Inspection on 10/10/08 for Locharwoods of Birkdale

This inspection was carried out on 10th October 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Locharwoods of Birkdale 01/08/07

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 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Locharwoods of Birkdale 45 York Road Southport Merseyside PR8 2AY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Daniel Hamilton     Date: 1 0 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Locharwoods of Birkdale 45 York Road Southport Merseyside PR8 2AY 01704564001 01704564002 locharwoods@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Karen Heather Weekes Type of registration: Number of places registered: Valmar Care Limited care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: 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 Brief description of the care home 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. Locharwoods of Birkdale 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. Care Homes for Older People Page 4 of 32 Over 65 19 0 Brief description of the care home There is a large well-maintained garden to the rear of the building and car parking is available at the front of the premises. A Statement of Purpose and Service User Guide have been developed to provide information on the service. A copy of the documents is displayed on the notice board and spare copies are available from the manager upon request. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately 8.5 hours. A partial tour of the premises took place and observations were made. Three care files were examined and a selection of staff and service records were also viewed. The owner, manager, two support staff, two relatives and eight residents were spoken with during the visit. An expert-by-experience also assisted in the inspection process. An expert-byexperience is someone who, because of their shared experience of using care services Care Homes for Older People Page 6 of 32 or ways of communicating visits a service with an inspector, to help get a picture of what it is like to live in or use the service. Survey forms were distributed to a number of residents or their representatives prior to the inspection in order to obtain additional views and feedback about the service. All the core standards were reviewed and previous recommendations from the last inspection in August 2007 were reviewed. The Care Home Fees for this service range from 412.50 to 430.00 pounds. What the care home does well: What has improved since the last inspection? Since the last visit, the contracts had been updated to include the room number allocated to each resident. The assessment records for the service had been updated to include information on physical wellbeing and equality and diversity issues, to ensure an holistic assessment of needs. Medication consent forms had been completed by each resident or their representatives, to confirm the wishes of the people using the service had been taken into consideration in the management of medication. Furthermore, a competency assessment had been developed by the manager to review and monitor staff awareness of medication policies and procedures. Progress had been made in developing the range and frequency of activities, to ensure the recreational needs and expectations of the people using the service were planned for. The home had continued to receive ongoing investment and maintenance to improve Care Homes for Older People Page 8 of 32 the environment. A new conservatory had been built, a new washing machine had been installed and the laundry floor covering had been replaced. Furthermore, the dining room and lounge furniture had been replaced and seven bedrooms had been redecorated and refurbished. Health declarations had been completed for new employees, to confirm staff were physically and mentally fit for their roles. The Registered Manager had enrolled to undertake the National Vocational Qualification in Care at Level 4, to ensure she has the necessary qualifications for her role. A service certificate had been obtained to confirm the fire extinguishers and other equipment in the home was maintained and operating effectively. Records also provided evidence that the emergency lighting had been tested on a monthly basis to safeguard health and safety. What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 9 of 32 following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessment and service information is in need of review to ensure prospective service users have the information they require to make an informed decision about where to live. Evidence: A Statement of Purpose and Service User Guide had been developed in a standard format to provide information for prospective and current residents on the service provided at Locharwoods of Birkdale. The Service User Guide detailed that the document could be produced in large print upon request and the manager reported that the information could be translated into different languages, subject to individual need. At the time of the visit, the documents were in need of review as the Statement of Purpose did not include information on the qualifications and experience of the Care Homes for Older People Page 12 of 32 Evidence: manager or the contact details of the Commission for Social Care Inspection. Likewise, the Service User Guide did not include information on the manager. The homes Annual Quality Assurance Assessment detailed that policies and procedures for referral and admission had been developed. The files of three residents who had moved into the home since the last visit were viewed. Each file contained a pre-admission assessment of needs however gaps in assessment practice was noted for each assessment viewed. For example, one assessment did not include information on past medical history, history of falls, medication information, family input and religious and cultural needs. Other examples were noted which were discussed with the manager. The assessment document for the service was well constructed and, if fully completed, would enable the service to undertake a comprehensive assessment of needs for prospective residents. The assessment form had been updated as recommended at the last visit, to also include information on equality and diversity issues. A copy of an assessment completed by a social worker had also been obtained for one resident who had been referred through care management arrangements. Since the last visit, the