Inspection on 11/04/07 for Lancaster House

This inspection was carried out on 11th April 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lancaster House 11/01/06

Lancaster House 04/08/05

Lancaster House 11/10/04

Lancaster House 28/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Lancaster House 3 Lancaster Place Blackburn Lancs BB2 6JT Lead Inspector Jane Craig Unannounced Inspection 11th April 2007 10.00 Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 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 House DS0000005804.V330766.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancaster House Address 3 Lancaster Place Blackburn Lancs BB2 6JT 01254 681243 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) Mrs Marilyn Clarke *** Post Vacant *** Mrs Marilyn Clarke Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 (one) named service users requiring personal care within the category of MD (E). 11th January 2006 Date of last inspection Brief Description of the Service: Lancaster House forms part of the Almond Villas Group and is registered to provide 24hour accommodation and rehabilitative support for 6 adults with mental health needs. The home is registered to provide personal care for 5 adults aged between 18 and 65 and one person over the age of 65. Service users generally move to Lancaster House from Almond Villas. Whilst the emphasis is on longer term care and support, service users are still encouraged and supported to develop independent living skills. Lancaster House is a large terraced property situated in a residential area close to Blackburn town centre. The house has a small front garden and a rear yard with a patio area. Parking is on the road. A bus stop, local shops and other amenities are within easy walking distance. The ground floor comprises a smoking and non-smoking lounge, a kitchen and separate laundry room. Six single bedrooms and a shared bathroom are on the first floor. The offices and staff facilities are on the third floor. A second bathroom for the use of service users has also been added to this floor. Information about the home is given to prospective residents during their trial visits. Copies of Commission for Social Care Inspection reports are available on request. At 12th April 2007 the weekly fees ranged from £448.25 to £1,141.00. There were extra charges for personal toiletries, newspapers and magazines. Residents were also asked for a small contribution towards activities not on their programme. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Lancaster House on the 11th April 2007. At the time of the visit there were 6 residents accommodated. The inspector met five of the residents and talked to three about their experiences of living in the home. Some of their comments are included in this report. Five residents and six visitors/relatives returned comment cards before the inspection. Their comments about various aspects of the home, and especially the staff, were all very positive. Discussions were held with the registered provider/manager, two other members of the management team and two other staff. A partial tour of the premises took place and a number of documents and records were viewed. This report also includes information submitted by the home prior to the inspection visit. What the service does well: The process for assessing and admitting new residents was very thorough. This meant that prospective residents had enough information to help them decide whether Lancaster House was right for them and staff knew that they would be able to provide the right care. Residents were involved in planning their own care and drawing up their weekly programmes, which meant they could make decisions about what care they received and what they did with their time. One resident said, “If you don’t want to do anything they don’t force you, you can pretty much choose.” Residents were happy with their lifestyles and the opportunities they had for activities inside and outside the house. They could have visitors whenever they wanted and staff also helped them to keep in touch with their families and visit them wherever possible. Staff treated residents respectfully and made sure their rights were regarded. Lancaster House provided a safe environment where residents were encouraged and supported to engage in rehabilitation programmes in preparation for independent living. Staff helped residents to look after their health and wherever possible supported them to take their own medication in preparation for independent living. Staff organised and managed other medicines safely. None of the residents had any complaints about the home but all said they knew who to speak to if they did. They were confident that staff would be able to help them if they had any concerns. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 6 The manager made sure that new staff had thorough checks before they started work at the home. This provided protection for residents. A relative commented that staff were chosen very carefully. Staff received a high level of training, which helped them to understand and meet the needs of the resident group. A relative wrote that staff showed a high degree of skill in looking after the residents. Residents and relatives made very positive comments about the staff team. One wrote that they were very pleased with the commitment shown to their relative and another commented, “I can’t sing the praises of the staff highly enough.” The registered person and the rest of the team who managed the home were very experienced and well qualified. The staff and residents said the managers were knowledgeable, supportive and approachable. Residents had opportunities to talk about their views of the home and make suggestions for improvements. There were regular health and safety checks in the house. All equipment and appliances were serviced and maintained in order to protect residents and staff. When asked what they felt the home does well, all relatives made very positive comments. One relative wrote, “Strengths are honed and developed, weaknesses discussed and put into perspective,” another commented that Lancaster House, “meets the needs of the people they care for as best they can.” Residents were also very positive about the home. One said, “I’m very happy here I don’t want to move,” and another said, “I could stay here forever but I want my own place.” What has improved since the last inspection? What they could do better: Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 7 Staff should receive refresher training in all health and safety topics in order to protect residents and themselves. The worn stair carpet must be replaced in order to reduce the risk of accidents involving residents, staff and visitors. None of the relatives who returned surveys had any suggestions for improvements. One wrote, “nothing obvious.” 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. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The admission process ensured that prospective residents had enough information to make a decision as to whether the home was suitable for their needs and staff had a clear understanding of the resident’s needs and how they were to be met. EVIDENCE: Residents were usually admitted to Lancaster House from Almond Villas. One resident described in their survey about how the transfer had been arranged. They wrote, “I was consulted about my move. They informed me of what I could expect and let me visit before I moved in. I was very pleased with the accommodation and the support system within.” Residents who were admitted directly to Lancaster House were usually referred several months before their discharge from hospital. During this time they were visited several times and assessed by a member of the management team. Assessment information was obtained from all appropriate sources and communicated to the staff team before the resident was admitted. The resident, their family and health care professionals were fully involved in the process. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 10 The prospective resident also had trial visits and short stays at the home. They were given a service user’s guide and a welcome pack. The pack had been put together by the service user’s forum and included frequently asked questions and descriptions written by other service users about their experiences of living at Lancaster House. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents set their own goals and took a lead role in drawing up care plans, which meant that staff had sufficient information to help to provide support in accordance with the resident’s wishes. Residents were supported to maximise their independence by taking responsible risks and making decisions about their own lives. EVIDENCE: Residents and key workers drew up plans together. A resident wrote, “plans are made after discussion with your keyworker. I am listened to and we draw up a programme that suits all my needs and helps me plan and prepare for the future.” Care plans for two residents were looked at as part of the case tracking process. Both had very detailed plans for all aspects of their personal, health and social care needs. Plans demonstrated that staff clearly understood the residents’ individual needs and their preferences for support. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 12 Plans were reviewed every six months or beforehand if the resident’s needs changed. Plans also took into account advice and information from other professionals. A resident said that if they wanted any changes to their plans they would talk to their key worker. Staff confirmed that plans were resident led, that they discussed with the resident how they wanted support. The plans were working documents and another member of staff confirmed that plans were discussed during staff handovers and they were allocated time to read them. Staff said that residents were encouraged to make decisions about all aspects of their lives in preparation for independent living. This was confirmed by residents. One resident said, “I make my own decisions about everything.” Another wrote, “within reason I am free to do what I want, as I have a weekly programme to follow.” Programmes were drawn up by the resident and their keyworker. Both staff and residents said the programmes were flexible and could be changed at any time. There was a policy on risk taking and risk management. Staff said they supported residents to take risks. One said “we start off by doing for or with and gradually withdraw as they become more confident and competent.” All files contained risk assessments and detailed risk management strategies specific to the resident. Where there was any possibility of risk to others, the assessments were done in collaboration with other professionals. Risk assessments were reviewed if there were any changes in the resident’s needs or behaviour. For example, one resident said that he had recently had his activities restricted slightly. He said, “it is to keep me safe and I know it wont be forever.” Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents were supported by staff to engage in a lifestyle of their choosing, whilst working towards independent living. EVIDENCE: Residents’ weekly programmes ensured they had a mixture of therapeutic, leisure and domestic activities in preparation for independent living. All residents were supported to access local facilities either independently or with staff. One resident listed the recent groups and activities he had attended which included sports, voluntary work, NVQ training, anger management group and holidays. Another resident said that since going to Lancaster House their confidence had improved, they were going out more and had met new friends. Staff talked about how they tried to adapt some activities to ensure that all residents had opportunities to access them. Residents would have one to one time with staff if they were unable to join a group. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 14 One resident wrote, “My weekly programme allows me to partake in activities around my needs. I’m supported to do things which I enjoy and will benefit me.” A relative wrote, “they give my son the support he needs and a purpose in life, they encourage him.” Staff talked about how residents’ rights were upheld. One said “I have always had a thing about participation – here I feel that it is genuinely service user led.” Another member of staff said, “we are just in the background supporting them to make changes.” Staff spoke to and about residents with respect. Care plans included strategies to maintain residents’ privacy and dignity. There were no restrictions on visiting. One resident said that they sometimes brought a friend back to the house. Relatives who completed surveys indicated that the staff helped the residents to keep in touch with their families or friends. Staff regularly took residents who could not use public transport to see their families. Relatives also indicated that they were kept up to date with important issues affecting the resident although staff said that information would only be shared in accordance with the resident’s wishes. Residents planned, shopped for and prepared some of their own meals, with staff support where necessary. Residents sometimes ate together as a group with different residents helping the staff and choosing what meal to cook. One resident said their cooking skills had improved since being at Lancaster House and they felt confident enough to cook for everyone. Staff provided advice about healthy eating and encouraged them to shop for fresh food wherever possible. All relatives who returned surveys indicated that staff supported residents to live as they chose. One wrote that the residents were very well supported and “lucky to have such a good home to live in.” Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs were clearly identified and met by staff, with support from the multi-disciplinary team. Staff handled and administered medication in accordance with robust policies and procedures. EVIDENCE: Residents who required assistance with personal care had detailed care plans to direct staff as to the type of support they should give. This meant that residents received consistent levels of help without compromising their independence. Residents received very good emotional health care. All plans took into account residents’ individual mental health needs and included triggers and signs of relapse and clear interventions for staff to follow. Residents had regular contact with other members of the multi-disciplinary team and regular CPA reviews. One resident said staff knew everything about his illness and had recently helped him through a few bad weeks. Relatives indicated that the home met the needs of the residents. One wrote that they were, “very pleased with the commitment shown to my son.” Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 16 All residents had a care plan with regard to health care checks or monitoring of ongoing physical health needs. The records showed that any new healthcare needs were identified and referred to health care professionals if necessary. Any advice was included in the care plan. Staff kept records of healthcare appointments and prompted residents to ensure they attended. One resident said he usually asked staff to make appointments for him. There was a full set of medication policies and procedures. All residents had an individual medication procedure on their file, which outlined any special needs. Care plans contained a current list of medicines and information about effects and potential side effects for staff to monitor. Residents were supported to self medicate in stages, starting with identifying which tablets they should take from the monitored dose system and concluding with them storing and administering their own medication. There were records of risk assessments and random checks. One resident had temporarily stopped self medicating because of discrepancies discovered during a spot check. Medication was stored safely and access was restricted to staff who had received training in handling medication. Residents who looked after their own medication had lockable storage in their rooms. There were complete records of medication entering and leaving the home. Medicines handed to residents going on leave were recorded as were any homely remedies taken. There were weekly checks of stocks but the levels were not recorded. This meant the audit trail was complex and staff would have to go back to the date the medication was first dispensed in order to check that administration was completely correct. Although Medication Administration Record (MAR) charts were home made, they were typed and very clear. The instructions matched the instructions on the medicine containers. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew how to make a complaint and were confident that their concerns would be dealt with appropriately. Staff had a thorough understanding of adult protection issues ensuring that any allegations would be investigated. EVIDENCE: There was a clear complaints procedure included in the service user’s guide and also on display in the house. The procedure included contact details of organisations residents could go to if they were unhappy with the response from the staff. There had been no complaints to the home or to CSCI since the last inspection. Residents and relatives who completed surveys indicated that they knew how to make a complaint. Some named specific members of staff they would talk to if they were unhappy. A relative wrote that the staff were, “without exception good listeners – approachable.” At the time of the visit one resident said, “it’s a waste of time making a complaint, there is nothing ever wrong.” Another resident said he could talk to his key worker if he were unhappy. Staff had access to written guidance about safeguarding adults. They received training during their induction and then attended the course run by the local authority. Training was updated every two years. Staff were aware of their responsibilities in reporting any allegations to their line manager and outside Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 18 the home if necessary. One said that allegations would always be taken seriously. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment suited the needs and lifestyles of the majority of residents. The standard of cleanliness and hygiene was satisfactory. EVIDENCE: Several areas of the home had been redecorated and refurbished since the last inspection. There was a new bathroom suite on the first floor, which a resident said was better and more modern. The area of stair carpet identified at the last inspection had worn into a hole that could present a trip hazard. The registered person said that the stairs had been measured for new carpet. Residents spoken with were satisfied with the house and with their bedrooms. One resident said “downstairs is lovely.” Another resident said his bedroom was fine and there was very nice decoration. At the request of residents, the Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 20 majority of whom smoked, one of the lounges had been changed to a smoking lounge. The registered person was aware that one of the bedrooms did not provide a homely and comfortable space for the resident. The room was smaller than the rest and one of the walls was only partition standard and did not reach the ceiling. This meant that the resident could be disturbed by light and sound from other areas. The registered person had made some improvements to the room over time and continued to try to address the problem. The resident and their family had not made any negative comments about the room. At the time of the inspection the home was clean and tidy. Residents who completed surveys indicated that it was always like that. Residents’ responsibilities for domestic tasks were included in their weekly programmes. Domestic style laundry facilities were provided in a separate utility room. Hygiene and infection control procedures were incorporated in the induction training programme and there was written guidance for staff to refer to. Some residents had recently participated in a health and safety group, which included elements of infection control. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Recruitment practices safeguarded residents. Residents were supported by a competent and qualified staff team, in sufficient numbers, to meet their individual needs. EVIDENCE: Staffing levels were completely flexible to meet the needs of the residents. The core numbers had recently been increased as the resident group had changed. In addition to the core numbers, extra staff were rostered to provide supervision for one to one and group activities. One of the management team took responsibility for staff training across the group of homes. Training needs were identified through a training needs analysis, supervision and appraisal. The induction training programme had been revised to meet the 12 week common induction standards. The training included discussions, self study and shadowing. Some aspects of the foundation programme were still in place in order to give new staff add-on training in certain topics, such as mental Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 22 health. New staff were mentored by their line manager and there was an assessment of competency at the end of the training. The content of the training exceeded the recommendations of the common induction standards. All staff received training in safe working practice topics during their induction. The aim was to provide update training annually at a level relevant to the member of staff. For example, staff who prepared meals or provided a high level of practical support to residents did an external food hygiene course, whilst others had awareness training. However, awareness training in moving and handling, infection control and food hygiene was not up to date for all staff. Staff said opportunities for training were very good. A number of other courses relevant to the resident group were available and courses were put on to ensure that staff had the skills to support new residents. For example, a recent workshop in self harm. A member of staff talked about a recent course in tackling prejudice which she said had affirmed that staff were doing things right and that none of the residents were excluded or treated less favourably. 50 of staff had achieved NVQ level 2. Residents made very positive comments about the staff. One said, staff are great, they never shout, they understand me.” Another said, “they have been great here, really helped.” Residents who completed surveys also wrote some very complimentary comments. One wrote, “staff are all excellent and are happy to listen to you at all times.” Another wrote, “I never knew them to be anything other than great people to work with.” All relatives indicated that staff had the right skills and experience to look after people properly. One relative’s response was, “unequivocally.” Another wrote that staff, “show a high degree of skill in looking after their charges” There was a low turnover over of staff and no agency use. The file of one recent employee showed that all pre-employment checks were carried out. Staff commenced their induction programme but were not able to work without supervision until their full CRB disclosure had been returned. This was recorded on the file. All the required information and documents were present. Residents who were involved in the service user forum (a group of resident representatives) had input into the recruitment of new staff, either by formal or informal interview. Staff received supervision approximately every month. A programme of group supervision had been introduced, which staff said they preferred because of the opportunities for sharing knowledge and experiences. Staff also had the option to request one to one supervision at any time. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a safe and well managed home. There was a high level of consultation which enabled residents, staff and other stakeholders to contribute to service development. EVIDENCE: The registered person managed the home on a day to day basis. She was supported by a management team who each took responsibility for a different area. In addition to holding three nursing registrations, the registered person was qualified to NVQ level 5 in management. She also held qualifications in therapy and counselling and undertook short courses to keep her clinical and managerial skills up to date. Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 24 The rest of the management team were also appropriately qualified and experienced. The registered person and the management team were fully conversant with their roles and responsibilities. They took a proactive approach to ensure that the service continued to develop and evolve. Staff said the home was very well run. One member of staff said that their line manager was very good and kept all the team focused. Another said both her and the registered person had been particularly supportive in helping her to progress in her work. Residents confirmed that the management team were good. One said, “the management are all as good as each other.” There were excellent quality monitoring systems in place. The home held three external awards for quality, one of which judged the service as excellent. The group of homes had also been given an award by their employment consultants for being employers of excellence. Annual surveys were sent out to residents, relatives, staff, and referrers. Residents could also complete a questionnaire relating to their admission experience. Results of surveys were evaluated and an action plan drawn up to address any shortfalls. Surveys seen at the time of the inspection were all very positive. Residents also had opportunities to make their views known during the weekly house meetings or in their one to one sessions. A member of staff said, “residents have such a lot of input, they make suggestions and are usually accommodated.” There were also several internal systems for monitoring the quality of the service, including audits of systems and records. The service had an identified health and safety manager who liaised with external health and safety consultants. There was a full set of policies and guidelines accessible to staff. Servicing and testing of the fire system, equipment and alarms was up to date. Residents had received fire safety training alongside staff and had been involved in practice drills. Residents had also been involved in a recent health and safety group. Certificates were available to evidence maintenance of installations and equipment in the home. There were risk assessments to cover all aspects of the environment and safe working practices. As previously required, open storage of potentially hazardous items was reassessed when a new resident was admitted or when there were any changes to a resident’s individual risk assessment for self-harm. Lancaster House DS0000005804.V330766.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 26 No 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. 1. Standard YA24 Regulation 13(4)(a) Requirement The worn stair carpet must be replaced. Timescale for action 30/06/07 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 YA20 Good Practice Recommendations The registered person should review the systems for recording medication carried over from the previous month to ensure that there is a clear and simple audit trail. The programme to update awareness training in moving and handling, infection control and food hygiene should be completed. 2. YA35 Lancaster House DS0000005804.V330766.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 House DS0000005804.V330766.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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