Inspection on 07/02/06 for Honresfeld Cheshire Home

This inspection was carried out on 7th February 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Honresfeld Cheshire Home 22/11/06

Honresfeld Cheshire Home 18/05/05

Honresfeld Cheshire Home 16/02/05

Honresfeld Cheshire Home 29/07/04

Honresfeld Cheshire Home 05/03/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Honresfeld Cheshire Home Halifax Road Littleborough Rochdale Lancashire OL15 0JF Lead Inspector Jenny Andrew Unannounced Inspection 7th February 2006 9:00 Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 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 Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 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 Adults 18-65. 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. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Honresfeld Cheshire Home Address Halifax Road Littleborough Rochdale Lancashire OL15 0JF 01706 378627 01706 370678 honresfield@leonard-cheshire.org.ukq 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) Leonard Cheshire Mrs Laura Janet Keita Care Home 28 Category(ies) of Physical disability (28), Terminally ill (2) registration, with number of places Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the total of 28 places there can be a maximum of:28 Physically disabled (PD) 2 Terminally ill (TI) Date of last inspection 18th May 2005 Brief Description of the Service: Honresfeld Cheshire Home is a large period building with extended accommodation, situated in 2 acres of beautiful well maintained lawns and gardens. Patio areas are accessible to people in wheelchairs. There are good car parking facilities. The home is approximately half a mile from Littleborough centre where there is a good selection of shops and other community services, including the train station. Hollingworth Lake Country Park and the Pennine Way are also situated nearby. Whilst the home is on a main bus route, the service is infrequent. The home accommodates male and female residents aged between 18 and 55 years (on admission), in single bedrooms on two floors. Qualified nurses, supported by care assistants, physiotherapists and therapists, provide twenty four hour nursing care. Staff are also able to access other specialist nursing services as necessary. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last unannounced inspection in May 2005, an extra visit was made in September 2005 to check whether the home had put right all the things they needed to do from the last inspection. This inspection was carried out by 2 inspectors over one day. The inspectors looked around parts of the building, checked care plans, some records, watched how medication was given out, noted what activities residents did and also watched how much time staff were able to spend with them. The manager, deputy, 1 nurse, 3 care assistants, 2 administrators, 6 residents, 2 relatives, an aromatherapist, assistant therapist, physiotherapist and a domestic were spoken with during the inspection. What the service does well: The manager gave good guidance and support to the staff and since she had come to work at the home, a lot of improvements had been made. The manager and staff were well trained and had a lot of experience in caring for people with disabilities and different illnesses. The staff worked well together as a team so that the residents were cared for in the way they liked. The residents said the staff were “good”, “fine”, “look after me well” and “are caring”. One resident, who spent a lot of time in her room, said “the staff come quickly if I ring my bell”. A relative said “they were happy with things all round”. The care plans were very detailed and kept up to date so that all the staff were working in the same way with each person to give the right care. The home was very clean and the staff were making sure they used gloves and aprons which could be thrown away after they had been used. Liquid soap, paper towels and bins were in each bedroom to try and reduce the risk of passing on infections. New staff were getting good training and were being booked on health and safety training as soon as they started work at the home. More than half of the care assistants had done their NVQ level 2 training which meant they knew a lot about caring for the residents. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Core standard 2 was assessed at the last inspection. EVIDENCE: Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 An effective care planning and risk assessment system was in place, which provided staff with the information they needed to satisfactorily meet the residents’ needs. EVIDENCE: Three care plans were inspected, including one for the most recently admitted resident. Since the last inspection, the care plans had all been reviewed and updated and identified goals for each person had been formulated. It was clear that staff had spent time and effort in this task. Two of the care plans seen were comprehensive and gave a very clear picture of the holistic needs of each resident. The care plan for the most recently admitted resident, who had only been in the home for 5 days, was in the process of being written. The nurse responsible for the care plan was spoken to and she demonstrated her awareness of the resident’s needs. She had already spent time with the resident, getting basic information about his likes/dislikes and chosen routines, which she had documented. This information, together with the pre-admission assessment, was being used to formulate a care plan, which would then be discussed and agreed with the resident and his relative. The resident confirmed that discussion about his chosen routines had taken place and that he was satisfied with his care so far. Residents were given a copy of their care Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 10 plan, together with a briefer version, which was kept in the residents’ bedrooms. Feedback from residents indicated their care plans were regularly discussed with them, but care plans were not always being signed to show this. Care of individuals was evaluated daily and record sheets were in place in each of the three files inspected. The content and information contained in the daily sheets was excellent, ensuring that each person received consistent care from both nursing and care staff. During the inspection, care staff were seen referring to care plans and one of the most recently recruited carers had been instructed to ensure he familiarised himself with each resident’s care plan as soon as possible. Two of the files contained up to date risk assessments with regard to nutrition, skin care (Waterlows), moving/handling, the fitting of bedsides, and other identified risk areas. Where risk areas had been identified, appropriate action was being taken to address them and the daily record sheets recorded the care given and progress made towards goals. The moving and handling assessor had recently assessed the most recently admitted resident and was in the process of writing the risk assessment. Management strategies were in place for the protection of both residents and staff. Two of the staff interviewed demonstrated their awareness of the strategies, thus ensuring that consistency and continuity of approach was ongoing. Responsible risk taking was regarded as part of the normal expression of people’s independence. In addition to individual resident risk assessments, general health and safety assessments were also in place. The good practice of including core values such as privacy, dignity and independence within care plans was noted. It was also recorded on care plans when residents preferred a male or female worker. Care workers are divided up into three teams, one team being all female, and the other 2 being mixed. This ensures the needs of all residents can be met. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 Opportunities for personal development were limited and leisure activities needed to be expanded so that residents could develop their skills and live more independent and fulfilling lifestyles. The home valued the role, which relatives and friends could continue to play in the lives of residents and their participation was encouraged. EVIDENCE: From speaking to residents and staff, it was identified that at the time of the inspection, there were no residents attending any college courses or involved in any employment or voluntary work. One resident, had in the past, attended college but the course had finished. Whilst it is acknowledged that many of the residents, through illness and/or disability would be unable to take part in such activities, staff should be pro-active in sourcing other stimulating external opportunities. This would enable residents to be offered the opportunity to enjoy age and peer appropriate activities outside the home. The Service User Guide, which was reviewed and updated in March 2005 and the Statement of Purpose, set out a programme of activities which are offered Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 12 to residents i.e. occupational therapy on Monday and Wednesday mornings, trips to the theatre, cinema, bowling, in-house parties and entertainment. It was apparent, from discussion with the residents and staff that such activities are on an occasional basis apart from the exercise classes. These were organised weekly by the physiotherapist and usually attended by the same small group of people. A minority of people enjoyed occasional quizzes and painting. Staff said in the afternoon they tried to organise table games such as chess or cards but that this was difficult due to interruptions when having to attend to call bells. The home has always relied on volunteers to assist with the social activities side, but volunteer numbers have, over the years decreased, and the home cannot continue to rely on the goodwill of the volunteer visitors. Many of the residents, currently living at the home are, through disability and illness, spending long periods of time in their rooms. Staff said they had very little time to spend sitting and chatting to people. The home clearly does not have the resources to meet these residents’ social, psychological and emotional needs and this must be addressed. Whilst an activity/volunteer co-ordinator is in post, only 14 hours per week of his time are allocated for arranging outings and in house activities. Given the home have continued to fail in this area over an extensive period of time and it has been identified in previous inspections that the activity programme is not meeting the needs of this service user group either individually or collectively, action must be taken to address this continued shortfall. Residents said “there was nothing much to do” “watched telly all day” and “wanted to go out”. Whilst some trips out had been organised since the last inspection, several residents said they would prefer to go out locally to pubs, shops, cafes etc. Staff said they sometimes supported people to go out in their own time, as they were aware that their social needs were not always being met. Lack of drivers was an identified problem and this has been previously identified at other inspections. Two residents had already booked holidays for this year, which they were financing themselves. It was not usual for the home to finance residents’ holidays. Residents in long-term placements, as part of their basic contract price, should have the option of a minimum 7 day annual holiday, which they choose and plan. Since the last inspection, some improvements to the snoezelen had been made and the inspector was advised that the room was now being used and enjoyed by more residents. Relatives and other visitors spoken to said they could visit at any time and were made welcome by the staff. They were offered drinks and for a nominal price, could choose to eat with the person they were visiting. The food was said to be “excellent” and “of a high quality”. One relative chose to assist the Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 13 person she visited with bathing, and the staff encouraged this. Many of the staff had attended Disability and Equality training and felt this had raised their awareness of residents’ needs to develop relationships with people of their choice. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 Whilst clear medication policies/procedures were in place, staff were not always following them, which could potentially place residents at risk. Good staff training ensures that residents who are ill or dying are cared for with respect and dignity. EVIDENCE: The Boots monitored dosage medication system was in place and staff were adhering to the policies/procedures in place for the receipt and storage of drugs. There were however, discrepancies identified on the medication administration records where after administering drugs, the person responsible was not always signing to say the drugs had been given. This must be addressed. An audit by the Boots representative had been undertaken on 17 October 2005 and there were still some recommendations outstanding from this visit. Due to the level of need, there were no residents currently holding their own medication but a risk assessment system was in place should a resident wish to self medicate. The system in place for the storage, disposal and administration of controlled drugs was satisfactory. Nursing staff were responsible for the administration of all medication. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 15 The Boots disposal system had recently been changed. Whilst staff were recording all returns before putting the medication into the containers, the sheet was not always being signed by two staff and this should be addressed. Health care professionals, reviewed medication as and when needed. Policies and procedures in relation to death and dying were in place and the home is registered to care for people who have palliative care needs. The care plan for one resident, who was very poorly was checked and seen to contain very detailed information as to all care needs. The G.P. was very involved and had contributed to the care plan. This good practice is acknowledged. Access to support services is provided if deemed necessary and on the day of the inspection, a Macmillan Nurse and Counsellor were visiting different residents. Spiritual support is arranged if the family/resident request it and family members are able to stay on site as there is a room, which can be used for overnight stays. The qualified staff are experienced nurses and well able to address the physical and psychological needs of a dying person. The carers interviewed, also demonstrated their knowledge and awareness of caring for residents who were very ill. The nurses were good at passing their knowledge to the care staff team and effective team working was evident. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 A satisfactory complaints system was in place with some evidence that residents feel their views are listened to and acted upon. EVIDENCE: Since the last inspection in May 2005, the Commission for Social Care Inspection had not had cause to investigate any complaints. The home had recently completed its own investigation of a complaint, which had been appropriately recorded and actioned. A complaints procedure entitled “Have Your Say” is issued to each resident as part of the admission procedure. A simplified version was also contained in the service user guide and the new resident said he had received a copy. It was noted that the leaflet did not contain reference to the Commission for Social Care Inspection (CSCI), but the manager said the pamphlet was currently being revised and this was being added. The Honresfeld procedure made reference to agreeing when an issue is a complaint. Several examples were given to inspectors where issues had been raised but not been recorded, even though they had been addressed. Good practice would dictate that all complaints/grumbles are recorded so there is evidence to show that the problem has been satisfactorily addressed. Whilst standard 23 was not fully assessed on this visit, it was pleasing to note that the organisation have introduced refresher Protection of Vulnerable Adult work books, which when completed, will be checked by the training department. Residents and relatives spoken to felt that the staff listened to them and acted on any problems raised by them. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home was clean and hygienic and good infection control practices were in place, ensuring residents were protected as far as possible. EVIDENCE: Policies/procedures were in place for the control of infection and it was evident that staff were adhering to them. The home was clean and hygienic throughout and the domestic spoken to was able to give good practice examples of how she ensured the spread of infection was minimised e.g. use of different coloured mops for bedrooms, bathrooms/sluices and toilets; new disposable gloves for each bedroom, toilet that she was working in. Staff were also seen to observe good hygienic practices by wearing blue disposable aprons for serving of food and white ones for assisting with personal care tasks. They used differently coloured bags for soiled laundry. There was a plentiful supply of disposable gloves, and liquid soap and paper towel holders were fitted throughout the home. Staff were aware of the importance of washing their hands after attending to each resident. Laundry facilities were inspected at the last inspection and found to be satisfactory with two new washers having been purchased, guaranteed to kill all bacteria, including super-bugs such as MRSA. Laundry assistants are employed 7 days a week. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 The staff team had the collective skills, training and expertise to undertake their roles efficiently and effectively which ensured the personal care needs of the residents were being well met. Good recruitment and selection procedures were in place providing the necessary protection for service users. The arrangements for the induction of staff are good, with the staff demonstrating a clear understanding of their roles. An effective supervision system is in place, which supports the staff in caring well for the residents in their care. EVIDENCE: Care at the home is delivered by a multi-disciplinary team of staff. The team comprises of nurses with general training, mental health and those with experiences in younger adult disabilities and palliative care, together with many care assistants who have achieved NVQ level 2 training or above. The services of Physiotherapists and Occupational Therapists are purchased independently by residents as needed. Assistant therapists are also employed who ensure that the exercises prescribed by the physios, are implemented. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 19 Feedback from the residents and relatives was good with regard to the staff team, the only criticism being that they could not spend much time with them on a one to one basis. The use of agency staff had significantly reduced, with the home’s bank staff providing cover for any shortfalls identified. The home have a large team of bank staff, who are used on a very regular basis and are therefore familiar with the needs of the residents. At the last inspection, a requirement was made to review staffing levels to ensure the needs of the residents were being met. As a result of the review, the manager had identified there was a shortfall on the “twilight” shift (17.00 to midnight), and action had been taken to address this. One external applicant had been recruited who was due to commence induction the day following the inspection. In addition a care assistant already working at the home was going to do additional hours. The staff team worked well together and staff morale was good. A staff handover was seen during the inspection, which was informative and thorough. All staff were involved and encouraged to add any pertinent information and feedback about individual residents, with the lead being taken by a nurse. A thorough recruitment and selection system was in place with all necessary checks being undertaken before staff are able to commence working at the home. Where staff had begun work following a Protection of Vulnerable Adult check, they were working alongside an experienced staff member who was closely supervising them. This practice remained in place their Criminal Record Bureau check was cleared. Staff personnel files were in order save that two of the files inspected did not contain an identity photograph. Photographs were said to have been taken but the film had not been developed and this must be done. The good practice of involving residents in the recruitment process had been introduced but the two people who had been so involved had now moved out of Honresfeld to live more independently. The manager was in the process of consulting other residents to find out whether anyone would be interested in taking over this role. The staff spoken to were clearly committed to any training opportunities afforded them. One carer said that if any care assistants identified a training course they felt would be beneficial, this was facilitated. They said their training needs were discussed during supervision when the supervisors had access to the training matrix. It was however, identified that the training matrix had not been updated. Several of the staff on the matrix had left and some staff training had not been recorded. Staff personnel files must contain a training profile, identifying what each person has undertaken and the date of the training, together with copy certification. This was highlighted at the last inspection and action must now be taken, as a matter of some urgency; staff training records must be updated accordingly as accurate records are required on site. A large percentage of the staff had undertaken training in “disability and the law” and “disability and you”. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 20 Since the last inspection, the induction training programme has considerably improved, ensuring that all new staff receive mandatory training within the first 8 – 12 weeks of their employment. As soon as they start work, they are signed up for all the relevant training courses. One care assistant, who had commenced work in late November 2005, had already undertaken training in first aid, infection control, basic health and safety, fire awareness, moving/handling and disability and the law. She still had some of the foundation modules to complete. Another carer interviewed, who had only started work the week of the inspection, confirmed he had been booked to start his induction on 26 February 2006. He said he had received some on-site basic induction on the whereabouts of fire points and extinguishers, basic procedures and had received the staff hand-book together with the General Social Care Council’s “Code of Practice”. He had also been instructed to read the organisation’s policies/procedures and residents’ care plans in any spare time he had. Although some staff who had undertaken their NVQ training had left, the home