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Inspection on 14/02/06 for Lister House, The Royal British Legion

Also see our care home review for Lister House, The Royal British Legion for more information

This inspection was carried out on 14th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff were observed to work with service users in a considerate and respectful way. Service users said that they found staff to be helpful and courteous. Policies and procedures and other statutory records are well organised ensuring that the home can be run in an efficient manner

What has improved since the last inspection?

Since the last inspection, work has been completed to improve care planning. The environment has improved with the reconstruction of accommodation, re decoration and refurbishment.

What the care home could do better:

Nothing was found at this visit that needed any action to improve the way the home operates.

CARE HOMES FOR OLDER PEOPLE Lister House, The Royal British Legion Southgate Ripon North Yorkshire HG4 1PG Lead Inspector Chris Taylor Unannounced Inspection 10:00 14 February 2006 th 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, The Royal British Legion DS0000039577.V260319.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 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, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lister House, The Royal British Legion Address Southgate Ripon North Yorkshire HG4 1PG 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) 01765 607878 01765 690917 The Royal British Legion Mrs Mary Edna Petronelle Fowler Watts Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (55), Physical disability (5) of places Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: Lister House is a large purpose built building set in its own well kept grounds within reasonable wlaking distance of Ripon town centre. The home is owned by The Royal British Legion and admission to the home is generally specific to people who are serving or have served in the Military or Associated Arms and their dependants. There is a hydrotherapy pool on site and a staffed physiotherapy department. A major redevelopment programme to the facilities has recently been completed this included building a purpose built 16 bedded unit for people with dementia. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two inspections carried out this year. The inspection was carried out at short notice to ensure that the manager could be present. Two residents were asked about their experience of living at the home and staff were observed carrying out their duties. The inspection concentrated on assessing those standards not assessed at the previous inspection and checking on compliance with recommendations. This included checking records kept about staff and service users and polices and procedures. Major alterations have been completed in order to improve accommodation and these areas were visited. A dementia unit, named The Coleston Unit, has recently been built in the grounds and is registered with the CSCI. The home is currently assessing service users to move into the unit. The inspection took five hours including preparation time. This report should be read in conjunction with the report for the inspection of 23rd August 2005. What the service does well: 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. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 6 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, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Service users’ health and social care needs are met. EVIDENCE: Although service user plans were inspected at the previous inspection and they were of a good quality some improvements were required with regard to information about service users social and emotional needs. These are now included and provide detail of the support service users need and how that support is provided. Individual needs are cross-referenced to risk and moving and handling risk assessments. Daily records provide a good record of daily life. One service user plan checked indicated needs that would be better met in the Coleston Unit. The manager confirmed the service users needs had been re assessed and discussions with relatives about a transfer to the unit were taking place. Previously there were some delays in answering call bells, however the manger has installed new alerting panels which can be easily seen by staff. No further problems with delay have been reported. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users live in a home that is clean, comfortable and well maintained. EVIDENCE: The refurbishment work is now completed. All bedrooms are en suite and have up to date specialist aids and adaptations. Those rooms visited had all been personalised by the service user. Service users commented favourably on the new refurbishment stating larger rooms and better equipment make life more comfortable. The grounds are spacious and are accessible to all service users. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. Recruitment procedures protect service users from abuse. EVIDENCE: The previous report commented that the format of the application form does not require a full employment history. The manager is unable to amend a corporate document and it is now being amended nationally, but has yet to be implemented. Until such time the manager ensures employment history is addressed during the recruitment process. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Staff are supervised appropriately. EVIDENCE: The previous inspection reported on the workload for the manager. At that time she was overseeing the new build of the dementia unit and refurbishment of the main building as well as being responsible for the day-to-day management of the home. A recommendation was made that a deputy manager be appointed as soon as possible. The deputy manager commenced in post in November 2005. The manager and deputy have clear roles and responsibilities and it was clear during the inspection that they work well together. Senior staff are due to attend specific training with regard to providing supervision and appraisal. A format for supervision is also due to be implemented. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 14 The manager and deputy work alongside staff and as such monitors their practice. At every shift change there is handover where specific issues relating to service users are discussed. Polices and procedures are discussed at regular staff meetings. Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 15 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 3 x x Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Lister House, The Royal British Legion DS0000039577.V260319.R01.S.doc Version 5.0 Page 18 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!