CARE HOMES FOR OLDER PEOPLE
Ince Blundell Hall Ince Blundell Liverpool Merseyside L38 6JL Lead Inspector
Miss Diane Sharrock Unannounced Inspection 18th January 2006 11.00 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 Ince Blundell Hall DS0000017243.V288068.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 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. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ince Blundell Hall Address Ince Blundell Liverpool Merseyside L38 6JL 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) 0151 929 2596 0151 929 2188 Augustinian Nursing Sisters Sister Gemma Maria Hughes Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to Include up to 22 (OP) Date of last inspection 10th February 2005 Brief Description of the Service: Ince Blundell Hall is registered to provide 24 hour accommodation, support and nursing care for up to 22 older people. The Home is owned and managed by the Augustinian Nursing Sisters, several of whom have lived and worked within the Home for many years. At present the Home is not admitting Residents for long term care, but is supporting Residents and families with short term, post operative or respite care needs. The Home has strong catholic links and provides support to many members of the catholic clergy and faith, however the Home, also offer’s a service to people with differing religious beliefs. The Manager of the Home is Sr. Gemma Hughes who has managed the Home for the last 13 years. Ince Blundell Hall is set in extensive well maintained private grounds. The majority of Residents accommodation in the Home is provided in single rooms, with one double room available. Bedrooms are located on the first and second floor and a lift is also available. The Home offers Residents the benefit of living in quiet surrounding with picturesque views of the surrounding countryside As a listed building, the Home are obliged to provide tours on request to people who express an interest, however, these are limited to the grounds and lower communal rooms and pantheon. The village church for Ince Blundell is internally accessible from the Home and Residents can attend, however, this does not form part of the registered premises. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There has been no cause for any visits to the home since the last routine inspection. A partial tour of the home was carried out. Care records and other care home records were inspected and general discussions took place with various residents, staff and relatives and a selection of comment cards were left. In total 5 comment cards have been returned to CSCI all with complimentary comments about the home. During this unannounced inspection, feedback from everyone involved was very positive. It was evident that the Manager continues to implement all parts of the National Minimum Standards. What the service does well: What has improved since the last inspection?
Some of the comments made in the comment cards stated,
Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 6 “welcoming and peaceful”, “Ince Blundell Hall is a home from home….” “This is a superb place with every care and attention from the wonderful Sisters and Staff” Sister Gemma explained that they are in the process of implementing a new Quality Assurance system that will eventually benefit everyone at the home. A major redecoration programme has been implemented in the home, with those areas already seen having been maintained to a very high standard. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 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 Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 /3 A statement of Purpose is available and in place. Staff carry out assessments to new Residents to ensure their needs can be met. EVIDENCE: The home has available a detailed Statement of Purpose, Service User guide and a copy of a Residents contract which enables new Residents to make an informed choice and others living at the home to have all the necessary details to tell them about ongoing issues and development at the home. Staff carry out pre-assessments to any new resident prior to admission so that they can assess whether they can accommodate all of the residents needs. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7/8 The care plans included details for health, personal and social care needs of residents which meets all parts of these standards. EVIDENCE: Residents and relatives were happy with the care provided at the home. The care records seen had a lot of detailed information and residents said they were happy with the care. One comment made from a relative and resident during the inspection praised everything about the home including the staff and nursing care. All of the comment cards received gave complimentary examples and statements about the care received. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13/14 Visitors explained they are made to feel welcome whenever they visit. Residents gave examples of how they are supported to make choices about their daily life EVIDENCE: Visitors explained that they are welcome to visit at any time of the day and are always made to feel at home. One resident stated clearly how they are supported in choosing what they want and was very happy with their facilities and ability to enjoy them in their own room, and feeling confident in receiving the care as needed to a very high standard. Although standard 15 was not measured in full during this inspection several residents stated they were very happy with the food and menus offered. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16/18 The home has a complaints policy in place accessible to all parties. Residents are protected by the staff trained in abuse awareness and the homes policies. EVIDENCE: The home has its own complaints policy record book which was seen during this visit and noted to not have any complaints received since 2004. The Home has appropriate arrangements for Protection of Vulnerable Adults including regular training for staff. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19/26 The home is well maintained, clean and tidy with both standards met. EVIDENCE: The home is maintained, decorated and refurbished to a very high standard, with an ongoing programme noted to maintain these standards and help evidence the ongoing investment into the home. Most of the laundry is cleaned external to the Home. The home is consistently meeting these standards on each unannounced inspection. Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27/28/30 Residents and visitors say they are very happy with the home and the care provided by staff. NVQ training is available at the home with access to ongoing general training. EVIDENCE: Residents and Visitors say they are happy with the care and say the staff are lovely. The atmosphere was very informal and happy were everyone was helped to feel comfortable. Most staff had worked at the home for many years and offered a great stability to the workforce. Staff stated there is a variety of training opportunities available and one of the Staff are qualified to carry out training within the home. The manager produced detailed records of recent training provided for all staff covering a wide range of topics Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31/32/33/38 The manager runs a well managed home in the best interests of all Residents. Detailed records are in place for health and safety. EVIDENCE: There were many complementary comments from Residents, Visitors and staff regarding the Manager and her team as also pointed out at previous inspections. Staff have implemented all parts of the National Minimum Standards although a sample only were measured during this inspection. The home had a relaxed and open atmosphere. A quality assurance scheme has been commenced and the Manager is in the process of developing this further. The home has various health and safety records kept to ensure the ongoing maintenance and safety of the home, including a maintenance file, fire book, accidents records and risk assessments. The Manager also produced a finance plan for the home for march 05 and a business plan which helped evidence the ongoing management of the home.
Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 15 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 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ince Blundell Hall DS0000017243.V288068.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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