Inspection on 15/08/05 for Lisburne

This inspection was carried out on 15th August 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lisburne 17/10/08

Lisburne 23/10/07

Lisburne 16/05/06

Lisburne 10/01/06

Lisburne 02/03/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Lisburne 36 - 38 Church Hill Honiton Devon EX14 8DB Lead Inspector Susan Lyons Inspection 15 August 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lisburne Address 36 - 38 Church Hill, Honiton, Devon, EX14 8DB 01404 42364 01404 42364 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Devon Partnership NHS Trust Paula May Allen Care Home 6 Category(ies) of LD: Learning Disability (6) registration, with number of places Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users must be in the age range 21 - 50 years 2. Variation dated 11.07.2003 allows one named person aged over 50 to remain in the home 3. The maximum number of placements including that of the named person will remain at 6. 4. That on the termination of the placement of the named person the registered person will notify the commission and the particulars and conditions of this registration will revert to those held on the 8th November 2002. 5. The manager must complete NVQ level 4 in Management and Care by April 1st, 2006. Date of last inspection 2nd March 2005 Brief Description of the Service: Lisburne was originally two semi-detached modern bungalows, now converted into one large property. The home is situated in a residential area, near to the railway station and within walking distance of the centre of Honiton. The home cares for younger adults who have a learning disability, autistic spectrum disorders, are highly dependent, and with challenging behaviours. Accommodation for residents is provided in six single bedrooms. There are two lounges. There is a separate dining room. There is a garden at the rear of the property and some parking on site. It has nothing to distinguish it as a residential home. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon. The findings were gained by the following methods; Meeting and talking to residents Discussion with staff Discussion with the manager Feedback cards from some relatives Looking at records and documents within the home Tour of the building It was difficult to gain much information from residents as they have limited communication. Therefore much of the information had to be gained by discussion with staff and observation. What the service does well: In-house assessments have been completed on residents. The home has produced a Statement of Terms and Conditions, a copy of which was seen on individual files. Risk assessments were seen incorporated into the care plans for individual residents. Residents use community facilities as much as possible within the local area. The home tries to encourage residents to maintain links with families and friends and to this end will take residents to see their families. This is considered to exceed the standards and is thus reflected in the score. Records indicate that nutritious and varied meals are provided which residents are involved in choosing where possible. Residents receive medical attention from a variety of health professionals and medication is supplied from a local pharmacy in a monitored dosage system. On the day of the inspection the home was seen to be clean and hygienic. Although there have been a great many staff changes during the past year, new staff have been recruited. and those that met the inspector seen committed and enthusiastic. Supervision is taking place and staff feel it meets their needs. They also commented on the fact that they feel supported by the manager and able to discuss issues they may have with her. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 6 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. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 & 5 Residents’ needs are identified through admission procedures. Communication needs are met through multidisciplinary working. Residents are informed of their rights and responsibilities within the home. EVIDENCE: There have been no new admissions to the home for some time therefore not all the residents have a copy of the shared assessment . However in house assessments have been completed. The home is currently working with a speech and language therapist to develop communication systems to meet individual residents needs. These include picture boards and objects of reference. Copies of Statements of Terms and Conditions were seen on individual residents’ files. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Lack of detail in care plans means that staff are not adequately provided with information to consistently meet residents’ needs. Personal risk assessments identify and minimise risk to residents. EVIDENCE: Three care plans were sampled. They contain details of how residents’ needs are to be met and also behavioural guidelines where they are required. Individual risk assessments are incorporated into the care plans. One of the three care plans needed further detail in relation to how the residents needs were to be met especially in relation to personal care. Guidelines in relation to specific behaviour in relation to one resident are being developed with the clinical psychologist and staff are being asked for their comments throughout the development. Care plans also contain guidelines from other professionals where they are required. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 & 17 Residents lack variety in the activities offered within the home. Use of community facilities supports service users social opportunities. The encouragement of family and friends involvement enriches service users lives. The meals at the home are good offering both choice and variety. EVIDENCE: Over the past few years day services have been reduced for the majority of the residents living at the home. Some limited day service have been resumed often this has only been achieved by staff from the home staying with the resident whilst they are accessing the service. The manager and staff recognise the fact that they will now have to provide the baulk of formal activities for residents. One member of staff explained that they are currently collecting ideas of activities for all of the residents and developing a weekly plan for everyone. This is to be displayed for all staff to follow. She was not sure how this would be monitored. One resident said she did not go out much however the record in relation to this resident showed that they had either been out most days or offered the Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 11 choice of going out. The manager is arranging staffing levels to ensure that all residents have opportunities to go out. Opportunities also need to be available for activities to take place within the home, it was noted that photographs of one resident enjoying varied indoor activities some years ago at a special venue were available but it didn’t appear that anyone had thought to see if the resident would like to continue these within the home. Where possible residents make use of community facilities these include one resident using a hairdresser’s, visiting local places of interest, shops, pubs, cafes and the swimming pool. On the day of the inspection one of the residents was shopping at the local supermarket with staff for the food for the home. There are no restrictions on visiting from families or friends and residents are able to see their visitors either in their own room or the lounge. The home will also take residents in the mini-bus to see their families if this is required. The home is working with the speech and language therapist to develop photographs of meals to assist residents with choice. Currently the menu for the week is chosen on a Sunday and residents are involved as much as possible. Records indicate that meals are nutritious and varied. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20. The lack of staff attention to guidelines places a resident at potential risk and discomfort. Systems are in place to refer to appropriate medical professionals. Lack of training in the safe administration of medication and invasive treatments has the potential to place residents at risk. EVIDENCE: Guidelines are available within one care plan in relation to how a resident is taken to the bathroom. On a previous inspection it was noted that staff were using an alternative method of doing this which the inspector felt did not maintain the resident’s dignity and may be unpleasant for the resident. At this inspection not all staff were following the guidelines in the care plan. One member of staff said that this had been discussed at some training and the trainer felt that the method used was acceptable. The manager agreed to discuss this with the professional who had first issued the guidelines. It was not clear that one resident was spending regular time out of the wheel chair on a regular basis. Currently female residents receive care from female members of staff and male residents receive care from both female and mail staff. All residents are registered with a GP and other health professionals are involved in the care as and when they are required. Medication is supplied by a local pharmacy in a monitored dosage system Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 13 and stored in a locked cupboard. Recording was seen to be appropriate. Staff have not yet been trained in the administration of medication despite it being a recommendation following the last inspection. One resident has been prescribed an invasive medication and not all staff have been trained in the administration. The manager said she was unable to guarantee that one such trained member of staff would be on each shift. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Service users are protected by the complaints and adult protection procedure but lack of knowledge of the complaints procedure by families and staff awareness of adult protection may compromise this. EVIDENCE: Several relatives who completed feedback forms said that they did not know about the home’s complaints procedure. A procedure is available with photographs displayed. The one displayed needs to be up dated as it contains details of staff who no longer work at the home. Since the last inspection one complaint has been received a copy of which was sent to the Commission. This is being investigated by TRS (Trust Residential Services). Currently staff have not received any training in relation to Adult Protection or watched the ‘No Secrets’ video however they said that they are aware of the procedure for whistle blowing and when asked, were able to answer appropriately as to what they would do if they knew a resident was being ill treated. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 & 30 Residents benefit from the home being clean and recent redecoration. The standard of the environment is adversely affected by lack of suitable adaptations. EVIDENCE: The fabric of the building receives a lot of rough treatment from residents and therefore is constantly needing to be redecorated. Staff have tried to imaginatively meet the needs of residents whilst trying to make the building more homely. Where curtains are pulled down they have put them on a special fastening or frosted windows with stencils. They have also made good use of stencils and large murals to meet individual residents interests. In the garden there is a shed which is used for art and craft activities. However this is not accessible to all the residents and although a recommendation was made following the last inspection some residents are still not able to use it. A recommendation was made following the last inspection that a specialist equipment be available in the bathroom to enable staff to change a resident. This recommendation remains outstanding. On the day of the inspection the home was seen to be clean and there were no unpleasant odours. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 & 36 Staff time spent on redecoration of the home is detrimental to residents Residents benefit from well supervised staff who have been appropriately recruited. Lack of statutory training places residents at risk. EVIDENCE: During the past year the home has been through an unstable time in relation to staff turnover. A lot of staff left around the same time and the home has had to rely heavily on agency staff, whilst they have tried to maintain continuity be getting the same agency staff this has not always been possible. Whilst there are still some staff vacancies most have now been filled and the agency staff reduced. All the internal redecoration to the home has to be completed by the staff whilst they are also looking after the residents. On the day of the inspection the manager was just about to start some painting. This is not good use of staff’s time. It is extremely difficult to involve the residents in decoration of the home and therefore time which could be spent in undertaking activities with residents is being used for redecoration. The manager has tried to find ways in which this can be achieved without staff being taken away from residents. Three staff were spoken to. Two of the staff Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 17 were relatively new and expressed a great enthusiasm for the job. All three staff seemed committed to the residents. Recruitment paperwork was seen for the most recently recruited staff and was seen to be in order. The home has a training and development plan but because there have been so many new staff not all staff will have completed their statutory training. The manager is currently ensuring that staff are booked on courses which they need to undertake. Staff confirmed that they receive formal supervision which meets their needs, one member of staff said that she would like it to be a longer session. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41 & 42 Residents benefit from well supported staff. There is no clear vision for the home as views in relation to the care provided have not been sought. Lack of records within the home and fire safety checks has the potential to place residents at risk EVIDENCE: Staff spoke positively about the manager and said that they felt well supported and able to discuss any issues they may have with her. A requirement was made following the last inspection that a system should be in place for reviewing and improving the quality of care within the home and an annual development plan be put in place. This requirement remains outstanding. Not all records required to be within the home were checked. However it was noted when checking recruitment paperwork that a copy of a passport was not available for one member of staff. The member of staff confirmed that he did have a passport. It was noted that the fire alarms are not being tested weekly. Other tests have been completed within the timescales required. The folder in which the fire Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 19 safety records are maintained needs to be ‘slimmed down’ it contains too many out of date records. Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 3 Standard No 11 12 13 14 15 16 17 x 2 3 x 4 x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lisburne Score 1 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 1 x 1 1 x D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA18 Regulation 13 (5) Requirement Timescale for action 16-9-05 2. YA24 23 (2) 3. YA39 24 (1) (b) 4. YA41 19 (1) (i) 5. YA42 23 (4) You are required to ensure the correct way of moving a resident is established and that all staff are following the guidelines in relation to this. (o) You are required to ensure that all residents have safe access to the grounds. (Timescale of 31-705 not met) (a) You are required to establish and maintain a system for reviewing and improving the quality of care and introduce an annual development plan. A copy of which be sent to the commission. (Timescale of 3110-04 & 30-6-05 not met) (b) You are required to ensure that a copy of each member of staffs passport (if they have one) is available. (Timescale of 30-6-05 not met.) (c ) You are required to ensure that the fire alarms are tested weekly. 31-10-05 31-10-05. 30-9-05 16-9-05 Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA2 YA12 YA20 YA22 YA23 YA24 YA27 YA32 Good Practice Recommendations It is recommended that sufficient detail is included in all care plans to ensure that staff support residents in a consistent way. It is recommended that residents are offered a wide range of activities both inside and outside of the home. It is recommended that staff who administer medication are trained to do so and that staff who administer invasive medication receive training in how to administer. It is recommended that a copy of the complaints procedure is sent to all relatives. It is recommended that staff through either training or other means receive input in relation to Adult Protection It is recommended that alternative means of decorating the home are found rather than staff undertaking the task. It is recommended that equipment is available within the bathroom to enable a resident to change It is recommended that staffs core training is kept up to date Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Suite 1, Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lisburne D54-D06 S21967 Lisburne V236204 150805 Stage 4.doc Version 1.40 Page 24 - 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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