Inspection on 01/03/06 for Lisieux Hall

This inspection was carried out on 1st March 2006.

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

Lisieux Hall 15/11/07

Lisieux Hall 30/01/07

Lisieux Hall 23/11/05

Lisieux Hall 26/11/04

Lisieux Hall 10/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Lisieux Hall Dawson Lane Whittle-le-Woods Chorley Lancashire PR6 7DX Lead Inspector Phil McConnell Unannounced Inspection 1st March 2006 10:00 Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 Adults 18-65. 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. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lisieux Hall Address Dawson Lane Whittle-le-Woods Chorley Lancashire PR6 7DX 01257 266311 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) Brothers Of Charity Services Mrs Jacqueline Murphy Care Home 52 Category(ies) of Learning disability (52) registration, with number of places Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 52 service users to include up to 52 service users in the category of LD (Learning Disability). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 23rd November 2005 Date of last inspection Brief Description of the Service: Lisieux Hall is located in a rural setting approximately half a mile from the A6, which is one of the main roads linking the towns of Preston and Chorley. It is also approximately 1 mile from the A49, one of the main roads linking Preston and Wigan. Because of its rural setting, access to local facilities such as post office, shops and public houses is not easy, with the nearest being a half-mile away. Service users access these by walking, or, where appropriate, an escort is provided from the home. A wider variety of shops can be found in Chorley, which service users access via public transport, taxi, or transport provided by Lisieux Hall. Lisieux Hall is run by the Brothers of Charity and is part of a wider service, which also provides day care, supported employment, and domiciliary services to service users with learning disabilities in the Chorley & South Ribble areas. The Lisieux Hall site comprises of 8 residential units (with 5 units in use at the time of the inspection). The home is registered to accommodate a total of 52 service users with a Learning Disability, with some service users having nursing needs. There were 30 people resident at the time of the inspection and there are plans to reduce the numbers of service users accommodated as appropriate housing stock in the community becomes available. Lisieux Hall is the administrative centre for the Brothers of Charity Services in the North West and has additional resources on site. Service users also have access to a range of work, educational and leisure opportunities in the local area. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, which meant that the provider was unaware that the inspection was to take place. The inspection lasted approx, 8 hours. During the course of the inspection, discussions took place with service users, the registered manager, the residential manager, the director of services, the operations manager, and care staff members. There was a good atmosphere within each of the units visited, with the service users and staff being positive about living and working at Lisieux Hall. Service users personal files and records were inspected to make sure they were accurate and current. The homes Policies and Procedures were looked at to make sure they gave good information and advise about the home. Lisa Fitszimmons is to apply to be the registered manager; she presently has the responsibility of managing the day-to-day running of the home. The present registered manager Jacqueline Murphy is now a director with the organisation. A tour of Lisieux Hall was carried out, visiting four of the units were service users live and all of the units were homely, comfortable with each having a relaxed and calm atmosphere. The inspection concluded with giving feedback to the director of services and the residential manager. What the service does well: More than 50 of care staff have now completed NVQ (National Vocational Qualification) training and the remaining staff are in the process of receiving NVQ training. The staff training in general is appropriate, relevant and of a good standard, helping to ensure that people are supported and cared for by well trained and proficient staff. Lisieux Hall has received an award for medication administration training from North West training and has maintained the Investors in People Award for the 6th year, which is a quality assurance monitoring organisation, demonstrating that the provider is both committed to delivering good training and dedicated to providing a quality service. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 6 Another vehicle has been acquired which can transport two service users who need to use wheelchairs. This helps to promote independence and social inclusion. The organisation has been proactive in carrying out there own audit / survey of the service they provide and this was seen to be honest, informative and constructive. Some positive changes have already been implemented following the audit. It was highlighted throughout the inspection that service users and staff members are consulted and involved in planning their own futures. This was evidenced in minutes from meetings, diary entries and in discussion with staff and service users, demonstrating that individuals rights and choices are acknowledged and recognised. 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. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 18 and 19. Service users are supported and cared for in a sensitive and dignified manner. The health needs of service users are monitored and responded to accordingly. EVIDENCE: Service users’ files contained up to date information, including: care plans; health care checklists and self help checklists, giving clear guidance about the level of individual personal care that service users have been assessed as needing. Staff have received training regarding respect, privacy and dignity, and this was positively demonstrated during the inspection in the way that staff members spoke about service users and in the way they interacted with individuals. There was a key worker system in place; helping to promote trust and confidence between the service user and the staff member, thereby, helping to ensure a service users’ changing needs are identified and acted upon as quickly as possible. There was documented evidence of service users receiving other specialist support, including: speech and language therapy, independent advocates and the GP visiting Lisieux Hall fortnightly to attend to the service users who are Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 12 unable to access the surgery. Regular individual medication reviews have been carried out for all service users. Appropriate health action plans and individual health assessments were in place containing relevant and comprehensive information. Demonstrating that service users’ healthcare is monitored, maintained and promoted ensuring that individuals’ health is a priority. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 13 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 24 and 30. The standard of the environment within the individual units / homes is good, providing service users with a homely, safe and pleasant place to live. EVIDENCE: Lisieux Hall is located in a rural setting with extensive and attractive grounds, with separate units / homes within the grounds. During the inspection four units were inspected, including one of the homes, which has been completely refurbished, with service users planning to move back into the home the following weekend. All of the homes inspected were decorated to a satisfactory standard with service users’ bedrooms being bright, comfortable and containing service users’ individual and personal belongings. The homes were clean and hygienic with appropriate laundry and washing facilities provided to help ensure that the risk of infection is managed and controlled. Training in the control of infection had been provided to staff, in order to promote a clean and safe environment for service users and staff. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 15 The bathroom floor in St Edwin’s had recently been renewed to a very good standard, with a non-slip surface, (This was a previous recommendation) helping to provide and promote safer working practices and conditions for staff and service users. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Suitably qualified and trained staff provide a caring and supportive service. A robust recruitment process is in place, helping to ensure that service users are protected and safeguarded. EVIDENCE: Staff files contained information with regards to the experience, skills and training that staff have received with mandatory training being provided to all staff including: lifting and handling, food hygiene, fire safety and first aid, with other relevant and appropriate training also being provided. In one of the units, staff were observed preparing the evening meal for service users and it was apparent that appropriate training in food hygiene had been undertaken. One staff member said, “The training within Lisieux Hall is excellent and outside courses are also available”. Other members of staff also confirmed this. All staff are either in the process of achieving the National Vocation Qualification (NVQ) or have already obtained the qualification. In the units where nursing care is provided, there is always a qualified nurse on duty, ensuring that service users are cared for and supported by suitably qualified and experienced staff. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 17 Staff members have varied experience in working with people from different cultures and faiths. In discussion with staff, there was an understanding and awareness of people’s cultural and religious needs. Service users’ care plans clearly indicated their assessed needs and after speaking to some individuals, it was evident that their needs were being met. Members of staff were observed supporting and interacting with service users who have complex and profound disabilities. The staff demonstrated a caring, sensitive, dignified and respectful approach, with service users responding positively and it was evident that good relationships existed between service users and the care staff. A thorough recruitment policy was in place with satisfactory procedures taking into account the need to protect service users. Staff files contained evidence that Criminal Record Bureau (CRB) checks had been carried out and staff are only employed on the satisfactory completion of these checks with two independent satisfactory references being obtained, thereby helping to ensure that service users are protected and safeguarded by having a robust recruitment and selection process. Individual staff supervisions are held on a four to six week basis, where any further identified training needs are discussed and acted upon. Supervision and training records were inspected and found to be satisfactory. Demonstrating overall that staff are suitably qualified, well-trained and supervised in order to meet the service users’ assessed needs. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The home is well managed and organised, ensuring as much as possible that service users receive a good quality service. EVIDENCE: The registered manager of the home is also the area director for Lisieux Hall; she is a registered qualified nurse (RGN) and has many years of experience in social care work. However, the person presently responsible for the day to day running of the home is the residential manager of Lisieux Hall and is also a RGN with lots of experience in care work and is presently in the process of studying for a BA honours degree in learning disabilities, it is planned for her to become the registered manager for Lisieux Hall. Service users’ files were well organised, containing up to date assessments with appropriate and comprehensive care plans. Pre–admission assessments and minutes of meetings were observed, involving the service users who are moving out of Lisieux Hall into community living. Documentation revealed that one service user was initially reluctant about going to live in the community, but after visiting the new accommodation and Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 19 being involved in every stage of the process, the persons’ key worker commented that the service user is now, “very excited, positive and looking forward to moving”, demonstrating that service users are (where possible) actively included in making decisions and choices in their lives. Lisieux Hall has maintained the ‘Investors in People Award’ for the past six years, which is an independent quality assurance-monitoring organisation. Evaluation questionnaires were recently completed by staff and the feedback was described as ‘good’, some comments from staff were, “ The management have taken notice of the things that were said in the questionnaires”, “We feel that we are included more than we used to be”, helping to demonstrate that service user’s and staff are consulted regarding their opinions and concerns and knowing they are taken seriously. There was documented evidence that all staff have received mandatory training, including: moving and handling, protection of vulnerable adults (POVA), the control of substances hazardous to health (COSHH) and infection control, with refresher courses being available when needed. There was an up to date health and safety policy, with comprehensive, individual and corporate risk assessments, promoting the health, safety and independence of service users. All inspection certificates were in place and up to date, including: gas safety certificates, electric check certificates, fire extinguisher checks, lifting hoists and emergency lighting certificates. The health and safety of service users and staff is promoted as much as possible to help ensure that people live and work in a safe and healthy environment. Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X 3 X Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 21 NONE 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lisieux Hall DS0000025567.V276421.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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. 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