Inspection on 21/04/05 for Lancaster House

This inspection was carried out on 21st April 2005.

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 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 House 08/07/08

Lancaster House 05/07/07

Lancaster House 29/06/06

Lancaster House 04/08/05

Lancaster House 07/02/05

Lancaster House 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lancaster House 2 Portal Avenue Watton Thetford IP25 6HP Lead Inspector Ruth Hannent Announced 21 April 2005 09:30 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 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 House Version 1.10 Page 3 SERVICE INFORMATION Name of service Lancaster House Address 2 Portal Avenue Watton Thetford IP25 6HP 01953 883501 01953 883501 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Sarath Ekanayake Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lancaster House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Nineteen (19) Older People may be accommodated Date of last inspection 07/02/05 Brief Description of the Service: Lancaster House was originally built as officers’ quarters for the RAF and is situated near the entrance to the former barracks on the outskirts of the Breckland town of Watton. The barracks are no longer operational and have since become a private residential area. The house itself has been extended and adapted to provide residential care for a maximum of 19 older persons. The accommodation is all within single rooms. The 10 ground floor rooms all have en suite facilities. The upper floor is accessible by a stair lift and rooms in the older part of the house have wash-basins and share toilet facilities that are close by. The care home has a large and pleasantly appointed lounge dining room with 2 access points out into the rear garden. All the main doors into the house have ramped access. There is a private car park at the front of the building. Lancaster House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of four and a half hours. Two posters were on display for people to know the inspector was in the building and available to talk to them if they so wished. 9 people who live at Lancaster House and 1 relative had completed the comment cards and a pre inspection questionnaire had been completed by Mr. Ekanayake. The day started with a discussion on the past requirements. These were seen by the inspector as having been done since the last inspection. Records were looked at that included care programmes, staff recruitment and training files, quality monitoring systems, finance systems, medication and maintenance records. A tour of the building and the time to spend talking with the staff and people who live in the home was how the majority of the inspection was carried out. The midday meal was observed with the 17 people who live at Lancaster House. 8 of these people were spoken to along with Mrs. Ekanayake, 3 care staff and 1 visitor. What the service does well: What has improved since the last inspection? As the last inspection was only 2 months ago not enough time has past for improvements especially as the Home has recently had the new extension and energy is being put into making sure this area is running smoothly. All requirements from the past inspection have been carried out and new documentation was seen for the planned supervision sessions for staff. Lancaster House Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lancaster House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Lancaster House Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3and 5 People who want to live at Lancaster House have a full assessment of need to ensure that their needs can be met. Families and friends are encouraged to be involved in this assessment process. EVIDENCE: 2 people who have recently been admitted to Lancaster House had previously been seen by either Mr or Mrs. Ekanayake. A detailed assessment had taken place that was seen on the day of the inspection. Mr. Ekanayake explained that he has a list of people waiting for a place within the Home and he has to show quite clearly if he can or cannot meet the needs required. The form seen gave clear details of the individual needs to help formulate a care plan on admission. During the morning one family member was spoken to who gave a full account of the process prior to admission that included reading the service users guide and terms and conditions before a decision was made as to the suitability of the Home. Visits were made and questions were answered giving the family a reassurance that they were making the right choice for their mother. Lancaster House Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 The people who live at Lancaster House have their health, personal and social care needs met and are shown respect and privacy. Medication recording practice needs to be improved. EVIDENCE: 3 care plan files were looked at during the inspection. These files are very comprehensive. Details of the care and medical needs are clearly shown with records of regular reviews seen. One particular care plan had a very detailed form that had been completed by the family giving excellent social history details, enabling the staff to produce a tailor made care plan. The local GP practice will visit on the day a call is made and the district nurse visits weekly. Dates of these visits and the outcomes are recorded in the care plan folder. All the medication is now stored in a lockable trolley which was a purchase required in the last inspection with some stock stored in the locked office such as paracetamol for only when required. Some records show that medication had not been administered as stated on the medication charts. All medication Lancaster House Version 1.10 Page 10 charts state if medication is not given a code must be entered into the appropriate box. (Requirement). Throughout the day staff were seen talking and assisting people in a manner that showed respect by knocking on doors before entering and explaining clearly why they have entered the room. On discussing with the people how they feel they are cared for, answers such as “I can do what I like and the staff will listen and help me”. Or “I can stay in my room if I wish and I do” were some of the comments heard. Lancaster House Version 1.10 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,14 and 15 It is clear that opportunities for residents to have their expectations met do take place. These opportunities should also be available through offering a choice of the main meal of the day. EVIDENCE: Lancaster House tries to ensure all the people who live there have the opportunity to enjoy their day by offering different individual stimulating activities. On the day of the inspection people were seen reading, doing the crossword, being entertained