Inspection on 29/12/06 for Lancaster House

This inspection was carried out on 29th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lancaster House 13/10/08

Lancaster House 24/10/07

Lancaster House 21/03/06

Lancaster House 31/10/05

Lancaster House 11/03/05

Lancaster House 29/07/04

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

CARE HOME ADULTS 18-65 Lancaster House 10 Eccles Old Road Salford Gtr Manchester M6 7AF Lead Inspector Val Bell Key Unannounced Inspection 29th December 2006 10:00 Lancaster House DS0000008366.V301926.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 DS0000008366.V301926.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 DS0000008366.V301926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancaster House Address 10 Eccles Old Road Salford Gtr Manchester M6 7AF 0161 737 1536 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 Audrey Kelly Mr A Kelly Mrs Audrey Kelly Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Physical disability (1) of places Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One place is available on the ground floor for a person who has a physical disability as well as mental ill health 21st March 2006 Date of last inspection Brief Description of the Service: Lancaster House is a registered care home providing support, personal care and accommodation to 12 residents with mental ill-health and one resident who also has a physical disability. The home is privately owned and registered to Mr and Mrs Kelly and Mrs Kelly is the Registered Manager of the home. The property is a large 3 storey detached house, which has been converted from 2 semi-detached properties. The home is situated in a residential area of Salford, within easy access to public services and amenities. Lancaster House is next door to Cairn House, another care home owned by Mr and Mrs Kelly. At the time of this inspection the fees charged for this service were £330 to £340 per week. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted during daytime hours on 29th December 2006. During the inspection conversations were held with staff and management on duty and six residents. Various records including care plans were examined and a tour of the homes communal and private space was undertaken. The registered person had completed and returned a preinspection questionnaire prior to the site visit and two satisfaction surveys were completed and returned to the Commission. Three of the four requirements made at the last inspection had been met. What the service does well: What has improved since the last inspection? Residents had all been offered annual health checks and staff were being supervised on a regular basis. Improvements had been made to medication records by obtaining signed authorisation from general practitioners when resident’s medication needed to be changed. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 6 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 DS0000008366.V301926.R01.S.doc Version 5.2 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 DS0000008366.V301926.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Thorough assessments of need ensure that resident’s needs are identified and recorded. EVIDENCE: There had been no admissions to the home since the last inspection. When a referral is made the home obtains a copy of the care manager assessment of need and care plan and a senior member of staff visits the potential resident to discuss their needs and how these can be met. People are encouraged to state their preferences in the way that their individual needs can be met. This process makes sure that the home and potential resident have enough information to decide if the placement is appropriate. One resident commented in his satisfaction survey that he had visited the home with his social worker before he made a decision to move in. An example of the way the home has responded to resident’s preferences is by providing two rooms to a married couple so that they have a bedroom and private lounge. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 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): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. A robust system of care planning, monitoring and review ensures that residents assessed needs are met. EVIDENCE: The home had developed detailed care plans from care manager and in-house assessments of need. The care plans belonging to four residents were examined. Risk assessments and risk management plans had been undertaken and this ensured that resident’s needs could be met safely. The home had adopted a policy of reviewing residents needs on a weekly basis, which gave them the opportunity to identify changing needs so that timely referrals to health and social care professionals could be made. Care plans also contained evidence that referrals had been followed up consistently with the outcome that residents had optimum opportunities to maximise their potential. This system of assessment, care planning, monitoring and review was commended as an area of best practice. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 10 Six residents were asked if their right to make decisions was respected and all these residents confirmed that staff provide the right level of support for them to make decisions that affect their lives. One resident said that the staff are approachable and offer guidance and information on request. This resident said that the support from staff had enabled her to develop her self-confidence in doing voluntary work. One resident commented in his satisfaction survey, “I have been in this home for about twelve years and I like it here. If I did not like it here I would not have stayed here all this time.” Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents enjoy a variety of leisure and social activities and are provided with a varied diet that suits their individual preferences. EVIDENCE: From conversations with six residents and from evidence in care plans it was confirmed that the home placed high importance on providing residents with opportunities to develop their self-help skills and participation within the local community. In-house activities were varied including a weekly baking session, manicures, parties, arts and crafts and prize bingo. Three residents attended basic skills courses and two residents undertook voluntary work at a garden centre and a charity shop. One resident showed the inspector the craft work that she had done and said that she thoroughly enjoyed these activities. Other activities included shopping trips, attendance at a day centre for social activities such as playing pool and dominoes. The residents had recently Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 12 enjoyed a Christmas party and had been to see a pantomime. The response from a resident who completed a satisfaction survey was, “I can make decisions on what I do each day, but the home offers a lot of services. Yoga on Mondays, craft on Tuesdays, exercises on Wednesdays, manicures on Thursdays and hairdressing on Fridays and Saturdays. I work around these activities.” Care plans contained written evidence that the home encouraged residents to develop and maintain personal relationships with family and friends. Residents said they could receive visitors in the home and one resident said that they also visited their relative’s home. The comment from a resident who completed a satisfaction survey was, “At weekends my family come and see me and the staff welcome and encourage this.” Copies of the homes weekly menus had been submitted to the Commission prior to this inspection. Residents were offered two options at mealtimes, although a resident said, “There are always more alternatives if you ask.” A record was held detailing the meals eaten by each resident. The kitchen and food stores were clean and hygienic and the inspector was told that kitchen equipment had been regularly maintained. Fridge and freezer temperatures had been recorded daily. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 13 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): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home demonstrates respect and value in meeting clients’ diverse support needs. However, the home should make improvements to the medication administration records to ensure that resident’s health and welfare is not at risk. EVIDENCE: Care plans contained detail of individual residents health appointments and their outcome and evidence that the staff worked in partnership with health professionals in the best interests of residents. Those residents spoken to said that staff respected their preferences in the way their care was delivered and several residents said that they could choose when they wanted some privacy in their own rooms. One resident had undergone a cataract operation and this had a positive outcome on his independence. All residents had been offered annual health checks and were weighed every month. Two residents were attending a weight management group. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 14 The home was supplied by a local pharmacy with the Venalink medication administration system. The pharmacy did not, however, supply medication administration records, which were being typed up by staff in the home. It was of concern that this potentially placed the residents at risk if staff did not transcribe the medication administration instructions correctly. Furthermore, the records did not specify the general practitioners instructions on administration frequency or the actual times of administration. It is recommended that these issues are reviewed with the pharmacist in order to agree and implement a safer system of medication administration. Improvements had been made to the way changes in medication were being recorded with general practitioners completing signed authorisation forms. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 15 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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Failure to provide staff with training in the awareness of abuse and the procedure to follow when there are allegations or suspicions of abuse potentially places the welfare and safety of residents at risk. EVIDENCE: The home had an electronic complaints system that included a complaints log, although no complaints had been received in the previous twelve months. Residents told the inspector that they would speak to staff if they had any concerns or complaints and they were confident that staff would take the necessary action to put things right. A resident who completed a satisfaction survey commented, “I approach the deputy manager if I have any complaints and usually get an answer or Mrs Kelly (the owner) if it is serious.” Another commented, “I don’t have many problems myself but if I do I can rely on staff to sort something out.” Salford local authority’s policy and procedures on the protection of vulnerable adults from abuse had been implemented by the home and the inspector was told that an introduction to abuse was covered during staff inductions. Consequently, staff spoken to appeared to have a basic understanding of the procedures that should be followed if abuse was suspected or alleged. However, it was disappointing that the requirement made at the last inspection for staff to undertake abuse awareness training and how this applies to the procedures on the protection of vulnerable adults had not been addressed. It is important that staff have an in-depth knowledge of how to recognise the Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 16 signs and symptoms of abuse and the correct procedure to follow as this affords protection to residents’ welfare. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were provided with a safe, clean and comfortable living environment. EVIDENCE: A tour of the home was undertaken and this included the communal areas and one of the bedrooms. The home was pleasantly decorated, clean, and hygienic and no unpleasant odours were present. The home was furnished to a high standard with all furniture and fittings of a domestic nature. A resident showed the inspector her bedroom, which had been personalised to reflect her personality and interests. This resident told the inspector that she had everything that she needed in her room and also that she valued her private space. A comment made by a resident who completed a satisfaction survey was, “We dust and clean our own rooms, then there is a cleaner who does each room once a week.” Equipment in the home had been regularly serviced and maintained. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 18 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, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Failure to obtain current Criminal Record Bureau checks for all staff working in the home potentially places the welfare of residents at risk. EVIDENCE: Staff had received medication and health and safety update training and future planned training included moving and handling and challenging behaviour. Nine of the ten support staff had achieved a relevant National Vocational Qualification. From observation and conversations with staff it was evident that they possessed the personal qualities, knowledge and skills to meet the assessed needs of residents. A selection of personnel files was examined. These contained the required preemployment checks such as Criminal Record Bureau (CRB) checks, two written references and evidence of identity. However, in conversation with a member of domestic support staff it transpired that the home had not applied for a current CRB certificate. Current CRB certificates must be obtained for all staff employed by the home. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 19 Since the last inspection a system of regular staff supervision had been implemented. The supervision agenda detailed items for discussion and written minutes were held for all supervisions undertaken. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is managed efficiently and there was evidence that residents’ views are listened to. However, the home has not implemented a formal system of quality assurance that provides for consultation with residents and their representatives. EVIDENCE: The home was managed efficiently and it was evident from conversations with staff that they had a clear sense of their responsibilities in meeting the aims and objectives of the home. Lines of accountability were clearly defined and the home’s ethos was open, positive and inclusive. Staff had developed good relationships with residents, based on mutual trust and respect. Residents confirmed that they were treated as individuals and that staff provided support for them to try new life experiences and situations. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 21 The home was displaying its certificate of registration. However, the public liability insurance certificate on display had expired in September 2006. The owner said that a current certificate had been received. This must be displayed. A quality assurance system had been purchased, although at the time of inspection this had not been implemented. The inspector was told that satisfaction surveys would be issued in the New Year. No health and safety issues were identified during this inspection. Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 22 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 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 23 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. Standard YA23 Regulation 13 (6) Requirement Staff must undertake specific Adult Protection and abuse awareness training. Previous timescale of 30/06/06 not met. The registered person must obtain a current Criminal Record Bureau certificate for all staff working in the home. The home must display a current certificate of public liability insurance. The registered person must implement the formal quality assurance system as soon as possible. Timescale for action 01/03/07 2. YA34 19 (b) 29/01/07 3. . YA37 YA39 18 24 29/01/07 29/03/07 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 home should review the current system of medication administration to ensure that resident’s welfare is safeguarded. DS0000008366.V301926.R01.S.doc Version 5.2 Page 24 Lancaster House Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lancaster House DS0000008366.V301926.R01.S.doc Version 5.2 Page 25 - 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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