Inspection on 31/10/05 for Lancaster House

This inspection was carried out on 31st October 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 13/10/08

Lancaster House 24/10/07

Lancaster House 29/12/06

Lancaster House 21/03/06

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 Unannounced Inspection 31st October 2005 11:30 Lancaster House DS0000008366.V257347.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 DS0000008366.V257347.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 DS0000008366.V257347.R01.S.doc Version 5.0 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.V257347.R01.S.doc Version 5.0 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 11th March 2005 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. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Monday, 31st October 2005. During the inspection records were examined, a tour of the home was undertaken and conversations were held with residents and staff. The focus of this inspection was to find out what progress had been made in addressing the requirements outstanding from the previous inspection in March 2005. The inspector also assessed activities and the suitability of the living environment particularly in the area of health and safety. The eleven requirements made at the previous inspection had been met. What the service does well: 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 DS0000008366.V257347.R01.S.doc Version 5.0 Page 6 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.V257347.R01.S.doc Version 5.0 Page 7 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 Standards in this section were assessed on this occasion. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 8 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 and 10 Significant progress had been made on improving the type of care plan used. This ensured that the needs of residents were identified and met. EVIDENCE: Care planning and review documentation was available for inspection. A new care plan format had been implemented since the last inspection and a copy of this was made available for inspection. The format contained all the information required. Each resident had a care plan and these were being reviewed at the time of inspection. A full assessment of the content of care plans will be undertaken at the homes next inspection. Progress had also been made in the way confidential information was being stored at the home. Residents’ personal information was no longer being entered into the homes communication book. All confidential information was being stored in individual resident’s personal files. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 9 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, 14 and 16 Meaningful social and learning opportunities were well organised and these provided stimulation and personal growth for residents living in the home. EVIDENCE: The home placed a high importance on ensuring that residents had opportunities to engage in a varied range of activities both inside and outside the home. Residents were observed to participate in the daily tasks around the home, such as laying tables, helping with the shopping, bringing the washing in and keeping their private space clean and tidy. Daily activities were provided in the home. These included manicures, crafts and a baking session every Friday. Residents were also making good use of community resources. Two residents were attending aqua-fit sessions and resource centres and one resident had volunteered to work in the Age Concern charity shop. Residents had the opportunity to have a holiday every year and a trip to Blackpool illuminations had been organised. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 10 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 Significant improvements to the administration of medication ensured that resident’s safety, heath and welfare were protected. EVIDENCE: It was most encouraging to find that significant progress had been made in the area of administration of medication as required at the last inspection. A safe system had been implemented and the six outstanding requirements had been met. It was also encouraging to note that the home had encouraged several residents to order their own prescriptions and self-administer their medication. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 11 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 Standards in this section were assessed on this occasion. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 12 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, 26 and 30 The home provided a comfortable and safe environment for people living in Lancaster House. The home was commended for ensuring that the individual needs of residents were met and that people were enabled to maximise their independence. EVIDENCE: A tour of the home was undertaken and the environment was found to be clean and hygienic and no offensive odours were present. There was evidence of a rolling programme of re-decoration, replacement and renewal. Furnishings and fittings were of good quality and domestic in nature. Residents said that they were consulted on the décor and one resident said that his bedroom had recently been fitted with new wardrobes. A resident who had mobility needs had been provided with an en-suite bathroom that was fitted with an electric bath chair, which he could operate independently. This resident said that his recent move into the home had been the best thing that had happened to him. He felt that he had been provided with the facilities to maximise his independence. The homes attention to detail in this area is considered to be an example of best practice and was commended. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 13 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): 34, 35 and 36 Effective management and a well-trained staff team ensured that the identified needs of individual residents were being met. EVIDENCE: At the time of inspection contracts of employment were being agreed with the staff. Contracts included a statement that required staff to inform the manager if they became subject to any criminal investigations or convictions. Notable progress had been made in the areas of staff development and supervision. Copies of training certificates were held on staff files. Staff had undertaken training in the areas of medication management, food hygiene and care planning. The home was looking into a suitable moving and handling training course. Two senior carers had completed NVQ 3 and two members of the night staff had achieved NVQ 2 and 3. Four carers were currently working towards NVQ 2. This meant that the home had achieved its target of 50 of the staff team qualified to NVQ 2 or above. The home manager and deputy manager had undertaken training in the supervision of staff during October 2005. At the time of inspection they were developing schedules for the supervision of staff. An action plan was in place to assess the training needs of staff once supervision was underway. This will be fully assessed at the next inspection. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 14 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 The home was effectively managed and the leadership, guidance and direction to staff ensured that residents received consistent quality care. This promoted and safeguarded the health, safety and welfare of the people living in the home. EVIDENCE: The home was well run and residents and staff benefited from good leadership. Staff were observed to be open, honest and approachable. All residents spoken to said that they were very happy living in the home and that they were satisfied that their needs were being met on an individual basis. The home had a formal quality assurance system in place. The selfassessment process had highlighted several areas for improvement and the management had taken action to address all the shortfalls identified. The inspector was told that quality assurance questionnaires were being developed in consultation with staff and residents. This will be assessed at the next inspection. No health and safety issues were identified during this inspection. Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 15 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 3 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 4 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 3 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 X X 3 X X 3 X DS0000008366.V257347.R01.S.doc Version 5.0 Page 16 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. Standard Regulation Requirement Timescale for action 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 Standard Good Practice Recommendations Lancaster House DS0000008366.V257347.R01.S.doc Version 5.0 Page 17 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. 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