Inspection on 23/02/06 for Lenore, The

This inspection was carried out on 23rd February 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lenore, The 19/03/08

Lenore, The 29/03/07

Lenore, The 12/10/05

Lenore, The 04/02/05

Lenore, The 16/09/04

Lenore, The 18/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Lenore, The 1 Charles Avenue Whitley Bay Tyne & Wear NE26 1AG Lead Inspector Glynis Gaffney Unannounced Inspection 23rd February 2006 17:00 Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 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 Lenore, The DS0000000382.V276127.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 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. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lenore, The Address 1 Charles Avenue Whitley Bay Tyne & Wear NE26 1AG 0191 2513728 0191 2513728 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Teresa Duchett Mr Paul Royston Duchett Mrs Jennifer Catherine Ashworth Care Home 21 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (18) of places Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of persons for whom residential accommodation with board and care is provided shall not exceed 21 men and women The category of persons received into the Home shall be restricted to the following categories LD & MD Maximum service users with LD should not exceed 5 without prior negotiation with CSCI. 12th October 2005 Date of last inspection Brief Description of the Service: The Lenore is a large older style Home situated in a residential street within Whitley Bay. Local facilities such as shops, restaurant and pubs are all within easy walking distance. The Home caters for 21 residents with a range of mental health care needs. Single room accommodation is provided and is spread over the first and second floors of the Home. En-suite facilities are not available. Communal facilities are provided as follows: - a dining room; four lounges; eight toilets; two showers and three bathrooms. Pleasant outdoor areas are provided to the front and side of the Home. Street parking is available. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over seven hours and 30 minutes. A sample of care and other records were examined. The two staff on duty at the time of the inspection and six residents were spoken to. The Provider and Manager were also interviewed. What the service does well: The Home encourages residents to: • • • Make everyday choices and decisions; Take control of their own lives; Take an active part in the preparation of their care plans. Residents spoken with praised the Home and its staff and said that they were very happy living there. Residents’ meetings take place on a regular basis and residents are given the opportunity to comment upon the way in which the Home is run. The Provider also uses these meetings to share important items of information with residents.Generally, the Home was well maintained and had an ongoing programme of refurbishment and redecoration. The Lenore provided a safe environment and was clean, hygienic and had a domestic atmosphere. The Manager and Provider were willing to support the process of inspection and were happy to engage in a constructive debate about inspection outcomes. Staff were kind, respectful, considerate and had developed warm and caring relationships with the people in their care. Residents were very satisfied with the care and support provided. Staff communicated with residents in a positive manner. The Provider, Manager and staff team are very positive about, and display a real commitment to, the work they carry out with residents. Residents are able to access the office on an ‘as and when required’ basis. The Provider and her Manager are committed to ensuring that staff have access to whatever training is required to satisfactorily meet residents’ identified needs. The Home has retained a core group of staff that have worked at the Lenore for a long period of time. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 6 The Provider funds residents’ holidays and trips out. What has improved since the last inspection? What they could do better: All radiators need to be guarded starting with those bedrooms which are occupied by the most vulnerable residents. Where a resident refuses a radiator cover, a note of this should be made in their risk assessment and care record. Bedrooms, bathrooms and toilets occupied and used by residents over 65, should be assessed by a person with specialist knowledge of the aids and adaptations required to meet the needs of older people. Improvements need to be made to the quality of information held in some residents’ risk assessments and care plans. Staff should receive formal supervision at least six times a year. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 7 Arrangements must be put in place to ensure that staff receive certificated fire training on an annual basis. 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. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 8 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 Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 1, 2, 3 and 5 were assessed as part of the 2005 Announced Inspection. