Inspection on 22/01/07 for Lester Hall Apartments

This inspection was carried out on 22nd January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lester Hall Apartments 01/12/05

Lester Hall Apartments 15/08/05

Lester Hall Apartments 13/10/04

Lester Hall Apartments 26/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Lester Hall Apartments 15 Elms Road Stoneygate Leicester Leicestershire LE2 3JD Lead Inspector Susan Lewis Unannounced Inspection 22nd January 2007 09:45 X10029.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 Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lester Hall Apartments Address 15 Elms Road Stoneygate Leicester Leicestershire LE2 3JD 0116 2745400 0116 2745400 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) Lester Hall Apartments Limited Mr David Goodwin Mrs Marina Philomena Lester Care Home 19 Category(ies) of Past or present alcohol dependence (19), Past or registration, with number present alcohol dependence over 65 years of of places age (19), Past or present drug dependence (19), Past or present drug dependence over 65 years of age (19), Dementia (19), Dementia - over 65 years of age (19), Mental disorder, excluding learning disability or dementia (19), Mental Disorder, excluding learning disability or dementia - over 65 years of age (19), Old age, not falling within any other category (19), Physical disability (19), Physical disability over 65 years of age (9) Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No person under 50 years of age falling within categories MD, DE, A or D may be admitted to the home. No person under 55 years of age falling within category PD may be admitted to the home. No person falling within category PD(E) may be admitted to the home when 9 persons of that category are already accommodated within the home. The home may accommodate the person identified in correspondence with the previous registration authority dated 14th June 2000. Date of last inspection Brief Description of the Service: The fees for 2006/07 are £310-£450 The most recent inspection report is available in the office. Lester Hall Apartments is situated on Elms Road, Stoneygate off London Road and is registered for 19 service users of multi categories. The home is close to local amenities, bus routes and places of worship. The accommodation is made up of spacious apartments and single and double accommodation. The home has a service users kitchen on the third floor. The home is furnished and decorated to a high standard with period furniture/furnishings. There is an attractive private garden accessible for service users. A minibus exclusive to service users is also provided with a driver. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records, talking with them where possible, and observing staff that provide their care. The inspection was unannounced and took place over 7 hours one Tuesday in September 2006, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ and staff records were inspected and visitors, residents and staff on duty were spoken with. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: Residents are provided with spacious accommodation that enables them to live as independently as possible. They are supported by well trained and knowledgeable staff. The management of the home is generally good and based on up to date practice that again supports residents to be actively involved in the running of the home. Residents were positive about the experience of living in the home and comments were received such as’ ‘I can’t fault the staff they are very good’. ‘I receive the help I need’ Meals are well presented and nutritious, residents are able to have meals and snacks whenever they fell hungry and all residents commented on the quality of the meals. ‘We have two choices daily. It is very good, plenty of it’. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 6 Residents feel confident to make complaints and knew whom they needed to speak to if they were unhappy. Staff were equipped during their induction to help support residents if they needed to make a complaint and the management had put in place a variety of strategies to ensure that they were aware of residents views about the service they received. The management are clear about their role in ensuring the safety of residents and work closely with social services and health care professionals in ensuring residents receive a good quality service. What has improved since the last inspection? What they could do better: Although care plans were acceptable and staff found them useful they appeared to be more complicated than they needed to be and the care plan appeared to duplicate what the assessment was doing it is recommended that the Registered Person simplify the documents to provide clear information on what is the assessment and what is the care plan. Although most of the medication administration records were pre printed on some occasions it was necessary to add medication to them by hand. Where this is necessary it is strongly recommended to sign and countersign them to ensure the additions are written correctly. It is also recommended that information on what to do in the event of a drugs is available near the drugs trolley to ensure that should this event happen staff have the information to hand quickly. There was evidence that a resident had been given their medication and staff had signed to say he had taken it but in fact had not. Although it turned out to be a vitamin tablet it could have been something more critical. Therefore it is required that the Registered Person ensure that staff who administer Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 7 medication follow the homes policy and procedure when administering medication. Although the residents considered the meals good in discussion with the cook it was clear that pureed meals for residents who needed soft diets were served mixed together. It is recommended that where it is necessary to provide pureed meals that they are served on plate separately to improve the presentation In viewing the staff recruitment files evidence was found of a serious shortfall. Criminal Records Bureau checks had not been obtained prior to two staff being given contracts and starting work in December 2006. Although remedial action was taken before the end of the inspection the Registered Person must not allow a person to work in a the care home until they have all the correct documentation to ensure residents are protected. Training records were available for staff, however as the records had been kept of staff who no longer worked at the home it was confusing as to who had what training