had maintained just over 50 of trained carers to NVQ levels 2/3. Staff were being encouraged to enrol on future courses so that the required 50 will be retained. Since the last inspection, staff supervision has considerably improved. Trained staff are responsible for the supervision of the care assistants and this was working well. Staff interviewed confirmed that the sessions were thorough and that their training needs were being identified. The newest employee had already been advised that he would be receiving supervision shortly. All supervisions are recorded with both supervisor and supervisee, signing to say they agree the contents. The nurse interviewed said she had received supervision training. One problem identified was the supervision of some of the bank staff, who worked irregularly and those who only did week-end shifts. This was however, being addressed. Appraisals are not currently undertaken and the manager should consider implementing such a system. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The manager provides strong leadership, guidance and support to staff to ensure residents receive a consistently good standard of care. More quality monitoring and reviewing processes had, or were in the process of being introduced, in order to seek the views of residents, staff and volunteers. EVIDENCE: The manager is registered with the CSCI. She is a Registered Mental Nurse (RMN) with a vast experience in the private and NHS services and has approximately 20 years of management experience. She has obtained several teaching and assessing qualifications and has undertaken regular clinical updates relevant to her working environment. She is currently on the Registered Manager’s Award and is hopeful of completing this training by the end of 2006. From interviewing staff and records seen, it was evident that the manager actively promoted staff training and development opportunities as already highlighted above. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 22 The Leonard Cheshire organisation has recently reviewed quality monitoring and reviewing methods and introduced a full service audit which was due to begin at the home on 13 February 2006. This will cover a wide range of areas including, health and safety, personnel and care. The audit involves a series of meetings and interviews with residents, staff, volunteers and purchasers. Comment cards had been sent out to various people. Two meetings for the residents had been arranged, one in the morning and one in the evening when relatives could also attend. In addition, a meeting was held at the home on 11 January 2006 where the Regional Director visited the home to update residents, relatives, staff and volunteers on the progress made towards the organisations new vision and future strategies. When the report is finalised, a copy should be sent to the CSCI. A corporate review was undertaken in 2005, resulting in an extensive report entitled “Service User Involvement in Leonard Cheshire – December 2005”, being written and published. This was a very comprehensive review, resulting in an action plan being formulated to address identified shortfalls. Copies of this report are available in standard, large print or electronically and other formats by request. On a more local level, the introduction of more regular supervision meetings, Regulation 26 visits and improved training has clearly benefited the residents. Resident and staff meetings are also held but not on a regular basis. More regular planned meetings should be arranged for both staff and residents. Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 x 14 2 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 3 3 X 3 X X X X Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 24 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 YA14 Regulation 16 Requirement The activity programme must be reviewed to reflect the needs, preferences and capabilities of the resident group, including those who are confined to their rooms. Such programme must be implemented and maintained. (previous timescale of 30/04/05 not met) The social and emotional needs of residents, who through illness, are confined to their rooms, must be addressed. The MAR sheets must be signed immediately after medication has been administered. The recommendations made by the Boots representative on 17/10/05 must be implemented. Up to date training and development records must be retained in each employees file and the staff training matrix must be kept updated. (Previous timescale of 30/04/05 not met) Each staff personnel file must contain a photograph. Timescale for action 31/03/06 2. YA14 12 31/03/06 3. 4. 5. YA20 YA20 YA32 13 13 18 28/02/06 28/02/06 31/03/06 6. YA34 19 31/03/06 Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 25 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. Refer to Standard YA6 YA12 Good Practice Recommendations Care plans should be signed by the resident and/or relative to show they have been consulted and are in agreement with the plan. Staff should further assist residents in taking up a wider range of opportunities i.e. further education, distance learning, vocational, literacy, numeracy training, voluntary work etc. More regular local trips out should be arranged. Residents in long-term placements, should be afforded the opportunity of a minimum 7 day annual holiday, as part of their basic contract price. Two staff should sign the drug disposal sheets. All complaints/grumbles should be recorded so there is evidence to show the problem has been addressed and resolved. More regular resident and staff meetings should be held. 3. 4. 5. 6. 7. YA14 YA14 YA20 YA22 YA39 Honresfeld Cheshire Home DS0000017344.V281203.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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