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Standards 7 and 8 were assessed as part of the 2005 Announced Inspection. The care plans and risk assessments examined did not fully reflect the range of care and support provided by staff to meet residents’ assessed needs. EVIDENCE: Residents’ care plans included objectives as well as details of the care provided by staff. However, timescales for achieving objectives were not always clearly stated. For example, a general timescale such as ‘ongoing’ was sometimes given. Some care plan objectives were too vague and did not fully cover all of the concerns identified by other professionals in their risk assessments and review information. In one of the care records examined, there was no care plan in place setting out how identified risks were to be managed. It was also noted that financial care plans had not been prepared for those residents who needed the Home to act as an ‘Appointee’ on their behalf. Care plans addressing residents’ longer-term support needs were not in place. The risk assessments viewed did not include a judgement of how likely the control measures put in place would minimise the risks identified by staff. Each Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 11 resident had signed their care plans and risk assessments. Residents’ care plans had been reviewed on a six monthly basis. Copies of Care Management Reviews were available in residents’ care records. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 12 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): Standards 12, 13, 15, 16 and 17 were assessed as part of the 2005 Announced Inspection. EVIDENCE: Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 assessed as part of the 2005 Announced Inspection. EVIDENCE: Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 14 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): 22 and 23. A satisfactory complaints procedure was available. that their views and opinions were listened to. Generally residents felt A satisfactory Adult Protection Policy had been put in place to ensure that an appropriate response is made to any suspicion or allegation of abuse received by the Home. Positive action had been taken by the Provider and Manager to protect the well being of vulnerable adults living at the Home. EVIDENCE: A copy of the Complaints Procedure was available in the main reception area and office. The Procedure included the required information and provided details of how to contact the Commission. A Suggestions Box was available allowing residents to submit anonymous concerns. Residents had been provided with a copy of the Home’s Complaints Procedure. A Complaints Book was available for recording details of concerns received by the Home. No complaints had been received since the last inspection of the Home. Residents said that they would feel comfortable about raising matters of concern with both the Provider and Manager. The Home’s Adult Protection Policy complied with relevant guidance and legislation. Two adult protection concerns had been raised with the Home since the last inspection. One of the concerns raised had not arisen as a consequence of poor practice on the part of the Home. Both adult protection matters had been appropriately handled by the Home and are being monitored by the Commission. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 15 Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30. The overall quality of décor, furnishings and fittings was good. Maintenance and decoration is carried out on a planned basis ensuring that the Home is maintained to a good standard. However, further improvement is required in some areas to ensure that residents are provided with a homely, comfortable and well-maintained place to live. All the remaining standards were satisfactorily met. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 17 EVIDENCE: All residents are accommodated in single bedrooms, two of which fall below the recommended bedroom size. Not all of the bedrooms visited contained the recommended facilities, i.e. a phone point; a table to ‘sit at’; two comfortable armchairs. However, residents said that they had what they wanted in their bedrooms. New residents are encouraged to bring their own possessions with them when moving into the Home and to personalise their bedrooms in line with personal preferences. The bedrooms and other areas of the Home visited were generally clean, tidy, warm and pleasantly decorated. However, it was also noted that: 1. The Home’s dining room trolley, tables and chairs were beginning to show signs of wear and tear; 2. Bedroom radiators remain unguarded and could pose a threat of potential harm to vulnerable residents. However, some residents have confirmed that they do not wish radiator covers to be fitted and have signed a disclaimer to this effect; 3. A carpet in one of the bedrooms visited was very stained and grimy looking; 4. Top floor toilet 1: there was water damage to the ceiling; 5. Top floor bathroom: there was no hand wash available at the sink; the bath panel had started to come away from the bath; 6. Top floor toilet 2: there was no hand wash available at the sink; 7. The small kitchen area to the rear of the Home was grimy and some of the units were in a poor condition. Following a recent inspection visit by the local Environmental Health Officer, a number of concerns were identified. The Provider and Manager confirmed that they had taken immediate action to resolve the concerns identified. On the day of the inspection, the laundry and main kitchen were found to be clean and hygienic. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36. Although staff are well supported by the Provider and Manager, satisfactory arrangements were not in place to ensure that staff receive formal supervision at the recommended frequency. EVIDENCE: Staff had been provided with supervision and records had been kept for the sessions held. However, staff were not receiving supervision at the recommended frequency. For example, one member of staff had only received two supervision sessions during 2005. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Residents live in a home which is run and managed by a person who is fit to be in charge, is of good character and able to discharge her responsibilities fully. Arrangements are in place to review the Home’s performance through a programme of self-review. This includes seeking the views of residents, and professionals visiting the Home, about the day-to-day performance of the Home. Although the arrangements in place to protect the health, safety and well being of residents were generally good, some improvements were required to fully comply with the Standards. EVIDENCE: The Manager is both competent and experienced in managing the Home. Mrs Ashworth is part way through her management qualifying training and has undertaken periodic training to update her knowledge, skills and competence. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 20 The Manager is well supported by the Provider. However, Mrs Ashworth confirmed that she intends to voluntarily cancel her registration. The Provider has already identified a prospective Manager and intends to make application to register this person as soon as possible. The Provider has adopted a quality assurance system for use within the Home. This allows the Provider to reach a judgement about the quality of care and services provided at the Lenore. The quality assurance system is based upon the National Minimum Standards and covers such areas as leisure activities, health and nutrition. As part of this process, residents, and visitors to the Home, are asked to comment upon the quality of care provided and how this might be improved. However, the Manager confirmed that an Annual Development Plan for 2006 had not yet been prepared. Service contracts and maintenance reports relating to such matters as electrical and fire safety were available for inspection. A range of signed and dated work place risk assessments had been completed. Risk Assessment and Health and Safety at Work Policies were in place. A tour of the premises revealed no health and safety concerns. An up to date fire risk assessment was in place and the required fire prevention checks had been carried out. However, the following concerns were identified: • • • Not all staff had received certificated fire training during the last 12 months; It was difficult to confirm that staff had participated in a minimum of two fire drills; A check for the presence of Legionella in the Home’s water supply had not been undertaken in the last 12 months. Staff had been provided with supervision and records had been kept for the sessions held. However, staff were not receiving supervision at the recommended frequency. For example, one member of staff had only received two supervision sessions during 2005. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 21 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 X 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 2 25 3 26 2 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x 2 X 2 x X 2 X Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The Manager must ensure that: • Timescale for action 01/07/06 2. YA6 Schedule 2 3. YA24 16(2) & 23(2) Each resident’s care plan has clearly stated objectives and specific timescales; • Identified areas of need as set out in a resident’s Care Management Assessment, Care Plan and Review information, are referred to in the Home’s in-house Care Plan; • Residents’ Care Plans are reviewed and updated following Adult Protection Strategy Meetings. The Manager must ensure that 01/07/06 where it has taken on the role of ‘Appointee’ for a resident, a supportive care plan is put in place. 01/07/06 Ensure that: • The Home’s dining room trolley, tables and chairs are either refurbished or replaced; The radiators without Version 5.1 Page 23 • Lenore, The DS0000000382.V276127.R01.S.doc • • • • • covers in bedrooms where residents are aged over 65 are guarded. Ensure that risk assessments are put in place until the above work can be completed. Ensure that guards are fitted as rooms become empty. Ensure that risk assessments are in place for all those residents who have chosen not to have a guard fitted; The carpet in bedroom ? is either cleaned or replaced; Top floor toilet 1: the ceiling is redecorated; Top floor bathroom: hand wash is provided at the sink. The bath panel is refitted; Top floor toilet 2: hand wash is provided at the sink; The small kitchen area to the rear of the building is kept in a clean condition. 01/06/06 4. YA39 24 An Annual Development Plan must be prepared and a copy forwarded to the Commission. The Plan prepared should take account of the following: 5. YA42 13(2) & 23(4) Requirements arising out of the most recent inspection reports; • Matters arising out of the Home’s first completed quality audit; • Matters arising out of resident and staff meetings and staff supervision sessions. Ensure that: 01/06/06 • Staff are provided with fire Version 5.1 Page 24 • Lenore, The DS0000000382.V276127.R01.S.doc • training from a ‘Competent Person’ at periods not exceeding six months; There is a clear record confirming which staff have participated in what fire drills. 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. 3. 4. 5. Refer to Standard YA6 YA6 YA24 YA39 YA42 Ensure that regular checks of the Home’s water supply are undertaken to test for the presence of Legionella. Good Practice Recommendations Ensure that revised risk assessment and care plan information is shared with the Care Manager of the resident concerned and their approval sought. Draw up care plans which address residents’ need for longer term care and support. Ensure that all radiators are guarded. Devise a questionnaire that can be used to obtain staffs’ views about the day-to-day management of the Home. Lenore, The DS0000000382.V276127.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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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