and when it needed updating it is recommended that these records are archived and only current staff records are kept. The home provides a service to a wide range of residents and although generally the training is very good for staff the area that may create some difficulty for staff that of drugs and alcohol they have received no training at all. It is strongly recommended that staff receive some training in this area. Residents money is handled carefully within the home, however to ensure that the manager is not compromised it is strongly recommended that all financial transactions have two signatures Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents do not move into the home without first knowing that their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed for the purpose of the inspection. All plans had both their own assessment completed as well as a social worker assessment. Assessments were pre printed and did not always provide specific information about the resident. However evidence was seen that the provider provided Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 10 written confirmation as to what care was needed and what the home would be able to provide. This ensures that any one moving to the home will know that their needs will be met and how. Staff spoken with said that they were able to read assessments and felt that they identified residents needs. Intermediate care is not provided at this service. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Individual plans address personal and health care needs and risks and residents are respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 12 Residents care plans are created from assessments but some of this information is duplicated and it is not always clear what is a care plan and what is the assessment. It is recommended that the Registered Person refer back to what is required in this standard and simplify the process so as to ensure that information regarding how a resident’s need is to be met is detailed not just what the need is. Although plans are reviewed they do not always evidence that residents are involved. In discussion with residents it was clear that most of them were aware that they had care plans and staff discussed with them the care they received when plans were reviewed. Resident surveys highlighted that residents felt involved in their care and that staff were meeting their needs. Evidence was seen that where residents have health care needs that these are met by involvement of health care professionals. There no incidences of pressure sores in the home but those residents who were identified at risk had appropriate aids to minimise the risk of sores developing. Residents spoken with were very positive about the staff and the care they received. ‘I can’t fault the staff they are very good’. ‘I am very well treated’ ‘If I feel unwell I see a GP when I need to’. Evidence was seen that residents weight is monitored to ensure that they are maintaining their nutritional levels. Where a resident self medicates this is risk assessed and shows what staff must do to support this. Residents are therefore supported to remain as independent as possible with their medication. Medication was stored appropriately and records were kept of all medication received, administered and leaving the home. It was noted that in one residents bedroom that a tablet was on the residents chair. It was evident therefore that staff were not witnessing residents taking their medication before signing the medication administration records to ensure that they had taken all their medication. The Registered Person must ensure that staff who administer medication do not sign to say it is taken until they have witnessed residents taking the medication. Some record sheets were hand written, particularly where resident had been prescribed medication part way through the month. Where it is necessary to Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 13 do this it is strongly recommended that the person adding them signs any additions to the sheet and then countersigned to confirm they are correct to minimise any risk of incorrectly writing the drug information down. It is also recommended that information relating to what to do in the event of a drugs error be posted in a prominent place near the drugs trolley providing staff with clear information on what action they must take in that event. Residents spoken with all said that they felt staff treated them with respect and maintained their dignity whilst carrying out personal care tasks. Throughout the day staff were observed with residents and were heard to speak to residents with respect. Residents wore their own clothes and were well groomed again showing that their dignity was maintained. Evidence was sent that residents were able to say if they wanted a male or female care to provide personal care and residents spoken with said that where they had expressed this wish it was respected. Staff spoken with said that during their induction period they were given clear guidance by senior staff on how to support and maintain residents privacy and dignity. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. The routine of the home meet the needs and wishes of the residents’ cultural expectations. The home encourages residents to take control of their lives and actively be involved in the running of the home. Staff at the home are aware of the importance of appetising food and it is served at times that are convenient to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 15 Evidence received from the pre inspection information including the residents’ survey showed that residents felt that they were able to make choices and take part in the running of the home. There was a residents meeting which took place regularly. This meeting did not just cover matters that were internal to the home such as meals, but also looked at the residents interaction with the wider community. The latest meeting looked at raising money for a local charity by having a coffee morning as well as how the home could become involved in recycling. Residents were given opportunities to take control of these projects. Information about activities including residents meetings was posted on notice boards around the home. Residents spoken with said that they were able to attend a religious service of their choice and that priest visited the home regularly. Care plans identified residents’ hobbies and cultural interests. Resident surveys received before the inspection identified that a variety of activities took place including going to the theatre and local garden centres. The