Inspection on 10/07/08 for Leighton House Retirement Home Ltd

This is the latest available inspection report for this service, carried out on 10th July 2008.

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

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

Leighton House Retirement Home... 13/03/06

Leighton House Retirement Home... 29/09/05

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Leighton House Retirement Home Ltd 170/172 Milkstone Road Deeplish Rochdale Lancashire OL11 1NA Lead Inspector Bernard Tracey Unannounced Inspection 10th July 2008 07:50 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 Leighton House Retirement Home Ltd DS0000064633.V368138.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. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leighton House Retirement Home Ltd Address 170/172 Milkstone Road Deeplish Rochdale Lancashire OL11 1NA 01706 352075 01706 631416 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) Leighton House Retirement Home Ltd Mrs Anne O`Reilly Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is registered for a maximum of 30 service users to include: up to 30 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 23rd August 2006 Date of last inspection Brief Description of the Service: Leighton House is a care home providing care and accommodation for 30 older people. The home is located approximately one mile from the town centre of Rochdale, in an area known as Deeplish. It is close to shops, a post office and other amenities. Leighton House was opened in 1981. Since 1988 it has been owned by the same provider, although registration changed in July 2005 when the provider set up a limited company - Leighton House Retirement Home Ltd. The provider is the responsible individual for the new company and continues his involvement at the home on a day-to-day basis. Leighton House is a three-storey building with lounge and dining facilities on the ground and first floors. There is also a large basement area, which provides a staff room, staff toilet, laundry, drying room, food storage areas, workshop and cleaning storage areas. The area had been modernised and was well maintained. Twenty-five bedrooms are provided, five double and 20 singles, of which two are en-suite. Bedrooms are provided on the ground, first and second floors. A passenger lift services all levels of the home. The home sits in its own grounds and has a well-maintained garden, which is easily accessible. Adequate parking is available to the front and side of the home. The home’s Service User Guide advises residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report is available in the reception hall. At the time of this inspection weekly fees were from £352.86p to £376.00 per week. Additional charges were for hairdressing, chiropody and taxis. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. We (the Commission of Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. The staff at the home did not know the visit was going to take place. Several weeks before the inspection, questionnaires were sent out to the residents and their relatives. The questionnaires asked what people thought of the care and services provided by the home. The manager was also asked to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, these comments have been included in the report. We spent over six hours at the home. During this time, we looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. A tour of the building was undertaken and we examined safety records to make sure that the equipment in the home was being serviced and checked on a regular basis. We also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. We spent time speaking to four residents, as well as speaking to five staff. We have received one complaint about the service, which was investigated under the Safeguarding of Adults by the Social Services. We have subsequently been informed that the complaint had not been upheld. What the service does well: Leighton House presents with a very warm, caring and friendly environment and residents appeared relaxed and comfortable with the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents’ individual care needs and the level of support required. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 6 During our visit staff were observed spending a great deal of time with residents either on an individual basis or within a group. Care was seen to be given in a discreet sensitive manner and staff were patient and gentle in their approach. Feedback from residents and relatives was very good, comments regarding the service included: “Very good home” “Lovely staff” “You could not want for more” “Superb home to live in” “A lovely place to live in” Prior to admission the manager or deputy manager assesses residents’ health and social needs. Information collated is then used to the form the basis for the plan of care. Assessment documentation seen had been completed to a good standard and included key areas regarding the residents’ health and general well being. Care files were organised, the information easy to read and care plans identified the relevant care and support required. Attention is paid to recording basic needs, such as dental, optical, hearing and foot care, which are so important to the care of an elderly person. Comments regarding the care included: “Excellent care” “Really good care by all the staff” “You could not want for better care and attention” “The staff help me when I need help and never mind what they do” “Absolutely excellent” “Most helpful nursing care and support” Residents interviewed confirmed that the daily routine was flexible and based very much around their wishes. A resident said, “The staff never mind what time I go to bed, they are very accommodating”. Other residents commented on the fact that they can choose what to do during the day and that there is always ‘something going on’ which they like. Staff have access to a good standard of training in safe working practice areas to ensure they have the skill and knowledge to provide the care and support needed. Over 50 staff are qualified to a (NVQ) National Vocational Qualification Levels 2 and 3 in care. The management of the home is of a good standard and the manager was able to demonstrate a sound understanding and knowledge of the home’s quality assurance processes and maintenance of health and safety practices to ensure the ongoing protection of the residents. The owner and the manager have a good understanding of the areas in which the home could further improve. The details of how they were going to achieve these improvements were provided in the AQAA. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 8 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 Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 9 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 (6) does not apply Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. The staff are then able to confirm that they can meet the needs of the individual. EVIDENCE: The owner and manager informed us in their AQAA that they are presently devising a new Statement of Purpose, Service Users’ Guide and Welcome Pack. A copy of these new documents will be submitted to the Commission for Social Care Inspection when completed. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 10 Admissions are not made to the home until a full needs assessment has been undertaken. Care files that we examined contained relevant paperwork, including social work assessments and reports from health care professionals, prior to a person choosing to stay at the home. The manager or her deputy also carries out an assessment, which includes a visit to see the person in his or her own home or while in hospital. In addition to the assessment, members of the resident’s family provide a social history, which is a brief outline of the person and their background, along with information on the resident’s social, cultural, ethnic and spiritual needs. These measures ensure that admissions to the home only take place if the service is confident staff have the skills and ability and qualifications to meet the assessed needs of the prospective resident. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 11 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, 10 Quality in this outcome area is excellent. Residents’ health and personal care needs are being met and are addressed in detailed care plans. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Significant progress has been made in relation to the care plan documentation and methods of recording how the needs of the residents will be met. Individual records are kept for each resident and contain comprehensive information relating to all aspects of health, personal and social care needs of the residents. From this information an individual plan of care is drawn up with the involvement of the resident or their relative to ensure that the care needs are met. Significant events had been recorded and daily entries made setting out the care given. Risk assessments were in place and covered such areas as moving and handling, nutrition, pressure sores, the use of bed rails and falls. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 12 Risk assessments and the care plans were evaluated as and when required but at least on a monthly basis, though we noted that the reviews had not taken place in the preceding month. The residents were weighed in accordance with their nutritional risk assessment but at least on a monthly basis and the weight recorded on a chart kept in their care plan. A relative survey stated “The residents are very well cared for. The staff are very pleasant and approachable if I need to ask them anything. The residents are very clean and are all well cared for personally and individually.” There is an efficient Medication Policy supported by procedures and practice guidelines. Staff follow robust systems to make sure that medication records are fully completed, contain required entries and are signed by appropriate staff. We found one error of counting in relation to the Controlled Drugs Register but this was corrected during our visit. Staff were observed delivering care in a sensitive and respectful manner: addressing residents by their preferred name; knocking on doors and enabling residents to maintain as much independence as possible. The home tries to gain as much information about a person’s past as possible, and staff were seen to use this information to engage with individuals and initiate discussion. In one instance the manager had contacted an interpreter to assist a resident whose first language was not English. Examination of three care files identified that the residents had access to health care professionals, such as dentists, opticians, chiropodists and district nurses. Equipment necessary for the prevention and treatment of pressure sores was readily available within the home. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 13 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. Social activities provide daily variation and interest for people living in the home. The dietary needs of the residents were well catered for with a balanced and varied selection of food being served. EVIDENCE: The residents’ involvement in social activities varies greatly according to their abilities and needs. Some of the residents spoken to preferred to stay in their own bedrooms and enjoyed reading, listening to music and watching the television. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 14 The home has a very pleasant friendly atmosphere and staff give a great deal of thought to arranging social activities to suit individual needs and preferences. Social needs are assessed in detail when a resident is admitted and residents spoken with were pleased with the home’s varied programme of social events. Staff work hard to ensure social interests are stimulating and it was evident through discussion with a number of residents that they enjoy a lifestyle that meets their preferences. In the AQAA we were informed that an activity person is responsible for organising a programme of activities. A care worker was also allocated on a daily basis to work with the residents in taking part in the activity of their choice. Active Minds, an outside organisation, is now coming to the home every six weeks. Other recent innovations include: We have bought two new electric organs that have a 100 plus songs without an organist. Provided more craft activities. Purchased a new computer for residents and staff use. External entertainers are visiting more frequently. Organised more trips out. More in-depth knowledge of people’s past life and social history with more involvement from relatives/friends. This has assisted us in making sure the person’s usual routines and likes/dislikes are followed. A discussion with the residents and care staff confirmed that the residents were able to receive visitors in private and that they were able to choose whom they see and do not see. Visitors can be seen in the privacy of the residents’ bedroom, although many choose to sit in one of the communal areas. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised, with small pieces of their own furniture, pictures, photographs and ornaments, etc. We did not dine with the residents but observed lunch being served in the dining room. The meals served were of ample portion and looked appetising. The tables were nicely set with napkins, cruets and cold drinks. Staff discreetly assisted some residents to eat. There was always a choice of meal at lunchtime and evening. The menus were inspected and they looked varied and nutritious. Mid-morning and midafternoon drinks were served and milky drinks were provided at suppertime. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 15 A discussion with the residents showed that they were very happy with the choice and quality of the food provided. Comments made by residents included: “You could not have better” “Very good food” “Such a good choice” Leighton House Retirement Home Ltd DS0000064633.V368138.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. The home has a clear complaints procedure and residents and their families know action will be taken to resolve their concerns. Staff have a good knowledge and understanding of Adult Protection issues which safeguards residents from abuse. EVIDENCE: The complaint policy is displayed for residents or their relatives to view. Residents interviewed had no concerns at this time and reported that they would speak to the manager if they were at all unhappy. Complaints are logged and are audited by the manager and the owner. There has been one complaint made to Social Services in respect of a resident who is no longer living at the home. Social Services have informed the Commission of Social Care Inspection that the complaint is not upheld and a meeting with the manager had been arranged for the following week to finalise the investigation. A staff member interviewed said that they knew what procedure to follow should a resident wish to make a complaint. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 17 There is a copy of the Rochdale Guide for the Protection of Vulnerable Adults in the home and some of the staff have undertaken training in relation to the Protection of Vulnerable Adults. The home also has an abuse policy and whistle blowing procedure. The staff training record evidenced abuse awareness training for a number of staff with more training places booked and staff interviewed had an understanding of how to report an alleged incident. Leighton House Retirement Home Ltd DS0000064633.V368138.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. Residents live in pleasant, safe, comfortable and well-maintained surroundings. EVIDENCE: Leighton House is a comfortable, clean home that is pleasantly furnished and decorated. Areas seen had been maintained to a good standard and the maintenance person completes everyday jobs and repair work. The home has a large hall, which has plenty of information regarding the service, and visitors and residents are asked to sign in and out of the building. Records were available to confirm that health and safety checks of the building and the external grounds are well maintained. Residents reported that they enjoy sitting out in the garden, which have plenty of benches and garden chairs. Wheelchair access is available to the grounds. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 19 The lounges and dining rooms are attractively decorated. There are comfortable armchairs and coffee tables and the dining room tables are laid for each meal. Residents who wish to smoke use one lounge and there is a large widescreen television in the main lounge. The manager confirmed that this maintenance is ongoing. Staff stated that there is a good standard of equipment and this includes moving and handling hoists and variety of walking aids. Bathrooms are suitably adapted to assist those less able. The bathrooms were found to be very clean and odour free. The corridors are narrow, however they do provide access for wheelchairs. Wheelchairs seen had footrests in place to minimise the risk of injury to the resident. Bedrooms viewed had been personalised by the residents with items from home and residents interviewed stated that they were comfortable and cleaned regularly by the staff. They are also able to lock their bedroom door if they wish. Emergency lighting is checked monthly in-house and is subject to an annual safety contract. Checks of the hot water temperatures to the baths are undertaken to ensure the hot water is delivered to a safe temperature. Records seen were current. The laundry room was tidy, clean and organised. Infection control training is given to staff to ensure they are familiar with the correct procedures to be followed. Residents reported that the care of their laundry was good and that clothes were returned promptly. Comments regarding the accommodation included: “Nice home to live in” “My room is cleaned each day” “It is very comfortable” “The grounds are lovely, especially in summer, and the gardener does a wonderful job” “I have everything I need in my room” Leighton House Retirement Home Ltd DS0000064633.V368138.