Inspection on 28/02/07 for Hourigan House

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Hourigan House 23/02/09

Hourigan House 15/02/06

Hourigan House 14/09/05

Hourigan House 17/01/05

Hourigan House 17/08/04

Hourigan House 21/01/04

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 HOMES FOR OLDER PEOPLE Hourigan House Myrtle Avenue Leigh Wigan Greater Manchester WN7 5QU Lead Inspector Kath Smethurst Unannounced Inspection 28th February 2007 10:00 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 Hourigan House DS0000005741.V304525.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. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hourigan House Address Myrtle Avenue Leigh Wigan Greater Manchester WN7 5QU 01942 672922 01942 672104 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) www.clsgroup.org.uk CLS Care Services Limited Mrs Elaine Wilson Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age (8) of places Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include:up to 40 service users in the category of OP (Older People) up to 8 service users in the category of PD(E) (Adults with Physical Disability over 65) The service should employ a suitably qualified and experienced Manager who is registered by the CSCI 15th February 2006 2. Date of last inspection Brief Description of the Service: Hourigan House is a two-storey building with well maintained garden areas, situated in the middle of a housing estate, half a mile from Leigh town centre. It is close to shops and other local facilities and is well served by public transport. The Home is spacious with several lounges. All bedrooms are single and some have an ensuite toilet facility. There are ample communal toilets and bathrooms situated throughout the home. Hourigan House provides personal care and support for forty people over the age of sixty five years. The home is owned and managed by CLS Care Services Limited who have 40 plus homes around Cheshire and the Wigan area. Fees range from £312.15 to £370 per week. Additional charges are made for hairdressing. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection site visit took place over a period of five and a half hours. The home had not been told that the inspector would visit. The inspector looked around parts of the building, tasted the food served at lunch and checked some paperwork about the running of the home and the care given. To get more information about the home six residents, the manager, home services manager, care team leader and three care staff were spoken with. Care staff were also watched as they went about their work. Before the inspection comment cards were sent to residents, relatives and people such as social workers, district nurses and doctors. Ten residents and two relatives returned comment cards. What the service does well: From speaking to residents and from comments made by residents and relatives in comment cards it was clear all were very happy with the care provided. Staff were described as “very good”, “very friendly” and “kind”. One relative wrote, “We are more than satisfied with the overall care and respect our mother receives, we are always made welcome and try to join in all the events at the home”. Before people come to live at the home staff visit residents, either at home or in hospital, to make sure the care needed can be provided. Residents and relatives are welcome to visit before they decide to come and live at the home. Each resident had a named carer, called a key worker, who would help them have a bath, go shopping for them or keep their clothes tidy. The records kept on residents (care plans), includes a lot of information about the things residents need support with. The home is good at making sure residents health was taken care of by seeing doctors and other health care workers. Relatives who returned comment cards said they could visit at any time and staff always made them feel welcome. Staff have done a lot of training, which helps them look after people properly. For example understanding the special needs of people with dementia, how to Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 6 move residents safely, first aid and what to do if a resident isn’t being treated properly. The home makes sure that before staff starts work they are properly checked to make sure they are suitable to care for people living in the home. 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. The summary of this inspection report can be made available in other formats on request. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Proper assessments are carried out prior to admission ensuring the home is able to meet prospective residents identified needs. EVIDENCE: Inspection of the records of two of the most recent admissions showed a full assessment of physical care needs had been completed and where applicable social work assessments had been taken note of. Discussion took place in respect of the assessment process undertaken. The manager advised that if possible prospective residents are visited prior to admission at home or hospital, whether they are paying for themselves or the local authority funds their care. This was felt important to ensure the home was able to meet needs. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 9 Prospective residents are encouraged to visit the home. If this is not possible relatives usually looked around the home prior to their relative’s admission. New residents are allocated a key worker. Feedback in returned resident and relative comment cards indicated they were provided with sufficient information prior to coming to live in the home. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 10 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, good. This judgement has been made using available evidence including a visit to this service. Health and care needs were well met. In the main care plans were detailed, up to date and reflected the care needed, but some relevant records had not been completed, which meant important information had not been documented. Personal support is offered in such a way as to promote residents privacy. EVIDENCE: Three care plans were examined. Two of the care plans contained comprehensive information relating to residents personal and health care needs. Each area of risk has a separate record. Supplementary information includes personal care and weight records. Daily entries in care notes were completed in all the plans examined and gave a good indication of the care provided and residents well being. In addition to internal reviews there was evidence of (Social Services) external reviews having taken place. Risk assessments were in place. They covered areas such as nutrition, falls, pressure areas and moving and handling. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 11 Residents are allocated a key worker. The key worker assist residents with bathing, shopping and keeping their clothes tidy. Shortfalls were noted in one of the plans examined. This resident had been admitted in December 2006 but some sections of the care plan and some risk assessments had not been completed. The profile section and mental health assessment sections were blank, as were the waterlow and moving and handling risk assessments. This was discussed with the manager who offered assurances this would be addressed immediately. The life profile section in two plans was blank and incomplete in one. The manager advised that this was in the process of being addressed. One of the care team leaders was currently working on a supernumery basis and was gradually working through the plans to ensure the life profile sections were completed. Once completed the information in life profile will provide readers with detailed information about important events, previous jobs, places visited on holiday, war experiences, interests, style fashion, memorable moments, current interests, sporting interests, preferences and aims and aspirations. Feedback from residents who were able to comment was very complimentary about staff and the care provided. One described staff as being “very kind”. Relatives who returned comment cards were also pleased with the standard of care. One wrote, “We are more than satisfied with the overall care and respect our mother receives”. There was evidence that the residents’ health care needs are regularly monitored. Individual care records inspected showed evidence of visits from GPs, district nurse, continence advisor, chiropodist and optician. Records also indicate when residents have visited hospital outpatients departments. All staff involved with medication at Hourigan House have received relevant training. Staff are undertaking further training in March 2007. It was positive to note that only a small number of designated staff are allowed to handle medication. The home has regular contact with the local pharmacist for advice, information and medication checks. Samples of MAR (Medication Administration Records) were examined and were found to be up to date and accurate. Medication storage was secure and orderly with no evidence of overstocking. Separate safe storage and recording systems are provided for Controlled Drugs. A lockable drug trolley is provided which when not in use is securely stored. A lockable medication fridge is also available which is used to store eye drops, antibiotics etc. The temperature of the fridge is monitored. During the inspection staff were observed to treat residents with respect and consideration, were attentive to individual needs and were discreet. Residents Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 12 were seen to be dressed in clean well maintained clothing. Staff were observed knocking on doors before entering rooms and toilets. Residents who were able to comment were very positive about how staff assisted them with personal tasks. For example staff did not make them feel embarrassed when assisting with intimate care tasks, made sure they wore their own clothing and knocked on doors before entering. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 13 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. Resident’s interests and links with visitors are encouraged, to ensure residents live as normal a life as possible. Meals are good and the needs of residents are well catered for with a balanced and varied selection of food provided. EVIDENCE: On the day of the visit, the routines of daily living were observed to be flexible. Residents were seen to be getting up in the morning at times that suited them. Staff were attentive to the needs of the residents. A friendly but respectful banter was observed between residents and staff. The home employs a part time activity organiser who works twenty-five hours a week. On the day of the visit the activity organiser was not working so it was not possible to speak to her about her role. Details of weekly activities are displayed. Activities advertised include dominoes, manicures, handicrafts, bingo, entertainment, reminiscence, films and exercise. Trips out are also arranged. Recent outings include a visit to a Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 14 local garden centre and Blackpool. The individual activity records of three residents were examined. The activities undertaken by these residents included, exercise, bingo, entertainment, lunch out and film. Staff also document when residents have declined to take part in social activities. Age appropriate games and a good supply of books were in evidence. Televisions are provided in all lounges. In addition care plans take note of residents social interests. Regular residents meetings are held and well attended. The minutes of the last meeting were examined and indicated residents were satisfied with the range and frequency of activities available. Residents spoken with and those who returned comment cards had no complaints about the activities provided. During the visit staff were observed spending time socialising with residents