Inspection on 02/02/06 for Katherine Lowe House

This inspection was carried out on 2nd 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 but made no statutory requirements on the home.

Other inspections for this house

Katherine Lowe House 04/08/09

Katherine Lowe House 13/08/08

Katherine Lowe House 27/09/06

Katherine Lowe House 17/05/05

Katherine Lowe House 24/02/05

Katherine Lowe House 20/07/04

Katherine Lowe House 28/10/03

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 Katherine Lowe House Barton Road Urmston Manchester M41 7NL Lead Inspector Helen Dempster Unannounced Inspection 2nd February 2006 2:20 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 Katherine Lowe House DS0000032577.V275597.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. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Katherine Lowe House Address Barton Road Urmston Manchester M41 7NL 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) 0161 748 2844 0161 747 5377 Trafford Metropolitan Borough Council Mrs Rosemarie Hargreaves Care Home 45 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides accommodation for a maximum of 45 service users, 24 of whom require care by reason of old age (OP) and 21 of whom are older people who require care by reason of dementia (DE(E)). Separate lounge and dining space must be provided to meet the needs of the service users who require care by reason of dementia (DE(E)). There are currently 3 named older service users who require care primarily by reason of mental ill health (MD(E)) and 1 named service user who requires care primarily by reason of physical disability (PD(E)). Should any of these service users no longer require accommodation at the home, these places will revert to the service user category (DE(E). The Statement of Purpose must be maintained in line with the requirements of Schedule 1, of Regulation 4(1) of the Care Homes Regulations. The Statement must be kept under review and updated. Any changes to the home’s purpose must be agreed with the Commission for Social Care Inspection prior to implementation. The staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum, Care Staffing in Care Homes for Older People`. This must be reflected in the Statement of Purpose. The home must be managed at all times in accordance with the guidance and regulations issued in respect of older peoples` homes by the Secretary of State for Health under Sections 22 and 23(1) of the Care Standards Act 2000. The authority must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 17th May 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Katherine Lowe House is a purpose built local authority residential home, which provides accommodation and personal care to 45 older people. Of these places, 42-offer long-term care and the remaining 4, short term care. The home is located in a residential area of Davyhulme, Manchester, close to public transport routes into the City Centre and surrounding areas. The home has three floors and nine lounges are located throughout the building near bedroom areas. Sufficient communal space, bathrooms and toilets are available to meet residents needs. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection of the year and was unannounced. It was carried out on the afternoon of 2nd February 2006. Time was spent discussing welfare matters relating to the residents the home supported and examining documentation in relation to the running of the home, staffing, care planning and the residents’ satisfaction. The term of address preferred by the users of the service was confirmed as “residents”. It was felt this best reflected the function and purpose of the service. The inspection only looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? Lots of things had improved since the last inspection. These improvements included: The admissions policy had been reviewed to provide accurate information for people coming to live at the home. Each resident had a copy of his or her terms and conditions of stay at the home. Care plans had improved and care plans and risk assessments were being consistently reviewed. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 6 Medication practice had improved. Familiarity with the protection of adults from abuse had improved by providing staff with training in implementing the policy. The organisation was sending a representative to conduct monthly, unannounced visits to the home and to report, in writing, about the conduct of the home. Fire safety practice had improved. 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. Katherine Lowe House DS0000032577.V275597.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 Katherine Lowe House DS0000032577.V275597.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): 5 and 6. Prospective residents were provided with clear and detailed information to allow them to make a choice about where to live. EVIDENCE: The admissions policy had been reviewed to provide accurate information for people coming to live at the home. A sample of residents’ files was viewed and they all had a copy of the residents’ terms and conditions in response to a requirement made at the previous inspection. The files sampled during the inspection all contained a multidisciplinary assessment of individual residents’ needs. The home does not provide intermediate care. Katherine Lowe House DS0000032577.V275597.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, 9 and 10. The residents’ care, health and medication administration was well documented by the home in a comprehensive care planning and record system. Staff needed guidance in recording information about residents in a respectful way. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 10 EVIDENCE: Four residents’ files were sampled. Overall, the home had made progress with care plans in response to a requirement made at the previous inspection. In particular, there was a good audit trail of residents’ health needs being met and care plans and risk assessments viewed had been consistently reviewed. The interaction between staff and residents was seen to be respectful. However, when viewing records, examples of records which could be viewed in a less than positive way were seen. This included a resident’s file noting that the resident was “prone to temper tantrums”. Through discussion, the need for staff to record information about residents in a way, which demonstrates respect, was stressed. Staff were not signing records to endorse their entry and a requirement was made accordingly. Overall, medication practice was good. A requirement made at the previous inspection to the effect that there is a clear auditing trail for all medication prescribed and administered and the reasons for administering when required (PRN) medication must be clarified in the care plan had been addressed. There were a couple of examples of errors on the MAR sheet relating to ‘when required’ medication. However, there was a good audit trail and control measures in place and good use was made of the carers notes on the back of the MAR sheets. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. Residents were able to exercise lifestyle choices, including choice of meals. EVIDENCE: Records demonstrated that residents were supported to make choices about aspects of daily life and were also supported to maintain family links. Records also demonstrated that the home consults with residents and their family/representatives. Good informative records about residents’ moods and wellbeing were seen. Cultural details were recorded reflectively in the care plans. Menus were in place which gave residents choices and these choices were documented. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 12 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 and 18 Residents benefited from having a clear complaints procedure and staffs’ familiarity with the protection of adults from abuse procedure. However, managers and staff having training in dealing with complaints and customer service would enhance this. EVIDENCE: The complaints record contained the record of 2 complaints made since the previous inspection. The record of one of these complaints, made in May 2005, was viewed. The complainant’s letter and the manager’s response were on file. A further letter from the complainant was also on file, which suggested that the complaint was not fully resolved. The senior member of staff on duty said that some meetings had been held to resolve this complaint, but copies of these were not in the complaints file. It was discussed that it would be useful to demonstrate that the complaint was resolved and closed off. Overall, it was felt that the management team would benefit from training in dealing with complaints and customer service and a requirement made at the previous inspection was repeated accordingly. The home had a copy of Trafford Metropolitan Borough’s ‘Protection of Adults from Abuse Policy’ and staff had been provided with training in implementing the policy in response to a requirement made at the previous inspection. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 13 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): N/A EVIDENCE: These standards were assessed at the previous inspection and will be reassessed at future inspections. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 14 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, 29 and 30. Residents benefited from being cared for by well-trained and well-supported staff in sufficient numbers. EVIDENCE: Of the 25 care staff employed, 13 held NVQ Level 2 and some staff had almost completed this training. The home met the target of having 50 of staff with NVQ Level 2. Staff supervision was also consistently offered to staff. The home has a recruitment policy. The file of a staff member recently recruited was viewed. Recruitment practice was appropriate and a clear audit of the contents of the file was in place. In response to a requirement made at the previous inspection, staffing levels had been reviewed in the context of service users dependency levels and there was evidence of consistent monitoring of staffing levels. The audit of staff training was an example of good practice as it was clear and user friendly and availability of staff training was good. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 15 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): 33, 34, 35 and 38. The residents benefited from a well ran home, with a management team who promoted health, safety and welfare of residents. EVIDENCE: The organisation has a quality assurance package. This included holding residents and relatives focus meetings, the minutes of which were informative about the home in general and entertainment. However, the last quality assurance survey was conducted in November 2004 and the results of this survey had not been collated, analysed and put into a report. A requirement was made accordingly. In response to a requirement made at the previous inspection, the Responsible Individual for the organisation had appointed a representative to conduct monthly, unannounced visits to the home and to report, in writing, concerning the conduct of the home. This had proved helpful in developing practice at the home. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 16 Systems for the management of residents’ finances included using banking external to the organisation. This enabled residents to get interest on their savings and bank statements were held at the home. Fire safety practice had improved in response to requirements at the previous inspection. In particular, fire safety checks were consistently made and the outcomes recorded. Clear and detailed records of fire drills were also in place. Just prior to the inspection, the inspector had met with senior managers from TMBC to discuss fire safety work, which needed to be completed at the premises. TMBC had costed the work to be done and were in the process of inviting tenders to complete the work. A requirement was made, however, it was acknowledged that TMBC are working towards meeting this requirement. Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 17 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 X X 3 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 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 3 X X 2 Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 02/03/06 2. OP16 22(1) 3. OP33 24 4. OP38 23(4) Staff must consistently record information about residents in a way, which demonstrates respect. Staff must also sign residents’ day-to-day records to endorse their entry. Staff must receive training in 02/06/06 dealing with complaints. (Previous unmet timescale of 7/08/05) The home must review and 02/06/06 develop their quality assurance system to provide a verifiable method, which involves residents, to audit the service and report on the findings. All fire safety issues, which 02/06/06 require addressing outlined in Greater Manchester County Fire Services report, dated 14 June 2004, must be actioned without delay. (Previous unmet timescale of 7/08/05) Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 19 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 Katherine Lowe House DS0000032577.V275597.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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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