by the cat or dusting the tables. One group were singing and many board games were available and used occasionally. Conversations about re planning the garden were in full flow and when the weather improves a few of the residents are keen to be involved. A church service is held regularly and one visitor who was spoken to said how welcome she was made to feel whatever time of day she arrives. Sitting with a resident in her room a long conversation took place on how involved she is in the day to day choices of her life. “ I can get up and go to bed when I like” or “I love toast with half a pound of butter on it and I get it” were some of the comments made. Lancaster House Version 1.10 Page 12 The meal appeared well balanced and appetising. The conversations around the table and the clear plates showed how much the meal was enjoyed. Mr. Ekanayake has found it difficult in the past to offer choice but suggestions discussed could aid the choice of meals in the future. (Recommendation) Lancaster House Version 1.10 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The Home has a good complaints procedure. EVIDENCE: A clear complaints procedure is part of the statement of purpose showing how to complain, the contact number for the Commission of Social Care Inspection, plus some free writing space if the person wishes to write their complaint down. On talking to Mr. Ekanayake any concerns raised by a person who lives at Lancaster House or their families and friends would be dealt with immediately. Lancaster House Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20, 21, 23,24,25 and 26, The Home has a clean and well-maintained environment both indoors and out. Most rooms have en-suite facilities or lavatories and washing facilities that are suitable. There is no odour and the home is set with comfortable, appropriate furnishings. The heating and hot water supply is too hot and could put the people at Lancaster House at risk. EVIDENCE: On walking the building it was noted that it was light, bright and clean. Each room was furnished in suitable fabrics and appropriate furniture. Some people had their own furniture with many having ornaments and pictures around to make the room look individual. The Environmental Health Officer had visited only 2 days previous to this inspection and no problems were found within the kitchen area. Records were up to date with environmental checks carried out by the manager and on looking at the fire extinguishers they had been checked in the past 12 months. Lancaster House Version 1.10 Page 15 The hot water system is too hot for the hand to be held under the flow in certain parts of the building, especially in the assisted bathroom. Although valves are in place they were not functioning on the day of inspection. (Requirement). The radiator in room 5 was too hot to touch and did not have a cover on it. The valve was faulty and appeared loose. This presented a risk to anyone falling against it. (Requirement) Lancaster House Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 30 The staff are competent and trained to carry out their duties. The recruitment procedure needs to be clearer to include CRB’s that are relevant for the Home (not transferred) and POVA checks. EVIDENCE: 3 care staff members were spoken to in detail. They have various experiences and all appeared competent in carrying out their duties. One had just completed an NVQ, one was moving into nursing in September and one has 4 years experience. An induction check list was signed and completed for the latest member of staff when recruitment files were looked at but there were no POVA checks, one CRB was outstanding with another to be sent for due to a misunderstanding that the CRB checks are not transferable from home to home. (Requirement) Training that had taken place in the last 12 months were first aid, fire training (a full detailed explanation was given on the event of a fire by the staff to the inspector), moving and handling and infection control. Lancaster House Version 1.10 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33, 35,36and37 The manager at Lancaster House is a fit person to be in charge of this residential home. EVIDENCE: It was evident on talking to the staff and residents that the Home is managed by a person who is a good leader. Staff were able to relay how open and clear with communication the Manager is. Meetings that are held every two months and daily handovers are used to keep everyone involved and up to date. In place were policies and procedures to guide the readers and to ensure the smooth running of the Home. This is the second home Mr. and Mrs. Ekanayake have run over many years. To aid the service the Home offers, the Manager uses a quality assurance system that is comprehensive. Questionnaires were seen from families and residents which assists with the development and planning for the future. Lancaster House Version 1.10 Page 18 Policies and procedures are looked at regularly and updated as required. This was seen in the statement of purpose that had recently been changed to include the new extension. Financial records for 2 residents were looked at and clear accountable details were seen with 2 signatures in place for all transactions. The Manager is about to start the supervision of staff and showed the format ready and files all ready named for each staff member. Lancaster House Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 1 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 3 x 3 2 3 x Lancaster House Version 1.10 Page 20 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 9 Regulation OP13 (2) Requirement The registered person must ensure all staff who adminiister medication complete the medication records The registered person must ensure the hot water valves in the home are working correctly and that checks are in place to monitor the temperatures of the sinks and baths. The registered person must ensure the radiators that are too hot are thermostatically controlled or covered. The registered person must ensure all CRBs are in place and POVA checks on new staff take place. Timescale for action Immediatel y 31st May 2005 2. OP25 OP13 (4)a 3. OP25 OP13 (4)a 30th June 2005 31st May 2005 4. OP29 OP 7,9,19 5. 6. 7. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Version 1.10 Page 21 Lancaster House 1. Standard 15 The registered person should offer a choice of main meals for the main meal of the day. Lancaster House Version 1.10 Page 22 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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. Extracts may not be used or reproduced without the express permission of CSCI Lancaster House Version 1.10 Page 23 - 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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