Inspection on 11/01/06 for Lancaster House

This inspection was carried out on 11th January 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lancaster House 11/04/07

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 January 2006 09:00 Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 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.V270723.R01.S.doc Version 5.0 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.V270723.R01.S.doc Version 5.0 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 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.V270723.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 (one) named service users requiring personal care within the category of MD (E). 4th August 2005 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 two lounges, 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. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over half a day. The previous statutory inspection was done on 4th August 2005 and information on the findings of this can be obtained from the home or from www.csci.org.uk. There had been no additional visits to the home. At the time of the inspection there were 6 residents accommodated. The inspector met with all of the residents, one resident agreed to talk about their views and experiences of the home, others made brief comments. Some residents’ comments are quoted within this report. During the course of the inspection discussions were held with the registered provider, three members of the management team, 2 support workers and a visiting professional. A partial tour of the premises took place and a number of documents and records were viewed. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: Residents were involved in planning and reviewing their care. Their plans were clear and detailed which meant that staff had good directions for assisting residents to meet their goals. Residents said they were able to make decisions about their day to day life and routines. Staff helped residents to make decisions by providing them with information and advice. Staff helped residents to form new friendships and to keep in touch with family and friends. They also gave practical help with transport arrangements for residents whose family lived out of the area. The manager made sure that new staff had thorough checks before they started work at the home, which provided protection for residents. The registered person and the rest of the team responsible for managing the home were very experienced and well qualified. The staff and residents said the managers were supportive and “knew what they were doing.” A visiting professional said the home was professionally run. Residents were consulted about what they thought about the home. Any new ideas or suggestions for improvement were listened to and acted upon. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 7 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.V270723.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were assessed during this inspection. Standards 2, 4 and 5 were assessed and met during the inspection of 04/08/05. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The care planning process enabled residents to be involved in setting their own goals and ensured that staff were provided with sufficient information to help residents to meet their needs. Residents were supported to make decisions about all aspects of their lives. EVIDENCE: Care files for two residents were seen. Care plans and risk assessments addressed all aspects of the resident’s needs. All residents had a weekly programme of activities, drawn up with their key worker. Care plans contained excellent directions for staff to follow to support residents. The plans were updated as and when changes occurred and following formal reviews with the wider team. Residents were fully involved in the care planning and review process if they wished and were able. A visiting professional commented that the staff were knowledgeable about the residents’ needs and there was always a good exchange of information. Residents said they made their own decisions about most aspects of their daily life. One resident said there were some restrictions but the doctors usually made them and he was happy with that. Examples were given of residents making decisions about activities, where to go on holiday and daily routines. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 10 Each resident had a care plan to assist with decision-making in areas of particular importance to them. For example, one plan directed staff to provide information and advice about finances to assist one resident to make choices and decisions with regard to how he spent his money. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents were supported to form and maintain appropriate relationships with family and friends. EVIDENCE: Residents had individual plans with regard to their needs in forming and maintaining relationships. Staff assisted residents to maintain contact with their families by providing emotional and practical support. Staff provided transport or escorted residents to visit family who lived out of the area. Residents were encouraged to make friends outside of the home by establishing independent activities such as community groups, voluntary work and leisure pursuits. One resident said he had made friends “on both sides of the bar” in the local pub. Residents and staff from Lancaster House were to be involved in a new group looking at forming and maintaining appropriate relationships. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents were safeguarded by medication policies and practices. Residents were supported to handle their own medication within a risk management framework. EVIDENCE: There was a complete set of policies and procedures for management of medication. Residents who administered their own medicines had risk assessments and care plans to support them. There were regular random checks to ensure that residents were managing safely. One resident said he took his medication unobserved and had spot checks at any time. There were complete records of medication entering and leaving the home. Medication Administration Records (MAR) charts were complete and up to date. Storage was safe. Residents who self administered had lockable storage which could be accessed by staff. Staff who handled medication had received appropriate training. There were patient information leaflets in the home and all medication care plans included information about effects and side effects. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were assessed during this inspection. Both were assessed and met during the inspection of 04/08/05. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents were satisfied with the environment, which suited their needs and lifestyle. EVIDENCE: Residents said they were happy with the layout, décor and furnishings in the house. One said, “it suits me, I’ve got a good room upstairs and the lounges are alright, enough room.” Another said “it’s fine, very comfortable.” Minor faults were reported to maintenance staff at Almond Villas. A resident said, “If anything’s broken they are on to it quickly.” Another resident said he had just got a new set of drawers because the old ones were broken. Décor and furnishings in the lounges and kitchen were satisfactory. The first floor bathroom needed some attention. The walls, ceiling and window frames looked damp and mouldy. The floor covering needed replacing. The room was cold even with the radiator on. The stair carpet was worn in places and may pose a risk to safety in the near future. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34 Recruitment policies and practices provided safeguards for residents. Staff had access to a variety of training, which increased their knowledge and understanding of the needs of the residents but the targets for NVQ training had not been met. EVIDENCE: Both support workers spoken with were going through the induction training, which they said was very good. Other staff had training and qualifications relevant to the resident group. 45 of staff had achieved NVQ level 2 or above. Other staff were undertaking the course and the target of 50 should be reached on completion of this training. Files of new employees showed that all pre-employment checks were carried out. Staff said they were supervised until their CRB disclosure was returned. This was recorded on staff files. All the required information and documents were present on staff files. Residents from Lancaster House who were involved in the service user forum (a group of resident representatives) had some input into the recruitment of new staff. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents and staff benefited from a well managed home. Systems were in place to review the quality of care provided, which included seeking views of residents, relatives and other stakeholders. Policies and practices protected the health and safety of residents and staff. However, inadequate risk assessments of hazardous substances may lead to ineffective control measures. EVIDENCE: The registered person managed the home on a day to day basis. A management team, who each took responsibility for a different area of the service, supported her. 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. 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. Residents said the home was well managed. One said, “they know what they are doing, they have done it for years and it works well.” Another said, “you can always speak to a manager.” Staff said that they were Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 17 happy with the management structure. One support worker said of the management team, “I can always get help and advice, they don’t make you feel as if anything is too trivial.” A visiting professional said that the home was run very professionally. As part of the Almond Villas Group, Lancaster House held the Blackburn with Darwen quality assurance award and the Investors in People award. There were also several internal systems for monitoring the quality of the service, including audits of systems and records. Annual questionnaires were sent out to residents, staff, relatives and other professionals involved in the service. Action plans to address any issues were drawn up and monitored by the management team. House meetings were held every two weeks and residents said they could bring up any ideas about activities, food, care, staff and any suggestions for change. One resident, who was a member of the service user forum said, “you get to say what you think about everything and you can get staff to change things.” Current residents’ views about the service were very positive and all said they were happy with the home and got on very well with staff. The records for training in safe working practice topics were not clear and indicated that some training in safe working practice topics may be out of date. The current set of fire safety training records was not available at the time of the inspection. Fire alarm systems and equipment were tested and serviced. Residents and staff spoken with were aware of the fire procedure, and fire drills were carried out regularly. A previous requirement with regard to the storage of potentially hazardous materials had only been partially met. Risk assessments had been conducted but not reviewed as new residents were admitted. Other environmental risk assessments were in place and had been reviewed. A weekly health and safety audit highlighted any problems. Maintenance and servicing of electrical and gas installations and equipment was up to date. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lancaster House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 4 X 3 X X 2 X DS0000005804.V270723.R01.S.doc Version 5.0 Page 19 Yes 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. 2. Standard YA24 YA42 Regulation 23(2) 13(4)(a) Requirement Refurbishment of the first floor bathroom must be added to the annual maintenance plan. Risk assessments must be carried out with regard to the storage of potentially hazardous items in parts of the home accessible to residents. The assessments must be updated as new residents enter the home. (Timescale of 30/09/05 not met) Records of staff training in safe working practice topics must be completed and any shortfalls in training must be addressed. Timescale for action 31/01/06 28/02/06 3 YA42 18 31/03/06 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 YA24 Good Practice Recommendations The worn stair carpet should be checked regularly to ensure it does not become a hazard to residents, staff or visitors. Repair or replacement should be included in the maintenance plan. DS0000005804.V270723.R01.S.doc Version 5.0 Page 20 Lancaster House 2. YA32 50 of care staff should be trained to NVQ level 2. Lancaster House DS0000005804.V270723.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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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