Inspection on 13/10/09 for The Leys

This is the latest available inspection report for this service, carried out on 13th October 2009.

CQC found this care home to be providing an Adequate 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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Leys Old Birmingham Road Alvechurch Birmingham West Midlands B48 7TQ Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 13th October 2009 09:00 DS0000071685.V377937.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Leys Address Old Birmingham Road Alvechurch Birmingham West Midlands B48 7TQ 0121 445 5587 0121 445 0675 leys@crystal-ns.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) Crystal Nursing Services Ltd Mrs Jeanette Westwood Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (20), Physical disability over 65 years of age (20) The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia over 65 years of age (DE)(E) 20 Mental Disorder over 65 years of age (MD)(E) 20 Physical Disability over 65 years of age (PD) (E) 20 Old age not falling within any other category (OP) 20 The maximum number of service users to be accommodated is 20. 2. Date of last inspection 13th October 2008 Brief Description of the Service: The Leys is registered to provide residential care for up to twenty older people. The Leys is a large Victorian house, which has been upgraded and adapted for its present purpose. The premise is located just outside the village of Alvechurch, along a country lane close to the Birmingham to Redditch Road. The home is easily assessable from the M42 and has parking to the front of the building The home has 16 single and 2 double bedrooms. Eight of the single and both double bedrooms have en-suite facilities. The home is situated in approximately 2 ½ acres of ground, with pleasant gardens, which are well kept and accessible to people using the service. The accommodation provided for people using the service is comfortable and well maintained. The Service Users Guide states that The Leys aims to provide a warm, homely, safe and supportive environment to help you make the most of your time here. The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 5 The most recent Service Users Guide states that fees depend upon the care needed and accommodation provided. It continues saying that fees start at £430.00 per week depending upon the care needed and accommodation. For the most up to date information regarding fees charged the reader should contact the service directly. The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The last inspection at The Leys was undertaken during October 2008. This inspection was what we call a key inspection; this is one when we look at what we believe to be the most important National Minimum Standards. This key inspection involving one inspector and was carried out over two separate days. As part of this inspection, in addition to the visit to the home, we also took into account other information we had received. Prior to our visit we requested an Annual Quality Assurance Assessment (AQAA) from the registered persons. This is a document within which providers of care services are able to demonstrate to us where they believe they are providing a good service and where they believe they could improve in the future. The AQAA also provides us with certain data which we need to know. The AQAA was completed by the registered manager and returned to us. Prior to the inspection we posted out some surveys to residents, their representatives and staff. We have taken account of the surveys returned as part of this inspection report. During this inspection we had a look at communal areas of the home as well as some bedrooms. We read available care plans, daily records and risk assessments regarding some people living in the home. We also viewed other documents such as medication and staffing records. We spoke to a number of people in the home including the provider, some members of staff, residents and visitors. We observed care practices throughout our time in the home. What the service does well: Information about the home is available. Care needs are assessed prior to admission to ensure that the home is able to meet these. Relatives are pleased with the support that people receive at The Leys in relation to their health and personal care. One relative wrote ‘I can not express how well The Leys looks after people in their care. Food is particularly excellent.’ The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 7 Other relatives wrote: ‘My xx is very well cared for by all the staff.’ ‘Care is of a very high standard, very caring, approachable and able staff.’ They make the leys home from home and each individual is cared for with a real family feel. People tell us that they enjoy the food provided. The home is clean and tidy , people are able to personalise their bedrooms as they wish. Recruitment procedures are in place to ensure that unsuitable staff are not employed. Staff have knowledge about adult protection procedures which assist in safeguarding people. People are confident that any complaints would be heard. Staff receive training in order that they have knowledge to assist them in carrying out their roles. The number of staff who have achieved an NVQ (National Vocational Qualification) in care is commendable. What has improved since the last inspection? What they could do better: Since our last inspection as a means to try and improve on care planning and risk assessments the provider had introduced a computerised system. Unfortunately problems with the software used and a lack of confidence amongst some members of staff has resulted in some records not existing or not up to date. Improvement in data recovery or a different system needs to be put into place to ensure that carers have the information they need to deliver the care required. Some management systems need to be improved to ensure that all areas of the home are safe and to ensure that quality assurance systems are in place. These will ensure that people are better protected and have their needs met. The Leys DS0000071685.V377937.