Inspection on 11/03/06 for Lee House

This inspection was carried out on 11th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lee House 04/08/06

Lee House 02/11/05

Lee House 14/03/05

Lee House 14/06/04

Lee House 04/02/04

Lee House 11/11/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Lee House Longley Lane Northenden Manchester M22 4HT Lead Inspector Mrs Jennifer Dunkeld Unannounced Inspection 11th March 2006 10:00 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 Lee House DS0000021557.V285066.R01.S.doc Version 5.1 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. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lee House Address Longley Lane Northenden Manchester M22 4HT 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) 0161 945 5204 0161 945 7635 www.harvesthousing.org.uk Manchester and District Housing Association Jacquelyn Shaikh Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: Lee House is a care home providing personal care and accommodation for 25 older people (65 and over). The home is owned by Manchester and District Housing Association and is a member of Harvest Housing Group. The home was opened in 1986. The home is located in the town of Northenden, close to shops, pubs, a post office and other amenities. The home consists of a purpose built two-storey building that stands in its own grounds, surrounded by mature trees to the rear of the property. There are parking facilities at the front of the home. All of the bedrooms are single and 18 of the rooms have en-suite facilities. There are adequate toilet, bathroom and shower facilities. The home has two lounges/dining areas, a treatment room and a self-service kitchen for use by the residents and their relatives. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Saturday 11th March 2006 over a five-hour period. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. Residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. This inspection included discussion with residents, Manager, Team leader and staff in addition to viewing the home’s required written information such as the residents’ plans of care. The Care Standards Act requires that each resident has a written plan of care, which is a document outlining the needs of the individual resident and how these are to be met. They should cover all aspects of the individual’s life including health, personal care and social activities. Thereby ensuring people are content in the care they receive. The residents the inspector spoke with were generally happy with life at Lee House. A number of requirements were identified in the inspection carried out in November 2005. Most of these requirements had been completed, however, where a requirement was found to be still outstanding it has been stated again in this report. Not all standards were checked at this inspection as some of the key standards were met during the previous inspection and it is strongly advised that this report should be read together with the last inspection report to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: The residents spoken with during this inspection were very positive about the support they receive from staff in the home. Comments such as “I am happy here” “The staff are kind, nothing is too much trouble” and “I don’t think you could find a better home” were made. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 6 There is a pleasant atmosphere at Lee House where several relatives of the residents spoken with during this inspection stated “it is always pleasant here” “We are always made to feel welcome” and “ They look after my Mum very well” Sixteen (16) of the existing staff have achieved an National Vocational Qualification with 3 staff currently working towards the National Vocational Qualification level 3 in care. This reflects the importance that the service providers and manager place upon having an appropriately trained staff team. What has improved since the last inspection? What they could do better: The manager has endeavoured by writing to the pharmacist, to ensure that all medication, which have an inner container and an outer box, such as, creams for external application, have labels attached to both inner and outer containers. However, during this inspection some creams were not appropriately labelled. Advice has been given in respect of this and is included in the requirements at the end of this report. There are occasions when it has been necessary for the home to have new members of staff commence work prior to having received a clear Criminal Records Bureau check, however the ‘Protection of Vulnerable Adults First’ has been received. Advice has been given that the manager must discuss the circumstances of the need for the person to commence employment without a Criminal Records Bureau with the Commission for Social Care Inspection. Of the three residents’ care files viewed as part of the case tracking process only one contained a care plan. Of the other 2 residents one had been admitted to the home 1-week earlier and the other 3 months ago. Care plans are a vital part caring for people ensuring consistency of care and that people’s needs are met in the most appropriate manner. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 7 There is a need to ensure that all bedroom floors are carpeted unless the person’s Care plan outlines the need for an alternative type of floor covering. 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. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 8 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 Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 9 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): 1 The manager ensures that potential residents have all the information they require to make an informed choice about where to live. EVIDENCE: The home’s Statement of Purpose has been updated to outline all criteria for admission including the policies and procedures for emergency admissions. Discussion with the manager confirmed that no prospective resident moved into Lee House without a pre-admission assessment being completed by one of the management team. This assessment would normally take place in people’s own home or hospital environment. A comprehensive assessment document is completed and covers all aspects of support and need relating to the individual seeking residential accommodation. Copies of this document seen on file were fully completed, dated and signed. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 10 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&9 Arrangements to meet the health care needs of the residents are good. The residents are generally protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: One of the three care files viewed contained a care plan and risk assessments. The plan of care covered all aspects of the person’s needs including health care. However, the care plan had not been reviewed for 4 months. It is important that plans of care are kept up to date ensuring that people’s changing needs are identified and met. The other 2 residents had no written plan of care but the residents stated that they were happy at Lee House and that their needs were being met. As one man had been living at the home for 3 months a plan of care should have been developed. His comments included “The foods good” and “ The staff are good”, we added, “ I have no complaints, I’m quite happy”. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 11 It is essential that care plans are drawn up for all residents and reviewed on a regular basis ensuring people’s changing needs are identified and goals set to meet those needs. The advice offered during the previous two inspections in relation to ‘medication dispensed in 2 containers e.g. creams and eye drops had a label affixed on the outer container only. In that the manager had written to the pharmacist. The letter requested that such medication is in future appropriately labelled or it would not be accepted at the home. However, during this visit some creams were found to only have the label on the outer box and as such the frequency and dosage of application could become unknown should the tube become parted from the outer container/box. There is a need for the manager to carry out the actions she wrote to the pharmacist about and not accept into the home creams etc that are in appropriately labelled. Residents who are assessed as capable of administering their own medication are supplied with a cabinet to safely store their medication. However, all the current residents have their medication administered by the manager/ senior care staff who have been appropriately trained. It is advised that all residents in receipt of medication should sign a ‘Medication Declaration’ form, outlining their preference as to how medication is administered, for example self administer or administered by the management. An example of such a form has now been supplied to the home’s registered manager. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 12 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): 15 Good nutritional meals are provided at Lee House and the residents benefit from a healthy diet. EVIDENCE: The residents spoke positively about the meals they receive including comments such as ‘we get a choice of meals but if we don’t like or fancy either the staff will offer us something else.’ One lady said she sometimes’ just fancies’ soup and the staff make it for her. The menus reflected a healthy balanced diet including fresh fruit. The manager recognises that diet is an important part of being healthy and stated that ‘Nutritional Screening’ will in future form part of the individual’s plan of care. There is a menu board on the main corridor of the home ensuring residents are aware of the days choice of lunch and tea. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 13 There is a snack/drinks making area on the first floor that residents could use if they choose or are assessed as being able to prepare beverages without calculated risks. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 14 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): 18 There is an intention at Lee House to ensure the residents are protected from abuse. However, some improvement in the vetting of staff is necessary. EVIDENCE: The management and staff at Lee House see protecting people from abuse as extremely important. The policies and procedures are in line with the Department of Health guidance ‘No secrets’. There are appropriate locks on all outer doors to prevent unwanted intruders. The home’s recruitment procedure is robust until it comes to the practice of regularly having staff commence employment without a full Criminal Records Bureau clearance. The management routinely allow new employees to commence employment once they have received a ‘Protection of Vulnerable Adults First’. However, this should be the exception and on the occasion this happens appropriate arrangement must be in place for supervising the staff members. However, all staff must be Criminal Records Bureau cleared prior to commencing employment unless the Commission for Social Care Inspection have agreed that the circumstances are exceptional for instance the home is desperately short staffed and agency staff can not cover the shifts. The issue relating to Criminal Records Bureau clearances has been raised during the previous two inspections and as such gives concern at the continued practice of agreeing that someone can commence employment without a Criminal Records Bureau clearance. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 15 It maybe that this has been a misunderstanding of the requirement but nonethe-less this is a practice which must cease to ensure the residents are fully protected from possible abuse. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 16 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): 25 The residents at Lee House are happy, and live in safe and comfortable surroundings. EVIDENCE: Lee house was seen to be clean and well decorated. Some bedrooms are carpeted. However, some rooms were fitted with none slip and none porous floor covering to suit the individual resident. It must be however, emphasised that once the room becomes vacant the floor covering must revert back to carpeting in order to enhance the dignity of the new occupant. All bedroom doors have magnetic self closing devices fitted that is a device which enables doors to be held open but that would automatically close should the fire alarm be sounded, this is commendable and reflects an understanding of the needs and wishes of the individual to have their door wedged open but protects them from the spread of fire should one break out. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 17 One resident explained how she had moved bedroom in order to have one with an ensuite toilet. The manager explained that they endeavour to ensure people are happy in their environment for instance if someone comments ‘I’m happy living here but---‘ they would ascertain what it is that is not to the individual’s liking and endeavour to rectify it. The home is bright and in good decorative order. When rooms are to be decorated the residents are involved in choosing the paper/ colour scheme. Regular checks are made of the building and recorded in the ‘hazard and fault’ file to ensure the home is free from risks to peoples’ health, safety and well being. The home’s fire alarm is sounded on a weekly basis and recorded, last recorded alarm test was dated 6/3/06 (5 days prior to this inspection). The home operates a ‘stay put policy’ that is each resident remains where they are providing they are not in the vicinity of the fire and are at least two fire doors away from the source of the fire. The staff would assist those closest to the fire to an area of safety. Fire drills are carried out 2 times each year. . Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 18 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): 29 & 30 The home has a team of appropriately trained staff, which results in the residents being well cared for. EVIDENCE: Staff records of training reflected the management’s recognition of the benefits of having staff appropriately trained in order to meet the needs of the residents. Listed below are some of the courses completed by the staff; Induction training at a pace according to the individuals need. Moving and handling Health and safety Food hygiene Basic First aid 4 day advance First Aid Fire safety Effective supervision Customer care Infection control Care of medicines Cultural awareness Equality and diversity Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 19 Seven members of staff have successfully completed National Vocational Qualification Level 2 and five had achieved the Level 3 Award. Three (3) Staff are currently undergoing training to obtain National Vocational Qualification Level 3 and two (2). Domestic staff have also obtained a National Vocational Qualification. The manager and assistant manager have achieved National Vocational Qualification level 4. In addition to this, the manager has obtained the Registered Managers Award. This record exceeds the requirement of standard 30. Indeed all staff except the newest employee are either attending a National Vocational Qualification course or have already successfully completed one. The manager said the home has a large budget for staff training and this is reflected in the above list of training and indicative of the importance that is placed upon ensuring staff are able to meet the needs of the residents. As previously stated in Standard 18 of this report, there is a need to ensure that whenever possible a full Criminal Records Bureau clearance is received for all new staff prior to them commencing employment in order to ensure the residents are in safe hands at all times. Where there is an urgent need for the member of staff to commence prior to a clear Criminal Records Bureau a Pova First must be received and the staff must be supervised. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 20 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 Lee House is well managed and the residents know that their needs will be met EVIDENCE: Throughout this inspection the manager was observed communicating with the residents in a respectful, polite and caring manner. The residents spoke highly of the manager and made comments such as ‘she’s a lovely person’ ‘whatever you want she’d get it for you’ and ‘she’s very good and listens to what we have to say’ The manager has successfully completed a number of courses as listed in the ‘Staffing’ section of this report. She has also obtained the Registered managers Award. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 21 The residents said that they were happy at the home with comments including ‘it’s home from home’ ‘we can do what we want’ and ‘family and friends are made welcome’ these comments indicate that the home is run in the best interests of the residents. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 22 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X 3 X STAFFING Standard No Score 27 X 28 X 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X X X X Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement The service provider must ensure each resident has a plan of care outlining his or her needs and wishes. For medication which have an inner container and an out box i.e. creams and eye drops the label should be applied to the item instead of or as well as the outer container. (Previous timescale not met 31/05/05) 3. OP29 19 It is required that all staff have completed and received an appropriate Criminal Record Bureau check prior to commencing their employment at the home. 07/04/06 Timescale for action 14/04/06 2. OP9 13 07/04/06 Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 24 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 OP25 Good Practice Recommendations Carpeting should be fitted to all bedrooms unless a risk assessment or the individuals needs dictate otherwise. Lee House DS0000021557.V285066.R01.S.doc Version 5.1 Page 25 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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