Inspection on 15/11/07 for Lisieux Hall

This inspection was carried out on 15th November 2007.

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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lisieux Hall 30/01/07

Lisieux Hall 01/03/06

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 Mrs Marie Matthews Key Unannounced Inspection 15th November 2007 10:00 Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 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.V346754.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 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.V346754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lisieux Hall Address Dawson Lane Whittle-le-Woods Chorley Lancashire PR6 7DX 01257 266311 01257 265671 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 Lisa Fitzsimmons Care Home 32 Category(ies) of Learning disability (32) registration, with number of places Lisieux Hall DS0000025567.V346754.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 32 service users in the category of LD (Learning disability). 30th January 2007 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. Residents 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 residents access via public transport or taxi. 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 people with learning disabilities in the Chorley & South Ribble areas. Lisieux Hall is the administrative centre for the Brothers of Charity Services in Lancashire and has additional resources on site. The home is registered to accommodate a total of 32 residents with a Learning Disability, with some having nursing needs. There were twenty-four people resident at the time of the inspection and there are plans to reduce the numbers of residents accommodated as appropriate housing in the community becomes available. The Lisieux Hall site comprises of five small residential units in use at the time of the inspection visit. Residents have access to a range of work, educational and leisure opportunities in the local area. Information about the services offered by the home is provided in the form of a service user guide and is available, with a summary of the most recent inspection report, to existing and prospective residents and their relatives. At the time of the key inspection the weekly fees for this service range from £420.76 to £2074.30 dependant on the needs of the individual. Items not included in the fee include newspapers, toiletries, hairdressing, private chiropody and dental fees, holidays and transport. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection, including a visit to the home, took place on 15th November 2007. The inspector looked at records, talked to the person in charge, five staff and two people who lived at Lisieux Hall; the inspector also had a look around the houses to check if they were suitable and safe for people to live there. Four visitors, two doctors and one social worker also gave some information about the home. The inspection also looked at what had been done to improve things since the last visit. There were twenty-four residents living in the home on the day of the inspection. What the service does well: All residents at the home had an individual plan; the plan contained lots of useful information about them that would help staff to look after them properly. The person in charge made sure the individual plans were up to date and had been filled in properly to show what sort of help residents needed from staff. Residents, their relatives and friends and other useful people had been asked what care was needed. Staff made sure that residents were ready to move out of Lisieux Hall and helped them to visit the new homes so they could look around and meet the other people living there. Residents could do most things that they wanted. There was lots of different equipment around to help residents to do things on their own and to keep them safe and comfortable. Each resident had a special member of staff whom they could spend time with; this person was called a key worker and one visitor said her relative had an ‘excellent key worker’. Residents had an activity plan that showed they were able to take part in lots of different and exciting activities. Staff had collected lots of information about what resident’s liked to do and this helped when activities, work and outings were being planned. Staff said residents were involved in choosing the meals for each week; this helped to make sure that everyone enjoyed them and that the meals were suitable and healthy. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 6 Staff had been shown how to look after medicines and how to make sure residents were given the right medicines to keep them well. Staff knew how to keep residents safe and protect them from harm; people knew whom to go if something wrong. Staff knew how to look after residents properly. Staff said there were enough staff to make sure people were looked after and they were able to spend time with residents who needed their attention. Most of the staff had worked at the home for a long time and had got to know the residents and their families really well. The home made sure that people were safe by making sure all the proper checks on staff were done. Regular checks were done to make sure the home was running well and people were asked if things could be made better for them. Three of the houses had been decorated and looked nice and bright. Resident’s bedrooms were cheerful and comfortable. What has improved since the last inspection? What they could do better: The information about residents could be made available in other formats that they may understand better. Staff needed to make sure that the right information was written down to show that residents were being looked after properly. The person in charge needed to keep a check on whether staff were looking after residents’ medicines properly. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 7 Two of the houses needed some work doing to make them comfortable and safe for the residents who were living there, as they were not as nice as the other houses. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 8 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.V346754.