Inspection on 30/01/07 for Lancaster Place

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lancaster Place 27/01/09

Lancaster Place 09/11/05

Lancaster Place 27/06/05

Lancaster Place 12/02/05

Lancaster Place 17/08/04

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

CARE HOME ADULTS 18-65 Lancaster Place 5-11 Lancaster Place Leicester Leicestershire LE1 7HB Lead Inspector Andrew Sales Key Unannounced Inspection 30th January 2007 10:00 Lancaster Place DS0000006414.V329534.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 Place DS0000006414.V329534.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 Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancaster Place Address 5-11 Lancaster Place Leicester Leicestershire LE1 7HB 0116 255 8649 0116 2558649 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Jason Reece-Sumner Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 9th November 2005 Brief Description of the Service: Lancaster Place is a residential home for up to 12 people with mental health needs. It is situated in a residential area near New Walk in the city of Leicester. The home consists of two adjoining buildings converted from four semidetached houses. There are two kitchens, two lounge/dining rooms, and 12 single bedrooms. To the rear of the home are gardens with lawn areas and garden furniture. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by A.J.Sales on 30 January 2007. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Views of other residents were also sought during the visit. What the service does well: What has improved since the last inspection? A new manager has been appointed and is committed to securing the best resources for the residents at Lancaster Place. Parts of the home have been refurbished or redecorated, including one of the bathrooms. More frequent residents meetings are now being held, to enable resident to air their views with each others support. Lancaster Place DS0000006414.V329534.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. The summary of this inspection report can be made available in other formats on request. Lancaster Place DS0000006414.V329534.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 Place DS0000006414.V329534.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. 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 this service. Prospective residents individual aspirations and needs are assessed prior to moving to the home. EVIDENCE: Two residents files were assessed and one of these residents spoke with the inspector. The assessments were comprehensive and contained sufficient information to help staff meet the residents assessed needs. The files also contained pre-admissions assessments. The inspector observed and was informed how the home obtains specialist advise from health care professionals. This was supported by documentation in care plans. Residents also spoke of visiting community health services, such as Community Psychiatric Nurses and doctor services. Lancaster Place DS0000006414.V329534.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assesses how each individual can be supported to maintain independence and take justified risks. EVIDENCE: Two residents support plans were viewed during this inspection. The assessment plans detail daily support and personal information. Files viewed were well organised, containing significant information regarding the individual needs of the residents. Care plans were comprehensive and clear about the level of assistance each resident requires. The manager, a staff member and a resident spoken with stated that care plans are discussed with the residents. The staff member commented that staff work towards enhancing residents independence. Most residents are encouraged to travel independently and are able to make trips into the city centre, depending on their daily condition of health. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 10 Records seen evidenced that care plans and risks assessments are reviewed regularly A number of residents introduced themselves to the inspector and appeared confident to approach staff and ask for support. One resident who was finding the day particularly difficult talked with the inspector and member of staff. The staff member was later able to describe how different conditions presented different challenges for the residents and how staff used different methods to support them. Staff were able to describe how daily discussions were held to assess the condition or progress of residents to keep colleagues informed. One resident was able to describe how he is supported with daily tasks within his accommodation and staff confirmed how they draw up a plan of assistance centred on the individual’s capabilities The staff and residents described how Residents meetings take place fairly frequently, where issues such as social activities are discussed. Lancaster Place DS0000006414.V329534.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Residents are given opportunities for personal development and are able to participate in appropriate activities. Though further benefit would be gained if extra staff resources were made available at key times. EVIDENCE: On the day of the inspection some residents were out. Two of the files viewed contained details of social activities they undertook. spoken with stated that the home arranges outings. Social activities by the staff include day trips, takeaways and some residents might the pub. Residents spoken with confirmed this. resident’s Residents organised go out to Residents are enabled to be part of the community, where staff hours permit. One resident described regular trips into the town centre. But this was limited Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 12 if he required assistance from staff, as two staff are required to be in the building. The staff and one resident commented that with two staff on duty, this limited any one to one support and in particular was limiting in enabling staff to leave the building to offer community, recreational or support. This leaves the home insufficiently staffed at key times, as two members of staff are required to be at the home Two residents and two staff members described how residents were supported to engage in building social contacts and relationships. They described how privacy was respected throughout the home and that any relationships that residents developed would be respected and assessed for risk in a sensitive way. The manager and staff said relatives are encouraged where possible to visit but this is limited due to family choices, but visits are documented when they occur. All members of staff are responsible for preparation of a mid-day meal. Residents stated they have a weekly menu, which is planned in consultation with them and that this has ‘improved a bit’ over the last few months. A take away lunch was briefly observed in the dining room, which was a social event with residents and staff interacting positively. The interaction between staff and residents was relaxed and friendly. Staff have a good understanding about the likes and dislikes of the residents, which was also documented in residents assessments. The food storage was clean and residents are also encouraged to buy foods of their choice. Lancaster Place DS0000006414.V329534.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs are met with support and assistance from staff and other health and social care professionals. The arrangements for the administration, storage and recording of medicines in the home generally ensure the residents safety, but require attention to risk management. EVIDENCE: Two resident’s files viewed at this inspection contained details of their personal and health care needs, which were clearly documented. Personal physical support is fairly low demand, most residents appear fairly independent, with most of their support requirements centering on their mental health issues, practical help in the home and social and community health support in their day to day life. Daily communications sheets and care plans confirmed residents receive input from health care professionals when required including the GP. Care plans contained details of other professionals involved in resident’s well being including social workers and specialist healthcare support. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 14 Staff spoken with were aware of residents individual health care needs and preferences. Health care professionals work closely with the home to improve resident’s health and well-being. Residents spoke positively about the quality of support provided by the staff. Medication was observed to be stored securely in a lockable cupboard in the office. Lancaster Place uses a monitored dosage system for the majority of the medicines. The home has policies and procedures in place with regard to administration and storage of medication. The manager stated that senior carers are responsible for administering medication. All staff have attended the Safer Handling Of Medicines, level two course, but had not been supplied with certificates yet for this. The Medical Administration Records were found to be well organised in the file and there was no gaps in the entries for the resident case tracked. There were no medication risk assessments present on files and these are required to be in place for each individual. A requirement was issued for this. Lancaster Place DS0000006414.V329534.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates suitable complaints and adult protection procedures, which help to promote the safety of residents at the home. EVIDENCE: A comprehensive complaints procedure was displayed around the home. Residents spoken with stated if they were unhappy about anything they would speak with their key worker. The manager stated that there have been no complaints and there the inspector observed a central record for the recording of complaints. Evidence of consultation was observed also from minutes of meetings and from the company audit, which is conducted annually and consults residents about issues within the home. A copy of the Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults from Abuse was in place. The homes whistle blowing policy was seen. The staff spoken with had a clear understanding of their roles and responsibilities. Certificates were observed on files to confirm staff had attended Protection Of Vulnerable Adults training provided regularly by the Prime life. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained environment. The home is clean, pleasant and hygienic. There are suitable communal facilities for use of by the residents. EVIDENCE: Generally Lancaster Place provides its residents with a homely environment. The inspector was shown round the premises by the manager and part of the premises by a member of staff. The home is well presented and domestic in appearance and atmosphere. There are adequate communal facilities and the manager described how some of these have been refurbished. The inspector did not see all of the facilities. There is a payphone available for residents to use. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 17 The residents spoken with said they felt comfortable in these surroundings and enjoyed the gardens as well in the summer. The home was clean on the day of the inspection. The manager has systems in place to ensure the home is clean, particularly the kitchen area which was in a good state of cleanliness at the time of the inspection. The staff files and their comments confirmed that they had attended training for the Control Of Substances Hazardous To Health (C.O.S.H.H.), which promotes the safety and hygiene within the home for residents. Lancaster Place DS0000006414.V329534.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. The homes recruitment policy and procedure helps to ensure the residents welfare is promoted. EVIDENCE: The staff and residents described how there are two staff members on duty during the day, including one senior carer. At night there is one staff member sleeping in who is supported by member of staff who is on call. Residents spoken with stated that the staff are polite, supportive and kind. The two staff files viewed both contained satisfactory Criminal Records Bureau checks. The files did also contained all the items required to ensure preemployment checks are carried out. This contributes to promoting the safety and welfare of residents at Lancaster Place. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 19 One staff member was spoken with who stated she enjoys working at the home and the current manager offers support and advise. The conversations with staff, the manager and evidence from staff files confirmed that suitable inductions to the work are conducted for staff and a regular program of training is in place. The induction program is followed by the Skills For Care (SFC) foundation program. Evidence was provide for the staff present as having undertake training in Control Of Substances Hazardous To Health (C.O.S.H.H), fire safety, food hygiene and the Safer Handling Of Medicines. Prime Life also runs frequent Protection Of Vulnerable Adults training, to ensure all staff are aware of procedures. The staff stated that supervision was conducted frequently and evidence was provided on staff files. The inspector observed minutes of staff meetings and residents meetings, which are held frequently the results of which are fed back through to the company, should anything be required. The staff said the Prime Life are responsive to the needs of the home and feel they have influence and the ability to get things done. The staff spoken with demonstrated a good understanding of the needs of individuals at the home. They have all had some years experience of working with this client group and had received some training to support this. They also demonstrated this in practice throughout he inspection as the inspector observed interaction with residents. The residents also said they felt supported by a competent staff group. The staff and one resident commented that with two staff on duty, this limited any one to one support and in particular was limiting in enabling staff to leave the building to offer community, recreational or support. This leaves the home insufficiently staffed at key times, as two members of staff are required to be at the home. The provider needs to review staffing levels to ensure that residents needs can be consistently met. Lancaster Place DS0000006414.V329534.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents interests are promoted by the management and policies of the home and the health, welfare and safety of the residents is promoted. EVIDENCE: The inspector observed a number of clear ways in which the provider measures quality, with evidence from a variety of sources, for example, meetings, reviews, daily feedback from service users, and internal audits. Residents commented how they are consulted over the services they receive and are invited to make suggestions for improvement or change. Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 21 All of the comments received as part of this inspection were very positive in terms of the quality of the service and the responsiveness of the organisation as a whole. Staff stated they contributed to quality monitoring and said they felt their views were listed to. The inspector observed a corporate quality review report, (last conducted July 2006), which is conducted annually. This includes similar outcome groups as are in the National Minimum Standards (NMS). The findings for each area identify shortfalls or areas for improvements and also include positive outcomes for residents. The home is then awarded star ratings. This is a positive and transparent way of promoting quality improvement. The Manager described how he is putting plans in place to address some of the some of the recommendations. Lancaster Place DS0000006414.V329534.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 3 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 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 x 3 X X 3 X Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA20 YA33 Regulation 13.2 18.1 Requirement Ensure Risk Assessments are conducted for each individual taking medication. Ensure staffing levels are reviewed regularly to ensure the needs of individuals are consistently met. Timescale for action 30/04/07 30/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lancaster Place DS0000006414.V329534.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Place DS0000006414.V329534.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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