Inspection on 29/06/06 for Lancaster House

This inspection was carried out on 29th June 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 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 04/08/05

Lancaster House 21/04/05

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 Norfolk IP25 6HP Lead Inspector Ruth Hannent Key Unannounced 29th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancaster House Address 2 Portal Avenue Watton Thetford Norfolk IP25 6HP 01953 883501 P/F01953 883501 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) Mr Sarath Ekanayake Mrs Jeeva Ekanayake Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nineteen (19) Older People may be accommodated. Date of last inspection 4th August 2005 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. Email sarath.ekanayake@btopenworld.com Fees £295 - £380 Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report that has looked at accumulated information received at the commission since the last inspection together with an unannounced visit, which took place over a period of three and a half hours. Since the last inspection which was in August 2005 the home has changed the way it is staffed with a new Senior carer about to become the Manager. Information received at the Commission has been very limited as there has been no incidents or deaths reported. Three relatives and three resident comment cards had been received and all had comments that praised the Home with no worries or concerns to share ‘well run home’, ‘couldn’t be better, ‘homely atmosphere’, ‘good food’ were just some mentioned. The pre inspection questionnaire was finished by the owner on the day of the visit and has been used as part of the recording in this report. The overall picture of the Home is a place that is run like a large family home with a warm atmosphere, owned by a person who cares about the people. Some of the paperwork that should be in place is not there but the residents are well cared for and appear happy. Their needs are well met and with a new Manager to implement procedures the Home should continue to offer a good service. No comments have been received for the community health team or other professionals involved with this Home. What the service does well: What has improved since the last inspection? The Home has employed a new Senior carer who is soon to be the new Manager who has already implemented ideas and seen the benefits of the Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 6 changes, from adjusting the rota’s to re thinking mealtimes and introducing new beneficial form for the care plans. The Home now has a designated staff member who will carry out activities in the afternoons from Monday to Friday. 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 DS0000027327.V302471.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 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 the following standard(s): 3 The quality outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. Residents have a comprehensive detailed assessment EVIDENCE: No further evidence was required on this inspection as past six inspections have shown comprehensive information is gathered to ensure the service can meet the needs of each individual resident. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 The quality outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. The Home is developing good care plans with clear information. Resident’s health care needs are met. The medication procedure has improved and is now carried out well. Residents are treated with respect and their privacy is upheld. EVIDENCE: The Home has made progress on developing the care plans for all residents. More information is recorded than previously seen and extra forms have been added to enhance the monitoring of care. Each plan is having a monthly review and involves the resident. Each resident is registered with the local GP practise and supported by the community nurse and health practitioner team. One gentleman was pleased to Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 10 be registered with the practice as he felt he had more support than he had experienced before entering Lancaster House. The medication administration and storage within the Home needed reviewing and this has now taken place with the help of the local pharmacists support. All shelves in the locked store are clearly labelled and each resident only has the stock required. Medication was noted to be in date and controlled drugs were recorded and administered correctly with two signatures for each stage of the process . This Home goes out of the way to ensure residents are treated with respect by knowing them well and offering the care appropriately. Doors were knocked on before entry and polite, calm conversations were overheard. All residents looked smart in appearance and were happy. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Residents do have a lifestyle that matches what they wish with recreational interests available. Residents are encouraged to mange their own affairs with assistance if required. The meals offered are well balanced and enjoyed by all. EVIDENCE: Since the last inspection the Home has recruited a designated activities worker who visits every afternoon through the week. The meal times have been tweaked since the last inspection to accommodate the needs of people to enjoy supper a little later and tea and cakes have been introduced in the afternoons. One visitor was at the Home on the day of the Inspectors visit who had also met the Inspector at the previous inspection. She was still full of praise for the Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 12 Home and enjoyed her visits, which are at least three times a week. ‘It is like a family home’ and everyone is welcomed. Resident’s who can, are encouraged to manage their own finances. One resident is helped, who has no other support, by the Manager of the Home and records are all correct on checking in the last inspection. The way meals are made available to residents has improved in the fact that each day a menu is displayed and actively used to discuss what is for lunch and supper. There is a choice for people who do not like certain foods and one gentleman who particularly likes curry has this offered to him when others may be having a casserole. On talking to this gentleman he feels the home treats everyone as individuals and get to know their likes and dislikes. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 The quality outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. The residents and their families can be confident that their complaints/concerns will be listened to and acted upon. The Home cannot ensure that residents are fully protected without the staff having the ability to recognise what could be abuse. EVIDENCE: By comment cards received, the pre inspection questionnaire, comment from relatives and residents and by talking to one person they feel very contented and have no need to complain but would have no worries about talking to the Management team if anything was bothering them. The Home has a policy that protects residents from abuse but have still to book the training for all staff members to ensure they recognise the signs to look for. (Requirement). All staff are POVA checked prior to being employed. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 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 the following standard(s): 19, 25 and 26 The quality outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. Residents do live in nice surroundings but some areas need to be improved. Some areas of concern need to be addressed to ensure all areas are safe. The Home is clean, pleasant and hygienic. EVIDENCE: The Home is maintained fairly well although some areas in the older part of the property are in need of improving. Carpets are stained and some areas require new carpet tiles. (The owner has purchased many new carpet tiles and is about to lay them in the needy areas). The Home is light and bright with a nicely kept garden and flower borders. The fire records are in order with alarms and emergency lighting checked weekly. The fire extinguishers all had stickers Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 15 showing the next date of service to be 02/07 and the last visit from the Fire Officer was 3/05 with no requirements made. The concern shared with the owner was the temperature of the water within the Home. On testing the bath water the thermometer registered over 50 degrees and was too hot and must be around the recommended 43 degrees. (Requirement x 2). A past requirement also asked for radiator covers to be on all radiators and must be in place for the safety of residents. (Outstanding Requirement x 2) The Home was clean and tidy and the new Senior Carer has improved on the cleaning schedule to ensure good infection control is in place. (new dispensers are about to be placed in each bathroom for hand cleaning). Each bedroom seen had clean linen and fresh towels. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. Residents do have their needs met and skill mix of staff. Staff are slowly increasing their knowledge and applying for NVQ training. The recruitment procedures within the Home must be improved to ensure residents are fully protected. Some training is missing or outdated and needs to be happening to ensure staff are competent. EVIDENCE: The Home has a team of long serving staff who show dedication to the residents they care for. Adequate numbers were on duty on the day of the visit. 3 carers, 1 senior and one cook were caring for 16 residents. All appeared competent as they carried out their tasks and residents all appeared happy. The NVQ qualification for care staff is in need of improving but on looking through records at least five staff all hope to begin the training in the autumn with the Home awaiting confirmation that they have been accepted. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 17 The records held on staff has in the past been lacking with some paperwork missing. The Home must ensure that all staff files hold the details as written in Schedule 2 of the National Minimum Standards. The new Senior staff member who is about to take over the role of Manager is aware of the inadequate stored records and has already compiled a list of paperwork required to ensure all residents are cared for by staff who have received all checks and have references in place. (Requirement) Also lacking has been the recording of induction and foundation for staff and although some staff members have been employed for quite a while the pending Manager is going through each staff members records to ensure they have been through the recognised induction and foundation. (Requirement). Also required is the need to get all staff up to date with the statutory training (Standard 38) to ensure safe working practises are in place. Files show some staff behind with training and some have very little. (Requirement). Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Residents do live in a well-managed Home run by a person who is fit. The Home does regularly check with residents on the service provided. Financial interests of residents are safeguarded. Some improvements are required to ensure health, safety and welfare is fully protected. EVIDENCE: The Home is about to undergo a change with a new Senior Carer about to be offered the post of Manager. This person has great experience and appears Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 19 capable with already new ideas and implementation of some good practise was seen but this person will need to attend a fit person interview with the Commission to clarify this when ready to be registered. Although this person has NVQ 2 and 3 the required Management qualification is applied for but is yet to be started. The Home owner sends out questionnaires to families and residents to monitor the quality of the service. The outcomes, according to the owner, have always been positive so no active plans or development of the service has been necessary. This area will need to be developed further once the Commission give guidance on the way quality should be monitored. (Recommendation). One resident has support with managing his personal allowance with records and receipts seen at the previous inspection. To ensure all staff are working safely the training mentioned within this report under staffing must be planned and monitored to ensure all staff are trained and regularly updated. On walking the building and reading the pre inspection questionnaire all areas are safe. Alarms are functioning, the building is secure and all cleaning chemicals are stored safely and have safety data sheets. The Home has introduced a new recording system for accidents and these were seen on the day of the visit. One concern shared was the non reporting of serious incidents/deaths to the commission by the sending of the Regulation 37 forms. None had been received since the last inspection yet some serious accidents were seen in the accident book and some residents have passed away. (Requirement) Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 1 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 21 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 OP25 Regulation OP13 (4)a Requirement 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. (Outstanding Requirement x 2) The registered person must ensure the radiators that are too hot are thermostatically controlled and covered. (Outstanding requirement) The registered person must ensure all staff have undergone a training programme to ensure residents are protected from abuse. The registered person must ensure all records required to be held in personnel files are in pace within the Home The registered person must ensure that all staff have the statutory required training and updates to meet the needs of the residents fully and appropriately. The registered person must ensure that all staff receive full induction and foundation training DS0000027327.V302471.R01.S.doc Timescale for action 01/08/06 2. OP25 OP13 (4)a 01/09/06 3 OP18 OP 19 01/09/06 4 OP29 OP 19 Schedule 2 OP 19 01/09/06 5 OP30 01/10/06 6 OP30 OP 18 01/08/06 Lancaster House Version 5.2 Page 22 7 OP38 OP37 when first employed. The registered person must ensure that the Commission is notified of all events that are listed within this regulation. 01/08/06 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 OP33 Good Practice Recommendations The development of who and how people are asked when the Home is checking quality, needs to be reviewed. Lancaster House DS0000027327.V302471.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000027327.V302471.R01.S.doc Version 5.2 Page 24 - 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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