Inspection on 13/02/07 for Limefield Court Retirement Home

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Limefield Court Retirement Home 05/06/07

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 Limefield Court Retirement Home 15 Limefield Road Bury Lancs BL9 5ET Lead Inspector Grace Tarney Unannounced Inspection 09:30 13 & 21st February 2007 th 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 Limefield Court Retirement Home DS0000068200.V316050.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. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limefield Court Retirement Home Address 15 Limefield Road Bury Lancs BL9 5ET 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) 01617615164 01617629316 Lily Care Limited Pamela May Hall Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (1) of places Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 32 service users to include: *up to 31 service users in the category of OP (old age not falling within any other category). *up to 1 named service user in the category of PD (physical disability under the age of 65 years). Date of last inspection Brief Description of the Service: Limefield Court is a two-storey property that has been extended and converted and it is situated off a main road on the outskirts of Bury Town Centre. It is within easy reach of bus routes and is not too far from the motorway network. The home has 18 single bedrooms and 6 doubles. All the bedrooms except for 2 singles have an en-suite toilet and hand-basin. The bedrooms on the first floor are reached either by stairs or a passenger lift There is a large lounge and separate dining room on the ground floor and bathrooms and toilets on both floors. There is plenty of parking and large safe garden areas with seating for the residents The home is registered to care for up to 32 people who need residential personal care. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection, questionnaires (comment cards) were sent out to the residents, their relatives, Doctors who visit the home and to the home itself. The questionnaires that were sent out to the residents were called Have Your Say and they asked what people thought about their care and of the quality of the service provided. . 11 comment cards were returned, 4 from residents, 6 from relatives and 1 from a local Doctor who visits the home. What they felt about the care and services provided is written in different sections throughout this report. The Inspector visited the home twice and on the second visit took her manager with her as they went in the evening to check if there was enough staff on duty. The Inspector spent a total of 10 hours at the home. During this time she looked at care and medicine records to ensure that the health and care needs of the residents were being met. She also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. To make sure that the home and the equipment in it was safe, the Inspector looked at some of the maintenance and service records of the equipment within the home. How the home manages the residents’ spending money was also looked at. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. The Inspector also looked at what the residents had for their lunch and evening meal. In order to get further information about the home the Inspector also spent time speaking to 2 residents, the owner, the manager, 3 care assistants and the cook. A copy of the last inspection report is kept in the reception area. The provider informed the inspector that the fees within the home ranged from £345 to £360 per week. Additional charges were made for private chiropody, hairdressing and newspapers. This information was received on the 27th November 2006. What the service does well: Before residents goes into the home one of the senior members of staff visit them in their own homes or in hospital to make sure that the care they need can be provided by the home. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 6 Residents spoke very positively of the kindness and consideration of the staff. Comments such as “They are all very nice”, “No complaints” were made. People visiting the home are made welcome and can visit at any reasonable time. Meals and mealtimes are considered to be an important part of the residents’ day. The dining room is a pleasant place to sit, eat and meet with other residents. The meals provided are varied and plentiful The Company is making sure that the staff are properly trained. The home makes sure that they check people out properly and safely before offering them a job. What has improved since the last inspection? 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 Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Limefield Court Retirement Home DS0000068200.V316050.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 Limefield Court Retirement Home DS0000068200.V316050.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. Quality in this outcome area is good. Residents have an assessment undertaken before their admission to the home and this gives an assurance both to residents, relatives and staff, that a resident is only admitted if the home can meet their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Inspection of 2 resident care files showed that before they were admitted to the home an assessment of their needs had been undertaken either by the manager or a senior member of staff. The resident files also had assessments undertaken either by the residents’ social worker or from the hospital they were admitted from. The inspector was shown the new form that is to be used for any future admissions to the home. This form was detailed and gave enough information to show that a detailed assessment could be undertaken. Standard 6 does not apply. The home does not provide Intermediate Care. Limefield Court Retirement Home DS0000068200.V316050.