Inspection on 21/12/05 for The Limes

This inspection was carried out on 21st 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Limes 04/04/07

The Limes 26/07/05

The Limes 02/11/04

The Limes 30/06/04

The Limes 09/03/04

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

CARE HOME ADULTS 18-65 The Limes 17 Walverden Road Brierfield Nelson Lancashire BB9 0PJ Lead Inspector Mrs Julie Playfer Unannounced Inspection 21st December 2005 12:45 The Limes DS0000009515.V261215.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 The Limes DS0000009515.V261215.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. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Limes Address 17 Walverden Road Brierfield Nelson Lancashire BB9 0PJ 01282 697414 01282 602121 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) Making Space Mrs Mary Caroline Spencer Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: The Limes is registered with the Commission for Social Care Inspection to provide accommodation and personal care for 7 adults with a mental disorder (excluding learning disability and dementia). The construction of the home dates back to the 16th Century and adjoins a Quaker meeting house. It is situated close to local amenities such as shops and pubs and is approximatley half a mile from Brierfield and one mile from Nelson town centre. Accommodation is provided on two floors in seven single bedrooms, all of which have ensuite facilities. There is a lounge on each floor, with the lounge on the ground floor providing space for dining. All furnishings and fittings are domestic in character. The home has designated smoking areas. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over half a day on 21st December 2005. The previous inspection took place on 26th July 2005. No additional visits have been made to the home since the last inspection. Not all aspects of the home were inspected on this occasion and it is therefore advisable to read this report in conjunction with the inspection report dated 26th July 2005. On the day of inspection there were 7 residents accommodated at the home. Information was obtained from staff records, care records and policies and procedures. The inspector also spoke to the residents, the staff on duty and a relative. A partial tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 6 The service users guide must be supplied to all residents to ensure they have the required information about the services and facilities provided in the home. The admission procedure must be improved to ensure residents are only admitted to the home following a full assessment of their needs and residents are informed in writing that the home is suitable for meeting their needs. The care planning system must also be improved to ensure all residents have a care plan and staff are provided with guidance on how to meet their needs. Attention must be given to the management of medication to safeguard the health and welfare of the residents. A recruitment and selection procedure should be devised to ensure the protection of the residents. The fire system must be upgraded in line with the advice of the Fire Authority. 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 Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 7 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 The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 8 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): 1, 2, 3 and 4 The admission procedure must be improved to ensure a full assessment of needs is carried out before the person moves into the home. Without such documentation it is not possible for the registered person to determine whether or not the home is able to meet the needs of a particular person. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. Both documents were presented in a suitable format and met with legal requirements. The service users guide had been distributed to all established residents, however, one resident who was new to the home could not recall being given any paperwork about The Limes. Care records indicated that all those residents who had lived at the home for sometime had an assessment of needs, which was reviewed at periodic intervals by the staff in the home. However, it was noted that whilst an assessment of mental health needs had been carried out with a resident who had recently moved into the home, there was no overall assessment of the person’s personal, social and healthcare needs. The resident had also not received a written assurance that his needs could be met by the home. The new resident told the inspector that he had visited the home prior to admission and was given the opportunity to view the vacant room and meet the other residents. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 9 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): 6 and 8 The care planning system addressed the needs of the residents and provided information for staff on how to meet these needs. However, all residents must have a care plan to ensure care is delivered effectively. The established consultation arrangements ensured residents were able to participate in all aspects of life in the home. EVIDENCE: From the case files seen, it was evident all established residents had a plan of care, based on their assessment of needs. The plans set out in detail the action needed to be taken by staff to ensure all needs were met. It was apparent the plans had been reviewed at least every six months and agreed with the resident. The plans had been updated in respect to any changing needs. However, it was noted that the new resident did not have a care plan and apart from information about his mental health needs, there were few details for staff on how to meet his overall needs. During conversations with residents it was evident they were consulted both informally and formally and they were able to participate in life in the home. Residents’ meetings had been arranged at regular intervals and all residents The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 10 were invited to attend. From the minutes seen it was evident a wide variety of topics were discussed and contributions had been made by the residents. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 11 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): 11, 12, 13, 14, 15 and 16 Residents were provided with opportunities to engage in a range of leisure activities and were supported to use community facilities. The residents maintained strong links with their families and enjoyed positive relationships within the home. Arrangements were in place to ensure the residents participated in the life of the home and their rights were respected. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills. Residents were encouraged and supported to participate in the life of the home and carried out domestic tasks commensurate with their abilities and interests. These tasks included tidying bedrooms, helping in the kitchen, going to the local shops and light domestic chores, such as dusting. Residents engaged in activities in the local community, which included walking, cinema, shopping and restaurants. Staff provided assistance with activities as necessary and had knowledge of events in the nearby area. Several of the residents also attended a local college and one person visited a church on a The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 12 regular basis. Since the last inspection three residents had been on a holiday to Blackpool. The residents were supported to maintain relationships with their friends and families. During the inspection one resident returned from visiting her family. The relative told the inspector that she was very satisfied with the care provided in the home and added that she was always made welcome by the manager and staff. The residents said the routines in the home were flexible and were designed around their arrangements for the day. As such, there were different routines at the weekend. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 13 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): 18, 19 and 20 The established residents’ healthcare needs were identified and met. Personal support was provided in a manner, which respected the residents’ rights to privacy and dignity. Improvements must be made to the management of medication. EVIDENCE: The established residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. Staff spoken to confirmed personal support was provided in private and the residents’ rights to privacy and dignity were respected. The registered manager and staff ensured consistency and continuity for residents by the use of a key worker system. A record was also maintained of individual likes and dislikes as part of the assessment and care planning processes. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. Appropriate policies and procedures were in place to manage medication in the home. Since the last inspection a lock had been fitted to the medication fridge. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 14 The home operated a monitored dosage system for the administration of medication, which was dispensed into individual blister packs. Records were maintained for the receipt, administration and disposal of medication. However, it was noted that the instructions for the application of creams was not included on the medication administration record, one medicine had not been administered in line with the prescriber’s instructions and there were no protocols for the administration of medication prescribed “as necessary”. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 15 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): 22 and 23 Systems were in place to ensure any concerns of residents would be acted upon. Appropriate policies and procedures and staff training were in place to respond to any allegations or suspicions of abuse. EVIDENCE: Both informal and formal arrangements were in place for the registered manager and staff to listen to and act on the views and concerns of residents, by means of the resident’s meetings and everyday conversation. Since the last inspection the complaints procedure had been updated to include details about the Commission. The procedure incorporated the timescales and the address and contact number of the organisation. The home had a copy of “No Secrets in Lancashire” and a specific procedure for responding to any suspicions or allegations of abuse. In addition, all staff had attended mandatory training on the protection of vulnerable adults. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 16 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): 24 and 30 The residents were provided with a clean, safe and well-maintained home. EVIDENCE: The Limes is a listed building attached to a Quaker Meeting House. It is set in its own grounds with car parking facilities for visitors. Accommodation is provided in 7 single rooms, all of which have an ensuite facility. Communal space is provided in one lounge/dining room on the ground floor and a further lounge on the first floor. The furnishings and fittings were domestic in character and of a good quality throughout. At the time of the inspection, the premises were well maintained, comfortable, clean and free from offensive odours. The home had a planned maintenance and renewal programme in the form of a repairs and maintenance file and dilapidation reports for the fabric and decoration of the building. Records were maintained of the work carried out. Since the last inspection, the external woodwork had been painted. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 17 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): 31, 33, 34, 35 and 36 Staff were well qualified and had access to a wide range of training opportunities, which gave them a good understanding of their role and the needs of the residents. EVIDENCE: From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were regularly reviewed and additional staff were placed on duty, where necessary, to meet the needs of the residents. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. Staff were offered a range of training opportunities and information was available in respect to the care and support of people with an enduring mental illness. Each member of staff had a training assessment and profile and there was an overall training development plan for the staff team as a whole. The staff on duty confirmed they received regular supervision and had an annual appraisal of their work with their line manager. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 18 At the time of the inspection, it was unclear whether a recruitment and selection procedure had been developed. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 19 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): 42 Appropriate policies and procedures were in place to safeguard the health and safety of the staff and residents. EVIDENCE: Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation was seen during the previous inspection which, confirmed gas and electrical systems were serviced at regular intervals. To minimise the risk of scalding all water outlets were fitted with preset valves. Window restrictors were fitted as appropriate. The fire log demonstrated staff and residents had participated in regular fire drills. Whilst the fire alarm panel had not been upgraded paper work was seen during the inspection to indicate work was due to start in January 2006. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 20 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 2 2 2 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Limes Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000009515.V261215.R01.S.doc Version 5.0 Page 21 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 5 (2) Requirement The registered manager must ensure that all residents are provided with a copy of the service users guide. Accommodation must not be provided to residents unless all their needs have been assessed and the registered manager has a copy of the assessment. The assessment must be in sufficient detail so as to enable care staff to meet the resident’s needs. Following an assessment of needs the prospective resident must be given written confirmation that the home is suitable for meeting his/her needs. All residents must have a care plan based on their assessment of needs. The instructions for the application of prescribed cream must be included on the medication administration record. All medicines must be administered in line with the prescriber’s instructions. The fire alarm panel must be DS0000009515.V261215.R01.S.doc Timescale for action 31/01/06 2 YA2 14 (1) 21/12/05 3 YA3 14 (1) (d) 21/12/05 4 5 YA6 YA20 15 (1) 13 (2) 31/01/06 21/12/05 6 7 The Limes YA20 YA42 13 (2) 23 (4) 21/12/05 31/01/06 Page 22 Version 5.0 upgraded in line with the requirements of the Fire Authority. (Previous timescale of 31st August 2005 – not met). 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 YA20 YA20 YA34 Good Practice Recommendations Protocols should be devised for all medication prescribed “as necessary”. It is recommended that the details transcribed from the prescription label onto the medication administration record are witnessed by two members of staff. A robust recruitment and selection procedure should be devised. The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 The Limes DS0000009515.V261215.R01.S.doc Version 5.0 Page 24 - 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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