contracts had been updated to include details of the room number allocated to each resident. Care Homes for Older People Page 13 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of 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 Annual Quality Assurance Assessment for the Service detailed that policies and procedures had been developed for individual planning and review and for the control, storage, disposal, recording and administration of medicines. The files of three residents who had moved into the home since the last visit were viewed. Each file contained a care plan, which had been reviewed each month and outlined identified needs, aims and the support required from staff. The plans were based upon the activities of daily living model. The manager was recommended to also include information on how the routine health care needs of the people using the service were to be met. Supporting documentation including pen pictures, personal information, risk Care Homes for Older People Page 14 of 32 Evidence: assessments, daily record sheets, weight and health care records were also in place. Advice was given regarding the need to clarify in more detail how risks were to be managed, as some risk assessments viewed contained limited information. Health care records viewed detailed that residents had accessed a range of health care professionals including general practitioner, chiropodist, audiologist, district nurse and dietitian 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 and one resident reported The doctor is only next door so I can get there easily and quickly when necessary. The hservice had a medication policy in place. Since the last visit, the manager had developed a medication consent form, to confirm the wishes of the people using the service had been taken into consideration in the management of medication. Advice was given on how the form could be further developed and a sample copy was provided to the manager for reference. The manager had also developed a medication competency assessment, to review and monitor staff awareness of medication policies and procedures. Documentary evidence had been retained by the manager which confirmed staff responsible for the administration of medication had completed appropriate training. A record of staff authorised to administer medication, specimen signatures and photographs of residents was also available for reference. Medication was dispensed by a local pharmacist and was stored in a suitable cabinet. 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. There were no controlled drugs in the home on the day of the visit however storage and recording systems were in place. It was noted that the controlled drugs cabinet had not been secured to the wall using the correct fixings and the manager agreed to address this. Staff spoken with demonstrated a good understanding of the needs of the people living in the home and were observed to be attentive to their needs and support requirements. Staff were observed to provide care and support in a dignified and caring manner and the people using the service spoke highly of the care provided. Comments received from residents included; Its home from home here; I am content with my life here and I cant fault the care I receive. Care Homes for Older People Page 15 of 32 Care Homes for Older People Page 16 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life and social activities are flexible and geared towards the needs and expectations of the people using the service. The enables people to exercise choice and control over their lives. Evidence: A monthly activities programme and newsletter had been developed which was displayed on the notice board in the reception hallway for people to view. The activities programme detailed that a range of activities was coordinated for the residents each afternoon which included bingo, sing-a-long, walks to the village, nail and manicure sessions, quizzes, target basket ball, nintenedo games, entertainment, exercise to music, film shows, pamper sessions, dominoes, reminiscence and films. The manager reported that three external trips had also been organised since the last visit. This included a trip to see Blackpool lights, a meal out at Christmas time and a barge trip on the Leeds & Liverpool canal during May. Another trip to Blackpool to see the lights followed by a fish and chip supper has been arranged. Feedback from residents via discussion and survey forms confirmed they were Care Homes for Older People Page 17 of 32 Evidence: generally satisfied with the activities provided. Comments included; The staff are trying to provide more activities for us, Im quite happy with the activities. There are enough for me and We have quizes, dominoes, singers, outings and discussions. Residents spoken with also confirmed their religious needs were met and reported that a minister of religion visited residents in the home, subject to their individual religious beliefs. The homes Statement of Purpose highlighted that the friends and relatives of residents were welcome at any time convenient to individual residents. Relatives were observed to visit people living in the home during the visit and one relative reported; Staff are always pleasant and courteous to visitors and residents. The general atmosphere in the home was warm and welcoming. Residents spoken with confirmed they were able to follow their daily routines and exercise choice and control over their lives. 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 reported that the alternative choice of sandwiches for the tea time meal had been discussed with residents since the last visit. Previous inspection records detailed that cultural or special dietary needs would be assessed as part of the homes assessment process and information on the food preferences of residents had been obtained as part of the care planning process. Meals were served in the dining room, which was decorated and furnished to a pleasant standard. Since the last visit, new dining room furniture had been purchased and the tables were equipped with tablecloths, napkins, table mats, flowers and condiments. Staff were available to provide assistance to residents who required assistance at meal times. On the day of the visit the main course was fish, chips and mushy peas and the desert was rhubarb crumble and custard. Fruit juice was given out to residents who wanted it but no tea or coffee was offered during or after the meal. The manager