home has its own vehicle, which provides flexibility for residents to go out into town if they want to. Where residents left the building risk assessments were included in their care plan to show what support they needed to minimise risk. There was evidence throughout the home that residents were supported to access advocate services if they felt they needed to. Meals are served either in the dining room or in the residents’ apartments. The manager advised that meal times are split into two sittings to enable residents who need assistance with feeding can be given the support they need and that their dignity is maintained. Residents spoken with said that the meals were very good. ‘We have two choices daily. It is very good, plenty of it’. ‘I enjoy the food, even though I don’t eat much, I can have a salad if I want one’. ‘There are always at least three puddings on the sweet trolley’. ‘I get plenty of variety and lots of fresh fruit and vegetables’. ‘If I feel hungry I can have tea or a snack whenever I want’. ‘I’ve seen the meat being delivered and you can tell it is good quality’. In discussion with the cook it was clear that he had an understanding of how to meet residents nutritional needs. However where residents required pureed Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 16 meals these were served mixed together in a bowl. It is recommended that where it is necessary to provide pureed meals that they are served on plate separately to improve the presentation It was evident from records that for practicing Catholics, fish was available on Fridays to meet their cultural needs. There is a small kitchen where residents are able to access to make their own drinks and snacks if they so wish. Suitable risk assessments are carried out to ensure residents are safe when using it. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents are supported in making complaints and feel that they are listened to and taken seriously. They are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has not received any complaints about this service since the last inspection. From records seen during the inspection the home has not received any complaints since the last inspection. Residents spoken with and from residents’ surveys received prior to the inspection all residents know who to complain to and are confident that any concerns will be dealt with. ‘If I am unhappy about anything I will speak to the manager’. ‘Any problems I would go to Matron or David(manager). Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 18 In discussion with staff they were aware of their responsibilities in supporting residents in making a complaint and were aware of the policies and procedures for complaints. There is information about the complaints procedure displayed around the home including by the residents pay phone, there is also information about how to access the advocate service if they wish support in making a complaint. This is good practice. There have been no adult protection issues arising from this service since the last inspection. All residents spoken with said that staff were kind and they were made to feel safe in the home. ‘The staff are kind and I feel safe’. ‘I never feel frightened’. Staff records showed that all staff have had Adult Protection training and in discussion with staff they were aware of what to do if they suspected a resident was being abused. This ensures that residents are protected at all times from potential abuse. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. Residents live in a safe well-maintained environment it is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 20 The home is located in a residential area close to a main road. The home itself is on three floors and the upper floors are accessed via a through floor lift enabling people with mobility issues to access their apartments with minimal support. The home is generally well maintained and a maintenance man is employed to carry out general maintenance around the home. The home is in general good repair there is evidence that there is a programme of routine maintenance and that apartments are well maintained each decorated individually with residents personal possessions. It was noted that some curtains on one corridor were in poor repair, however the Registered Person was aware of this and evidence was given that the replacement of these is in hand. In the summer residents have access to a pleasant well-maintained garden. The fire officer and environmental health officer have inspected in the last twelve months and have found no areas of concern this shows that the Registered Person ensures the building complies with this legislation The home was clean throughout with a cleaner in evidence during the inspection. Residents spoken with all said that their apartments were always kept clean and tidy. There were no bad odours at any point during the inspection and effective infection control policies and procedures were in evidence throughout the home. The laundry was suitable and accessible to meet the needs of the home, and where residents were encouraged to do their own laundry suitable arrangements were in place to minimise any risk to the resident. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. There are sufficient trained staff to meet the needs of residents. The recruitment policies and procedures are not always followed and have the potential to place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From evidence seen in staff rotas and in discussion with both staff and residents it was clear that there are sufficient staff on duty at each shift to meet the needs of the residents. Residents spoken with confirmed that they receive the care and support they need that they do not feel rushed by staff when they are receiving care and they are always kind. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 22 ‘I always get the help I need’. From evidence provided by the pre inspection information there are 60 of staff with NVQ level 2 or above. This shows that staff are trained and competent to carry out the role of carer and that the Registered Person exceeds the minimum requirement of 50 this is good practice. Three staff files were viewed and all contained application forms and references. However two new staff had been recruited in the last four weeks and there was no evidence that they had a Criminal Records Bureau check or Pova First check to ensure that they were suitable to employ with vulnerable people. Evidence was seen that the manager had obtained the persons previous Criminal Records Bureau check. However these are no longer transferable and cannot be used to show that the person is suitable. In discussion with the manager and Registered Person they agreed to remove the two staff from shift to await the up to date checks. During the inspection the Registered Person contacted their Criminal Records Bureau umbrella organisation to find out where the checks were. The Registered Person also confirmed in writing a few days after the inspection the action plan she had put in place to minimise any risk to residents. As a result of the action taken by the Registered Person an immediate requirement was not left. However the Registered Person must ensure that appropriate checks are carried out on staff before they are confirmed in post. Staff spoken with confirmed that they are encouraged to access training and from records seen staff receive a wide range of training including all mandatory training such as Moving and Handling, Infection Control, Food hygiene and Fire training. Where the fire training has taken place they have also included residents who have shown an interest. Residents spoken with said, ‘Staff receive training they are good at their job’. More specialist training is also provided Dementia Awareness, Funeral Awareness and Diabetes. As the training records also included staff who had left it was not always clear who had done what and when. It is recommended that the Registered Person improve the method of record keeping for staff training. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 23 Also the home’s registration is multi category and includes people with alcohol and drug addiction but staff have not received any training in this area. It is very strongly recommended that the Registered Person arrange for suitable training. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 25 31, 33, 35 and 38 Quality in this outcome area is adequate. The home is generally well managed in the best interests of the residents. The residents and staff safety and welfare are generally protected through good management, however the fact that they did not follow their recruitment policy and procedures means this area cannot be considered good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is experienced in managing a care home and is currently undertaking his registered manager’s award and evidence was seen that he undertakes regular training to update his knowledge and skills. As mentioned in the previous section the Registered Person had not undertaken the appropriate checks when recruiting two staff. Although the management reacted to the inspector’s comments promptly it is still considered to be a serious shortfall in practice and should not require the inspector to tell them this is unacceptable. Evidence was seen that residents are regularly asked their views of the service they receive. There is a comments book that is used separate to the complaints records where any conversations that have been had with residents that may impact ion the service delivery can be recorded and the Registered Person can check them later. There is also another book where the Registered Person records any conversations she has with residents that are about the service they are receiving. There are regular residents meetings where residents are able to discuss any issues that are important to them. All this provides evidence that the provider is open and encourages residents to be involved in decision making within the home and be in control where possible of their lives. Residents commented, ‘We have regular meetings with the matron and she tells us what is going on. We can discuss things with her and influence what goes on they will change things accordingly’. ‘Recently a resident died and matron was very sensitive and told us all what was happening and it is done sensitively’. ‘Staff tell us when the fire alarms are being tested’. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 26 The manager does not act as appointee for any residents money, records are kept of all transactions including receipts however there was only one signature for each transaction. It is recommended that the manager ensures that two signatures are used to minimise the risk of any financial abuse to residents. Records were seen for all maintenance on equipment showing that everything was maintained to good standard protecting residents and staff. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 27 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 X 2 X 3 3 4 X 5 X 6 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 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 4 20 X 21 X 22 X 23 X 24 X 25 X 26 4 STAFFING Standard No Score 27 3 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 28 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 OP9 Timescale for action 13(2) The registered person shall make 01/03/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person must ensure that the medication administration sheet is not signed before the resident takes their medication. 19(1)(a-c) The registered person shall not 12/02/07 Sch 2 1-7 employ a person to work at the care home unless she has obtained in respect of that person the information and documents specified in paragraphs 1 to 6 of Schedule 2; including a criminal record certificate. 13(1)-(8) The registered person shall make 12/02/07 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The Registered Person must ensure that policies and procedures for recruitment are followed. DS0000006347.V328560.R01.S.doc Version 5.2 Page 29 Regulation Requirement 2 OP29 3 OP38 Lester Hall Apartments 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 6 7 Refer to Standard OP7 OP9 OP9 OP15 OP30 OP30 OP35 Good Practice Recommendations Care plans are simplified and show they are different from the assessment. Where medication administration sheets are hand written that these are signed and countersigned. Place information regarding what to do in the event of a drugs error in a prominent place near the drugs trolley. Liquefied meals are presented in a manner, which are attractive and appealing in terms of texture, flavour and appearance in order to maintain appetite and nutrition. Up date training records by removing employees who no longer work at the home and records that are out of date. Provide training for staff in understanding the needs of residents who have care needs due to drugs and alcohol abuse. Provide two signatures on residents financial records. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Lester Hall Apartments DS0000006347.V328560.R01.S.doc Version 5.2 Page 31 - 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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