Inspection on 26/04/07 for Lister House

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Lister House 01/12/05

Lister House 09/06/05

Lister House 02/11/04

Lister House 22/07/04

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

CARE HOMES FOR OLDER PEOPLE Lister House 13 Heaton Road Heaton Bradford West Yorkshire BD8 8RA Lead Inspector Mary Bentley Unannounced Inspection 26th April 2007 09:30 X10015.doc Version 1.40 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 Lister House DS0000019882.V335423.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lister House Address 13 Heaton Road Heaton Bradford West Yorkshire BD8 8RA 01274 494911 01274 547693 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) Lister House Limited Mrs Jacqueline Mitchell Care Home 32 Category(ies) of Physical disability (32), Physical disability over registration, with number 65 years of age (32), Terminally ill (2), of places Terminally ill over 65 years of age (2) Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Lister House is a large detached Victorian property, which has been extended to provide accommodation for thirty-two people who require personal and nursing care. The home is situated in a quiet area of Manningham on the outskirts of Bradford close to a bus route from the city centre. There is a small corner shop nearby. The home is situated in well-maintained attractive gardens and provides off road parking. A safe enclosed courtyard in the centre of the home is accessible from the communal areas. The home has twenty-six single rooms, half of which have en-suite facilities, and three shared rooms. There is a passenger lift to the first floor. The home has a no smoking policy. In April 2007 the weekly fees ranged from £456.95 to £757.52. Additional services such as hairdressing, chiropody, and physiotherapy are available at an extra cost. The fees are reviewed every year in November. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I did this unannounced inspection in one day and spent approximately 8 hours in the home. The purpose of the visit was to look at how the needs of people using the service are being met. During the visit I spoke to people who live in the home, visitors, staff and management. I looked at various records relating to care, staff, and maintenance and I looked at some parts of the home. The home completed a pre-inspection questionnaire and the information provided was used during the inspection. Before the visit we sent comment cards to 19 people, (9 to people who live in the home, 7 to relatives and 3 to GPs). Comment cards give people the opportunity to tell us what they think about the service. The information we get is shared with the home but we do not identify who has provided it. Ten cards were returned and the information provided has been included in this report. Overall people were satisfied with the service. What the service does well: People said they were well cared for; these are some of the comments we received from people living in the home: • • • “First class, we want for nothing” “I could not be in a better place”. “I feel I am very well cared for and the staff are always willing to help and encourage”. One relative said “Friendly home, visitors welcomed at any time. Staff are always pleasant. Keep you up to date with changes” People said the food was good and they were always offered a choice. During the visit I heard staff asking people what they would like for lunch. One person said, “If I do not like the offered menu the kitchen staff will bring me something else” The home is clean and comfortable, it is decorated and furnished to a good standard and provides a pleasant place for people to live. Suitable equipment is available to support people with disabilities such as a passenger lift, assisted bathing facilities and hoists. People who live in the home are encouraged to bring some personal belongings with them to make their bedrooms feel more “homely”. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given good information about the service and every effort is made to make sure that the home will be able to meet their needs before they move in. EVIDENCE: Most people said they had been given enough information to help them decide if the home was suitable to meet their needs. People are encouraged to visit the home before making a decision about moving in. Generally it is relatives who make the initial visit as most of the people living in the home come from hospital. A number of people said friends had recommended the home to them. One person said that when they were looking for a suitable home for their relative they had visited Lister House in the evening without an appointment. They said they had been given lots of information and all their questions had Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 9 been answered but they had not seen the Statement of Purpose. The manager said that everyone who enquires about a place is sent written information, this includes a print out of the home’s website which is an extract from the Statement of Purpose. The records showed that the home carries out detailed pre admission assessments. They visit people and get information from relatives and other professionals to help them decide if they will be able to meet people’s needs before a place is offered. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s health and personal care needs are met in a way that respects their privacy and dignity and takes account of their wishes. EVIDENCE: I looked at four people’s care records. Each person living in the home has 2 sets of records, one for nursing staff and one for care staff. The records show how people’s health and personal care needs will be met. There was evidence of involvement by other health care professionals such as GPs and speech therapists. Risk assessments are done in relation to falls, nutrition, moving and handling and the risk of developing pressure sores. Where necessary care plans are in place showing how the risk will be dealt with. The records of one person with a pressure sore showed that the tissue viability nurse specialist had been consulted about the treatment plan. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 11 People living in the home looked well cared for and they said they were. They said they have regular chiropody and eye tests. The majority of relatives said they were kept well informed by the home and consulted about how care needs would be met, one person said “staff are good at keeping in touch with me and letting me know about any changes, GP visits etc”. One person said they had not seen their relative’s care plans until they had asked about them. One GP practice expressed some concern about the availability of nursing staff to help with the examination of people during visits. This was discussed with the manager who said she thought it was unfounded as nurses are the only staff who deal with GPs when they visit people in the home. There are suitable systems in place to make sure that medicines are managed safely. None of the people living in the home manage their own medicines. There is a policy in place to deal with this should anyone wish to. Screens are provided in shared rooms. During the visit I saw that care was given in a way that showed respect for people’s privacy and dignity. People said staff are kind and caring. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are provided with opportunities to take part in a variety of social and leisure activities in the home; some people felt they would like more opportunities to go out. People’s individuality is respected and there is strong commitment to meeting people’s cultural and religious needs. EVIDENCE: Daily routines are flexible and people are encouraged to choose how and where to spend their time. One person was going to bed at 3.30 pm, she was very clear that this was what she wanted, she said she got tired sitting and liked to get into bed before her evening meal. The home offers a variety of social activities including bingo, quizzes, chair aerobics, craft sessions, and musical entertainment. People said there was plenty going on in the home. Some people said they would like to be able to go out more. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 13 Information about planned social events is displayed in the home. While I was in the home there was a quiz and a communion service in the morning. In the afternoon an aroma therapist visited and several people had hand massages. One of the activities organisers said that as well as organising group activities in the lounge she goes to see people in their rooms. The home has two cats and it was evident that people get a lot of pleasure from having them around. One person who prefers to spend most of her time in her bedroom said she looks forward to a visit from one of the cats every day. There are a number of people from eastern European backgrounds living in the home. In order to make sure their cultural needs are met the manager encourages their families to take an active part in their care. The home has purposely employed a number of care workers with eastern European backgrounds. The manager said this has been very successful, particularly for those people who cannot speak English. A number of people mentioned links with their local church and in some bedrooms people had religious symbols on display. The manager said she is very proud of pastoral care provided; the home has good links with the local Church of England vicar and the Roman Catholic and Ukrainian priests. Relatives said the home was friendly and they were always welcome. People said the food was good and there was always a choice. The lunchtime meal was nicely presented and looked appetising. Where necessary people were helped discreetly and staff chatted to people while helping them to eat. Aids such as plate guards are provided to help people eat independently. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People can be assured that any concerns they have will be taken seriously and acted upon. People are protected and their rights are respected EVIDENCE: The home has had one complaint since the last inspection and this has been dealt with. No complaints have been referred to us. There is a system for recording all complaints and the action taken. Most people said they know who to talk to if they have any concerns. One person said, “I very rarely have to make any complaint” and another said, “Can’t say I have actually seen the complaints procedure, but know who to speak to”. One relative said they were not aware of the complaint procedure. People said that when they had raised issues the home had dealt with them appropriately. The management team encourages people to talk to them if they have any concerns so that any issues can be dealt with as they arise. The majority of staff have had adult protection training and more training is planned. The manager is an accredited adult protection trainer and is able to Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 15 provide this training in house. Staff understand what is meant by abuse and know how to report any concerns they might have. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is clean, pleasant, and comfortable. It provides a safe environment and is properly equipped to meet the needs of the people who live there. EVIDENCE: The home was clean and there were no unpleasant odours. People said the home is usually clean and fresh. One person said “Everything looks clean when you go in no matter what time of day”. The home is well maintained inside and out. There is maintenance cover 7 days a week so that essential jobs such as replacing light bulbs can be dealt with immediately. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 17 The kitchen was recently inspected by the Environmental Health department of Bradford Council and was given the highest possible rating for its hygiene and food safety standards. The communal rooms are on the ground floor and there is direct access to an enclosed courtyard. Some people said they did not think this area was used enough and said they like to be able to sit outside more often. The dining room is relatively small for the size of the home; it can only accommodate 8 people. However, this is not a problem for the people living in the home at the moment. This is because most people choose to have their meals either in the lounge or in their bedrooms. The manager said they have tried to encourage people to use the dining room but generally people only use it when they have guests for a meal. There is a passenger lift to the first floor, which means that people with physical disabilities have easy access to this area. There are only 2 bedrooms that are not easily accessible because they are up some steps (two). The manager is looking at ways to improve access to these rooms. In the meantime the rooms are only offered to people who are able to manage the steps safely. People have easy access to communal toilets and assisted bathing facilities on both floors. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staffing levels are reviewed and adjusted to take account of the changing needs of people living in the home. Staff are supported in developing the skills and knowledge they need to meet people’s needs. EVIDENCE: Duty rotas are available for all staff. There are usually 5 or 6 care assistants on duty during the day with a nurse. Overnight there is one nurse and 4 care assistants. The home employs separate staff for housekeeping and catering, and also has a handyman and receptionist. People said the staff are very busy but overall they were satisfied that staff were available when they needed help. One person said it was very comforting to know that there was always someone around if she needed help. People said the staff are kind and always willing to help. Some relatives said that they didn’t often see staff in the lounge in the afternoon and always had to ring for help. When I was walking around the home it was evident that staff were busy caring for people who has chosen to stay in their bedrooms. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 19 Overall relatives felt staff had the right skills and experience to look after people properly, one person said they were not sure, as they did not know what training staff had received. The National Minimum Standards recommend that 50 of care staff are qualified to NVQ (National Vocational Qualification) level 2 or above, Lister House has exceeded this; 98 of care staff have an NVQ. The staff files showed that the home has good recruitment procedures and the required checks are carried out before new staff start work. The records showed that all new staff are given induction training and staff confirmed this. At the last inspection a recommendation was made that 2 people should conduct interviews, the manager said this is not always possible. The home is in the process of implementing a new system for recording training which, when completed, will show exactly what training each member of staff has done. The records showed that as well as mandatory training such as moving and handling and infection control, there has been training on falls prevention, palliative care, epilepsy, continence, communication, and mouth care. The home is in the process of setting up a staff supervision programme and I saw evidence of this in the files. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management team provide strong leadership and work hard to create an open and inclusive atmosphere where people are encouraged to make decisions, exercise choice, and express their views of the service. EVIDENCE: The home is owned and managed as a family concern and all members of the group are actively involved in the day-to-day running of the home. Staff said they felt supported and enjoyed working in the home. The home sends questionnaires to people once a year, usually in December. The results are looked at and feedback is given to people either individually or Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 21 in meetings. There is an internal auditing system, which means that different aspects of the service are looked at on a regular basis. For example there is a monthly room check to make sure that the bedrooms are being kept clean and in a good state or repair. There are residents meetings where people are encouraged to give their views of about all aspects of the day-to-day running of the home. The manager said they try very hard to promote an open culture where people feel able to make comments and suggestions about any aspect of the service at any time. The home does not get involved in dealing with people’s financial affairs but does hold small amounts of personal money for some people. There are records of all transactions and receipts are kept. The majority of the maintenance records were up to date and showed that equipment is maintained and serviced at the required intervals. The home does not have an electrical wiring certificate. The manager said she would arrange for the necessary work to be done as soon as possible and send us a copy of the certificate. Weekly checks are done on the fire safety systems and there are regular fire drills. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 X 2 Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1 2 Refer to Standard OP16 OP30 Good Practice Recommendations The home should make sure that everyone has written information about the complaints procedure. The home should make sure their induction training programme includes all the elements of the Skills for Care induction standards. Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Lister House DS0000019882.V335423.R01.S.doc Version 5.2 Page 25 - 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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