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 good. This judgement has been made using available evidence, including a visit to this service. There are appropriately trained and experienced care staff employed so that residents feel supported and that their needs are understood and met. The home’s recruitment policy is robust to protect the residents. EVIDENCE: The staffing rota was seen for the month of July 2008 and the planned rota for August and this evidenced sufficient numbers of staff on duty in relation to the number of residents in the home. The manager is supported by a full complement of staff, including a deputy manager. Three shift leaders take charge side and they provide support to the other care members. One shift leader has completed NVQ Level 4 in Management. Residents confirmed that staffing levels were good and that staff were around to help when needed. Sufficient numbers of staff are employed to ensure a good standard of cleanliness in the building. A resident said, “My room is cleaned every day, my carpet hoovered and my furniture polished”. Domestic staff have the use of a trolley for their cleaning products and gloves and aprons were being used appropriately. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 21 Care staff have a key worker role and a number of senior care staff are shift leaders. The key worker role enables staff to get to know a small group of the residents better when providing care and support. The AQAA evidenced that 60 of staff have achieved an NVQ (National Vocational Qualification) at Level 2 and above. All staff files viewed contained evidence of a certificate for their qualification. Three staff files were viewed to examine recruitment practices. The staff members had been recruited correctly to ensure the ongoing protection of the residents. The files contained completed job application forms with details of past employment, two references, POVA (Protection of Vulnerable Adult) check and CRB (Criminal Record Bureau) enhanced disclosure. References had been obtained from past employers where needed. Staff are provided with a handbook, contract and job description. New staff receive an induction and the manager now has the new documentation to commence the Skills for Care Induction Standards, which have replaced the TOPSS (Training Organisation for Personal Social Services) induction standards, which were withdrawn last year. Two staff members confirmed that they were shown round the home when they started, that the fire procedures were discussed at length with them and that they worked with an experienced member of staff. Staff receive training in safe working practices, including: moving and handling first aid, food hygiene, infection control and health and safety. The staff have individual training records to evidence courses undertaken. The manager has a training record to evidence training undertaken. There was evidence of a rolling programme for courses in safe working practices. Staff interviewed said that the manager arranges a good training programme. Other study days attended include: diabetes, medicine management, dementia care and nutrition in the elderly. Residents interviewed were pleased with the standard of care given by the staff and said that they were well trained and professional in their approach. A resident said, “The girls are really good indeed”. Leighton House Retirement Home Ltd DS0000064633.V368138.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, & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The registered manager provides guidance and support to staff, ensuring that the residents receive a consistently good standard of care. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong emphasis of being open and transparent in all areas of running of the home. The manager is supported by the owner, a competent senior staff team and the home generally has a low staff turnover rate. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 23 Care staff reported that they received good support from senior staff and had regular supervision to discuss their role and personal development. This leads to a stable and consistent service for people living in the home, which is particularly important. The home operates to a recognised Care Quality Assurance and standards that includes physical aspects of running the home, as well as monitoring the delivery of service. The provider carries out Regulation 26 monitoring visits. There are some good quality initiatives that ensure residents’ views are instrumental in the running of the home. Residents and relatives regularly attend meetings and are provided with survey forms to establish what they think of the home. Residents interviewed were satisfied with the management of the home and were pleased with the support offered by the staff. The home has effective systems in place to ensure the safety and upkeep of the physical environment, such as cleaning rotas and maintenance records. Portable Appliance Test Records, annual gas and electrical checks, and servicing of hoists were all checked and these were all up-to-date. The administrative systems within the home were found to be up-to-date and in good order, the manager supported by the owner, ensures the home is run in an efficient and effective manner. Residents manage their own money when appropriate. Where a resident needs support with managing their money, then a record of all money they give in and take out is kept and receipts are kept for purchases whenever possible. The Annual Quality Assurance Assessment (AQAA) requested by the Commission was returned in time and was completed with a high degree of detail. Within this document the owner and manager had made us aware of how the were operating the home and also identified how they felt they could improve. Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 25 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 Refer to Standard OP7 Good Practice Recommendations The manager should ensure that all staff members responsible for completing care plans update them as necessary and record sufficient detail when they are reviewed. An accurate record of all medicines held by the home is to be maintained so that all residents’ medicines can be accounted for. 2 OP9 Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Leighton House Retirement Home Ltd DS0000064633.V368138.R01.S.doc Version 5.2 Page 27 - 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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