Inspection on 09/11/05 for Lancaster Place

This inspection was carried out on 9th November 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 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 1 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 30/01/07

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 Fiona Stephenson Unannounced Inspection 9th November 2005 09:45 Lancaster Place DS0000006414.V255428.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 Place DS0000006414.V255428.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 Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lancaster Place Address 5-11 Lancaster Place Leicester Leicestershire LE1 7HB 0116 255 8649 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) Prime Life Limited Joyce Elaine Spriggs Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 27/06/05 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 semi-detached 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.V255428.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Wednesday the 9th November 2005. The inspection started at 09:45am and finished at 12:20pm, and was conducted by one inspector. The Commission for Social Care Inspection focuses it’s inspections on the ‘outcomes’ for service users living in a home. To do this, the inspector ‘case tracks’ clients living at the home. This means that clients are spoken with, their care records checked, and staff who support their care are also spoken with. This is the second regulatory inspection for the home this year, and the inspector also focused on the ‘standards’ which were not inspected during the previous inspection, and issues that resulted in requirements and recommendations from the previous inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home has improved it’s levels of cleanliness and hygiene, particularly in the kitchens where there is a vast improvement in hygienic levels. The living room in one of the houses has been newly decorated and furnished, with clients having input to their new décor. This has improved their physical environment. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 6 Although one client was identified as needing new bedding during the previous inspection, the Manager has ensured that all clients living at the home have been provided with new bedding. The lunchtime menus have improved since the last inspection with evidence that clients who do not cook for themselves are receiving a more nutritious and balanced diet. 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 Place DS0000006414.V255428.R01.S.doc Version 5.0 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.V255428.R01.S.doc Version 5.0 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 All clients living at the home have had their needs assessed prior to moving into the home. EVIDENCE: The inspector checked the files of one client who was case tracked and found that all the relevant assessment information was in the client’s record. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 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): 10 Staff have a good understanding of confidentiality and handle confidential information appropriately. EVIDENCE: Staff are informed about confidentiality as part of the induction process. The inspector noted that records are kept in a secure place. The manager ensures that the client’s wishes are respected, and demonstrated through discussion about a client that she has a clear understanding of the importance not to share the confidential information given by that client, with the client’s family as it is against their wishes. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 10 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): Not checked on this occasion EVIDENCE: Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 11 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): 21 The manager has appropriate systems for supporting clients in determining action to be taken in the event of their death. EVIDENCE: The inspector looked at two care records and found information on both relating to the clients wishes in response to their death. One was a detailed record of what the client would like to happen, the other, acknowledged that the client was not ready to discuss such issues. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 12 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): Not checked on this occasion. EVIDENCE: Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 13 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): 30 The home was found to be in a good state of cleanliness, hygiene and repair. EVIDENCE: The manager has put 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 living area in one of the homes has recently been redecorated and has new furniture and fittings, with clients being involved in the process. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 14 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 Service users are supported well by the home’s recruitment policy and practices. EVIDENCE: The inspector checked the file of a new member of staff and found that the manager had complied with all the standards relating to recruitment. Two references had been sought, and Criminal Records Bureau and Protection of Vulnerable Adult checks had been undertaken. The new worker had received induction training and a staff handbook with policies and procedures. The inspector noted that although the manager said the worker had undertaken training in the protection of vulnerable adults, they hadn’t signed to say they had received training, or understood the policy. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 15 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): 37,38,39 The manager demonstrates that she manages the home in the best interests of the clients who live there. EVIDENCE: Throughout the inspection the manager demonstrated that she had a thorough knowledge of the clients living at the home. The inspector observed discussions held with professionals attending to clients living at the home, which demonstrated her commitment to, and knowledge of the clients living at Lancaster Place. The manager has recently completed her National Vocational Qualification in Care (level 4) and her Registered Manager’s Award. The inspector was informed that there used to be regular client group meetings at the home to discuss issues affecting clients living at the home, however these have not happened over the past few months. The inspector also was informed that the new system from Prime Life to capture the views of clients is through a quality assurance book where clients write their views down. The manager informed the inspector that there had been no comments written in Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 16 the book, however the inspector was unable to see the book as it had been removed from its usual place due to re-decoration. The manager informed the inspector that steps had been taken to meet the requirement from the last inspection regarding insulin administration, and although the requirement hadn’t been met yet, she expected it to be met by the end of November. Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 17 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 3 X X X Standard No 22 23 Score X x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X x 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lancaster Place Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 4 3 3 X X X x DS0000006414.V255428.R01.S.doc Version 5.0 Page 18 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 YA20 Regulation 12 Requirement Ensure staff are provided with appropriate training to administer insulin. Timescale for action 27/11/05 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. 2. Refer to Standard YA39 YA39 Good Practice Recommendations Consider whether the current quality assurance book is an effective tool in providing the organisation with the views of clients living at Lancaster Place. Consider re-instating regular group meetings for clients living at the home to provide them with opportunities to talk about life at the home, and any problems or issues they may have. Consider asking staff to sign to say the have received and understand the policies and procedures relating to the Protection of Vulnerable Adults. 3. YA37 Lancaster Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Place DS0000006414.V255428.R01.S.doc Version 5.0 Page 20 - 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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