when their duties allowed. Residents wishing to maintain their religious links are encouraged to do so. Local clergy visit the home on a regular basis. The home has an open visiting policy. There are no restrictions on the time people visit evidence of which was highlighted in the visitor’s book, where entries showed residents friends and relatives visiting at different times during the day and the evening. The only time restrictions would be imposed is when requested by residents. ”. Feedback in returned relative comment cards and visitors spoken with indicated they were always made welcome when visiting. One relative wrote, “We are always made to feel welcome and try to join in all the events at the home”. Residents who were able to comment expressed satisfaction with the care provided. Residents said they had choices where they wished to sit, when they got up, when they went to bed and what clothes they wore. Hourigan Houses policy on admission is that residents are encouraged to bring in personal items that will help them to settle in to life at the home, the extent of which is agreed prior to admission. Evidence of personalisation was seen in resident’s bedrooms where personal mementoes and photographs were on display. It should be noted some residents have memory and communication difficulties so were unable to confirm they were able to exercise choice. Nevertheless observation of care practice indicated residents could make some choices for example in regard to meals and where they spent their day. Resident’s rooms are personalised and residents are able to bring personal items in the home. Menus were examined and were found to be well balanced and nutritious. Menus are compiled centrally for all CLS establishments but are adapted to suit resident’s preferences. A choice is offered at every meal. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 15 Breakfast is served on a flexible basis and residents were observed having their breakfast at various times during the morning. Lunch is the main meal of the day and there is always a choice of meals served with vegetables and potatoes. The evening meal offers a hot meal or soup or sandwiches. Drinks and snacks are available throughout the day. A detail of special diets, meal preferences and assistance residents may need is documented. The cook speaks to residents each day to ask them about their choice of meals. However if residents change their minds regarding their preferred meal option this is not a problem. Meals are eaten in the main dining room but if they wish residents may eat their meals in their rooms. The dining area was clean and efforts had been made to give an air of domesticity. Dining tables were tastefully set so ensuring a congenial atmosphere. The manager advised that CLS had undertaken a review of mealtimes. As a result new system called “marvellous mealtimes” had been introduced. The aim being to make mealtimes more leisurely and with fewer interruptions. This was observed on the day of the visit. The dining room door was closed, staff sat with residents, medication was given at a different time (unless required). The manager said the system was working well. Residents spoken with and those who returned comment cards had no complaints regarding the choice, quality and quantity of food provided. Hourigan House DS0000005741.V304525.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. The home has a policy and procedure on complaints and the protection of vulnerable adults, which ensures residents rights and well being is protected. EVIDENCE: A detailed complaints procedure is in place. Details of how to complain are contained in the “Service User Guide” which each resident has a copy of. A system is in place for recording complaints. The homes complaints book was examined and showed three complaints had been logged. The complaints made directly to the home related to care practice, choice of food and an out of order toilet. There was written evidence the complaints had been thoroughly investigated. All the concerns raised had been resolved to the complainant’s satisfaction. No formal complaints have been received by the CSCI over the past year. Residents spoken with and residents/relatives who returned comment cards confirmed they knew whom to approach if they had a concern or complaint. An Adult Protection and Prevention of Abuse policy is in place, which incorporates, whistle blowing. The home ensures all staff completes a POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 17 check before they commence work. No recent POVA (Protection of Vulnerable Adults) investigations have taken place. Staff spoken with understood the importance of reporting any allegations or suspicion of abuse. Training in the signs and recognition of abuse is covered during induction and in NVQ training. Good practice was noted in that staff routinely complete updated protection of vulnerable adults training. Hourigan House DS0000005741.V304525.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, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and comfortable and offers people a range of communal and private areas in which to spend their time. EVIDENCE: Hourigan House is a two-storey building with well maintained garden areas, situated in the middle of a housing estate, half a mile from Leigh town centre. It is close to shops and other local facilities and is well served by public transport. The garden areas are tidy, well maintained, safe secure and accessible for residents. The Home is spacious with several lounges, a conservatory and dining room. All these areas are nicely furnished and decorated. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 19 The manager advised that the home was soon to become a non-smoking establishment. The manager said this would not affect residents currently living at the home as none smoked. The service user guide will need to be amended to reflect this change and ensure any future residents are fully aware of the policy. A sample of bedrooms was examined. Bedrooms were personalised with photographs and personal mementoes on display. Doors are fitted with locks that can be opened by staff in an emergency. In the main the home is well maintained both internally and externally. Since the last inspection some corridors have been re-decorated and carpets (corridor) replaced. The manager advised that plans had been made to continue with the decoration of the corridors and replace the remaining corridor carpets. It was also noted that the wallpaper in some bedrooms was beginning to show signs of wear and tear and would benefit from redecoration. The manager said that bedrooms would be re-decorated on a gradual basis as part of the maintenance and renewal programme. On the day of the visit the home was clean and odour control was good. Residents spoken with and those who returned comment cards made no adverse comments regarding the environment or standard of cleanliness. The laundry was sited away from food preparation areas and was seen to be clean and orderly. Sufficient and suitable equipment was provided. Residents spoken with and those who returned surveys made no adverse comments regarding the environment or cleanliness of the home. Hourigan House DS0000005741.V304525.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. Staff are caring and committed and work hard to provide a consistent standard of care for people living in the home, but staffing levels need to be reviewed to ensure residents care needs are not compromised. The residents were cared for by staff that were safely recruited, suitably experienced and trained to meet the residents care needs. EVIDENCE: Staff turnover at Hourigan House is relatively low with a number of staff having worked at the home for some considerable time. This would indicate staff are well supported and happy in their role. All staff spoken with indicated they enjoyed working at Hourigan House. The atmosphere in the home was very relaxed and friendly. Interactions between staff and residents were frequent, natural and warm. During the visit staff were observed to respond speedily to requests for assistance made by residents and also spent time socialising with them. A written rota is maintained. The manager works on a supernumery basis from Monday to Friday. A home services manager, part time activity co-ordinator, and part time handyman are also employed Monday to Friday. During the day Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 21 each shift comprises of a care team leader and three care staff. Two staff work at night. Domestic and catering support care staff seven days a week. Discussion took place with the manager regarding staff ratios in the evening and at weekend. In previous inspections some concerns were raised in regard to staffing levels when the manager and other support staff are not at work. For example (evening and weekend) there are four staff working on each day shift, one of these is a Care Team Leader who is counted in staffing but who carries out administrative tasks and is also responsible for the shift when the manager is not on duty. These duties could at times take care team leaders away from providing direct care to residents. The manager said that current dependency levels were such that staff ratios were sufficient. The manager said she would not hesitate to increase the number of staff on each shift if needed. Staff spoken to during this inspection indicated staffing levels were sufficient. Nevertheless it is strongly recommended that staffing levels be kept under review to ensure care needs are not compromised. As noted in previous inspections there are only two members of staff on duty each night to assist up to forty residents to bed and support them throughout the night. Given the layout of the building and dependency levels of residents can rise significantly as a result of illness. Assurances were given that the number of staff at night and would be increased if necessary. Nevertheless this situation needs to be kept under review to ensure ratios at night are sufficient to meet residents care needs. The files of three staff employed looked at showed all necessary recruitment checks had been undertaken. All contained: written application forms, 2 references, Criminal Records Bureau (CRB) check and verification of identification. All prospective staff attends an interview. The acting manager and another senior member of staff conduct interviews. Interview notes are also maintained. All staff are issued with a statement of terms and conditions of employment. The home has achieved Investors in People status. A staff development programme is in place and records of training are maintained. Samples of training records were examined. There was evidence that new staff undertake induction training following which foundation training is undertaken. One relatively new member of staff spoken with confirmed she had undertaken induction and then foundation training. This member of staff said the training provided was “Very good”. Mandatory training needs are well met. Recent courses undertaken include, food hygiene, fire safety, moving and handling, first aid and protection of vulnerable adults. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 22 It was also pleasing to note that training opportunities are made available to catering and domestic staff. For example domestic staff have attained relevant NVQ awards. Training records also show staff have undertaken a range of more specialised training, including medication, supervision/appraisal, prevention of pressure sores, NVQ assessors course and dementia care. NVQ (National Vocational Qualifications) are promoted. Currently 98 of staff are in receipt of the award with the remaining staff undertaking training. The home is commended for its efforts in this area as the number of NVQ qualified staff is significantly above the required percentage. All staff spoken with were happy with the range of training provided by the home. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 23 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 manager is experienced and competent ensuring the home is run in the best interests of the residents. Regular maintenance and fire safety checks were carried out, promoting the health and safety of both residents and staff. EVIDENCE: The manager has extensive experience in running care homes for older people. Although she has considerable experience, she has continued her professional development and undertaken a number of courses relating to the care of older people and management. The manager is in receipt of the NVQ level 4 registered managers award. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 24 During the inspection, it was observed that staff and residents had no hesitation in approaching the manager if they had anything they wished to discuss. Staff spoken with described the manager as being “supportive”. There is a clear line of accountability in the home. Record keeping is in the main good and residents and relatives indicated they continue to be satisfied with the care and organisation of life in the home. Effective internal and external quality assurance systems are in place such as staff and residents meetings and visitor/residents surveys. Examination of the minutes of the last meeting showed residents felt able to voice their opinions. For example residents were asked for suggestions in respect of meals and the purchase of new equipment. CLS representatives visit the home on a monthly basis to audit records and speak to residents and staff. A written report is then produced of the findings. The home has a system for recording the complaints of those who don’t wish to complain formally. Residents are informed of CSCI inspections and inspection reports are available for visitors and residents to read. In the entrance to the home “customer feedback forms” are available for residents or their representatives to complete if they wish. The manager and senior staff undertake regular quality audits of records for example accidents and care plans. The Contracts Section of Wigan Social Services Department, in conjunction with a company called RDB Limited, has undertaken a voluntary star rating of homes in Wigan. As part of the rating process an annual audit of quality is undertaken. This includes consultation with service users and staff. Records are held of all residents financial transactions. A record is kept of monies credited and debited and receipts were obtained for financial transactions. All monies held for safekeeping are kept individually. The financial records for three residents were examined and corresponded to the amount recorded. Secure facilities are provided for the safe keeping of money. Discussion took place in respect those residents whose finances are managed by their relatives. The Home Services Manager advised that currently there were no issues with residents having access to their personal allowances. The only members of staff who had keys to the safe were the manager and the home services manager. Discussion took place as to how residents accessed their money when the manager and home services manager were not on duty. The manager advised that care team leaders had access to a “float” where residents could access funds. Any transactions would then be debited on resident’s financial records. It is fully recognised the policy of only designated staff having keys to the safe is to ensure financial interests are safeguarded, nevertheless this could lead to residents not having access to monies they are Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 25 entitled to. Therefore some consideration should be given to making alternative arrangements when designated staff are not working. With the pre-inspection materials, the manager provided a list of maintenance and associated records. A number were checked on the site visit including the gas, portable electrical appliances and lift servicing. All were up to date. Fire safety records showed that that all fire tests and maintenance procedures had been undertaken regularly. Records also indicated that fire drills and instruction had taken place at frequent intervals. An up to date fire risk assessment is in place. Training records indicated that training and regular updates are provided to staff in key areas such as moving and handling, food hygiene, fire safety awareness etc. There were satisfactory policies and procedures in place relating to the recording and reporting of accidents to residents and staff. Samples of accident records were examined and were found to be appropriately maintained. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement To ensure residents receive the care they need all sections of the care plans must be completed in order staff have the information they need to meet each area of need. To ensure resident’s health and wellbeing is not compromised staff must ensure risk assessments are completed Timescale for action 07/04/07 2. OP7 15 (1) 07/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations To ensure the environment does not fall below an acceptable standard for residents as planned corridors and DS0000005741.V304525.R01.S.doc Version 5.2 Page 28 Hourigan House 2. OP27 3. OP35 bedrooms should be re-decorated and corridor carpets replaced. To ensure residents care needs are not compromised staffing levels in the evening, weekend and night should be kept under review and consideration given to providing additional staff at these times. Consideration should be given to introducing a system whereby residents can access their personal allowance at any time. Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 29 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: 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 Hourigan House DS0000005741.V304525.R01.S.doc Version 5.2 Page 30 - 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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