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Inspection on 02/11/05 for Lee House

Also see our care home review for Lee House for more information

This inspection was carried out on 2nd 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Daily recordings on the care delivered to each resident over any 24 hour period was much better. In the past records did not necessarily link to the individual residents` care plan and offered little information about how the person had been over the past 24 hours.Daily records now included factual statements about the support given and, in most cases, gave a `pen picture` of the type of day the resident had had.

What the care home could do better:

A more robust system of ensuring that all pre-employment details/checks have been completed/received and checked before employing a new member of staff in the home must be developed. Lack of such a system means that one new employee has been offered a permanent post in the home before any Criminal Record Bureau check or Protection of Vulnerable Adults check had been fully completed. This can place residents and other staff at risk from unsuitable people working in the home.

CARE HOMES FOR OLDER PEOPLE Lee House Longley Lane Northenden Manchester M22 4HT Lead Inspector Unannounced Inspection 10:00 2 November 2005 nd 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.V262809.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 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.V262809.R01.S.doc Version 5.0 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 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.V262809.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 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.V262809.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 2 November 2005 over a six hour period. The inspection involved spending time talking with the manager, deputy manager and staff of the home who were on duty at that time. Time was also spent talking with a number of residents who wanted to say how they found living in the home. Further time was spent looking at various files and records. Time was also spent looking around the inside of the home. A number of requirements were identified in the inspection carried out in March 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 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: What has improved since the last inspection? Daily recordings on the care delivered to each resident over any 24 hour period was much better. In the past records did not necessarily link to the individual residents’ care plan and offered little information about how the person had been over the past 24 hours. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 6 Daily records now included factual statements about the support given and, in most cases, gave a ‘pen picture’ of the type of day the resident had had. 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. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5 and 6 Information was available to give to or inform a prospective resident about the service on offer in the home. However, the criteria for admission does need further information including. Prospective residents are assessed before being admitted into the home. EVIDENCE: At the time of the inspection the manager was updating the Service User Guide and Statement of Purpose, which are one inclusive document. Further information was needed relating to how the home arranges for the admission of the new resident and, what this procedure involves. 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. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 9 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. Information seen in those resident’s files examined during the inspection indicated that the needs of the individual was being met by the home. Three residents were spoken to about their care needs. All stated that their needs were appropriately met and were aware of their individual care plans. Residents spoken with also confirmed that trial visits to the home were offered to them before moving in. The home did not provide intermediate care services. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 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): 7,8,9 and 10 Information with regards to residents identified care needs was available to show how the health and social care needs were being met. EVIDENCE: Through discussion with the manager and deputy manager of the home it was very clear that the care planning process was given high priority. Each resident file examined included a comprehensive care plan that appeared to have been generated from the pre-admission assessment and the Care Management assessment in the case of those funded by the Local Authority. The plans were easy to read and clearly set out in detail the action that needed to be taken by care staff to ensure that all aspects of health and personal care needs were being met. Personal likes and dislikes were also included as was preferences for some female residents regarding wearing jewellery and carrying a handbag. Care plans and risk assessments seen during the inspection had been reviewed regularly and, wherever possible had been signed by the resident or their representative. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 11 At the time of the inspection and from information extracted from resident files, two residents were suffering with pressure areas. The district nurse had assessed both people and appropriate pressure relieving equipment had been provided. Evidence was seen that care staff maintained the personal and oral hygiene of the residents. It was clearly recorded on individual plans if a resident preferred to leave their dentures out over night or replace them after cleaning. All medication was stored and recorded correctly on the day of inspection. The deputy manager stated that the senior care workers, who had received training, had the responsibility for administering medication. It was noted however that medication dispensed in 2 containers e.g. creams and eye drops had a label affixed on the outer container only. For medications which have an inner container and an outer box the label should be applied to the inner item instead of or as well as the outer container. This was a requirement in the last report and has been reiterated again in this report. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 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): 12,13 and 14 Residents have choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: On the day of the inspection the routine of the home was very relaxed and informal. Discussion with the management team and staff of the home stated that residents could spend time socialising in communal areas or in the privacy of their own rooms. During the inspection residents were seen to enjoy using the comfort of their own rooms. Comments were very positive and included “you can have what you want (within reason) when you want”, “I get up later in the morning and take breakfast in my room – sometimes dinner as well”, “I used to be a carer so I know what care I should receive”, “you are very well looked after”. Resident meetings are held every three months and minutes of these meetings were made available during the inspection. Numerous visitors were seen to come and go during the inspection and it was confirmed by residents that their visitors were always made to feel welcome, whatever the time of day. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are taken seriously and acted upon by the management of the home. The home also has relevant policies, procedures and systems in place to protect residents from neglect and /or abuse. EVIDENCE: Discussion with the manager confirmed that the home had received no complaints or concerns since the last inspection was carried out. The complaints policy and procedure was available and clearly indicated the method in which complaints would be dealt with including timescales. The complainants right to contact the Commission for Social Care Inspection at any time regarding concerns or complaints was clearly stated. Residents spoken to during the inspection were clear about how and who to make a complaint to. The home had a policy for Adult Protection, which included a Whistle Blowing procedure. This complied with the Department of Health Guidance “No Secrets”. A majority of staff have previously received training in the protection of vulnerable adults. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 The general environment of the home was clean, tidy and comfortable with systems in place to protect the safety of residents. EVIDENCE: The home was bright, well decorated and had a warm and welcoming atmosphere. A programme of routine maintenance and renewal was in place and was on-going at the time of the inspection. A number of bedrooms seen during the inspection and all were found to be comfortably furnished and appeared to reflect the character of the resident whose room it was. All residents were offered a key to their room and each room had the benefit of a lockable storage facility for personal, sentimental and valuable items. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 15 The home was clean and free from any unpleasant odours. Laundry facilities were situated away from communal, dining and food preparation areas. An industrial washing machine, which met disinfection standards, and dryer were in place. Each resident had a separate basket with their name attached to ensure that their clothes were separated and returned to the appropriate owner. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 29 The home’s recruitment and training policies and procedures were in place and provided enough details to support the employment of sufficient well trained staff. However, these policies and procedures had not been adhered to in all cases. EVIDENCE: The staffing rota indicated that the numbers of care staff were adequate to meet the needs of the residents. There would be two waking night staff on duty each night, with a member of the management team on call from home. There was twenty two (22) staff holding the NVQ level 2 certificates, five (5) that had achieved NVQ level 3 certificates and four (4) currently working towards obtaining NVQ level 3 certificates. A number of staff files were examined and were found to contain appropriate information, which indicated relevant employment checks had been carried out prior to employment commencing. However, of concern was that one new member of staff had been working in the home and had been offered a permanent post, in writing, before a Criminal Record Bureau (CRB) check had been received. This can place residents at risk from unsuitable people being employed in the home. Evidence was available to show that the manager had requested that the personnel department ensure a CRB was completed and that a Protection of Vulnerable Adults check was also carried out. On checking with the personnel department the manager was informed that this had not been followed through. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 17 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): 35,36 and 38 Residents’ living in the home benefit from procedures that are in place to promote and protect their interests. The health, safety and welfare of residents and staff are promoted and maintained. EVIDENCE: The manager confirmed that residents or their next of kin/representative manage their finances. The home had secure facilities for the storage of any money or valuables handed over to the home for safe keeping. Appropriate records were kept and receipts given where required. Discussion with staff during the inspection confirmed that they received regular supervision. This enabled staff to discuss any areas of concern regarding their job role or any training and development needs they may have. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 18 The home was kept in a good state of repair and evidence was available to indicate that the servicing of equipment used by both residents and staff had been carried out. This ensured the safety of both residents and staff living and working in the home. Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 19 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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 X 3 Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 4 Requirement The Statement of Purpose must be updated to include all criteria for admission, including the policy and procedures for emergency admissions. 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) It is required that all staff have completed and received an appropriate Criminal Record Bureau check prior to commencing their employment at the home. Timescale for action 23/12/05 2 OP9 13 23/12/05 3 OP29 19 23/12/05 Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 21 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 Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Lee House DS0000021557.V262809.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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