agreed to review the arrangements for refreshments in consultation with residents. Residents expressed different views on the standard of standard of catering and some people reported that they were not always offered an alternative choice at dinner time. For example, comments received from residents included; The cook prepares a choice of nice food which I throughly enjoy; The main course is just brought to you and Meals and drinks not hot enough for my liking. Care Homes for Older People Page 18 of 32 Evidence: Records of meals served had been retained but the record did not identify whether choices had been offered to each resident at dinner time. The owner agreed to address this matter. Care Homes for Older People Page 19 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of 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 and 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 residents room. The Annual Quality Assurance Assessment for the home and Complaints log record detailed that no complaints had been received since the last visit. Likewise, no complaints or concerns had been received by the Commission for Social Care Inspection. Feedback received from residents via care home surveys and discussion confirmed residents were aware of who they could talk to if they were not happy and how to complain if a problem arose. The people using the service also confirmed that they were confident that staff would listen and act upon any comments or concerns. Policies and procedures were in place to ensure an appropriate response to suspicion Care Homes for Older People Page 20 of 32 Evidence: or evidence of abuse. The Annual Quality Assurance Assessment detailed that staff received annual updates to raise awareness of adult abuse and the manager and staff spoken with during the visit demonstrated a good understanding of the different types of abuse, reporting procedures and their duty of care to safeguard vulnerable people from abuse. Care Homes for Older People Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment continues to receive ongoing refurbishment and investment, to ensure the people living in the home have an attractive, safe and comfortable home. Evidence: A part time handyperson was responsible for keeping the premises in a good state of repair. Contractors were hired for specialised work as and when necessary. The handyperson undertook a weekly health and safety check and a monthly audit of each room to monitor the environment for hazards or maintenance work required. A maintenance and repairs book had also been established for staff to record jobs in need of attention by the handyperson. 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 in order to improve the environment. For example, since the last visit, a new conservatory had been built, a new washing machine had been installed and the laundry floor covering had been replaced. Furthermore, the dining room and lounge furniture had been replaced and seven bedrooms had been redecorated and refurbished. Care Homes for Older People Page 22 of 32 Evidence: Areas viewed appeared to be well maintained and the grounds of the home were pleasant. 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 and 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 annual quality assurance assessment for Locharwoods of Birkdale confirmed policies and procedures were in place for Communicable Diseases, Infection Control and the Control of Substances Hazardous to Health. The service continued to employ one part time domestic and areas viewed were generally clean and hygienic. Previous inspection records detailed that the care staff were responsible for managing laundry, in addition to their role as carers. Records showed that only six of the twelve care 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. One resident spoken with reported It is very hard to make friends in the lounge as it is set out as the chairs were arranged around the walls of the room with a fair distance between one side of the room to the other. This issue should be discussed with the people using the service to explore individual and group preferences. Care Homes for Older People Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment practice is not robust and does not adequately protect the welfare of the people using the service. Evidence: The manager reported that changes had been made to the night time staffing levels in the home since the last inspection due to an increase in the number of people living in the home. Examination of rotas and discussion with staff confirmed there were three members of staff (including the manager or a senior) on duty each morning and two in the afternoon. At night there were two waking night staff on duty. No issues of concern regarding the staffing levels of standard of care were raised during the inspection however the manager was recommended to monitor the staffing and dependency levels of the residents using a recognised tool. Feedback received from residents via care home survey forms and discussion confirmed that the care staff were available when needed and that the people using the service received the care and support they required. For example, comments included All the staff are happy and very caring; Excellent staff from management down and All the staff are very good both day and night staff. Care Homes for Older People Page 24 of 32 Evidence: The homes annual quality assurance assessment detailed that the home had policies and procedures in place for recruitment and employment. The manager reported that five staff had commenced employment since the last inspection and the recruitment records for the five staff were viewed. Since the last visit the manager had established a health declaration form. Concerns were noted regarding references as previously noted. For example, two staff members had commenced employment in the home with a reference dated after the employees had commenced employment and one of the two staff had only one reference on file. Furthermore, one employee had a photocopy of a CRB on file which had been processed by another employer and no POVA check had been requested by the home. The annual quality assurance assessment for the service detailed that the home had 13 care staff. Records showed that seven of the 13 staff (53.85 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care. The manager reported that a further two staff (15.38 ) had completed the award and were awaiting there certificates. Once the