Inspection on 04/05/07 for Lickhill Manor Nursing Home

This inspection was carried out on 4th May 2007.

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

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

Other inspections for this house

Lickhill Manor Nursing Home 14/06/10

Lickhill Manor Nursing Home 09/02/10

Lickhill Manor Nursing Home 07/04/09

Lickhill Manor Nursing Home 07/10/08

Lickhill Manor Nursing Home 25/01/08

Lickhill Manor Nursing Home 25/01/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lickhill Manor Nursing Home Lower Lickhill Road Stourport on Severn Worcs DY13 8RL Lead Inspector Christine Potter Key Unannounced Inspection 09:30 4th May 2007 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 Lickhill Manor Nursing Home DS0000064419.V333253.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. 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. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lickhill Manor Nursing Home Address Lower Lickhill Road Stourport on Severn Worcs DY13 8RL 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) 01299 827789 01299 878065 Gentle Care Services Limited Ms Lynda Ann Mason Care Home 36 Category(ies) of Physical disability (8), Physical disability over 65 registration, with number years of age (36), Terminally ill (2), Terminally of places ill over 65 years of age (2) Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2006 Brief Description of the Service: Lickhill Manor Nursing Home is a converted three-storey manor house situated on the outskirts of Stourport-on-Severn. The home is currently registered to provide nursing care and accommodation to a maximum of 36 residents. As part of this registration, the home can provide care for residents with a physical disability, both for older people and up to 16 younger adults. The home has thirty-one bedrooms; twenty-six are single rooms (five of which have en-suite facilities) and five shared rooms (two of which have en-suite facilities). Accommodation is provided over three floors, with a passenger lift providing access to upper floors. A registered nurse is on duty 24 hours a day. The home charges between £472.00 and £550.00 per week depending on the room and the care needs of the resident. The fees do not include hairdressing, daily newspapers and chiropody. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s key unannounced inspection for 2007. The inspection lasted a total of 7 hours, during which time the manager, deputy manager, administrator, three residents and four staff members were spoken with. At the time of the inspection the home was caring for 22 residents. Two comment forms were received by the commission prior to the inspection from residents who had been helped to complete the questionnaires by relatives and a member of staff. The inspection focused on the requirements and recommendations from the last inspection, and to inspect the key standards, using a range of documents, observation of the care process, a tour of the premises and discussions with staff and residents. Residents spoke well about the home and how the staff were meeting their care needs. One resident stated that they were “appreciative of everything that is done”. The registered manager was available to help throughout the day, and is thanked for her time and assistance. What the service does well: What has improved since the last inspection? Since the last inspection the home has further invested into the appearance of the home. This has been superficial given the home’s plans to extend and upgrade the home are imminent. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 6 The home has commenced a staff supervision program, which is to be expanded. Training courses for staff have improved since the last inspection and a record of all training is now maintained. A fire risk assessment and contingency plan have been implemented since the last inspection to further protect the residents and staff. The service User’s Guide has been updated and copies were available for residents and anyone enquiring about the home. 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. The summary of this inspection report can be made available in other formats on request. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 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 Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 (standard 6 is not applicable) Quality in this outcome area is adequate. The Service Users guide provides sufficient information about the facilities on offer and the philosophy of care. The Statement of Purpose is not completed. The pre – admission assessment provides adequate detail too ensure that the home can meet the assessed needs of prospective residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has updated their Service User’s Guide and confirmed that a copy was provided for all residents and anyone enquiring about the home. The home has all the information available in various formats required for their Statement of Purpose. This information should be Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 9 consolidated into a document called the “Statement of Purpose”. A copy of the document should be forwarded to the commission when completed. The Statement of Purpose should contain all the information detailed in Schedule 1 of “The Care Homes Regulations 2001”. Residents who were spoken to during the inspection stated that the home had been chosen for them by relatives. Generally residents do not visit the home prior to admission this is undertaken on their behalf by their family. Since the last inspection all residents have been provided with an updated contract and this reflects the change of ownership of the home. Three residents care records were reviewed during the inspection and these included a copy of the pre-admission assessment. This is completed by the manager prior to their admission into the home. Residents spoken with confirmed that a pre-admission assessment had been undertaken prior to the home accepting them. Comments received from the pre- inspection comment cards and from discussion with residents at the home were complimentary. Comments included: • • ” Staff are very satisfactory, appreciate everything that is done for me” “More than happy with the home and the stable workforce which have been created.” Residents also confirmed that they were more than happy with the size of their bedrooms and the homely environment. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. Care plans contain insufficient information about the residents care needs, and how care is to be delivered by the nurses and care staff. Where potential risks are identified a care plan should be developed to minimise that risk. Medication procedures are carried out according to the policy of the home, in a manner, which ensures the safety and welfare of the residents. The staffs ensure that the resident’s dignity and privacy is respected at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has changed their care plan documentation, and has transferred the information onto the new care documentation system. Three residents care files were reviewed during the inspection. The care files failed to reflect all the Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 11 care needs of the residents. In some examples risk assessments had not been completed for potential risks reported on the pre-admission assessment i.e. risk of falls. A risk assessment or care plan had not been developed to manage and minimise the potential risk of falls. Some routine risk assessments had been completed for the residents and were being reviewed frequently. Care plans also failed to demonstrate how care staff would deliver the care to the resident. For one resident the nurses had failed to develop a care plan for the management of the resident’s diabetes, rheumatoid arthritis and dementia. A wound record had been developed but failed to demonstrate the size and grade of the wound or the progress of wound healing. Another care plan included a photograph of a leg wound, but this had not been dated by the nurse when taken. The care plan also failed to contain a fall risk assessment and how this risk could be minimised. Another residents care record failed to provide sufficient information about meeting the care needs for a resident suffering from Parkinson’s disease and related poor verbal communication. The necessity to ensure that the recording within the care plans improved was discussed with the manager at the time of the inspection. The nurses must ensure that they record as to their professional guidelines provided by the nursing and midwifery council. All nurses and carers spoken with could verbally identify the care needs of the residents, and the importance of recording this information was emphasised. It was recommended that the nurses are provided with training to assist them in completing the care records and some time is allocated for them to do this properly. Staff were observed interacting well with the residents, and this adds to the relaxed atmosphere in the home. Thank you letters and cards from relatives were reviewed and these expressed thanks and gratitude for the care the home had provided for their relative. The medication procedure for the home was reviewed for the residents being case tracked. The system was well organised and no errors were identified at this visit. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. The independence of residents is encouraged. Activities for some residents have improved since the last inspection. The dietary needs of the residents are well catered for, for residents requiring a liquidised diet it could look more appetising. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has appointed an activities organiser for 16 hours per week. Residents spoken with were appreciative of the individual attention they are now receiving. One resident was pleased to show the inspector some of the craftwork she has made, which was on display in her room. Staff also confirmed what an improvement the new activities person had made for some of the residents. They confirmed that most of the residents enjoyed participating with the movements to music session. The activities for Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 13 the more dependant residents were not really suitable and this is being reviewed. Care staff also commented they wish they had more time to spend with the residents to take them out when the weather was good. During the inspection residents were observed in the lounges and their bedrooms. All residents appeared comfortable, and those residents interviewed stated that it was their choice to be in either the lounge or their bedroom. Residents confirmed that they had a choice on what time they got up and what time they went to bed. Relatives are allowed to visit at any time, and visitors were observed coming and going during the day. All residents spoken to during the inspection and feedback received prior to the inspection complimented the choice and quality of food available. A resident who stated that they were very “fussy” with food said that the home always provided them with their preferred choice of food. A general comment was made about the presentation of liquidised meals that the food should be liquidised into separate portions to make them look more appetising. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home has a complaints policy in place and residents and relatives are aware of this. All staff receive training to assist them in recognising potential abuse, staff clearly demonstrated that they would have no hesitation in reporting poor practise. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home receives very few complaints. Since the last inspection the home or CSCI has received no complaints. The majority of residents who were spoken to confirmed that they were aware of the homes complaints policy. It is recommended that the home encourage residents and staff to voice their opinions either on a one to one or in a group meeting. Protection of vulnerable adults policies and procedures include “whistle blowing”. Staff receive training to assist them in recognising any potential abuse and the procedure to follow. Staff spoken with confirmed that they were aware of the policy and would have no hesitation in reporting poor practise. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,23,24 and 26 Quality in this outcome area is adequate. The planned upgrade to the home has yet to commence, the home’s appearance would be further improved from the upgrade and provision of new furniture and furnishings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has commenced some minor refurbishment. Residents and staff were positive about the improvements. Several bedrooms have been painted and recarpeted to enhance their appearance in the interim period before the major refurbishment begins. The majority of bedrooms have been personalised to reflect the resident’s personality, and residents spoken with stated that they were happy with their bedroom. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 16 The external appearance of the home is in need of maintenance work. This is to be included with the major refurbishment program, which the inspector was advised should commence in June 2007. All windows above ground level have restricted opening, and all radiators have protective guards fitted to further protect the resident’s health and safety. No improvements to the bathing facilities have been made; this again is to be included in the refurbishment plans. It is recommended that the home review the domestic and laundry hours for the home. This should cover the seven days of the week. On the day of the inspection only one domestic was covering the whole home, and no laundry operative was on duty. This results in a carer being taken from care to work in the laundry. Two bedrooms had offensive odours present at the time of the visit and this is not pleasant for the resident or relatives and friends who visit. It is also recommended that the home review a variety of chairs and beds to suit their assessed needs as part of the refurbishment program. The home provides some lifting equipment. All nurses and care staff spoken with stated that an aid to assist residents to stand would further assist them in meeting the residents’ needs. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. There are sufficient staff on duty at all times to ensure the care needs of the residents are met. The home follow a rigorous recruitment policy to further protect the residents. The home is committed to training to assist staff to understand the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty records were examined during the inspection and these showed that the home was providing adequate numbers of staff for the number of residents being accommodated at that time. Staff spoken with confirmed that the staffing levels were about right for the number of residents. However they felt they still did not have enough time to socialise with the residents. All staff felt that the home would benefit from more domestic and laundry cover given carers have to undertake laundry duties when the operative is away. The home also provide administrative cover, catering and maintenance staff. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 18 The files of three recently employed staff were reviewed these showed that the home had completed the appropriate checks prior to their commencement. All staff confirmed that the home is committed to training and they felt that they had received appropriate training to assist them with their work. Since the last inspection 3 staff have completed NVQ level 3 with another 3 undertaking the award. 2 other staff are in the process of completing NVQ level 2. The home now has in excess of 50 of staff with their NVQ level 2 award that is commended. Staff spoken with are committed to their work and felt it was a pleasant atmosphere to work in. It is recommended that regular staff meetings are held and minuted to assist staff to voice their opinions about the home. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is good. The home is managed by a suitably qualified manager who is a first level nurse. Since the last inspection there has been little progress with the development of the quality assurance monitoring. All equipment is serviced and maintained to ensure safety and welfare of the residents. This judgement has been made using available evidence including a visit to this service. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 20 EVIDENCE: The registered manager has been in post for many years, she is a first level registered nurse and has completed the registered manager’s award. Staff and residents hold her in high regard and felt that they could talk easily to her. The manager demonstrated good knowledge and understanding of the resident’s care needs. The need to develop an effective quality assurance audit remains outstanding from the last inspection. The staff supervision program is well established and staff confirmed that they find the supervision sessions really helpful. Residents’ finances are not managed by the home; they are usually managed by their relative or an advocate on their behalf. The home has service and maintenance contracts for all equipment in the home: the records were available at the home and a copy of the service dates were provided by the home prior in the pre – inspection questionnaire. Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 2 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 3 X 3 Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement Timescale for action 07/09/07 2. OP8 15 (1) Care plans must be in place to include all the residents assessed care needs and to reflect how the residents’ care needs are being met. Care plans must reflect any changes in the residents care needs and be updated to reflect that change The residents’ care 07/09/07 documentation must include appropriate risk assessments included. From the assessed risk an appropriate plan of care to be implemented to minimise the risk. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations It is recommended that the home consolidate all the DS0000064419.V333253.R01.S.doc Version 5.2 Page 23 Lickhill Manor Nursing Home relevant information into the Statement of Purpose to reflect their homes philosophy of care. The document should include all the information as in Schedule 1. 2. 3 OP7 OP33 Nurses should attend training to assist them in developing care plans for residents. It is recommended that the home develop an effective quality assurance audit based on the views of the residents and other professionals. It is recommended that activities are further developed to suit residents who are more highly dependant. It is recommended that as part of the upgrade of the home a variety of chairs and beds are provided to suit the residents assessed needs. To further assist staff to meet the needs of the residents a stand aid hoist should be considered. It is recommended to ensure that the home is maintained to an acceptable level of cleanliness the domestic hours are reviewed and cover 7 days a week. The home must provide an action plan giving proposed timescales of the work to be undertaken both internally and externally to improve the home’s appearance during the planned refurbishment. 4 5 6 7 8 OP12 OP22 OP22 OP26 OP23 Lickhill Manor Nursing Home DS0000064419.V333253.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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