Inspection on 11/03/08 for Limecroft Resource Centre

This inspection was carried out on 11th March 2008.

CSCI found this care home to be providing an Excellent service.

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

Limecroft Resource Centre 30/06/09

Limecroft Resource Centre 12/10/06

Limecroft Resource Centre 23/01/06

Limecroft Resource Centre 06/07/05

Limecroft Resource Centre 19/01/05

Limecroft Resource Centre 16/06/04

Limecroft Resource Centre 09/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Limecroft Resource Centre Whitebank Road Limeside Oldham OL8 3JL Lead Inspector Sandra Buckley inspection completed by Michelle Haller Key unannounced Inspection 11th March 2008 10:15 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 Limecroft Resource Centre DS0000035289.V360277.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. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limecroft Resource Centre Address Whitebank Road Limeside Oldham OL8 3JL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 911 3490 0161 911 3501 limecroft.RC@oldham.gov.uk Oldham M.B.C. Mrs Nicola Jane Kershaw Care Home 21 Category(ies) of Dementia - over 65 years of age (21) registration, with number of places Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only PC, to service users of the following gender: Either, whose primary care needs on admission to the home are: Dementia over the age of 65 years (DE(E)). The maximum number of service users who can be accommodated is 21. 12th October 2006 2. Date of last inspection Brief Description of the Service: Limecroft is a large, purpose built establishment managed by Oldham Metropolitan Borough Council. The home has been adapted to provide shortstay accommodation for up to 21 older people, some of who may have dementia or a physical disability. The people who use the services of Limecroft return to their own homes at the end of their stay. The short breaks can also be part of a larger package of care arranged by a social worker in order that the service user is maintained within the local community. A day care facility also operates from the same building but is not subject to inspection. Both the respite and day care service provided by Limecroft supports large numbers of people in the local community. The establishment is well maintained and provides single accommodation over two floors. Eight bedrooms have en-suite facilities. Each floor provides small domestic style living and dining areas. The dining areas are fitted with kitchens for the service users to make themselves snacks and drinks. Adapted baths and toilets are located on both floors and there is a full passenger lift. The building is located within a residential area, close to shops and other community resources. It is understood that the establishment is well served by public transport. There are grounds to the front and side of the building and off road parking is to the front of the property. Fees for accommodation and care at the establishment are subject to a financial assessment the upper limit being £360. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 Star. This means the people who use this service experience excellent quality outcomes. This was a key inspection that included an unannounced site visit to the home. The manager was not informed beforehand that we were coming to inspect. We looked at all the information that we have received, or asked for, since the last key inspection. The annual quality assurance assessment (AQAA) was returned. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Fourteen surveys were returned to us by people using the service and from other people with an interest in the service, such as staff. The manager has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement that were taken into account. The inspection process also involved interviews with four people staying at Limecroft and two relatives. The plans of care and other records about care for three people were also fully examined. One member of staff was interviewed and in-depth discussions with the deputy manager and manager were also conducted. In addition, information was also gained through the training and employment records for recent recruits that were read. A tour of the living areas and some bedrooms was completed. During the course of the inspection the interactions and relationships between people in the home were observed. The previous key inspection report was also read through. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service for people could be improved if staff received training in how to work with people who have diabetes, so that people with this diagnosis receive the correct monitoring, diet and emergency treatment if required. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 7 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. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People’s strengths and needs are assessed in enough detail to enable staff to offer appropriate support. EVIDENCE: We (the commission) found that the manager made sure that people’s needs could be met through the provision of detailed needs assessment completed prior to admission to Limecroft. Each file examined contained either an assessment or checklist. The dates confirmed that these had been completed either prior to admission or very soon after. The file of the most recent admission, which had been a quick admission, held a detailed assessment and care plan that had been completed by the person’s social worker. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 10 The manager stated in the AQAA that each service user must have a comprehensive assessment completed by a social worker before admission. All staff who commented felt that they were provided with enough information. Comments made by staff included: ‘A handover is always done in each shift. Any new admissions that are taken in always have a personal file. Managers go through it with staff.’ Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People benefit from having their personal care, health and welfare needs met. They are treated with respect and their privacy is maintained at all times. EVIDENCE: We found that care plans had been developed from the assessments completed for people. These care plans usually provided detailed information about the steps staff must take to keep people using the service healthy, content and safe. These included moving and handling, care plans, nutrition and dietary needs, health diagnosis, allergies, communication needs and emotional and psychological needs. These care plans were updated each time a person returned to Limecroft for a period of respite care. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 12 We found that advice and treatment were made available to people from health care professionals, such as general practitioners, district nurses, dieticians, physiotherapists, continence advisors and falls assessment specialists. These instructions were usually made available to staff through handover of information at a change of shift and written into the daily records. During the inspection it was also observed that people wore hearing aids, dentures or prescription glasses in accordance with the information in their assessments and care plans. People who used the service and their relatives mostly felt that health care needs were ‘usually’ met at Limecroft, however, no-one, identified an incident where this was not the case. People who were spoken to stated that health needs were looked after and said ‘The district nurse has been and says I’m getting better.’ Observations of staff at work also showed that they arranged health checks and other care for people. Health care could be improved if care plans and risk assessments were developed to deal with the effects of diabetes. In addition, people at risk of developing pressure sores were not always fully assessed. These issues were discussed with the registered manager who acknowledged these findings. The manager also confirmed that plans were in place to provide diabetic care training, and that she was in liaison with the tissue viability service with regards to providing improved pressure area relieving cushions and mattresses. The interactions between staff and residents were observed. Staff spoke in a kindly manner at all times. People were listened to and given time to make decisions for themselves. People were encouraged to get on together and develop an understanding of each other’s differences. The atmosphere in the home was relaxed and there was no shouting. Daily records were clearly written and related to the care plans, as well as other information, such as family visits, used respectful language and showed that staff were, usually, sympathetic to people’s experiences. Medication management had been previously assessed and found to be good. There were good descriptions about how people had settled and the steps taken to help them to cope with the emotional aspect of moving into Limecroft. Personal care was dealt with discreetly and people were supported to maintain a good level of personal grooming. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 13 People identified that they were always cared for by staff and treated with dignity and respect. They said ‘Yes they are all very good (the staff)’ and ‘All the staff at Limecroft are very kind, caring and have always shown Mum respect. They are a wonderful team dedicated to their different positions.’ ‘The staff are very pleasant and polite.’ Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence, including a visit to this service. People receiving a service at Limecroft are able to enjoy a lifestyle of their choice and receive nourishing, well-prepared and enjoyable food in a pleasant setting. EVIDENCE: The organisation has employed three activities co-ordinators and they will be working in Limecroft to develop an activities programme. In the meantime, they and Limecroft care staff will organise games, film evenings, and singalongs on some afternoons and evenings. People using Limecroft are also part of the ‘life history’ project. This means that a person will spend time with them compiling a book about their personal history. The project includes using the person’s own words, pictures and other memorabilia items provided by family and friends. These documents are then used as a talking point and assist with getting to know the person when they go from one place to another. The book will also help in developing different activities that people may join in with. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 15 The information available about people who had completed their histories was very detailed. It is important, however, to collect some personal history information, such as likes and dislikes, work experiences, interests and family life about people, while they wait their turn to complete the Life Story books. This is because such information is essential in planning an initial person centred activities plan. People said that they enjoyed activities when they were offered. They especially enjoyed going on coach outings. Comments included ‘Yes I have been out for a trip and would like more outings/time with staff’ and activities are ‘always suitable if they’re going on.’ One person confirmed that her relative enjoyed the activities and said that he had told her that he had been out for a pub lunch and trips to local places of interest. Another relative said ‘yes the coach is wheelchair accessible and she has been on coach trips and sometimes a meal. The hairdresser comes every Thursday.’ People were observed reading newspapers, watching television and relating to staff and each other throughout the day. We found that the routines at Limecroft were flexible and met the needs of most of the people using the facility. The majority of people who returned surveys said they were always able to live the life they chose. Assessments highlighted likes and dislikes, preferred bedtimes and temperament. There were no restrictions on visiting at Limecroft, as people were seen visiting throughout the day and staff supported people to keep in touch with friends and family, for example, in one case, staff reminded a person to switch on their mobile phone so that a relative could ring. We found that people expressed a high level of satisfaction with the food and diet provided at Limecroft. Everyone who returned surveys said that they ‘always’ liked the meals. The fulltime cook said that she had attended catering courses to update her knowledge. These courses had taken place yearly at the local hospital. The menu at Limecroft has just been reviewed. The updated menu includes the following dishes: cottage pie gravy; Finney haddock, pork and apple casserole; scampi and salads; braised steak and herb dumplings; Cumberland sausages; fish in batter or sauce; lambs liver and onions; mashed potatoes; cheese and onion pie; cold meat salad; bacon hot pot; roast; tomatoes soup; with sandwiches or prawn cocktail; omelette’ beans; pea and ham soup; tripe and tomatoes; corned beef hash; red cabbage; macaroni cheese; buffet tea. Pasta Bolognese. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 16 The cooks are kept informed by staff of any special diets, including diabetic diet, ‘soft’ diets or allergies. It was observed that food charts were maintained for people as identified by their nutritional risk assessment. The mealtime on one of the dementia care units was observed. People were encouraged to sit at the table when the meal trolley had been brought up. They were not kept waiting for their meals. The table was laid and salt and pepper were readily available. People were encouraged to be independent and offered specialist aids, such as a plate guards (this was fitted only after they had agreed). Staff were aware of people’s preferences in relation to tea, coffee or other drinks but each person was offered a choice regardless, in case they wanted a change. The lunchtime meal on the day of inspection was a choice of fish in white sauce or sausage and mushroom casserole with potato wedges, green beans and mixed vegetables. The meal looked very appetising and people were appreciative, saying that it was ‘delicious’ and ‘This is tasty and it looks good’ Comments about the meals included: ‘The meals are 99 wonderful’; ‘He says the food is nice’; ‘The food is very good’; ‘There’s always plenty and it’s usually very, very nice - only thing is that breakfast bacon should be less fatty and more crispy’. Lunchtime was a pleasant sociable event. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence, including a visit to this service. The service users and staff were confident their complaints would be treated with respect and acted upon. The policies, procedures and staff training protect the residents from potential abuse. EVIDENCE: People at Limecroft told us they they know how to complain or who to talk to if they are unhappy. We found that they usually have their concerns listened to and dealt with fairly. The complaints record was examined. There was one complaint that had been dealt with in 2007. The issues was clearly described and it was clear that the manager made sure that person who made the complaint was satisfied with the outcome. People who receive support at Limcroft said ‘I didn’t know but staff explained again. Sometimes I know who to speak to but I forget’ Although the majority of those who returned surveys felt that concerns were dealt with properly, one person identifed that sometimes concerns are not always passed on or maybe forgotten. However, once the senior manager is aware, concerns are dealt with quickly. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 18 The complaints policy was looked at. The process appears fair and states who complaints can be made to and the timescale by which complaints will be dealt with. The policy does need updating, as the contact information about CSCI is incorrect. People who were interveiwed said ‘If I were unhappy I would talk to the manager’; ‘I have no complaints but I would talk to the social worker’ and ‘If I was unhappy I would talk to the manager but have never seen anything to be unhappy about’. All the staff who returned CSCI surveys were definite in the steps they would take if a person had a complaint or concern. Comments included: ‘Show complaints procedure, explain how it works, go through the document with them.’ Newly employed staff receive safeguarding adults training as a part of their induction. The training organiser stated that established staff had also attended training courses and there were certificates on file that confirmed this was true for some. Staff stated in their surveys that they had received protection of vulnerable adult training. The member of staff who was interveiwed was clear about how to treat people and what could be classed as abuse and what to do if they were suspicious about a situation. There has not been a POVA investigation in the home. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People at Limecroft enjoy a warm, clean, safe and well-maintained environment that has a good standard of decoration, furnishings and fittings. EVIDENCE: We conducted a tour of the three units at Limecroft. Each area was clean, well lit and free from unpleasant odours. Some areas were been adapted to meet the sensory needs of people with Dementia: bathroom and toilet doors were clearly labelled, with posters with clearly defined letters and line drawings. Handrails were strategically situated. Toilets were raised and baths with chair lifts are installed. There are also shower rooms. There are ample toilets on each floor and these are near to the lounge areas and bedrooms that do not have en-suite facilities. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 20 The lounge areas were clean and comfortably furnished. People were observed mobilising around the units independently, using walking sticks and Zimmer frames. The home is also able to accommodate wheelchair users as the doors are wide and there are two larger bedrooms in which hoists can be used easily. The bedrooms were warm and comfortable and people are able to bring in items that will make their stays at the respite unit more comfortable. Each unit has a satellite kitchen; these were clean and managed, like the main kitchen, under the ‘Safer Food, Better Business’ regime. This means that each kitchen had a cleaning schedule that made sure that someone was responsible for maintaining the cleanliness of the kitchen equipment and area. The laundry was looked at, the room was clean, with washable floors and walls. The main washing machines have a sluice facility. There is also a domestic washing machine used only for kitchen linen and towels. Outside there are pleasant and accessible landscaped gardens. This includes a raised bed so that people can sow seeds and put in plants during the autumn, spring and summer. People who returned surveys liked the environment and noted that Limecroft was always clean and free from unpleasant odours. One person said: ‘Every where is cleaned everyday’ and another commented that Limecroft … ‘‘provides a comfortable ‘homely’ environment and offers the privacy of a private room with en-suite facilities.’’ Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 21 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. This judgement has been made using available evidence, including a visit to this service. People at Limecroft benefit from staff who are trained to do their jobs and recruited following policies and procedures that reduce the risk of employing unsuitable people. EVIDENCE: The number of staff employed by Limecroft meets the needs of people using the service. On the day of inspection there were deputy managers on duty and two care staff in each unit. The maximum residents on each unit are seven people. In addition, there are cooks and domestic staff available for seven days each week. The induction process is thorough. The service uses the Skills for Care Common Induction training package. This provides staff with basic training in relation to understanding the principles of care; understanding the organisation they work for and their role; maintaining health and safety at work; communicating effectively, recognising and responding to abuse and neglect and personal development. These goals are met through staff attending different courses to deal with each area and completing a workbook to show their understanding. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 22 All staff who returned CSCI surveys said that the training provided by the organisation was very good and that the induction prepared them for their jobs. The training organiser stated that training is provided on a rolling programme. Certificates confirm the following courses have been completed: Yesterday, Today and Tomorrow (concerned with old age and dementia care); control of substances hazardous to health (Coshh); moving and handling facilitator refresher; Malnutrition Universal Screening Tool (MUST) training; medication; fire warden training; national Vocational Qualification in care levels 2 and 3; first aid; introduction to moving and handling; mental illness and older people; departmental induction; protection of vulnerable adults (pova); disability awareness; completing risk assessments; alcohol and older people; dementia care; infection control; deaf/blind awareness; and life story work. Domestic staff training also included POVA. The training programme would be improved if it included pressure area and diabetes care training. Comments from care staff about the training included: ‘The training is very valuable it gives more insight into the job, it is also very relevant to the job’; ‘felt very comfortable with my induction, as a person who had not been in care services before’; and ‘I find the training excellent and covers all areas of the service - mandatory and specialised. Although I have only been in the role of care assistant for 18 months, I have already received updated training on courses I have previously attended.’ The majority of relatives assessed that staff ‘always’ had the skills and knowledge to do their jobs. Staff files that were looked provided information about when they were employed, training and supervision. Oldham Metropolitan Borough Council human resources hold employment records centrally and it is they who complete all recruitment checks, such as taking up references, checking for gaps in employment history and completing Criminal Record Bureau and Protection of Vulnerable Adults checks. OMBC human resources provide the CRB reference numbers and these were looked at during the inspection. All staff who returned surveys confirmed that the employment process had been robust and that all checks had been completed before they began working at Limecroft. Comments about the employment checks included: ‘… the process of personnel checks takes far too long.’ Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 23 Staff who were interviewed were very enthusiastic about working at Limecroft. One said that even though he was a casual worker, all personal checks had been completed and he was able to receive the same training as permanent staff. He confirmed that the induction process included shadowing more confident and experienced staff, as well as attending training courses such as moving and handling, POVA and fire safety. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 24 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 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. People at Limecroft benefit from management and administration that is open and respectful, and quality assurance systems that are effective and well established. EVIDENCE: We found that the management at Limecroft is effective and ensures that people receive a service that is personal to them, responsive to their needs and ideas, and safe. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 25 As well as completing the CSCI registered manager process, the manager stated, in reference to her continued professional development, ‘I have an HNC in managing care and am qualified to NVQ level 4 in management and am a NVQ assessor. I have also completed various departmental courses and I am a manual handling facilitator. Staff meetings confirmed that the management style was open and that people were able to discuss how the home was run and be involved in identifying how things may improve. The quality monitoring for Limecroft includes an exit questionnaire that people fill in after each respite period. This questionnaire asks about levels of satisfaction in relation to meeting care needs; cleanliness; comfort; meals; facilities; and activities. The response was either excellent or very good in all areas except ‘activities’. However, as previously stated under ‘Lifestyle’ in this report, the organisation is working to make improvements in this matter. This information is then analysed and made available as a published document. There is also a suggestion box for people to use as they wish. When the manager takes responsibility for people’s private money, a receipt is completed for the amount. Expenditure is receipted and when the person leaves the home, the balance of the money and the corresponding receipts are returned. One person’s money was looked at. The balance recorded in the book was correct and when added to the receipts that were available, this also amounted to the sum of money that had originally been given in. The manager confirmed in the AQAA that all maintenance and safety checks had been completed in accordance with best practice in the different areas. The maintenance file was looked at and confirmed that there were weekly torch checks, a fire drill on 24th January 2008 and a visit by a fire brigade officer on 30th January 2008 who found no problems. The gas boiler and systems were checked on 3rd January 2007. An electric inspection and test record was completed on 15th January 2007. The lift hoists and other mechanical aids were inspected in December 2007. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 26 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 x x 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 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 3 X 4 X 3 X X 4 Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP30 OP7 Good Practice Recommendations The registered person should provide training for diabetic care so that people with diabetes always receive the correct care. The registered person should make sure that care plans always reflect the needs identified in the assessments, so that staff know what to do for all identified needs. Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Greater Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Limecroft Resource Centre DS0000035289.V360277.R01.S.doc Version 5.2 Page 29 - 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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