Inspection on 01/08/07 for Locharwoods of Birkdale

This inspection was carried out on 1st August 2007.

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

The inspector 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 of Birkdale 10/10/08

Locharwoods of Birkdale 19/05/06

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 of Birkdale 45 York Road Southport Merseyside PR8 2AY Lead Inspector Daniel Hamilton Key Unannounced Inspection 1st August 2007 09:15 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 of Birkdale DS0000066364.V341585.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. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Locharwoods of Birkdale Address 45 York Road Southport Merseyside PR8 2AY 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) 01704 564001 01704 564002 locharwoods@hotmail.com (see below) Valmar Care Limited Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP The maximum number of people who can be accommodated is: 19. Date of last inspection 19th May 2006 Brief Description of the Service: Locharwoods of Birkdale is a large two-storey detached property that has been converted into a residential care home. The home is registered to provide personal care and support for up to 19 older people. The property is situated in Birkdale village, which is near to the centre of Southport and all its amenities. There are shops, local bus and train services within close proximity of the home. The Priory has 19 single rooms, which are all equipped with en-suite facilities. Communal space comprises of a dining room at the front of the premises and a lounge to the rear. The first floor rooms are accessible via a passenger lift and a call bell system is in place. There is a large well-maintained garden to the rear of the building and car parking is available at the front of the premises. The Care Home Fee is £398.00 to £412.50 per week. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The inspector met with the Owner, Registered Manager, staff and residents during the visit. Care Home Survey forms were also distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional feedback about the home. All the core standards were assessed and action taken in response to the previous requirements and recommendations from the last inspection in May 2006 was reviewed. It should be noted that there had been a change of manager since the last visit. The new manager (Karen Heather Weekes) demonstrated a commitment to addressing the issues raised during the visit and to improving the overall service provided for residents. What the service does well: Feedback received from the people living in the home and / or their relatives was generally positive about the service provided at Locharwoods of Birkdale. Comments received from residents included; “The Staff are very caring people” and “I can’t get enough help. The staff are always willing and helpful”. An assessment and care planning system had been developed to ensure the needs of residents were assessed and to clarify the level of intervention required by staff to meet each resident’s needs. Staff reported that they had access to a range of training opportunities and demonstrated a good awareness of how to provide person centred care and appropriate support to residents. This was confirmed by one relative who stated; “The care staff seem to be well qualified and pleasant and attentive to X [a Resident’s] needs”. Feedback received from the people living in the home confirmed they were generally satisfied with the lifestyle, activities and meals provided in the home. Comments received from three residents included; “There are enough activities for me. I went on a canal cruise recently”; “The home is OK. It’s easy going Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 6 generally” and “I am pleased that I get a choice of food which is well presented.” The home had a satisfactory complaints procedure, which was displayed around the home for people to see. Safeguards were in place to protect residents from abuse and systems had been established to ensure the views of residents and their representatives were obtained on the service. The home had continued to receive ongoing investment from the owner and overall, areas viewed appeared clean and hygienic. What has improved since the last inspection? Since the last visit the date, quantity and initials of the person receiving medication into the home had been recorded on Medication Administration Records to provide an audit trail. Documentary evidence of staff qualifications had been obtained to verify staff were trained and competent in key areas. Furthermore, training resources had been purchased and records improved to ensure the training needs of staff were monitored and planned for. A service certificate for the bath hoist had been obtained, to confirm the equipment was safe to use. The manager had updated the home’s pre-admission assessment, to ensure personal safety and risk issues were assessed as part of the assessment process. A copy of the Complaints Procedure for the service had been displayed in the reception area of the home for residents and / or their representatives to view. The induction programme had been updated to ensure new staff were inducted in accordance with the Skills for Care Common Induction Standards. A residents meeting had been coordinated to ensure residents were consulted and their views listened to. The results of service user surveys had been displayed in the home for prospective residents, their representatives and other interested parties to view. Records of financial transactions had been maintained to account for money handled on behalf of residents and / or their representatives. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 7 What they could do better: Contracts should be updated to include details of the room allocated to each resident so the people living in the room know which room they have been allocated. Information on physical wellbeing and diversity issues should be obtained as part of the assessment process so that a holistic assessment of needs is undertaken. A record of each resident’s wishes in relation to the administration of medication should in place, to confirm the views of the people using the service have been acted upon in relation to management of their medication. The manager should continue to develop the assessment tool for monitoring the competency of staff responsible for medication. This will help to ensure the assessment is robust when checking staff knowledge and understanding of how to record, handle, store, administer and dispose of medication in the home. The range and frequency of activities in the home should be kept under ongoing review with residents, to ensure their recreational needs and expectations are acted upon. Furthermore, the tea-time alternative meal option should be reviewed to provide more variation. The damaged covering in the laundry room should be replaced to improve hygiene and ensure the floor is impermeable. Two written references should be obtained for all staff before they work in the home and health declarations should be completed by all staff, to confirm they are physically and mentally fit for their roles. The Registered Manager should complete the National Vocational Qualification in Care at level 4, to ensure she has the necessary qualifications for her role. Finally, in order to improve health and safety practice, the fire extinguishers should be serviced and a service certificate obtained to confirm the extinguishers are operating effectively. The emergency lighting should also be tested on a monthly basis to ensure the system is operating effectively and day and night staff should receive fire instruction refresher training at appropriate intervals, to ensure they are aware of the correct procedures to follow in the event of a fire. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 8 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. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 9 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 of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 10 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): 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally undertakes or obtains pre-admission assessments to ensure the needs of residents are identified. EVIDENCE: The home’s Annual Quality Assurance Assessment detailed that the home had developed policies and procedures for referral and admission. The manager was able to demonstrate a good understanding of the home’s assessment and admission process. The files of three residents who had moved into the home since the last visit were viewed. One of the residents had been admitted on an emergency basis and the manager had not completed an assessment as a copy of a social work assessment had been obtained prior to the resident being admitted. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 11 Another resident had been transferred from the owner’s other home. The owner and manager reported that the manager of the other home had undertaken an assessment prior to admission, but this could not be located at the time of the visit. The third file checked contained a pre-admission assessment however some key information including past medical history, personal safety and risk, religion and / or ethnicity had not been obtained. Similar issues were noted at the previous inspection. The new manager was able to provide evidence that she had updated the home’s assessment documentation to include personal safety and risk as recommended at the last visit. The manager was also advised to include physical wellbeing, past medical history and equality and diversity information, to ensure a holistic assessment of needs. Since the last visit, the owner had developed a new contract and copies were available for each resident. The manager was advised to update the contract to include details of the room number allocated to each resident. The relative of one resident expressed concern about the length of time taken to receive a contract and this was brought to the attention of the manager. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based upon their individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The files of three residents who had moved into the home since the last visit were viewed. Files viewed contained a Care Plan, which had been completed by senior staff. The plans were based upon the ‘activities of daily living’ model and outlined the health, personal and social care needs of residents and the support required by staff. Staff spoken with demonstrated a good understanding of the needs of the people living in the home and plans seen were personalised and had been kept under monthly review. Supporting documentation including; person-centred risk assessments, daily record sheets, weight and health care records were also in place. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 13 Health care records viewed detailed that residents had accessed a range of health care professionals including; general practitioner, district nurse, optician and chiropody appointments subject to individual needs. Feedback from residents via Care Home Survey forms and discussion confirmed that residents had access to the medical support they required. One resident said; “If you are not feeling well they look after you OK.” The home had a basic medication policy in place, together with a copy of the Royal Pharmaceutical Society of Great Britain guidelines for the Administration and Control of Medicines in Care Homes. None of the residents’ self-administered medication at the time of the visit and declaration of wishes with regards to medication were not recorded on individual files as previously noted. Staff responsible for the administration of medication reported that they had completed accredited training and a record of staff authorised to administer medication, specimen signatures and photographs of residents was available. Medication was dispensed by a local pharmacist and was stored in a suitable cabinet. There were no controlled drugs in the home on the day of the visit however suitable storage and recording systems were in place. Medication Administration Records (MAR) were viewed for a number of residents. Records had been signed to record the administration of medication and to account for medication received into the home. The balance of one resident’s medication did not correspond with the written records and this was discussed with the manager. Some progress had been made in reviewing the competency of staff responsible for administering medication. Advice was given to the manager on how to undertake a more detailed assessment. Staff spoken with during the visit demonstrated a good understanding of the principles of care and were observed to be attentive, caring and sensitive to the needs of the people living in the home. Likewise, feedback received from residents confirmed they were generally satisfied with the care provided by staff and that they were treated with dignity and respect. Comments from residents included; “They never make me feel uneasy” and “The staff are very caring people.” The representative of one resident expressed concern regarding gender specific care and this point was discussed with the manager during the visit. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to exercise choice in relation to daily life, social activities and meals in order to satisfy their needs and expectations. EVIDENCE: The home produced a monthly activities programme that was displayed on the notice board in the reception hallway for people to view. An activity book was also maintained which identified the date, type of activity and participants. Records showed that residents had participated in a limited range of activities for July. These included; music and movement, walks in the community, a residents meeting, afternoon tea and watching a film. Residents spoken with confirmed they were generally satisfied with the activities. Comments included; “I’m not interested in activities. I prefer my own company”; “There are enough activities for me. I went on a canal cruise recently” and “We go out to the village. I like to go to the shops.” The relative of one resident reported; “A little more in-house entertainment would be welcomed.” Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 15 The manager reported that no ministers of religion were visiting the home at the time of the visit and that the spiritual needs of residents would be kept under review as part of the home’s assessment and care planning process. The home’s ‘Statement of Purpose’ highlighted that the friends and relatives of residents were welcome at any time convenient to individual residents. This was confirmed by residents spoken with during the visit and one resident stated; “Visitors are always given a warm welcome.” The general atmosphere in the home was warm and friendly and residents reported that they were able to exercise choice and control over their lives and follow their preferred routines. “We can do as we chose” and “The home is OK. It’s easy going generally.” Residents were able to bring personal possessions into the home and rooms viewed had been personalised with pictures and personal belongings. The home had a four-week menu that offered an alternative choice of meals for residents. The manager was advised to display the menus on the notice board for residents to view and to review the alternative choice of sandwiches for tea-time meals. The relative of one resident expressed a view that; “Teas are unimaginative.” The manager reported that any cultural or special dietary needs would be assessed as part of the home’s assessment and provided for residents as required. Since the last visit, the dining room had been redecorated. The dining room was pleasant and tables were equipped with tablecloths, napkins, decorative flowers, placemats and condiments. Feedback from residents via Care Home Survey forms and discussion confirmed that residents were satisfied with the meals provided. Comments included; “I’m quite satisfied with all they do for me and the food is excellent”; “I am pleased that I get a choice of food which is well presented” and “The Cook is excellent.” Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns via a complaints procedure and systems are in place to protect residents from abuse. This protects the rights of residents and ensures an appropriate response to suspicion or evidence of abuse. EVIDENCE: Locharwoods of Birkdale had a Comments / Complaints procedure in place. A copy of the policy was displayed on the notice board in the reception area of the home and had been included in the Service User Guide, a copy of which had been placed in each resident’s room. The Annual Quality Assurance Assessment for the home and Complaints log record detailed that two complaints had been received since the last visit. One of the Complaints had been referred to the Commission for Social Care Inspection and concerned visiting arrangements / the human rights of a former resident. This complaint was withdrawn by the Complainant. The second complaint was also made by a former resident and concerned the attitude of two staff members. Records showed that the incident was investigated and acted upon promptly by the manager. Feedback from residents via Care Home Survey forms confirmed that residents were aware of who they could talk to if they were not happy and how to complain if a problem arose. Comments from two residents included; “I think the home is great. I have no complaints but I would speak to the manager if I Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 17 did” and “I couldn’t say anything wrong about this place. I am well looked after.” The relative of a resident reported; “We have never had occasion to complain about the services provided.” Policies and procedures were in place to ensure an appropriate response to suspicion or evidence of abuse. The policies had been updated since the last visit. The manager and staff spoken with during the visit demonstrated a good awareness of their duty of care and how to recognise and respond to suspicion or evidence of abuse. Training records showed that four staff required training in the Protection of Vulnerable Adults from Abuse at the time of the visit. The manager confirmed that she planned to address this training need as a matter of priority. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to benefit from investment and is generally well maintained and clean. This provides residents with an attractive and comfortable place in which to live. EVIDENCE: The home employed a part-time handyperson who was responsible for keeping the environment in a good state of repair. Contractors were hired as and when necessary and a gardener was observed to be maintaining the grounds on the day of the visit. The manager reported that the home’s handyperson continued to undertake a monthly audit of each room in the home to check for hazards and / or maintenance work required. A quality audit form was also completed on a monthly basis to monitor the condition of the home and a maintenance and repairs book had been established for staff to record jobs in need of attention by the handyperson. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 19 The home did not have a programme for the routine maintenance and renewal of the fabric and decoration however it was evident that the owner continued to invest money into the home to improve the environment. Since the last visit, the dining room, lounge and four bedrooms had been redecorated. Three rooms had been fitted with new floor coverings and new chairs had been purchased for the dining room. New gates had been fitted to the back and side entrance and the owner reported that he had successfully applied for a grant to assist in building a conservatory. A boiler had also been repaired. Overall, areas viewed appeared to be well maintained and the grounds of the home were pleasant and accessible to residents at the time of the visit. Rooms viewed were personalised with personal possessions, pictures and other memorabilia and the fabric and decoration was in good order. Residents were observed to have disability aids / equipment to maximise their independence and the home was equipped with a passenger lift and a call bell system. (Please refer to the ‘Brief Description of the Service’ section for more information on the premises). The home’s annual quality assurance assessment detailed that the home had policies and procedures in place for Communicable Diseases, Infection Control and the Control of Substances Hazardous to Health. The home employed one domestic and areas viewed were generally clean and hygienic. The laundry was appropriately equipped to meet the needs of the people living in the home however the laundry floor was in need of replacement. The manager reported that the home’s care staff were responsible for managing laundry, in addition to their role as carers. Records showed the majority of staff had completed infection control training. Overall feedback received from residents via survey forms and through discussion confirmed the home was kept clean, fresh and hygienic. The relative of one resident reported that a resident experienced an offensive smell outside a bedroom but this could not be substantiated on the day of the visit. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by trained and competent staff however some recruitment records / practice is in need of review, to fully safeguard the welfare of the people living in the home. EVIDENCE: The manager reported that no changes had been made to the staffing levels in the home since the last visit. This was verified by examining the rotas and through discussion with staff. Three members of staff remained on duty each morning and two in the afternoon. One waking night and a sleep in staff member were on duty through the night. The manager reported that the staffing and dependency levels of the residents were being kept under regular review. Feedback received from residents via care home survey forms and discussion confirmed that the care staff were generally available when needed and that the people using the service received the care and support they needed. Comments included; “The staff are very helpful. It doesn’t matter what you ask of them. They don’t hesitate to answer” and “I can’t get enough help. The staff are always willing and helpful.” Likewise, the relative of one resident reported; “The care staff seem to be well qualified and pleasant and attentive to X [a Resident] needs”. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 21 The home’s annual quality assurance assessment detailed that the home had policies and procedures in place for recruitment and employment. Records showed that six staff had commenced employment since the last inspection. The recruitment records of the six staff were viewed. Overall, the majority of records required under the Care Home Regulations 2001 were in place for the new staff. Some issues were noted and brought to the attention of the manager. These included: the absence of health declarations to confirm new staff were physically and mentally fit for their roles; one member of staff had only one reference on file and references had been received following the start date for another employee. Furthermore, written confirmation of the outcome of Protection of Vulnerable Adult Checks had not been received from the home’s umbrella organisation for two staff, however Criminal Record Bureau checks were on file to confirm the outcome of the checks. The manager reported that the home employed twelve care staff. Records showed that five of the 12 staff had completed a National Vocational Qualification (NVQ) at level 2 or above in Care (41.66 ). The manager reported that a further three staff (24.99 ) were working towards the award. Once the outstanding staff have completed the award, this will bring the total number of qualified staff to 8 (66.66 ). Two qualified staff had also left employment at the home since the last visit. Discussion with staff and examination of training records confirmed that new staff received an in-house induction and ongoing training opportunities. The manager was aware of the new Skills for Care Common Induction Standards and records were on file for all new care staff with the exception of one employee. The manager agreed to address this issue. Since the last visit, the new manager had developed new training files for staff, which included individual training records together with documentary evidence of training completed. The records enabled the manager to monitor and respond to the ongoing training needs of the staff team. The Owner had purchased training videos for staff to complete in-house training in a range of subjects including; Abuse Awareness, Basic Health and Safety; Fire in the Care Home; Basic Food Hygiene; Infection Control; Care With Medicines and Customer Care. The home also used external training providers for some training topics including first aid and medication awareness and the registered manager was qualified as a moving and handling trainer. Records showed that training in the following subjects were needed for some staff. Health and Safety (5); Fire Safety (2); First Aid (6); basic food hygiene (3); Infection Control (2); Care with Medicines (6) and Protection of Vulnerable Adults (4). Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 22 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, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is subject to ongoing development and review, to ensure the home operates safely and in the best interest of residents. EVIDENCE: Since the last visit, the home had appointed a new manager (Karen Heather Weekes) who had been registered with the Commission for Social Care Inspection during May 2007. Training records confirmed that Ms Weekes had completed the National Vocational Qualification (NVQ) Level 4 Registered Managers Award and a range of additional training that was relevant to the management of a care home for older people. Ms Weekes reported that she was also planning to enrol on the (NVQ) in Care at Level 4 in the near future. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 23 Feedback received from residents and staff confirmed the manager was approachable and supportive in her management role. Regulation 26 reports had not been completed by the Owner as he visited the home on a daily basis and considered himself to be in day-to-day charge. The Owner of the home continued to commission an annual external quality assurance assessment. This was last completed during April 2007. Records showed that the home had also previously distributed questionnaires to residents and / or their relatives as part of an in-house quality assurance process. The new manager reported that she planned to re-distribute questionnaires to residents and/ or their representatives as the in-house survey had last been undertaken in February 2006. Since the last visit a residents’ meeting had been coordinated and records were available to confirm staff participated in staff meetings and received regular formal supervision. The manager reported that she did not act as an appointee for any of the people living in the home. Residents were encouraged to manager their personal finances independently or with support from family members or personal representatives. Previous inspection records confirmed that systems had been established to enable residents or their representatives to pay by cheque or standing order. At the time of the visit, the manager looked after the personal spending money for ten residents. The manager demonstrated a good awareness of how to safeguard the financial interests of residents. Records of transactions, receipts and cash balances checked were also correct. The home’s annual quality assurance assessment detailed that the home had Health and Safety policies and procedures in place and that maintenance and associated records were in place for all key areas. Fire log and service records were checked during the visit. Records showed that the fire alarm system was generally tested on a weekly basis but some gaps were noted and brought to the attention of the manager. Furthermore, records detailed that the emergency lights had not been tested since February 2007 and there was no record of fire instruction training for day or night staff. A service certificate for the fire alarm and emergency lights had been obtained however there was no certificate to confirm that fire extinguishers had been serviced. The manager contacted the contractor and made arrangements to address this issue during the visit. Previous inspection records detailed that the home had a fire and a building risk assessment in place. The risk assessments had been kept under review. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 24 Since the last visit, the home had made arrangements to obtain a service certificate for the bath hoist. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 25 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 26 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 3 Refer to Standard OP2 OP3 OP9 Good Practice Recommendations Contracts should be updated to include the room number to be occupied by each resident. Information on physical wellbeing and diversity issues should be obtained as part of the assessment process, to ensure a holistic assessment of needs. Declaration forms should be completed by residents or their representatives to confirm their wishes (where practicable) have been taken into consideration with regard to the administration of medication. The system for reviewing the competency of staff responsible for administering medication should be further developed to ensure a more detailed assessment is undertaken. The range and frequency of activities should be kept under review in consultation with residents. The alternative choice of sandwiches for evening meals should be reviewed in consultation with residents. DS0000066364.V341585.R01.S.doc Version 5.2 Page 27 4 OP9 5 6 OP12 OP15 Locharwoods of Birkdale 7 8 9 10 11 12 OP26 OP29 OP29 OP31 OP38 OP38 13 OP38 The damaged / worn floor covering in the laundry should be replaced to ensure the floor finish is impermeable. Two written references should be obtained for all prospective employees before they are authorised to work in the home. Health declarations should be completed by prospective employees, to confirm staff are physically and mentally fit for their roles. The Registered Manager should complete an award equivalent to the NVQ level 4 in Care, to ensure she has the necessary qualifications for her role. A service certificate should be obtained to confirm the fire extinguishers are operating effectively. Day staff should receive fire instruction refresher training every six months and night staff every three months, to ensure they are fully aware of the correct procedures to follow in the event of a fire. The emergency lighting should be tested on a monthly basis, to ensure the system is operating effectively. Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG 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 Locharwoods of Birkdale DS0000066364.V341585.R01.S.doc Version 5.2 Page 29 - 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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