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 & 10. Quality in this outcome area is poor. The resident care records do not fully reflect the needs of the residents and their health and safety is, at times, put at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual resident care records, (called care plans) were in place for each resident. The care plans of 3 of the residents were looked at. The care plans were not detailed and did not give clear instruction and guidance on how the care needs of the residents were to be met. All the information about the resident and their care needs were written mainly on one page. This meant that if there was any change in the residents condition in relation to a particular problem it could not be written down where it should be (that is next to the problem already identified). The care plan of one resident showed that this resident had recently broken her wrist and had a Plaster of Paris splint in place. There was no care plan in place to show how staff needed to look after this resident now that she was wearing a plaster cast and what problems to look out for when a plaster cast is in place. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 11 The care plans were not reviewed on a regular basis. It is important to do this so that any change to the residents’ care can be made known and acted upon. The inspector was shown the new form that will soon be in use for writing the care plans and doing risk assessments. This looked very detailed and the new owner told the Inspector that it is his intention to get the care plans rewritten and new risk assessments undertaken as soon as the new senior member of staff starts working at the home. That was to be by the end of the month of February. Inspection of one care plan showed that this resident had fallen on several occasions but there was no falls risk assessment in place and no care plan in place to deal with the problem. Bedrails had been provided for this resident but the resident had been climbing over them and because of this they had been removed. There had been no risk assessment in place before providing bedrails. Following a discussion with the manager the inspector saw on her second visit that this resident had been referred to a Falls Coordinator at the local hospital. The Falls Coordinator hopefully would be able to advise the staff at the home of the best way to deal with this residents’ problem and reduce the risk of falling. The staff looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. The staff did not look at whether the residents were at risk due to problems with their food and fluid intake. This is called a nutritional risk assessment. None of the care plans had one in place. The Inspector was shown the new nutritional risk assessment form that will soon be in use. The Inspector was told that this would not be used until staff had had the proper training so that they could understand it. The Inspector saw that several members of the staff at the home had received the training, as the Inspector was also present at the training session a few weeks later. Residents were weighed at least on a monthly basis. Inspection of the care files showed that the residents had access to health care professionals, such as district nurses, dentists, opticians and chiropodists. In answer to the questions on the Have Your Say Questionnaire – 1.Do you receive the care and support you need? The following comments were made: 4 residents said always. One resident said that the manager always deals promptly with care and support. 2.Do you receive the medical support you need? 4 said always. Relatives commented that they were pleased with the care provided. The way that the medicines were handled was not as safe as it should be. The home does not have a separate medicine room however medicines are stored in a locked cupboard in the dining room and the medicine trolley is secured to the wall when not in use. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 12 Controlled drugs however were not stored securely and the medicine keys were not kept on the person but were left in a drawer. The manager was told to keep the keys on the person who was either in charge or responsible for the giving out of medicines. The home was using 2 cash boxes that were stored in the locked medicine cupboard for the storage of controlled drugs. One of the cash boxes was not secured to the cupboard and one of the cash boxes had a broken lock. All of the medication administration sheets and the controlled drug register were looked at. It was obvious from looking at the controlled drug register that staff were not counting the number of medicines left in the container when a medicine had been given out to a resident. Staff were also not properly recording in the register when medicines had been received. Temazepam, which is a sleeping tablet and must be stored as a controlled drug, was not being stored as such. The following areas also need putting right: • A handwritten instruction for medicines (Transcriptions) was not checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. • The homes’ staff had changed the dose of 2 medicines. Staff must not change a prescription. They must refer the issue back to the prescribing GP. • Stocks of internal and external medicines were stored in the same box. This is not good practice and could result in inadequate stock rotation and even drug errors. All staff, responsible for giving out medication, had received appropriate medication training. Residents looked clean and comfortably dressed. Staff were very discreet when helping the residents to move around the home or helping them to eat their meals. Staff spoke to the residents in a very respectful way. A resident told the Inspector that the staff “Were lovely”. When they first start working at the home the staff are reminded of the importance of maintaining the privacy and dignity of the residents. The Inspector was concerned however, about the nurse call bell system in place in the home, because at times it did invade the privacy of the residents. This call bell system was in place when the new owner took over the home. This system is such that staff are able to listen in as well being able to speak to the residents in their own room. One staff member told the Inspector that being able to listen in, especially during the night is very useful particularly if somebody is at risk of wandering about or falling. The staff member said that they do actually leave the system open to listen in. Staff and the manager told the Inspector that this system does give some residents a great degree of confidence and comfort because they can actually talk to a staff member and tell them whats wrong. The Inspector can understand that. Another problem however is the fact that when the call bell Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 13 does ring the staff member cancels the call at the call box and not in the residents’ room. The Inspector and her Regulatory Manager had a discussion about the concerns with the owner, who intended to look at what could be done to control the risk of intruding on the residents’ privacy. Limefield Court Retirement Home DS0000068200.V316050.