CARE HOMES FOR OLDER PEOPLE
Lisburne Court Lisburne Lane Offerton Stockport SK2 5LU Lead Inspector
Sylvia Brown Announced 20 April 2005, 08:00am 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 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. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Lisburne Court Address Lisburne Lane, Offerton, Stockport, SK2 5LU 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) 0161-483-0671 0162 483 0671 lisburnecourt@boroughcare.org.uk Borough Care Limited Mrs L Martin Care Home 42 Category(ies) of Dementia - over 65 years of age (4) registration, with number Old age, not falling within any other category of places (42) Physical disability over 65 years of age (1) Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22 October 2004 Brief Description of the Service: Lisburne Court is situated in the Offerton area of Stockport. Shops, public houses and other local amenities are close by. Stockport town centre and the motorway network are easily accessible by car. The home is registered to accommodate up to 42 service users, four of whom may have dementia, one place is offered for a service user with a physical disability. Lisburne Court also provides a day care service. The large building accommodates service users on two floors. There are 40 single rooms and one double room. A passenger lift and three stairways enable access to both floors. There are several lounges and dining areas for sharing during the day and evening. A separate lounge and kitchen are available for visitors, enabling privacy when visiting their respective relative or friend. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of Lisburne Court was announced took place over two days, starting at 1.30pm and finishing at 8pm on the first day; and 10am whilst 12pm on the second. The residents, relatives and professional visitors received questionnaires prior to the inspection, some of which were returned before the inspection date. During the inspection the manager had issued an open invitation for families to meet the inspector, four of who made appointments to speak with the inspector. Eight residents were spoken to at length, with the inspector spending time with them during meals, whilst sitting in lounges and in their private rooms. Comments received form residents and relatives are included within the report, as are comments from professional visitors. The home also completed a pre-inspection questionnaire which was used in the evaluation process. The overall inspection was positive with residents and relatives happy with the way the home was run and with the services provided. What the service does well:
Lisburne Court is a large home, however it does manage to provide a homely environment which is enjoyed by the residents who live there. Residents stated that they were made to feel cared for and felt that, in general, staff were “very nice and caring”. The home does try and enable residents to live as they wish and encourages individual routines for getting up and going to bed. Although meal times are set, residents were observed requesting and receiving their meals at different time to suit their own routines. The layout of the home offers residents a number of places to sit during the daytime. Some residents however prefer privacy and have made their rooms into bed sitting rooms. The inspector was invited to visit one resident’s room which was large enough to enable her to bring in small items from her own home, including a television. Comfy seating enabled the resident to use her room as a sitting room during the day and allow her to join in group activities within the home has she desired. Relatives spoken to stated that the home generally communicates well with them regarding any issues of concern and that they are made to feel welcome. One family stated that they had free access to the visitors’ kitchen which they and the resident use to make drinks and snacks during visiting times. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 6 The home also manages to, as far as possible, ensure residents’ good health. Appointments with health care professionals are made as required with staff providing support if relatives or friends are not able to escort the resident to appointments. Optical, dental and hearing check-ups are in place as are chiropody services. One resident was able to tell the inspector of the support in place if accidents happen, stating she felt assured that people “are keeping and eye on me”. Feedback from professional comment cards indicated that health care professionals felt, overall, that Lisburne court looked after the residents’ health appropriately. What has improved since the last inspection? What they could do better:
The home acknowledges that some of its recording systems could be developed, particularly the daily records for residents. The manager has identified that meals and menus could be developed, as could systems within the kitchen. She has already started to make changes and has appointed a person to oversee some developments. The manager also identified that some collective record keeping needs to be individualised. The manager was also able to identify that residents would benefit from having a ‘shop’ on the premises and has discussed how that could be developed with residents, who have given their opinions of what purchases they would like to be able to make. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 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. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 Standard 6 does not apply to Lisburne Court. Lisburne Court provides residents with sufficient information about the home to enable them to make informed decisions about their accommodation prior to and during their stay. EVIDENCE: Inspection of three residents’ files confirmed that assessments of need were in place prior to the placement commencing. Service users and families were able to say how they made a decision about accommodation, with some preferring to visit the home for a brief visit, with others preferring to stay for the day to look at routines before making any decisions about living there. Some resident made the decision to move in without visiting the home. Residents’ files also contained signed contracts and terms and conditions of residency. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 10 The manager stated that she visits residents in their own home prior to them being accommodated; to answer any questions they may have and to ensure that, as far as possible, all their needs have been identified. When asked, all service users stated they felt Lisburne Court was a good choice of home for them. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Systems were in place to ensure residents maintain good health. EVIDENCE: All residents spoken with were satisfied with the manner in which their health care needs were met. Both residents and family members confirmed that doctors’ appointments are made as required. Family members stated they were informed of any outcomes where concerns arise. Inspection of records identified general check-ups and routine eye and dental checks were in place. Residents held keys to their rooms, it was pleasing to see some residents maintaining their independence and privacy by locking their doors and retaining their own key. One resident and her family member, informed the inspector, that since the new manager has been in post, she had ensured that a lockable piece of furniture had been provided for the secure storage of personal items. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 12 Observation of medication administration identified that, in the main, medicines were administered appropriately. One person administered eye drops to a resident whilst the resident was sat at the dining table with others, and whilst they were still enjoying their meal. This is not best practice. The good practice of promoting residents to retain responsibility for administering their own medicines was evident. Risk assessments were in place, as was guidance and monitoring systems to ensure medicines are managed safely. Medication administration records were observed to be maintained correctly, as were stocks. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Meals and mealtimes are positive experiences for residents. Residents have the appropriate opportunities for daily activities and social interaction. EVIDENCE: The inspector was able to join in one meal at tea time and observed breakfast routines. Residents stated that, overall, they enjoyed the meals, although some commented on the toughness of the meat on occasions. Returned comment cards from residents indicated that there was room for improvement regarding the food served. The manager stated that she was aware that meals and kitchen routines needed developing and had met with residents to discuss the matter. Records confirmed the manager’s statements. As a consequence, improvements in the menu have been made offering increased variety and choice. In addition, the manager has appointed a senior member of staff to improve and develop meals, mealtimes and kitchen routines. Residents confirmed that things had improved since the manager had started. Residents stated they were able to have choice and arrange to have meals at different times if they preferred. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 14 Care plans recorded residents’ preferred activities and participation. The manager confirmed that she will be ensuring such recordings are stored on the resident’s own file. Six of the nine returned comment cards from residents stated they were satisfied with activities provided, with two stating they were sometimes satisfied and one stating they were not satisfied. Records of residents’ meetings confirmed that residents had been consulted regarding this matter and that, as a consequence, the manager had already commenced developing the activities programme and was considering ways in which residents could have increased opportunities for visiting outside places of interest. Residents confirmed that they were able to receive visitors in their preferred place, and that their visitors were always made to feel welcome. Relatives spoken to stated that visiting times were enjoyable and that they were able to make their own drinks and snacks in the visitors’ kitchen or were served by care staff. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18 Service users were protected from abuse and were aware of ways in which they could complain. EVIDENCE: It was evident from talking to some residents and their families that there had been issues of complaint in the past which had not effectively been dealt with, however all the persons spoken to at the inspection stated they had confidence in the new manager and felt they could report any concerns to her and that she would take their comments seriously. Eight of the nine returned comment cards from residents stated that they felt safe and had someone to speak to if they were not happy about something. All three relatives’ comment cards stated they were aware of the home’s complaint procedure. All three professional visitors cards stated they had no cause for complaint. The complaints record identified complaints received and of the actions taken to investigate, including its resolution. Training records identified that staff were trained in adult protection and were aware of their responsibilities to report any suspicions of abuse within the home. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24, 25 & 26 The environment was maintained to safe standards, it was is clean and well cared for, offering residents comfortable accommodation to meet their individual and collective needs. EVIDENCE: The home was observed to be clean and well presented, there were no odours and cleaning routines were sufficient to maintain hygiene standards. One resident explained that her room had been upgraded and included new flooring and decoration. Other residents stated they had “nice rooms” which were “comfortable”. The pre-inspection questionnaire identified continual investment in the home with a number of areas being redecorated and new carpets and fixtures and fittings to be fitted following the redecoration. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 17 The CSCI receives a monthly report from the company which confirms that they have visited the home and evaluated a number of areas, including the home’s environment. Servicing records confirmed equipment was safe for use. In fine weather residents have outside seating areas made available to them. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 Robust recruitment and selection procedures were in place for the safe recruiting of staff. Staffing numbers were sufficient to meet the needs of the residents on the day of the inspection. EVIDENCE: The company has written recruitment and selection procedures which are followed when vacancies on the staff team arise. Inspection of staff files identified that procedures are followed and that application forms contained sufficient information, references are received and that all staff have ‘POVA First’ checks or CRB checks in place before commencing employment. Induction programmes are in place with new staff having the opportunity of shadowing experienced staff prior to undertaking tasks on their own. The home provided the inspector with the staff training programme, which included planned training up to June 2005. Observations of practice on the day identified that staff were competent in moving and handling procedures. Residents confirmed they received good care and that they were satisfied with the manner in which staff conducted themselves and the manner in which they were treated. Family members commented on their own observations and were, in general, satisfied with the conduct of staff. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 & 38 Lisburne court is a well managed home. Systems ensure, as far as possible, the residents’ health, wellbeing and safety. EVIDENCE: Through speaking with residents and family members and consulting directly with the manager, it was evident that she is experienced and knowledgeable regarding the running and management of a care home. The manager was able to demonstrate a clear management style which has an ethos of ‘leading by example’ as well as implementing training and direction. At the time of writing the report the company had yet to submit an application for registration of the manager to the CSCI. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 20 Health and safety records and certificates were inspected and found to be up to date. The pre-inspection questionnaire stated that recommendations made have all been complied with. The home holds small balances for some residents, which are routinely monitored and agreed by at least two appointed people. Accurate financial records were in place, which were appropriately audited, with receipts for expenditure evident. Residents stated that, in the main, they receive financial guidance and support from their family and, where required, Social Services. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 x 3 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 2 3 3 3 3 3 3 3 Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 22 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. 1. Standard OP31 Regulation Regn Regs Requirement The registered person must submit an application for registration of the manager of Lisburne Court. Timescale for action 15/5/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The registered person should ensure that the practice of administering eye drops at the dining table whilst residents are receiving and/or eating food stops. Lisburne Court F54 F04 lisburne court A s8563 v214758 200405 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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