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents and their representatives were provided with information and support to enable them to make decisions about where to live. Each resident had an individual plan that contained detailed assessments of their needs and showed how these would be met. EVIDENCE: People had been given useful information about Lisieux Hall in an easy to read picture and word format that was suitable for the residents who lived at the home. A newsletter was also sent out to keep people up to date. There had been no new residents admitted to the home for some time. The number of residents living at Lisieux Hall had decreased as people were supported with the move into the community into supported tenancies. Records showed residents, their relative or advocate, key worker and care manager had been involved in ongoing discussions and decisions regarding the move into the community. Visits to the new accommodation had been arranged to allow the residents to view the house and meet with other people living there. Each resident had an individual plan that contained details of their assessed needs and how these would be met. There was evidence that relevant people Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 10 had been involved in the assessments; this ensured all aspects of care were considered. Records showed that all staff were provided with a range of training to help them to meet the needs of the residents in their care. Registered nurses provided care and support for those residents who needed specialised nursing care. Records showed that advocates had been involved for some residents who needed extra support, help and advice. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ needs and personal preferences were assessed and recorded in an individual plan. Residents and significant others had been involved in ongoing decisions about care. EVIDENCE: Three individual plans were looked at; the individual plans were person centred and looked at all areas of the resident’s life. Each resident had an individual plan that detailed the support and care needed to ensure their needs would be met. There was detailed information about resident’s likes and dislikes that would help staff to meet their needs. Any restrictions on choice and freedom had been identified and assessed to ensure the safety and well being of the individual. However the individual plans did not always include any action to be taken by staff to reduce or eliminate risks that had been identified particularly around health care needs (see standard 19). The registered manager completed six monthly audits of all individual plans to ensure staff were following policies and procedures and meeting resident’s Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 12 needs. Areas requiring action had been agreed with staff and this had improved the standard of the records. There was evidence that residents, their relatives, advocates and other professionals had been involved in the development and ongoing review of the plan and had been involved in decisions about care; visitors commented that they were kept informed of important matters. The plans were not yet available in other formats that the resident may understand better. Each resident had a key worker who they could spend one to one time with both inside and outside the home. One to one time was recorded on the staffing rota to ensure staff were free to spend uninterrupted time with the resident. There was evidence to support that some residents had advocates who would act on their behalf. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents were supported to take part in a range of fulfilling and stimulating activities both inside the home and in the local community and were able to maintain appropriate relationships with family and friends. The menus offered a choice of suitable meals that met resident’s individual needs and preferences. EVIDENCE: Activity plans showed that residents took part in a wide range of fulfilling and stimulating activities that met their individual needs and expectations. Staff had obtained lots of information about resident’s preferences and likes and dislikes and these were taken into consideration when planning suitable activities. Some activities were one to one and others were in small groups of people with similar interests; some residents had photographs displayed that showed many of the exciting activities they had been involved in. Support for residents both inside and outside of the home was flexibly provided and was recognised by staff as an important part of their key worker role. It was clear Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 14 that people were supported to live ordinary and meaningful lives both in the home and in the community. Two residents went to football matches, another regularly visited a family grave, other residents had attended church and been canoeing, shopping and walking. There was an activity centre on site and residents were able to make use of this to help them to plan their activities. One GP said ‘leisure activities were well planned’. Holidays and activities were arranged for small groups of residents with similar interests or who had developed special friendships. One resident attended college; the course related to life skills and leisure activities. Many of the residents had moved into supported living accommodation and staff said some residents still kept in touch with friends at Lisieux Hall. One resident had a cat which other residents enjoyed; staff helped her to care for it. Routines were flexible according to people’s preferences and needs. Some residents had locks on their bedroom doors and risk assessments were in place to explain non-provision for other residents. Suitable locks were provided on bathroom doors to ensure residents privacy and the home provided both male and female staff to support choice and dignity issues. Each unit had their own menus; these had been updated following specialist advice to provide nutritious appetizing healthy meals with different tastes and textures. Menus were planned following discussion with residents and taking into consideration their likes and dislikes. Meals were varied and nutritious although the menus did not show a choice; staff said they would provide an alternative if necessary but generally residents were involved in planning and enjoyed the meals. Records showed that any alternatives to the menu had been recorded. Meals were cooked in the unit kitchens by staff with some assistance from residents if able; some residents helped to shop for food and ingredients. ‘Smoothie’ machines had been provided on each unit to ensure residents were able to enjoy fruit and themed evenings had been introduced to allow residents to try different foods. Mealtimes were relaxed and flexible to suit resident’s activities and those who needed help at mealtimes were given sensitive support. Kitchen areas were clean and tidy although the work surface in St Edwins kitchen was cracked and needed replacement and the gap in the wall tiles behind the cooker on The Beeches needed to be filled to ensure hygiene standards were maintained. (See standard 24). Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s healthcare needs were identified and met and they were protected by the homes policies and procedures for dealing with medication. EVIDENCE: Individual plans detailed resident’s preferences about how they would like to be looked after and supported; assessments were in place to support whether they were able to make decisions regarding their care and safety. Staff were aware of resident’s needs and responded appropriately maintaining residents privacy, dignity and independence. One GP commented that there were ‘clear standards with regard to respecting individuals privacy and dignity’. Routines were flexible around meeting resident’s needs and choices. There were a range of technical aids and equipment to meet individual needs, safety and comfort and to help residents maintain their independence. The staff group enabled residents to have a choice of male, female and age related preferences. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 16 Each resident had a key worker who would give personal support and attention and help residents to maintain contact with friends and family; one visitor said her relative had an ‘excellent key worker’. Residents were dressed in age appropriate clothing and some residents were able to go on outings with their key worker to shop for clothes. Access to local healthcare advice and support was recorded in a separate healthcare plan; records showed that resident’s health was monitored and a record of any visits by health care professionals was maintained. Comments from visiting healthcare professionals indicated that staff responded appropriately to changes in resident’s health; this ensured resident’s health needs were met. It was again noted that two of the residents had been identified as a high risk of developing pressure sores and whilst it was clear that action was being taken to reduce or eliminate the risks there were no records to support this. Medication records were looked at on two of the units. The medication policies and procedures had been reviewed and were available on all houses to provide safe guidance for all staff involved in the management of medication. There were no residents who were able to self-administer and this had been risk assessed; consent for staff to manage resident’s medication had been obtained and included in the plan. Records were clear and accurate and showed that medication was safely managed. Areas of concern identified at the last inspection visit had been resolved; prescriptions were checked prior to dispensing and ‘PRN’ protocols were stored with the residents chart for safe reference. However staff were reminded that all handwritten directions should be witnessed to prevent any errors. Staff confirmed they had received drug administration training and assessments to ensure they had the appropriate skills. There were no formal audit systems in place to monitor whether staff were following safe policies and procedures. Advice was supplied to the registered manager to assist with this. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were protected from abuse, neglect and self-harm by staff awareness and the homes policies and procedures. EVIDENCE: The complaints procedure was clear and ensured that all complaints would be dealt with sensitively and appropriately. The registered manager said there had been no complaints since the last visit. The format of the procedure had been changed following discussion with residents and was now included in the service user guide in words and pictures and was given to residents and their representatives. Two visitors said they were unaware of a complaints procedure but were sure any concerns would be dealt with appropriately and staff were aware of the importance of listening and responding to peoples concerns. The safeguarding adults procedures had been reviewed and provided clear guidance for management and staff to respond appropriately to any suspicion or allegation of abuse. Records showed that staff received safeguarding training to refresh their knowledge and staff confirmed this was mandatory. The service used external agencies to assist them to achieve safe practice around safeguarding adults. Financial records were checked for two residents. Records were accurate and resident’s finances were safeguarded; it was discussed with the registered manager that the statements supplied to the houses relating to personal allowances should include resident’s names. Financial audits were in place to monitor whether staff were following policies and procedures and acting in the best interest of the residents in their care. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Attention was needed to ensure all residents were provided with a clean, safe and comfortable environment that met their collective and individual needs. EVIDENCE: Lisieux Hall is located in extensive and attractive grounds that are safe and accessible for residents, staff and visitors. Residents lived in separate noninstitutional units or houses; each house had its own facilities and designated staff team. During the inspection visit five houses were occupied and visited; the registered manager said that there were plans to close two of the houses early 2008 when more residents had moved into housing in the community. All of the houses were single storey buildings and easily accessible for people in wheelchairs. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 19 Three of the houses had recently been refurbished and provided bright, comfortable, clean environments that reflected the needs and choices of the residents who lived there. Whilst it was appreciated that two of the houses were planned for closure it was recognised that some work was needed to improve the environment for the residents who live there until alternative accommodation was provided. Areas requiring attention on The Chimes include: there were no restrictors on windows and the house was unoccupied and unlocked at the time of the visit which was a safety and security risk, the sofa in the lounge was badly damaged and the clock was broken, the corridor ceiling paper was hanging down in one area, curtains in one resident’s bedroom were falling off the curtain rails due to lack of curtain hooks, beds were not supplied with valances and bed bases were exposed and one was stained, wallpaper in one residents room was worn and the lounge contained only a small portable TV. Areas requiring attention on The Beeches include the bath base was exposed and rust evident around the sealant, there were no restrictors on windows, tins of paint were stored in toilet, double glazing units were faulty in the kitchen and small lounge, one unoccupied room had new furniture whilst another occupied room contained mis-matched furniture, the tiles above the cooker needed replacing and the kitchen fan was dirty. Areas requiring attention on other units included St Edwins needs a drawer repairing, the damaged kitchen work surface needed replacing and the trip hazard in the doorway to the laundry areas needed attention. The Woodlands needed a blind at the bathroom window as it overlooks a public pathway. Bedrooms were in the main comfortable and personalised and suited the needs and lifestyles of the individuals. There were locks on some bedroom doors and risk assessments were seen to support this. Bathrooms and toilets were fitted with suitable locking devices to ensure resident’s privacy whilst being supported by staff. Generally communal areas were bright and comfortably furnished. Various aids and equipment were provided to meet the assessed needs of individual residents. There was a plan for maintenance and renewals and a dedicated maintenance team was available for this. Staff said requests for repairs were attended to promptly to ensure the environment was safe and well maintained. Staff were responsible for the cleanliness of each house. The houses were clean, tidy and odour free. Laundry and sluicing facilities were available on each house. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Resident’s needs were met by an established team of qualified and competent staff who were well supported and supervised in all aspects of their work. The home followed a robust recruitment procedure that ensured residents were protected from unsuitable people. EVIDENCE: The rotas were clear and showed sufficient staff were provided to meet the needs of the residents; staff confirmed this and said time was designated for key workers to spend with the residents. Due to residents moving into the community no new staff had been employed and staff turnover was low; this was good for continuity of care. The service relied on some agency and bank staff but the same staff were provided where possible and were assigned to a named manager to provide them with the support they needed; an agency staff on duty at the time of the visit said ‘It’s a nice place I like coming here’. Regular staff meetings had taken place and staff were confident their concerns and suggestions would be taken seriously. Staff had been invited to join a staff consultation forum, which would allow them to have more input into decisions about how the service is run. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 21 Two staff recruitment files were looked at and both contained the appropriate checks and documentation that ensured the protection of residents. There was no evidence that residents had been involved in the recruitment process although an open invitation had recently been sent to relatives to become more involved in this. From records and discussions with staff it was clear that a number of staff had an appropriate NVQ qualification in care or were working to obtain one by an agreed date. Staff were provided with a wide range of training to ensure they had the skills and experience needed to meet resident’s diverse needs. Staff confirmed they received annual reviews and were regularly supervised to identify any need for extra training and support. All staff had training records and were advised what training they needed to attend each year to maintain their competency. One care staff said ‘the training is very good we are given the skills to look after people properly’. Training plans were available for each unit although one supplied for the inspection was not up to date and should be reviewed. People made positive comments about management and staff; these included they are ‘very respectful to individual needs’, ‘very good communicators’, ‘very caring and go out of their way to do extra if they think its appropriate’ and ‘ Lisieux Hall is a forward looking organisation’. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. People benefited from a well-run service that respected their views and opinions and protected them from harm. EVIDENCE: Lisa Fitzsimmons is the registered manager for the home. Lisa is a registered general nurse and has recently achieved a degree in Learning Disability Studies and is undertaking a management qualification to enhance her skills and knowledge. Staff made positive comments about Lisa’s contribution and said she was ‘approachable’, ‘supportive’ and worked hard to improve the service. There were quality assurance systems in place to monitor whether the service was meeting resident’s and relatives needs and expectations. One visitor said ‘regular support meetings are held to discuss any issues’. Annual stakeholder events and bi-monthly service users meetings are held to determine whether Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 23 they were meeting people’s needs and expectations; comments and suggestions from these meetings were used to improve and develop the service. The service had achieved the Investors in People Award and more recently the Charter Mark Award; these are nationally recognised quality systems that monitor day-to-day management of the home. Policies and procedures were regularly reviewed and updated in light of changes to legislation and residents needs. A development plan was available for the next 12 months; this showed that areas for improvement had been identified and would be kept under review. Audits were in place to monitor care planning, finances and environment although it was recommended these should be extended to cover medication (see standard 20). Records supplied prior to inspection showed that people’s health, safety and welfare was protected. Lisieux Hall DS0000025567.V346754.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 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 4 2 4 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 2 2 X 2 X 4 3 X 3 X Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 15 Requirement The individual plans must clearly indicate what action staff must take to ensure resident’s healthcare needs are met with particular reference to pressure risk assessment. Timescale of 19/03/07 not met. Timescale for action 07/01/08 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 Standard 1. YA6 Consideration should be given to providing individual plans in other formats 2. YA20 Handwritten directions on MAR sheets should be witnessed. Audit systems should be developed to ensure staff are following medication policies and procedures. A detailed audit of all houses should be completed to identify areas needing attention; this should be forwarded to the maintenance department for action. Consideration should be given to fixing restrictors to windows on The Chimes and The Beeches to improve security. Houses should be locked when unoccupied. DS0000025567.V346754.R01.S.doc Version 5.2 Page 26 3. YA24 Lisieux Hall 4. YA37 The torn sofa and the broken wall clock on The Chimes should be repaired or removed. Damage to the ceiling paper on The Chimes should be repaired. Curtain hooks should be provided for the curtain in a bedroom on The Chimes. Consideration should be given to providing valances and bed bases should be clean on The Chimes and The Beeches. Consideration should be given to providing a larger TV in the lounge at The Chimes. The paint tins should not be stored in the toilet on The Beeches. The gap in the tiles around the cooker on The Beeches should be sealed. The extractor fan on The Beeches should be cleaned regularly. The broken drawer and kitchen worktop on St Edwins should be repaired or replaced. The trip hazard on St Edwins should be re fixed. A bathroom blind should be provided on The Woodlands. The registered manager needs to obtain a management qualification at level 4 NVQ. Lisieux Hall DS0000025567.V346754.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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