Inspection on 18/12/06 for Lancaster Court

This inspection was carried out on 18th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Lancaster Court 24/01/06

Lancaster Court 27/09/05

Lancaster Court 14/03/05

Lancaster Court 28/04/04

Lancaster Court 18/03/04

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 HOMES FOR OLDER PEOPLE Lancaster Court 21 Lancaster Court Southport Merseyside PR8 2LF Lead Inspector Mrs Margaret Van Schaick Unannounced Inspection 18th December 2006 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 Lancaster Court DS0000005332.V321157.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. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancaster Court Address 21 Lancaster Court Southport Merseyside PR8 2LF 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) 01704 569105 Mr John Kershaw Mrs Joan Kershaw Mrs Kerry Norton Mr John Kershaw Mrs Joan Kershaw Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 30 OP The service should employ a suitably qualified and experienced manager who is registered with the CSCI 24th January 2006 Date of last inspection Brief Description of the Service: Lancaster Court is a privately owned care home that is registered to provide residential care for 30 older persons. Mr John Kershaw and Mrs Joan Kershaw own the home. Mr Kershaw is the registered manager. It is pleasantly situated in the residential area of Birkdale village, which lies within easy reach of Southport and all the amenities that the seaside town offers. Accommodation consists of 30 bedrooms, one of which has an en suite facility, that are situated over four floors and are accessible by lift. There is a separate dining room and a large sitting room with various seating areas. The home is equipped with ramp access at the front entrance and additional ramp access is available to the rear garden areas. Garden furniture suitable for the service users resident is also available. The home has suitably adapted equipment to assist with the needs of the service users and a call bell system is in place throughout the home and in each bedroom. Car parking facilities are available at the front of the home. The weekly fees are £420. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day and lasted 7 hours. This was the key unannounced inspection to be carried out as part of the regulatory requirements. As part of the inspection process all areas of the home were viewed including many of the residents bedrooms. Residents care records and other care home records were inspected also. Discussion took place with Mr and Mrs Kershaw (providers). Mr Kershaw is also the registered manager. The inspector also had discussions with the quality manager, shift manager and one to one interviews with three staff. Several residents were also spoken with. Residents were interviewed in private and their views obtained on how the home was run. Relatives and visitors to the home were interviewed also. Have your say about…questionnaires were sent out to the residents by the Commission prior to the inspection. These have been completed and returned and their views are included in this report. What the service does well: The home is owned and run by the same family. Residents and their relatives gave positive feedback on how the home was managed with comments such as, “It’s the little things they have thought of, greetings from Karen (quality manager) and her parents have made me feel very welcome”. The home has an effective and detailed pre admission assessment process, which ensures that prospective residents have their health and personal care needs identified prior to admission. This ensures the home is able to meet their individual needs. One visitor to the home stated, “I went round about 20-30 homes and this one stands out, inside and out”. The home places great emphasis on ensuring all residents have the appropriate personal care, healthcare and support required to meet the individual residents needs. Residents interviewed stated, “we discussed the care plan, medications and how much assistance I would need”. Residents are encouraged to spend their time as they wish within the support of a homely environment that includes the support of families and friends. Residents stated, “visitors can come at anytime”. The complaints procedure is effective and residents’ complaints are listened to, recorded, investigated and with outcomes recorded. One resident interviewed Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 6 stated, “I have no complaints, I like it, I would think it’s as good as any and better than some”. The home is well maintained and offers residents a very high standard of comfort. Residents interviewed stated, “it’s very nice, we have new chairs, it’s lovely”. The home ensures that staff selected to work in Lancaster Court are trained to a high standard to ensure residents receive the best care possible. Residents interviewed stated, “staff are very nice, we are looked after very well”. The home is run with the best interests of the residents in mind and ensures the health and safety of the residents and staff is paramount. 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 Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP6 is not applicable. OP3 was assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has an effective and detailed pre admission assessment process, which ensures that prospective residents have their health and personal care needs identified prior to admission. This ensures the home is able to meet their individual needs. EVIDENCE: Three of the residents care files were examined with regard to the assessment process. One resident recently admitted was interviewed and their relative was interviewed also to gain their feedback on the assessment process. Both resident and relative gave positive views on the assessment process. One visitor to the home stated, “I went round about 20-30 homes and this one stands out, inside and out”. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 10 For all three assessments a written pre admission assessment is evidenced in all three residents care notes. The assessment documentation identifies all healthcare and personal care support needs. The quality manager carries out all pre admission assessments and her signature and date is evidenced on all three of the assessment documentation. Relatives comments included, “I was made aware of the terms of the contract in a very friendly and caring way rather than a ‘business deal’, which was very important to me at this sensitive and emotional time of my life”, “the manager was only too pleased to answer questions and I was always welcome to come and view the home whenever and was also able to bring family and friends with me to gather their opinions of Lancaster Court”. Information recorded includes personal details, previous medical history and GP contact details. Areas addressed include communication, hearing, sight, diet/food allergies, medication and any allergies, oral health, mobility, risk of falling, personal safety, chiropody needs, mental health, District Nurse input, continence, sleep pattern and daily routines. The assessment documentation gives some detail with regard to the individual resident therefore this ensures that when the initial care plan is set up it is specific to their identified needs prior to admission. There is signed agreement of the care agreed from residents and relatives. Residents interviewed confirmed that they had discussed their care needs and signed to agree care planned. Residents interviewed stated, “we discussed the care plan, medications and how much assistance I needed”. A risk assessment is carried out for all three residents prior to admission and includes many areas such as lift use, finances, fire, falls and this is in place on admission and is reviewed within the first month if not sooner as evidenced. The quality manager completes and signs a pre admission notification of acceptance for the prospective resident. A first day admission form is also in use and evidences information including expected time of arrival and the residents signed agreement to the initial care plan. One resident’s daughter visited the home on her behalf as she lived some distance away. The resident and her daughter then visited the home together to view the home and meet with the staff and briefly meet the residents prior to accepting the room available. The manager was able to assess the resident’s needs during this visit. During discussion with some of the residents in the home it is apparent that they gained favourable impressions of the home when they first visited. Residents interviewed stated, “I was very impressed when I visited, my first impressions were of comfort, the home is very well maintained” and I was impressed with how pleasant the staff were”. One resident stated, “it’s the little things they have thought of, greetings from Karen (quality manager) and her parents (owners) you are made to feel welcome”. One resident has previously been resident in the home and therefore has prior knowledge of how the home would suit them. This is evidenced in care notes. Residents’ have copies of the hospitals/care homes healthcare assessments carried out prior to discharge/transfers. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards OP7,8,9,10 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home places great emphasis on ensuring all residents have the appropriate personal care, healthcare and support required to meet the individual residents needs. EVIDENCE: The three care plans and documentation case tracked evidenced well thought out plans of care with regular reviews evidenced throughout. Residents interviewed confirmed that their individual care needs had been discussed with senior staff and that they had agreed and signed their care plans. This agreement is evidenced with date and signature of resident/relative. Residents interviewed stated, “I have discussed my care and am happy with it, I have a key worker who helps me with my bath” The care plans are hand written on admission and a more formal and structured care plan is typed shortly after. The care plans and additional Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 12 records show that all areas of health and personal care have been addressed and the care plan identifies how the healthcare and personal needs/support is managed. One resident stated, “I have been asked, ‘did I want someone to check on me at night’, I get up to the loo”. Risk assessments are in place for many areas including, smoking, fire, hot water at sinks, using the lift, going out, finances, falls and pressure areas. Manual handling assessments are in place, which are reviewed regularly. Residents at risk when administering their own medication are assessed. One resident stated, “I am having my medication given by staff as I was getting mixed up at times before coming into the home”. The care documentation evidences other healthcare professional visits and residents interviewed confirmed they are able to access additional services either in the home or they can were able visit their health professional at their surgeries or clinics. One resident stated, “I don’t use the chiropodist as I can cut my own toe nails, I see the Doctor when I need to but it is a different one each time as it’s a group (group practice) and I go and see the dentist in Ainsdale. The home always provide a staff member to accompany residents to hospital appointments, this is good practice. Relatives comments include, “my father receives the best care and support, he is very happy with the home meeting his needs, as are the family”. Signed agreements of relatives are also in place where it is decided that it is safer for staff to store and administer residents’ medication, this is good practice. District nurse records are stored in the individual residents bedroom where they provide nursing care. Accident records were viewed and all are completed clearly and signed and dated. One resident who has a fractured lower limb and has ‘screws in place has herself caused a small cut to her other lower limb and this has been documented in the daily record. As this was not viewed as an accident by the staff on duty that day they did not enter it in the accident book. The home is advised to ensure all accidents/injuries are entered in the accident record. The District Nurse had been contacted and the small wound has a dressing in place. It is evident through examining care documentation and following discussion with residents that the home place a great emphasis on ensuring residents are able to benefit from health professionals advice and ensure they have optimum treatment where needed. Residents’ comments include, “I am delighted with Lancaster Court”. Residents interviewed confirmed that they were very happy with the care and support provided by the staff stating, “we are looked after very well, we have everything we need”. Relatives’ comments include, “my relatives needs have changed and these are always acted on by the staff and there is always a follow up to ask if things are better”. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 13 Medication is delivered to the home in a ‘blister pack’ system. These are stored in two locked cupboards. Medication records evidence the delivery date, amount of medication, dose and signature of person checking the medication into the home. The medication records are clear and there are no discrepancies. The homes pharmacist carries out regular audits, which were viewed during the inspection. There are no concerns recorded on any of the audits. An up to date BNF (British National Formula) is in place and a list of staff trained to administer medication with their initials and signatures is in place. Residents commented, “my medication is taken care of very efficiently and the staff help me apply my medication creams at the right time of the day”. Policies and procedures are in place. Photographs of residents are in place on medication files and the ‘returns’ book evidences the pharmacist’s signature on receipt of medication. Residents interviewed stated, “ Visiting health professionals and others visit the resident in the privacy of their bedrooms when providing healthcare or other advice/consultation. Residents confirmed during interviews that they have the same gender carer to assist with personal care. During the inspection visit staff were observed to treat residents with courtesy and kindness. Residents interviewed confirmed staff were kind to them, stating, “staff are very nice”. All of the residents were well groomed and dressed appropriately. Where wished residents have their own telephones installed in their bedrooms. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to spend their time as they wish within the support of a homely environment that includes the support of families and friends. EVIDENCE: On admission to the home residents are asked about their preferred daily routine including ‘getting up’ and ‘going to bed’ times. These are identified and included in care plans. Residents are then assisted through their daily routine where needed including, personal care, bathing, early morning cups of tea and attending mealtimes and activities throughout the day. The activities list for December was on display in the hallway and included many Xmas activities/celebrations such as sing a long, visiting entertainers, Golden Oldies with Fred, Xmas carols with the Scouts, Xmas party, musical presentation, Xmas gift sale, Xmas bingo and days gone by. Residents interviewed confirmed there are always activities on each day including, trips out (Safari Park), hand and foot massage, musical events, visiting entertainers and bingo. Residents stated, “they bring people in to entertain us” and “we have PT on Friday, keep fit and mobile”. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 15 Residents confirmed that they were able to receive visitors when they wish. The inspector observed this during the inspection visit. One resident interviewed stated, “my visitors can come anytime, I go out with my son for an hour, which is enough and I visit the shops each Sunday”. Residents comments include, “those activities I attend, I really enjoy, I especially enjoyed the summer barbecue and Christmas party, which was open for my relatives and friends to attend, the catering was excellent, a lovely party for all of us, very thoughtful on the part of the management”. Some of the residents visit the local churches and others receive Communion during visits from the local church representatives. One resident interviewed stated, “I don’t want to go to church and I don’t want Communion” and this is accommodated. Residents deal with their own finances and in some cases with the help of their family. One resident interviewed stated, “I control my own finances with the help of my son”. Residents are encouraged to personalise their bedrooms by bringing some of their own items of furniture/ornaments where wished. Residents interviewed stated, “I can bring whatever I want into the home”. The weekly menu is on display in the dining room reception area. Residents interviewed were very complimentary about the meals served in the home. Residents interviewed stated, “I eat better here than I ever had before”. The menu is varied and contains fresh vegetables, fruit and home baking. Residents interviewed stated, “meals are very nice” and “the food is very good, you couldn’t ask for much more”. Other residents stated, “we have tea and coffee regularly and I can have Complan when I wish and there is ‘cold water’ (dispenser) in the lounge”. Another resident stated, “the food is very nice indeed, grapefruit to start, chicken and vegetables with roast potatoes and fruit salad with cream and they are good at producing cups of tea and coffee”. Residents’ comments include, “if there are meals not of my choice I am always able to order an alternative which I do like, the food is of an excellent standard”. Residents are encouraged to eat their meals in the dining room. The dining room is pleasantly decorated and all tables are set with table linen and full sets of cutlery and crockery. Residents are offered sherry prior to lunch with many residents enjoying this during the inspection visit. One resident who was very complimentary about the meals served stated, “you can have sherry if you wish”. The kitchen was clean and organised during the inspection visit. The fridge was clean and food prepared for lunch and tea was protected prior to use. Staff working in the kitchen wore protective clothing. Lancaster Court DS0000005332.V321157.