Inspection on 15/12/05 for Lonsdale House

This inspection was carried out on 15th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lonsdale House 28/01/09

Lonsdale House 15/01/07

Lonsdale House 11/07/05

Lonsdale House 17/11/04

Lonsdale House 10/06/04

Lonsdale House 14/10/03

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

CARE HOME ADULTS 18-65 Lonsdale House 8 Lichfield Road Walsall West Midlands WS4 2DH Lead Inspector Mike Kirton Unannounced Inspection 15th December 2005 09:00 Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 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 Lonsdale House DS0000020830.V272756.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 Adults 18-65. 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. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lonsdale House Address 8 Lichfield Road Walsall West Midlands WS4 2DH 01922 721566 01992 722767 chris.male@caldmorehousing.co.uk 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) Caldmore Area Housing Association Limited Angela Crisp Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (male) may be accommodated at the home in the category MD(E). This will remain until such time that the identified service users placement is terminated. 11th July 2005 Date of last inspection Brief Description of the Service: Lonsdale House is registered to provide residential care for 15 adults aged between 18 and 65 who are experiencing mental ill health. The home aims to provide a rehabilitation service to enable service users to develop skills required for independent living and they are closely supported by the Walsall Community Rehabilitation Team. The property is a large detached house, which is situated close to Walsall Town Centre and local amenities including shops, a market, pubs, Arboretum park and has good access to local public transport. There are ample car parking facilities for visitors, a ramp for easy access at the front of the property, whilst at the rear are landscaped gardens. Accommodation is provided over three floors with a summerhouse and 2 selfcontained houses situated separately at the rear. There are 10 single bedrooms and 3 self-contained bed-sits within the main building. Additionally there is a large kitchen, smaller training kitchen, dining room, 3 lounges, office and separate staff sleeping in room and toilet. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours and included, examination of 2 individual care plans, 1 staff file, and records relating to health and safety requirements. The inspector was present during the staff handover meeting and informal interviews took place with the registered manager, deputy, and a newly appointed staff member. Several service users were met during a tour of the building. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 11th July 2005. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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, 9 The home has good systems in place to ensure service users are fully involved in any decisions that may affect their lives. EVIDENCE: Standard 6 was not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 11th July 2005. The home aims to promote independence and choice. Any differences of opinion or restrictions on lifestyles were recorded in the care plans. Risk assessments were seen for individual activities and used as part of the decision making process. Residents meetings are held regularly with a planned agenda drawn up. Advocacy contact details are also clearly displayed on the notice board in reception. Some restrictions have been introduced such as a new policy on no alcohol being allowed in the home. This followed concerns about the effects this was having on service users and was implemented after a survey to find out everyone’s views. A roster has also been introduced to allow equal access to the cooking and laundry facilities in the training kitchen. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 11th July 2005. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has good systems in place to enable service users to live as independently as possible whilst ensuring their personal and medical care needs are met. EVIDENCE: The individual records for 2 service users were examined. These contained detailed information on how they are to receive personal care. Additionally everyone has his or her own daily living plan as identified through their care needs assessment. Many residents had gone out for the day and were observed to be making their own decisions on how to live their lives, such as when to get up or whether they wanted to go out. Comprehensive records were also being maintained to ensure that all medical needs were being met and monitored. Some service users are able to manage their own appointments whilst others are entered into the homes diary with outcomes recorded on a separate log sheet. All mental health needs are discussed at multi-disciplinary meetings at least every month. This can be increased if needed and emergency outpatient appointments can be arranged. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The homes complaints and adult protection procedures are good enough to ensure service users are protected however some minor alterations are required to bring them up to date. EVIDENCE: The home has a comprehensive comments and complaints procedure in place, which meets all the minimum standards. A summary is clearly displayed on the notice board in reception. This needs to be updated to include the new address and telephone number for the Commission. The home has a copy of the Walsall Multi Agency Adult Protection Procedures (Oct 2001) from which their own policy is taken, and the Department of Health Guidance ‘No Secrets’. These are discussed and read by all staff during their induction. Training has been provided and the manager has recently attended a local adult abuse protection meeting. A specific document needs to be developed for the home to give guidance for all staff. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 11th July 2005. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The home has a good staff team who appear well trained, experienced, friendly and approachable. EVIDENCE: A newly appointed staff member was interviewed and their personal file examined. This contained a copy of their application form, including a list of all previous employment and reasons for leaving, health check, 2 satisfactory references, photograph, proof of identification, successful checks against the list for people who may be at risk to adults (POVA) list and criminal records history (CRB). A copy of their personal details, job description and contract of employment was also on file. The file was organised and easy to follow. The homes procedure requires all potential applicants to be short listed for an interview from which records are kept. Once appointed they follow a planned induction procedure over 6 weeks and are registered for training equivalent or above NVQ level 2 in care. During their first week they worked in addition to normal staffing levels and do not work alone until they have completed their induction period and the manager is satisfied they are competent to do so. All records were examined including a competence assessment and probationary interview. Staff have an individual training plan which is used to identify training needs within the home. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 32 The home continues to be managed well and recent improvements to the decoration and furnishing have been carried out. Good systems are in place to ensure the health and safety of service users, staff, and other visitors to the home are protected. EVIDENCE: Standard 37 was not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 11th July 2005. The manager has now completed a successful interview and become registered with the Commission. The home does obtain information, which is required for a quality assurance monitoring system. This needs to be developed with the results published on an annual basis with an action plan implemented for improvements. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 15 A tour of the buildings communal areas showed that the home was clean and tidy and well maintained. New flooring had been laid but is still required on the stairs, and many areas had been redecorated. New blinds were also in the process of being fitted and the training kitchen was now finished. The fridge, freezer, cooked food, and water temperatures were being recorded and monitored. Servicing of the fire equipment, gas, electrics, and portable electrical appliances was been undertaken. Fire evacuations were being carried out, a fire risk assessment was in place, and the alarms were tested every week. Risk assessments have also been completed on the buildings and all activities, which effect service users, staff, and other visitors to the home. Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lonsdale House Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000020830.V272756.R01.S.doc Version 5.0 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 6 Timescale for action The homes Statement of Purpose 01/04/06 and Service Users Guide requires updating with a copy sent to the Commission. This is an outstanding requirement from the last inspection. The homes policy and 01/04/06 procedures for ordering and administering medication must be updated in line with current practices. This is an outstanding requirement from the last inspection. The homes complaints procedure 01/01/06 must be updated to include the current address and telephone number for the CSCI. A specific Adult Protection 01/04/06 Procedure needs to be developed for the home to give guidance for all staff. The current practice of having 31/04/06 only 1 night staff on duty from 18:00 hrs must be continually monitored and assessed against service users needs and health and safety requirements. Requirement 2. YA20 13 3. YA22 22 4. YA23 13 5. YA33 17 Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 18 6. YA39 24 The quality assurance system 01/11/05 must be formalised and based on a systematic cycle of planning, action and review covering all aspects of Standard 39 of the National Minimum Standards This is an outstanding requirement from the last inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Lonsdale House DS0000020830.V272756.R01.S.doc Version 5.0 Page 20 - 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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