certificates have been received, this will bring the total number of qualified staff to 9 (69.23 ). Discussion with staff and examination of training records confirmed staff received induction and ongoing training and development opportunities. Induction records showed that new staff had completed induction training that was compliant with the Skills for Care Common Induction Standards however staff had not completed the training within 12 weeks of their start date. The manager agreed to address this issue. Examination of the training matrix for the service showed that staff had access to safe working practice training, abuse awareness, medication, mental capacity act and national vocational qualification training. Training records had been established, together with documentary evidence of training completed. Previous inspection records detailed that a range of training videos had been purchased for staff to complete in-house training in a range of subjects. These included 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. Examination training records highlighted gaps in training topics for some staff. The manager had established tools to enable herself to monitor the outstanding training Care Homes for Older People Page 25 of 32 Evidence: needs of staff and when refresher training was required. Care Homes for Older People Page 26 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is subject to ongoing development and review, to ensure the home operates in the best interests of the people using the service. Evidence: Locharwoods of Birkdale was managed by Karen Heather Weekes who was registered with the Commission for Social Care Inspection. Previous inspection records records detail 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 had recently commenced the NVQ level 4 in Care and training records confirmed the manager had also completed an NVQ assessors award, medication, managing conflict and assertiveness, manual handling and food hygiene training since the last visit. Feedback received from residents and staff confirmed the manager was approachable and supportive in her management role. Regulation 26 reports had been completed by Care Homes for Older People Page 27 of 32 Evidence: the Owner who also visited the home on a daily basis. The Owner of the home continued to commission an annual external quality assurance assessment. This was last completed during May 2008. Records showed that the manager had also distributed questionnaires to residents or their relatives as part of an in house quality assurance process during April 2008. Residents meetings had been coordinated on a regular basis and the minutes of a meeting held in September were displayed on the notice board for residents and their representatives to view. Discussion with staff and examination of records confirmed staff had also participated in staff meetings and received formal supervision and appraisal from the manager. Residents were encouraged to manager their personal finances independently or with support from family members or personal representatives. At the time of the visit the owner acted as an appointee for one resident and the manager looked after the personal spending money for eleven residents. Previous inspection records confirmed that systems had been established to enable residents or their representatives to pay by cheque or standing order. The manager demonstrated a good awareness of how to safeguard the financial interests of residents and records of transactions and receipts were maintained. Cash balances checked were also correct. The homes 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 and up-to-date 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. For example, there was no record of the fire alarm system being tested from 10/06/08 to 30/06/08. This issue was brought to the attention of the manager. Records were in place to confirm the fire alarm system, extinguishers, portable appliances and nurse call system had been routinely serviced and maintained and a fire and building risk assessment had been completed. Monthly tests of the emergency lighting and visual inspections of the extinguishers had also been undertaken and records confirmed that health and safety checklists and water temperature checks had been completed by the handyman. Care Homes for Older People Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 29 19 Staff must not commence 10/11/2008 employment in Locharwoods of Birkdale until the employer has obtained two satisfactory references and a Protection of Vulnerable Adult or a Criminal Record Bureau certificate. This will help to protect the welfare of vulnerable adults. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose should be updated to include information on the qualifications and experience of the Registered Manager and the contact details of the Commission for Social Care Inspection. This will ensure prospective residents have up-to-date information on the service. An holistic assessment of needs should be undertaken before people move into the home, to confirm the needs of prospective residents have been fully assessed and are able to be met by the service. Risk assessments should clearly outline the action required 2 3 3 7 Care Homes for Older People Page 30 of 32 to control potential risks, to ensure the welfare of the people using the service is safeguarded. 4 7 The care plans should be updated to include information on how all the routine health care needs of residents are to be met. This will help to provide evidence that all the general health care needs of the people using the service are planned for. The controlled drugs cabinet should be secured to the wall using the correct fixing method, to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 1973. Records of individual meal choices should be maintained for all mealtimes, to provide evidence of the dietary intake for each resident. A system should be established to monitor the dependency levels of the people using the service and the resultant staffing levels in the home. This will ensure best practice and confirm appropriate staffing levels are in place at all times. New staff should complete the Skills for Care Common Induction Standards within the first 12 weeks of their employment, to ensure compliance with national training targets. 5 9 6 15 7 27 8 30 Care Homes for Older People Page 31 of 32 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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