Inspection on 26/08/05 for Locharwoods

This inspection was carried out on 26th August 2005.

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

Locharwoods 19/04/07

Locharwoods 18/08/06

Locharwoods 10/02/06

Locharwoods 01/10/04

Locharwoods 18/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Locharwoods 23 Carrs Crescent Formby Liverpool Merseyside L37 2EU Lead Inspector Mrs Trish Thomas Unannounced Inspection 26th August 2005 10:00 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 Locharwoods DS0000038689.V252967.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. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Locharwoods Address 23 Carrs Crescent Formby Liverpool Merseyside L37 2EU 01704 832047 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) locharwoods@hotmail.com Mr Stuart Gordon Pearson Mrs Charlie Pearson Mrs Linda Margaret Anderton Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 18 OP. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the CSCI. 1/10/04 Date of last inspection Brief Description of the Service: Locharwoods is a care home for 18 older people. The home is owned by Mr. S. and Mrs. C. Pearson. Mrs. Linda Anderton is the registered manager. Locharwoods is a large converted house in pleasant and secluded gardens. Situated in a quiet residential area of Formby, the home is close to shops and local amenities. Locharwoods is staffed throughout the day and night and provides personal care, single accommodation, meals, laundry and in-house social activities. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The methods used in the un announced inspection were, discussion with residents, with Mr.& Mrs. Pearson(the owners), and one member of care staff, by reading records maintained in the home and by direct observation of the environment and practice. The inspection took place during the afternoon period and the manager was not on duty at this time. Minor shortfalls were noted with regards to record keeping in relation to care plans, medication and residents’ safekeeping and recommendations are made in the relevant section of this report. A requirement is made in relation to fire safety procedures. There is a pleasant atmosphere in the home and the residents appeared at ease, spending time where and how they chose. The majority were involved in a quiz in the conservatory. Three residents joined me in the front lounge, they said they were satisfied with the service and could not ask for more. All residents looked well cared for and appeared at ease in each other’s company and with staff and the owners. What the service does well: Mrs. Anderton and Mr. & Mrs. Pearson have been pro-active in reviewing policies and procedures in accordance with National Minimum Standards and improvements to this aspect of service have been noted over recent inspections. A copy of the Service User Guide is left in the reception area and is available to residents and visitors who may wish to read it. The building is well maintained and a refurbishment programme has been undertaken since the present owners took over. The environment is bright, clean and comfortable and residents’ bedrooms are pleasant and personalised. The home provides single accommodation, some bedrooms having en-suite facilities. Communal space consists of two lounges, a conservatory and a dining room. A training programme has been established in line with mandatory and NVQ requirements, and there is a system for formal supervision and appraisals. Mrs. Anderton holds a management qualification. She has worked in the home for a number of years and along with the long-term staff, has provided continuity to residents through the change of ownership. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 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. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 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 Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 The home was meeting standards 2 and 3. All residents are issued with a written contract, statement of terms and conditions. Admissions are subject to professional assessment and a home’s assessment post admission. The home does not provide intermediate care and will not be measured against standard 6. EVIDENCE: Standard 2. Reference was made to a copy of the home’s Statement of Terms and Conditions. All admission s to the home are subject to contracts of residence and the terms include conditions of residency, notice period, rates and additional service charges. Standard 3. Assessments are held on residents’ care files. Home’s assessments are comprehensive and refer to the individual’s health and personal care, sensory impairments, and mobility needs. The assessment forms the basis of the care plan. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 9 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): 7,8,9,10 The home was meeting standards 8 and 10. Shortfalls were noted regarding standards 7 and 9 with regards to maintaining records and recommendations are made. EVIDENCE: Standard 7. Care plans for all residents were in place. A sample of three care plans was tracked. One was for a recent admission and the review date had not been reached. This resident was assessed as of low dependency, whose needs could be met within the resources available in the home. There was an assessment of health and personal care, diet and social preferences. Two care plans, which were read, had been recently reviewed. Weight loss for one longterm resident, (whose condition was deteriorating), was cross-checked on the care plan, and it was on record that staff had taken appropriate action by contacting the G.P. Advice was given with regards to residents’ personal details, which are recorded in a daily report book. It is advised that as an alternative to the report book, daily diary sheets should be completed using an individual page for each resident, to be filed with the care plan. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 10 Standard 8. All residents are registered with a G.P. who was named on their care records. There was evidence on care plans that referrals are made to doctors and district nurses, in accordance with ongoing assessment. Referrals are made for nursing assessments in cases where the home is unable to meet the resident’s needs, due to increased frailty and deterioration in general health. Standard 9. Reference was made to the home’s medication policy and relating records. Prescribed medication is blister packed and stored in a trolley, which is secured and the keys held by the responsible person for the shift. Staff who administer prescribed medication receive training with updates. Mrs. Pearson said that further instruction had been arranged with the pharmacist. Shortfalls were noted on the Medication Administration Records. It is good practice to obtain a pharmacy label for any changes in prescribed medication. In instances where staff have handwritten/altered Medication Administration Records, it is advised that the writer signs the alteration and a colleague checks and signs it. Standard 10. Residents who commented had no concerns relating to staff conduct with regards to respect and privacy. Residents occupy single rooms and bathroom and toilet doors were closed at the time of inspection. Staff were observed speaking respectfully with residents and there appeared to be a pleasant and relaxed atmosphere in the home. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 11 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): 12,15 The home was meeting standards 12 and 15 at the time of inspection. The evidence obtained was supported by residents’ comments. EVIDENCE: Standard 12 was not fully assessed as the activities diary and the outcomes of consultation with residents on social activities, were not seen. In conversation, residents mentioned liking bingo and music. A quiz was in progress in the conservatory at the time of inspection. About ten of the residents were taking part and appeared to be enjoying themselves. Residents were moving freely throughout the home and appeared relaxed in the company of staff and Mr. & Mrs. Pearson, who assisted with the inspection. Standard 15. The dining room is bright and in good decorative order with adequate seating space for eighteen residents. The tables were well-presented and the environment pleasing and suitable for its purpose. Menus gave evidence of a good choice of meat and fish dishes with seasonal vegetables and desserts. Choices and alternatives are provided and special diets catered for. A chef is employed five days a week, and her days off are covered by a part-time replacement chef. The kitchen was clean and well organised at the time of inspection, and all equipment was said to be in working order. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 12 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): 16,18 The home was meeting standards 16 and 18. The home has a complaints procedure and an adult protection and whistle blowing policy. EVIDENCE: Standard 16. Reference was made to the home’s complaints procedure, which is accessible to residents and provides stages and timescales for investigations. A record of complaints is held on the premises. Standard 18. Reference was made to the home’s Adult Protection and Whistle Blowing Policy. Staff receive training in Protection of Vulnerable Adults. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 13 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): 19,26 The home was meeting standards 19 and 26. Since they purchased the home, Mr. & Mrs. Pearson have undertaken a programme of decoration and refurbishment. The home was clean, well organised and odour freeing the areas which were visited. EVIDENCE: Standard 19. The home looks bright and clean and recent attention to decoration, furnishings and flooring throughout the communal areas was evident. Mr. Pearson said that en-suites had been refurbished, non-slip flooring has been fitted where necessary and a new carpet is planned for the hallway and stairs, which have recently been decorated. Decoration and furniture replacement in bedrooms is ongoing, and a ground floor bedroom was in the process of refurbishment at the time of inspection. The exterior of the building and gardens are well maintained and give an excellent first impression of the home. The rear garden has seating arranged and is accessible to residents who wish to sit out in fine weather. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 14 Standard 26. The building was maintained to a good standard of cleanliness at the time of inspection. The home employs domestic staff, who are provided with protective clothing. There is a secure area for storing cleaning materials and utensils. The home has policies on COSHH and infection control. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 15 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): 27,30 The home was meeting standards 27 and 30. Staffing levels were maintained in accordance with the rosters. Staff training is ongoing and updates in mandatory training had been arranged. EVIDENCE: Standard 27. Reference was made to the staff roster, which provides evidence that agreed staffing levels are maintained. No review of staffing levels was necessary with regards to the levels of dependency amongst residents, at the time of inspection. Staff on duty did not appear to be rushed and had time to organise activities in the conservatory. Residents expressed no concerns with regards to staff availability and said they were always prompt and helpful if needed. Standard 30. Reference was made to training plans and Mr. Pearson confirmed the current position with regards to training. NVQ was at about 48 achievement level, and is ongoing due to staff turnover. Updates in mandatory training have been undertaken or arranged as follows : First Aid, Moving and Handling, Basic Food Hygiene, Health & Safety, Protection of Vulnerable Adults. Mr. Pearson confirmed that staff receive formal supervision every two months. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 16 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): 35,38 Standard 35. The home does not become involved in residents’ finances other than management of their personal allowances held on the premises. These were audited and in good order at the time of inspection. The home was not meeting this standard, as a minor shortfall was noted in record keeping. Standard 38. Certification was up to date. The home was not meeting the standard, as the weekly fire alarm system tests had not been maintained, last recorded was 31/7/05. EVIDENCE: Standard 35. Since taking over the home, Mr. & Mrs. Pearson have reviewed procedures with regards to residents’ money. Mr. Pearson confirmed that the home does not take responsibility for residents’ finances. Responsibility for residents’ personal monies remains with the resident or their representative. In certain instances, residents’ personal allowances, are held on the premises and their money is available to them on request. Reference was made to the safe-keeping book which records all personal allowance transactions. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 17 This was well maintained with regards to credits and debits and receipts for purchases are retained. Mr. Pearson was advised to obtain two signatures for all transactions relating to personal allowance. The signature of the resident/relative and a member of staff, or two members of staff should be obtained to provide accountability and protection. A recommendation is made. Standard 38. Reference was made to health and safety certification and the fire log book. Water temperatures are tested monthly and were maintained at a safe level at the time of inspection. Gas Certificate 28/1/05, Electric Certificate 4/3/05, Lift August 05, Portable Appliance Tests due September 05, Fire Drill and Instruction 12/7/05, Emergency Lights, 12/7/05, Extinguishers 12/7/05. Last weekly fire systems test recorded 31/7/05 (out of date), a requirement is made. Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 18 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 2 Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 19 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. 1. Standard OP38OP38 Regulation 23 Requirement The manager must ensure that fire systems tests are carried out weekly and the fire log is satisfactorily maintained. Timescale for action 26/09/05 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. 3. Refer to Standard OP7OP7 OP9OP9 OP35OP35 Good Practice Recommendations The manager should arrange for the use of individual daily diary sheets for residents, as an alternative to the report book. The manager should ensure that handwritten MAR sheets are signed by the writer and checked and signed by a colleague. The manager should arrange for two signatures to be obtained for all transactions in the safe-keeping book(resident/representative and a member of staff, or two members of staff). Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Locharwoods DS0000038689.V252967.R01.S.doc Version 5.0 Page 21 - 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. 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