Staff asked residents what they would like after lunch for the next days meals and a record was made of this and kept so that it could be seen whether residents were ordering a balanced diet. There was sufficient food in stock and this included fresh fruit, vegetables and salad. Appropriate records were kept of storage and cooking Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that any concerns or complaints would be listened to and acted upon. The procedures for the home and training given to staff ensured that residents were protected. EVIDENCE: There was a complaints procedure on display in the foyer and this was also in the Service User’s Guide. The procedure told people what to do and when they could expect a response to their concern. The procedure also told them how to contact the Commission. Records were kept of any complaints made. These were in a loose leaf format but were numbered so it could be seen if any had been lost or mislaid. One complaint had been made direct to the home since the last inspection. There was a record of the issues, the process, the outcome and a copy of the letter that had been sent to the complainant. Two complaints had been made direct to the Commission. These had been sent to the manager and had been dealt with appropriately. Residents spoken to said that they were happy living at the home and had no complaints. One of the surveys returned said the home always responded appropriately, one said usually and one said sometimes. There was a comment made “The management will discuss issues and concerns always – unfortunately very little ever seems to change and meetings seem worthless”. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 17 There were procedures for Safeguarding Adults and whistle blowing. These told staff what to do should they see, hear, or suspect that something was not right. Telehone numbers were included which meant that staff had this information immediately to hand should anything happen when they were in charge of the home. All staff had Safeguarding Adults training as part of their Inducion to the home and there were training records to confirm this. A member of staff spoken to was aware of what to do if something was not right. A resident said, “I feel safe and don’t worry here”. There were other policies and procedures that helped to safeguard residents. These included dealing with aggression, safeguarding residents’ finances and a missing persons procedure. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home was furnished and decorated to a high standard and provided a very pleasant and safe place for residents to live. EVIDENCE: The home was a purpose built property in a residential area of Haslingden. It had an appropriate layout for the care of elderly people. The home was in an excellent state of repair and minor repairs could be done immediately as a Handyman was employed. There were local shops nearby. There was access to a garden from the conservatory on the ground floor and a first floor terrace could be accessed from french doors on the landing. There was a lounge and dining room with a kitchen area on both floors. The home was extremely well decorated and furnished. The furniture was arranged in a homely manner. It was clean throughout. All residents spoken to said that Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 19 they were happy with their accommodation. One visitor spoken to said that they though there was an odour in the building. All bedrooms were en-suite with a shower, wash basin and toilet. There were disabled toilets near to each lounge. There were two bathrooms and one shower room on each floor. Bath hoists were fitted for assisted bathing. There was a separate sluice room on each floor that was kept locked. There were bedrooms on both floors and the first floor could be accessed by a passenger lift or the stairs. All bedrooms were of an ample size with sufficient quality furnishings. These included a flat screen TV and DVD player. There was an integral fridge in the wardrobe so that residents could safely store food and drink items in their room. There was a call system to each bedroom and wander leads seen for those who could not easily reach the wall point. There was some evidence of personalisation in bedrooms, for example, small items of furniture and pictures. The windows were placed low down in the room so that residents were able to sit in a chair nearby and look out at surroundings. All laundry was done on site. There was a separate laundry on the second floor that was suitably equipped. Liquid soap and paper towels and plastic gloves were seen in the laundry area, which meant staff were protected from infection. Extra staff had been employed so that there was four hours each day dedicated for laundry assistance. A new tagging system had been introduced to enable clothes to be tracked and returned to right residents. Liquid soap and paper towels were provided in each en-suite area to promote good infection control. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty met the needs of the residents. Recruitment practices safeguarded residents. Staff were given training and this ensured that they had the skills and knowledge to meet residents’ needs. EVIDENCE: At the time of the inspection there were 33 residents accommodated at the home. There was a duty rota that showed the name of the staff, their grade and the hours worked. The rota showed some nights over the recent week-end as only having two staff on. The manager said this was due to sickness. Staff members spoken to said that the staffing levels were generally fine. Two residents spoken to made comments about the high turn-over of staff. A relative spoken to said they thought there were staffing problems. The Manager said that the staff turn-over seemed high as some staff had switched units and residents and visitors thought they had left employment. The records of three recently employed staff were examined. These showed that a thorough recruitment procedure was followed and all the required documents were in place. Staff spoken to confirmed that they had completed an application form and had an interview. They said they had supplied the name of two referees and had a Criminal Records Bureau check before starting employment. There were equal opportunities procedures and an equal opportunities monitoring form was completed on application for employment. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 21 All staff were given a copy of General Social Care Council’s code of conduct and a contract. All new care staff came in for basic Induction training before starting employment. This inlcuded: fire safety; Health & Safety; COSHH and infection control; and Safeguarding Adults training. Moving & Handling training was also completed. Staff spoken to confirmed that they ahd doen this training. Once employment began then the Skills for Care 12 week Induction training was started so that staff had the basic skills and knowledge to care for residents. Staff kept care of their own booklets, which were completed as tasks were done and competancy achieved. New staff shadowed a more senior carer until competent. There was a training matrix available to show that staff had completed mandatory training. Other training had also been done by some staff. There were 38 care staff employed of which 21 had the National Vocational Qualification in care level 2 or 3. Other staff were enrolled on the course. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed. There were systems to monitor quality and ensure that the home was run in the best interests of the residents. Health and safety of staff and residents was protected. EVIDENCE: There had recently been a change to the registration and management arrangements at the home. The two units (Hall and Lodge) were now one 76bedded home with one registered manager. The registered manager was doing the National Vocational Qualification in care at level 4 and the Registered Manager’s Award and hoped to have this finished soon. She had a job description and was aware of her role and responsibilities and lines of accountability. She said that she felt well supported by the Company and her Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 23 Area manager, who visited frequently. Staff spoken to said that they felt that the home was well managed. There were Quality assurance systems in place. These included daily, weekly and monthly audits. An action plan was prepared for any deficiencies identified. The Area Manager visited each month and completed a report of what she found at that time. The views of residents and relatives were identified and acted upon. Meetings were held for residents so they could talk about the home and what they wanted from it. Anonymous surveys were sent out to residents and returned to Head Office. The results of these were then sent back to the home for action on any points raised that showed residents were unhappy with anything. A meeting for relatives had been held the previous week so that they could discuss their opinions of the home and how it was working. The views of staff were also taken into account. This was done through staff meetings and the last one had been held in September 2007. Staff spoken to said that were asked their views and could speak freely at the meetings. They said that things brougth up were listened to and acted upon. Policies and procedures were in place and available to staff for reference. All fees were managed by relatives. Only a few residents had money kept at the home. There was an individual wallet kept in the safe and a recording sheet of the tranactions. These were checked and found to be correct. Receipting system were available for any items of value of money left at the home. Servicing contracts had been set up with appropriate Companies. The fire alarm system was tested each Friday and the result recorded. A member of staff spoken to was aware of what to do if the alarm sounded. The emergency lights were tested monthly. Risk assesments were in place, including a work based fiire risk assesment, and there were health and safety policies and procedures. The Acting Managers, Care Manager and Senior Carers all had first aid training so there was always someone on duty with this knowledge. Training in safe working practices was done for all staff. All accidents were recorded and an analysis done each month. Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 24 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The plan of care for each resident must include all their personal, health and social care needs so that staff know how to meet these. (Previous timescale of 28/08/07 not met) Risk assessments for health related issues must be undertaken for all residents and kept under review. (Previous timescale of 03/05/07 not met) All medications in the Controlled Drug cupboard must remain there until the Community pharmacist comes to remove them. This is to prevent them being misused if they are put in the returns carton. The record of drugs returned must be an accurate record of what has been put in the carton so that these are not open to being misused. Timescale for action 31/12/07 2 OP8 13(4)(c) 25/10/07 4 OP9 13(2) 26/09/07 5 OP9 13(20 26/09/07 Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP7 OP7 OP9 OP9 OP9 OP12 Good Practice Recommendations The plan of care should be signed by the resident or their relative to show that they are in agreement with the care to be given. The review of the plan of care should given an indication of what progress has been made over the month. All handwritten medicines records should be doublechecked and counter signed so that any errors are detected. Dates should not be altered on the Medication Administration Recording chart as this makes errors more likely. Medications should not be classed as Controlled Drugs unless there is a valid reason for this, for example concerns about misuse. The use of a dedicated person for activities should be explored as this would enable proper pre-planning to ensure that the programme met the recreational needs of as many residents as possible. It may be beneficial to ensure that concerns brought o the attention of management are followed up to see if the complainant is satisfied with the outcome. The number of staff on duty should be maintained at a suitable level. 7 8 OP16 OP27 Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haslingden Hall and Lodge DS0000067729.V352442.R01.S.doc Version 5.2 Page 28 - 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. 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