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): Standards 16,18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is effective and residents’ complaints are listened to, recorded, investigated and with outcomes recorded. EVIDENCE: The complaints procedure is in place and a copy of this and the advocacy contact has been made into large print with a copy of both in residents’ bedrooms. The complaint log was viewed and evidences all concerns/complaints are recorded in a clear format with a full investigation and record of outcomes also. The home investigates all concerns no matter how small. This is good practice. Through discussion with residents it is apparent that all are very happy with how the home is run and residents interviewed confirmed that they attended residents meetings were they could if wished discuss any concerns. One resident stated, “we have meetings in the lounge, about monthly”. One resident interviewed stated, “I have no complaints, I like it, I would think it’s as good as any and better than some”. Residents’ comments include, “since coming into the home there has been very little to complain about”. The home does not hold any residents monies. The home does not have a valuables book. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 17 Staff attended abuse training as evidenced in staff files and confirmed through staff interviews. Policies and procedures are in place to ensure resident and staff safety. The home has a copy of the Sefton Adult Protection Procedure. Lancaster Court DS0000005332.V321157.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): Standards 19,26 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained and offers residents a very high standard of comfort. EVIDENCE: Lancaster Court is a well-maintained service. All of the grounds are kept tidy and safe. The gardens, front and rear are maintained to a very high standard with many flowers, shrubs trees and pots for residents to enjoy. There are patio/seating areas situated in the rear garden with suitable garden furniture for residents/visitors use. One of the residents whose bedroom overlooks the garden stated, “the view is nice”. Another resident commented, “we have lovely grounds, it’s nice sitting out”. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 19 New windows have been fitted to the rear and basement side of the building giving residents a clear outlook and draught free space. The call bell system has been replaced throughout the home and can be used independently from the wall, which means that residents can sit where they wish and still have access if needed. The front of the home has been refurbished and looks very welcoming. A programme of routine maintenance is kept and records evidence ‘jobs done’. An audit is carried out each daytime and evening and includes checks on residents bedrooms, lights, bathrooms and any concerns are recorded and attended to as soon as possible. The home is tastefully decorated throughout to a very high standard including residents’ bedrooms and public areas. Residents interviewed stated, I like my bedroom, it isn’t big, but bigger than others, I’m quite happy with this” and “I thought my room would be smaller but I can fit my belongings in”. Through discussion with other residents it is apparent that they are happy with the décor throughout the home commenting, “it’s very nice, we have new chairs, it’s lovely, homely”. The home is well lit throughout ensuring a bright and safe environment for residents. The home is cleaned to a high standard throughout with no odorous smells. Residents interviewed stated, “everywhere is clean”, “it’s very clean, the home is efficiently run” and “everything is very nice and clean”. The laundry has one washing machine and a tumble drier. The washing machine has a foul laundry capacity. The laundry floor has a permeable surface and this has been identified as needing repainting as the surface is well worn due to heavy use. The laundry facility is separate from the cooking facilities. Residents’ comments include, “a lot of time and care is given to keeping the home clean, the laundry service provided is also very good”. Lancaster Court DS0000005332.V321157.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): Standards 27,28,29,30 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensures that staff selected to work in Lancaster Court are trained to a high standard to ensure residents receive the best care possible. EVIDENCE: The staffing rota evidences all staff working at the home. Staff on duty included the manager, quality manager 7.30-5pm, two care assistants 8-5pm, domestic 8.30-4.30pm, cook 7.15-5pm, kitchen assistant 7.30-5pm, shift manager 2-10pm, and care assistant 5-10pm. The home seldom uses agency staff but when they have to they request staff that are experienced and familiar to the residents and the home. Staff interviewed stated, “we are not left short staffed, as agency can be called in” and “we have enough time to carry out our work”. New staff attend an induction as evidenced in staff files and confirmed during staff interviews. The home employs 22 staff. Six of these have the NVQ Level 2 qualification, seven are commencing Level 2 in January 2007, two are commencing Level 3 and two staff are already doing Level 3 NVQ. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 21 The home is keen to ensure that the ‘right’ staff is employed so detailed pre employment checks are in place and fully completed prior to employment. Residents comments include, “the staff have gone out of their way to help me settle and are always kind, pleasant and helpful”. Staff interviewed stated, “I get a lot of pleasure working here, it’s a lovely home” and “it’s a nice environment, the family treat us well, we have breaks and are looked after”. Three staff files were case tracked. Each file contains a new employee sheet with personal details, application forms, signed contract and hours worked, two written references, interview notes, checklist to ensure all pre employment data has been gathered prior to offer of employment, offer of employment letter, training and development plans, POVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks, TOPSS (induction) course, supervision (signed by carers), key worker system, and the Sefton Adult Protection Procedure explanation, which has been read, understood and signed by the staff member concerned. Certificates of mandatory and other training attended including, POVA, death dying and bereavement, infection control, first aid, manual handling, fire, heat wave, Doctors visits, care plans, communication, health and safety basic food hygiene, up to date policies and procedures and medication training for staff who administer medication. Evaluation forms are in place for staff to complete following any training attended. Residents interviewed stated, “staff are very helpful” and residents comments include, “when staff have their hands full I may have to wait a small time but they are always there to answer my calls, I always find if they haven’t received a call from me for a while, some staff member calls in my room to make sure I am alright”. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run with the best interests of the residents in mind and ensures the health and safety of the residents and staff is paramount. EVIDENCE: Mr Kershaw has been the proprietor of the home for 20 years and the registered manager for 19 years. The manager has continued to keep up to date with all mandatory training and holds the RMA (Registered Managers Award). The manager is in daily charge of the home with the quality manager and shift managers supporting him. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 23 Staff interviewed stated, “senior staff are approachable and resolve any problems and other staff are nice” and “the home is very friendly, it’s like a family home”. Other staff comments include, “we have regular staff meetings and John (registered manager) and Karen (quality manager) phone regularly. The home has gained two quality assurance awards. The managers carry out a checks of the home each shift and includes kitchen and food, toilets, bedrooms, residents grooming, care needs of residents being met, care plan changes, complaints, maintenance, health and safety, fire, and evening checks also include security checks and fridge/freezer temperatures. A record is also kept of when the manager saw individual residents following commencement of shift. Past shift records where viewed during this visit. Residents are consulted on their views throughout the year using regular meetings and questionnaires with relatives canvassed for their views also. Residents meetings are held regularly and the inspector viewed the minutes from the November meeting. Residents interviewed confirmed that meetings were held monthly. Minutes are published and families are sent a copy. The minute’s evidence which residents attend, subjects discussed including social activities, menus, proposed care reviews and the complaints procedure. The cook is also present at some of these meetings, which gives residents the chance to discuss any requests/ideas for meals. Residents interviewed confirmed they attended the meetings. Care plan reviews take place regularly throughout the year as confirmed during residents’ interviews and evidence on care notes. For the review the resident, their relative/significant others are invited where agreed. The home seeks the views of families with regard to reviewing care plans. A letter is sent out to the family concerned explaining the review process therefore this gives the family time to reflect and consider any areas of concern/information they need to discuss on their relatives behalf. People who participate in setting up the care plans are identified with residents/relatives signature. Residents’ key workers complete a questionnaire prior to the residents review to give their views on how the home is managing to meet the residents’ needs. Where relatives are unable to attend reviews the manager will discuss any concerns over the telephone as agreed. The home canvasses residents and relatives’ views through regular questionnaires, the results of which are positive with the home scoring highly. The home does not hold any of the residents’ money. Family support is provided where needed for finances. The home has no valuables book. All mandatory training is held each year and is up to date for all staff employed in the home. Staff files evidence the training attended/certificates held throughout the years. Staff interviewed stated, “I get enough training to do the job”. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 24 Through discussion with staff it is evident that they attend training on a regular basis and confirm that they have received a full induction on commencement of employment. The home place great emphasis on promoting the health and safety of the residents and staff by ensuring that all equipment in use at the home is regularly serviced by approved contractors. Certificates of servicing are in date for all appliances including fire equipment, electrical appliances and systems, gas appliances/systems, lift servicing, hoist servicing, emergency call systems and portable appliance tests. The home have all dates of servicing/contractors listed and the next due dates for servicing are planned for this year. Legionella testing has been carried out and water temperatures are checked and records kept. Risk assessments have been carried out for all safe working practices. Accident records are completed clearly and the manager is aware of RIDDOR (Reporting of Injuries and Diseases and Dangerous Occurrences Regulations). Safety notices are in place where needed. All staff receives an induction and updates that meets with the TOPSS (now skills for care training) specifications on all safe working practice. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 25 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 26 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. 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. 1. Refer to Standard OP18 Good Practice Recommendations The inspector recommends the home should have a valuables book in place. Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Lancaster Court DS0000005332.V321157.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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