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 & 15. Quality in this outcome area is good. The home enables the residents to have as much choice and enjoyment as possible, both with the meals and activities available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ routines of daily living and their social interests were recorded in their care plans but not in any detail. The new owner told the Inspector that when the new care plans are in place this will change. It was obvious from watching how the staff were caring for the residents that they knew what the residents liked to do and how they liked to spend their day. The home does not employ an activities organiser and the Inspector was told that the carers undertake activities for the residents. The carers spoken to felt that this was suitable and acceptable. The Inspector was also told that singers/entertainers are invited into the home on a regular basis. Also a Company that specialises in reminiscence and other activities goes into the home every month. The Inspector was also told the parties are held regularly for any special events such as Christmas, Easter and birthdays. Photographs of the recent Christmas party were displayed. In answer to the question on the Have Your Say Questionnaire the following comments were made: Are there activities arranged by the home that you can take part in? Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 15 1 said always, 2 said usually and 1 said sometimes. One resident commented: I enjoy the exercise routines. Others commented: I have a try. I like dancing. Staff confirmed that there were no unreasonable restrictions on visiting at the home and that visits could be conducted in the privacy of the resident’s room or quieter areas of the home. During the evening visit the Inspector saw a visitor sat in the lounge area. He seemed very much “at home” and staff made him very welcome. Staff told the inspector that the residents are encouraged to bring personal possessions into the home. Some of their bedrooms were personalised with small pieces of their own furniture, pictures, photographs and ornaments etc. The Inspector did not have a meal with the residents but watched what they were having for their lunch and evening meal. The tables were nicely set with tablecloths, napkins and salt and pepper. The residents have the main meal at lunchtime and the lighter meal in the evening. Inspection of the menus, a discussion with a resident, the cook and care staff showed that a 3-course meal is always offered. The residents also always have the choice of a main meal and sweet. The cook told the Inspector that she asks the residents before each meal what they would like to eat. Hot and cold drinks were available. The cook and staff told the Inspector that the residents can have more or less what they want for supper. It can be toast, crumpets, sandwiches or crackers. For drinks they can have tea, coffee or any milky drink. The Inspector saw that Ovaltine and Horlicks drinks were stocked in the kitchen cupboards. In answer to the question on the Have Your Say Questionnaire the following comments were made: Do you like the meals at the home? 2 said always, 1 said usually 1 said sometimes. One resident commented: Always ready for my meals. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 16 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 & 18. Quality in this outcome area is good. The complaint system in place enables residents to feel that their views are listened to and acted upon. Staff have a good knowledge and understanding of adult protection procedures thereby reducing the possible risk of harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A detailed complaints procedure was in place and was displayed in the reception area. The complaints procedure was also included in the Service User Guide. It was an old complaints procedure because it made reference to the previous owner. The new owner agreed to change the complaints procedure as soon as he was made aware of the new address and telephone number of the local office of the CSCI. A discussion with a resident showed that there was a general awareness of how to make a complaint. It was clear in discussion with staff that they also knew what steps to take should a resident make a complaint In answer to the questions on the Have Your Say Questionnaire the following comments were made. 1.Do you know who to speak to if you are not happy? 2 said always, 1 said sometimes and 1 said usually One resident commented: I always ask the girls. 2.Do you know how to make a complaint? 1said always, 2 said sometimes and 1 said usually Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 17 I would complain to the girls on duty. A policy and procedure was in place in relation to the detection of abuse and neglect (including whistle-blowing) and how to respond to suspected abuse. The home had a copy of the Local Authorities procedure for protection of vulnerable adults. A discussion with care staff showed that they were aware of the different forms of abuse and the procedure to follow in the event of any allegation of abuse. Training records were inspected and showed that training in the protection of vulnerable adults had been undertaken and was an ongoing process. There was a notice showing that some training had been organised for the following week. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 18 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 20 21 24 25 & 26. Quality in this outcome area is adequate. The residents live in clean and comfortable surroundings but some areas of the home present a risk to their safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The front door is kept locked for security reasons and an intercom system is in place. The corridors are wide with grab rails along the side to assist the residents with mobility problems. The radiators along the corridors were unguarded. There is a large lounge and separate dining room on the ground floor. Both of these were clean, warm and suitably furnished. Apart from 2 bedrooms upstairs, each bedroom has an en-suite toilet and washbasin. There are two toilets off the lounge area. They had a lock on the door to ensure privacy. These toilets however did not have a call bell in place. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 19 There is a further toilet upstairs that is used by staff and by the residents who do not have an en-suite toilet. This toilet had an unguarded radiator and no staff or resident hand washing facilities. Upstairs there is a room with a shower that is not suitable for disabled access. There were no staff hand-washing facilities in place. Downstairs there is a shower room that has an unguarded radiator. There is also a bathroom with an assisted sit in bath. This bathroom has no toilet but there is a commode in this room that is used by the residents. This bathroom however was also being used as a storeroom. All the bedrooms were looked at. They were all clean, warm and suitably furnished. The majority did not have a lockable space for the residents to store anything that was important or valuable to them. All the bedroom doors had overriding safety locks but they were not the type of lock that had a key. This means that residents cannot lock their door when they leave their room. Most of the bedrooms had an unguarded radiator both in the bedroom and the adjoining en-suite toilet. Window restrainers were fitted to all first floor windows. In answer to the questions on the Have Your Say Questionnaire the following comments were made Is the home fresh and clean? 4 said always. The home was adequately heated. All the rooms were centrally heated with radiators in place, however they were not suitably protected to prevent any accidental burning. The home was clean and free from odours. Hand washing facilities were not in place however in bedrooms, bathrooms and toilets. To prevent infection they must be in place wherever personal care is being delivered. Disposable gloves and coloured aprons were provided for staff use. . The laundry area was clean, well equipped and looked well organised. . Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. The residents are being cared for by caring and conscientious staff that are safely recruited and trained and therefore have the knowledge and skills to meet the residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the duty rotas, observation by the Inspector and a discussion with staff and residents plus comments from the questionnaires showed that the home, at times was working with the absolute minimum amount of staff and at times was not staffed sufficiently. The owner told the Inspector and her Manager that for the 26 residents in the home he expected to have 4 staff throughout the day and 2 staff at night. The duty rotas showed that on several occasions the home had only 3 care staff on duty throughout the day. The Inspector was told that new staff had been recruited and would be starting the following week. The Inspector did not look at the documented needs of the residents who were sat in the lounge but it was clear that they were highly dependent. The Inspector did find that the residents’ needs were being met and this has to be attributed to the hard work, careful planning and management by the staff. The home must be staffed in accordance with the needs of the residents and not by how many residents are living there. The staff were seen to have a natural and comfortable understanding with the residents and they found time to sit and talk with them. In answer to the questions on the Have Your Say Questionnaire and the relative comment card the following comments were made: Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 21 Are the staff available when you need them? 2 said always and 2 said usually. 1 relative commented “I have discussed the staffing levels with the manager and expressed my concerns as some of the residents can be quite disruptive”. 3 relatives felt that there was not always enough staff on duty. There were 2 residents in the home who were not White British. One was from Poland and the other resident was of African Caribbean origin. The resident from Poland had a good command of English and her care plan showed that her religion was duly respected. The Inspector spent time talking to the other resident and her command of English was also very good. Her care plan showed that she liked Caribbean food and even included a pamphlet for her favourite “Takeaway” food shop. Information from the pre-inspection questionnaire showed that of the 15 care staff employed, 8 have obtained their NVQ level 2 or above in care. This is a percentage of 53 and therefore the home has met the Standard. The pre-inspection questionnaire also details that NVQ 2 and NVQ 3 training for staff is also ongoing. The personnel files of 3 staff members were inspected. All were in order and these staff had been properly and safely employed. They had a completed application form, 2 professional references, an enhanced criminal records disclosure (CRB) or POVA 1st check and a health status declaration. The Inspector was not able to see what the induction training had been for previously employed staff, however she was informed that the Skills for Care induction training will be in place for all new staff. Since the Company took over the ownership of the home they have signed a partnership contract with Bury Social Services and started to undertake training in several areas. These were the: Moving and handling. Fire. Infection control. Protection of vulnerable adults (POVA) Food hygiene. First aid. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 22 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 & 38. Quality in this outcome area is adequate. Equipment and services within the home are kept safe, however some current practices do not promote and safeguard the health, safety and welfare of the people using the service This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has a lot of experience of caring for the elderly and has worked in the private sector for several years. She keeps herself updated by attending various courses such as nutritional needs of the elderly, moving and handling, medication management and the Protection of Vulnerable Adults. She has not yet started to do her management training but has been enrolled on the course to undertake the Registered Managers Award. The manager is skilled at caring for the residents, and both residents and staff spoke positively about her attitude and kindness. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 23 The director of the company/owner told the Inspector that he intends to put a number of quality assurance measures in place just as he has done in his other home in a neighbouring town. This will be in the form of an annual quality assurance survey involving residents, relatives/friends and staff. Upon completion, the results will be published, displayed within the home and included in the Service User Guide. He also told the Inspector, and staff confirmed this, that he visits the home every evening to make spot checks, discuss any problems, check on supplies and talk to staff, residents and visitors. It is also his intention to undertake regular resident/relative meetings. The system in place for the management of the residents’ spending money was good. The Inspector was told that their families generally undertake the management of residents’ finances. The home had a satisfactory accounting system in place. Receipts were retained for all financial transactions. The home had a detailed Health & Safety Policy. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. The concerns identified are in relation to the unprotected radiators and lack of staff hand washing facilities. Information obtained from the pre-inspection questionnaire and from random checking of servicing records showed that the homes fixtures, fitting and equipment are properly maintained and regularly serviced. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 24 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 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 2 x x 2 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 2 Standard OP7 OP7 Regulation 15(1) 15(2)(b) Requirement Care plans must be in place for any identified need. Staff must continually look at the changing needs of the residents and review the care plan at least on a monthly basis. Staff must make sure that any risk to the health and safety of the residents is identified and action to reduce or stop any identified hazard is then taken. Therefore risk assessments for nutrition, falls and general safety must be in place. All medicines, including controlled drugs must be stored safely and the medicine keys must always be kept on the person. Staff must make sure that they count the number of medicines that are left in the container when they have to record in the controlled drugs register, the amount of controlled drugs remaining. They must also make sure that they accurately record the number of controlled drugs DS0000068200.V316050.R01.S.doc Timescale for action 30/04/07 30/04/07 3 OP8 13(4)(c) 30/04/07 4 OP9 13(2) 13/02/07 5 OP9 13(2) 13/02/07 Limefield Court Retirement Home Version 5.2 Page 26 6 OP9 13(2) 7 OP9 13(2) 8 OP21 13(4)(a) 9 10 OP24 OP25 23(2)(m) 13(4)(a) 11 OP26 13(3) 12 OP27 18(1)(a) received. Medicines that are to be stored as a controlled drug must be stored in the designated controlled drug cupboard. Staff must not change a prescription. They must refer the issue back to the prescribing GP. You must make sure that residents are protected from avoidable risks to their health and safety. Call bells must be fitted in the toilets adjacent to the lounge. A lockable space must be provided in all bedrooms. Make sure that residents are protected from avoidable risks to their health and safety. For example, unless a risk assessment has shown that the unguarded radiators are otherwise safe, you must fit radiator covers or provide low surface temperature radiators. Wherever personal care is being delivered and in all bathrooms and toilets, staff and resident hand washing facilities such as liquid soap and paper towels must be provided. The home must be staffed to meet the individual needs of the residents and not according to how many residents are living there. 13/02/07 13/02/07 30/06/07 30/06/07 30/06/07 30/06/07 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000068200.V316050.R01.S.doc Version 5.2 Page 27 Limefield Court Retirement Home 1 2 3 4 Standard OP9 OP9 OP3 OP4 To ensure the accuracy of a handwritten transcription they should be checked with another member of staff, signed and countersigned. To prevent the possibility of drug errors stocks of internal and external medicines should be kept separate Management should look at ways of fixing the call bell system so that the risk of invading the residents’ privacy is reduced. Over riding locks that have keys should be fitted to bedroom doors and the residents provided with a key unless their risk assessment indicates otherwise. Limefield Court Retirement Home DS0000068200.V316050.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Limefield Court Retirement Home DS0000068200.V316050.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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