Inspection on 23/11/05 for Lisieux Hall

This inspection was carried out on 23rd November 2005.

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

Other inspections for this house

Lisieux Hall 15/11/07

Lisieux Hall 30/01/07

Lisieux Hall 01/03/06

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 23rd November 2005 10:00 Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 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.V264348.R01.S.doc Version 5.0 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.V264348.R01.S.doc Version 5.0 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.V264348.R01.S.doc Version 5.0 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. 26th November 2004 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 32 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.V264348.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and it was completed by two inspectors and took place over one day. During the course of the inspection, discussions took place with service users, the director of services, the operations manager, and the care staff. The inspectors were able to observe service users throughout the day and also observed how staff members interacted with them. Four of the five homes that are still remaining at Lisieux Hall were inspected and a significant amount of time was spent in one of the homes. All of the five homes are registered to provide nursing care. What the service does well: What has improved since the last inspection? More than 50 of care staff have now completed NVQ training and the remaining staff are in the process of undertaking training. Lisieux Hall has received an award for medication administration training from North West training demonstrating that staff are competent in this area of care. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 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. An internal management audit has commenced to identify and address any gaps in the delivery of service provision demonstrating a pro-active approach to care delivery. Appropriate records are kept of menus and meals provided, demonstrating that adequate meals are given to service users. 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.V264348.R01.S.doc Version 5.0 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.V264348.R01.S.doc Version 5.0 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): 2 There is insufficient documented evidence that service users needs and aspirations are assessed. EVIDENCE: No new service users have moved to Lisieux Hall for quite a while and the majority of the service users who presently reside there will be moving into supported living accommodation and their support and care will continue to be provided by Brothers of Charity Services, thereby further promoting independence and social inclusion. For the service users who have more complex needs requiring nursing care they are likely to remain at Lisieux Hall, where their needs can continue to be met. The inspectors were able to case track a service user who will be moving into the community in the very near future. The service users file was examined and there was no evidence within the file that a needs assessment had been completed or any consultation carried out with the service user or with a representative of the person regarding the proposed changes. There was the opportunity to speak with the service user and the person was obviously aware that they would very soon be moving and said “I am really pleased to be moving to another home and glad that I will be living with people that I want to live with”. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 9 The staff who support this service user were also aware that the person would be moving to another place and confirmed that the person had been very much involved with all of the decision making, thereby demonstrating that service users rights and choice’s have been upheld. Eight of the service users individual plans were examined and these contained information relating to, personal profiles, important contacts, education, occupation, health checklists, communication checklists and self-help checklists. Although the plans had been regularly reviewed, there was insufficient information in the plans, mainly in relation to people’s aspirations, their likes and their dislikes. This had also been identified by a recent internal audit, carried out by Lisieux Hall and this is in the process of being addressed. Inclusion of this information will help to ensure that service users needs and aspirations are recognised and acted upon. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 10 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): 6,7,8 and 9. Care plans need to reflect the information gathered in the assessment process in order to ensure that identified needs are met. Service users are supported to make decisions and to take risks in order to promote an independent lifestyle. EVIDENCE: The service users plans that were examined were seen to contain relevant and appropriate information to cover service users basic care needs, although as already identified in standard 2, there is a need for more detail, in relation to service users changing needs, goals and aspirations. The inspectors had a discussion with two of the management team about this issue and there was an agreement that this would be addressed. The inclusion of this information would help to ensure that service users would receive the correct level of care and support. Each service user has a named key worker and for the service users who need nursing care, they have a named nurse and a key worker. This system of working helps to maintain consistency and continuity of care. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 11 There was documented evidence that six monthly care plan reviews take place with family involvement and annual reviews were social workers are invited to reassess if necessary any changed support needs. Again helping to ensure that service users needs are identified and met. The service users individual plans demonstrated that where service users are more independent, they were supported and encouraged to make informed decisions. For the service users who were less able, their individual plans highlighted that decisions were made in consultation with family members, key workers and advocates. In discussions with staff members, it is apparent that service users are empowered to be involved in making decisions in all aspects of their lives ensuring that their rights and choices are upheld. There were general risk assessments in the service users files, with information on pressure area risk assessment, manual handling, and risk assessments related to bathing and showering. These assessments demonstrated that service users health and safety is paramount at all times. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 12 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): 12,13,15,16, and 17. Service users were well supported to access appropriate activities in the local community. Service users are encouraged and enabled to make decisions and choices about their lives. EVIDENCE: In discussion with some of the service users and some staff members, it is evident that people are involved in various educational activities and in supported employment. There were charts in the units showing when service users are attending college or other vocational activities and this is also documented in care plans. This gives service users the opportunity to develop new friendships and relationships. In one of the units where people have complex needs and mobility problems, they have recently acquired their own transport, which can be used by people with wheelchairs. This has given the service users much more independence, Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 13 enabling them to access the local community, join other service users in social activities and promote community participation and inclusion. The service users files contained evidence that family links are encouraged and maintained. There is an open visiting policy within the units and staff ensure that family and friends are made welcome, to ensure that contact is kept with service users. Within each of the units there was evidence that where possible, choice and freedom of movement is promoted. This was documented in the policies and procedures and the inspectors also observed that service users have access to any part of the home. The inspectors observed that staff were very aware of the communication difficulties with service users and showed a range of communication skills, whether it was by behaviour, facial expressions or what certain movements may mean to each individual person, ensuring that as much as possible people are listened to and understood. If service users want to spend time alone, they are supported to do so and there were safety risk assessments in care plans demonstrating this, thereby allowing people to have their own space. Staff were observed, treating service users with respect and dignity during meal times and when service users were assisted to participate in activities. Some of the service users were able to perform certain household tasks, with the support of staff. This helps to increase independence and confidence. There were records of menus in place in each of the homes and staff informed the inspectors that service users, wherever possible have input into the development of menus. The inspectors were present during the lunchtime and observed that staff members supported service users in a calm, relaxed atmosphere, with sensitivity and gentleness. Records are kept in each home of all meals that are served and they were seen to be varied and healthy. In one of the homes, procedures are in place to provide guidance for staff in caring for a service user who requires percutaneous endoscopy gastronomy feeding (PEG). Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 14 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): 20 Medication is stored, administered and recorded correctly. Good Policies and procedures are in place covering all aspects of medicine control. EVIDENCE: Policies and procedures are in place regarding the control and administration of medication. There were capacity and consent to medication forms in individual service users files. Where service users were unable to give consent, there were statements in their files confirming this, demonstrating that service users are involved, were possible to make decisions. Medication sheets were recorded correctly with times and dosages of medicines and were seen to be up to date, ensuring that medicines are administered correctly. Room temperatures are recorded daily to monitor and ensure that medication is kept within the correct recommended temperatures. The organisation has been given an award for providing a good standard of medication training to staff. Only staff who have undertaken the training can administer medication ensuring the safety of service users. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 15 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): There were suitable policies and procedures in place to ensure as much as possible that service users are protected and safeguarded from harm and abuse. EVIDENCE: There was a thorough and adequate complaints policy and procedures in place for dealing with a complaint. This had been recently reviewed and updated and contained appropriate phone numbers and details of who to contact. The inspectors spoke to members of staff and they were fully aware of how to manage any complaint brought to their attention. The service users also knew what to do if they were unhappy about anything. There was a policy and robust procedures in place, to ensure that service users are protected as much as possible from any form of abuse. No employee can start employment without a criminal records bureau check (CRB) and a protection of vulnerable adults check (POVA) being made. This helps to safeguard that only appropriate people are employed to support and care for vulnerable adults. The inspector spoke to a number of staff all of whom knew what to do should an allegation or suspicion of abuse be brought to their attention. This demonstrated that staff are adequately trained in the protection of vulnerable adults. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: These standards were not inspected on this occasion. Although senior management informed the inspectors that the organisation is in the process of ensuring that service users have their own rooms, this was identified at the previous inspection. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 17 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): EVIDENCE: These standards were not inspected on this occasion. Although it was noted by the inspectors that the recommendation from the previous inspection regarding NVQ training for staff has been addressed. More than 50 of care staff have now completed NVQ training and the remaining staff are in the process of undertaking training. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not inspected on this occasion. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lisieux Hall Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000025567.V264348.R01.S.doc Version 5.0 Page 20 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 YA2 Regulation 14(1)(a) (c) Requirement The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (a) Needs of the service user have been assessed by a suitably qualified or suitably trained person. (b) The registered person has obtained a copy of the assessment. The registered person shall ensure that the assessment of the service user’s needs is – (a) Kept under review; and (b) Revised at any time when it is necessary to do so having regard to any change of circumstances. The registered person shall – (c) Keep the service users plan under review. (The timescale of 28/02/05 was not met) Timescale for action 28/02/06 2 YA2 14(2)(a) (b) 28/02/06 3 YA6 15(2)(b) 28/02/06 Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA24 YA25 Good Practice Recommendations The bathroom floor in St Edwin’s home should be repaired. This was recommended in the previous report. The registered person to provide each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyle. Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lisieux Hall DS0000025567.V264348.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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