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable at The Leys. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is available to help people make a choice about whether they would like to live at The Leys. The care needs of people who may use the service are assessed so that individuals and their relatives can be assured that staff will be able to meet these. EVIDENCE: When we last visited The Leys we saw draft copies of the homes Statement of Purpose and Service Users Guide. During this inspection we were given a copy of the home’s current Service Users Guide. The document, dated September 2009, is informative and well set out although it does not contain any comments from people using the service. Having information available about the home may assist potential users of the service decide whether or not it is suitable to meet their care needs. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 11 We asked on our surveys whether people had received enough information about the care home before moving in. On all the surveys returned to us people stated they had received this information. One relative wrote The Leys have welcomed ** and us and made the transition into care with the up most respect, care and consideration to all of us. Within the AQAA the registered manager wrote that over the next twelve months it is planned to launch a web site and introduce a welcome pack for all new residents. The vast majority of people indicated that they had also received information about the homes terms and conditions or a contract. The Service User’s Guide states that ‘The Care Manager / Deputy Care Manager will assess your needs before you move into the Home, to ensure that we can provide the appropriate care for you.’ The guide also informs people that they will be able to spend a day at the home prior to an admission so that their needs can be assessed further. We viewed the assessment carried out on a resident prior to his admission. The assessment form gave brief details of care needs under a range of headings. The information provided was sufficient to draw up an initial basic care plan in order for care staff to be able to meet care needs. We also saw an assessment carried out by the purchasing local authority which also informed staff about identified care needs. People are initially admitted on a four week trial period. The Leys does not take people on an emergency basis and does not have any plans to provide either this or intermediate care in the future. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are pleased with the health and social care they receive but the quality and consistency of this is not assured because care practice is not supported by good record keeping. Systems are in place to ensure that people receive their prescribed medication. EVIDENCE: The registered manager wrote on the AQAA returned to us prior to the inspection ‘We are at present changing the whole system on care planning, report, risk assessments for all people who live at the Leys , from paper version onto a computer system’. We were also told that ‘training for all care staff is being arranged.’ The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 13 During this inspection we asked to view the care plans and risk assessments as well as other written records regarding a number of people living within the home. A care plan is a document designed to give guidance to carers in order for them to provide the care required in a consistent way. A care plan needs to be reviewed and amended as required, at least monthly, to ensure that it is up to date and an accurate reflection of an individual’s care needs. On arriving at the home we were informed that certain elements of care planning were now held on computer. We become aware, during our visit, that some staff were more confident than others regarding the introduction of a computerised system. We previously found care plans to be comprehensive covering a range of aspects in relation to care needs. However we had previously commented that some information within care plans and risk assessments was conflicting. At the time of this inspection it became apparent that some information continued to be in written format while other information was on the computer. On arriving at the home we were told that staff had needed to revert to written documents due to a failure with the computer system. The registered provider was in discussion with the software company in attempts to reinstate information which was lost from the computer. Initially, it appeared that information was recovered however, we later found that this was not the case. Within one section of the computer programme staff had recorded see keyworker notes. However when we looked at the keyworker notes section no information was there. It was confirmed that all this information was lost even after data recovery had taken place. Due to missing information it was difficult to assess whether records were up to date or not as we continually found information was missing. We saw a risk assessment regarding pressure care dated August 2009. This risk assessment was due to be reviewed in September 2009 but had not been done. A care plan on the computer made reference to the use of a heel boot to prevent pressure damage to the residents heel. The notes being made by community nurses also made reference to the heel boot. A record dated July 2009 stated not putting on for a while. However, the care plan on the computer said that staff were to ensure the boot is used. Within the nurses notes we also saw reference to two skin breaks and in the daily notes we saw an earlier reference to skin damage. No care plan regarding pressure care was devised at the time. The health care plan made no reference to pressure damage and indicated that skin was intact. The personal care plan made no reference nor did information about Getting up and going to bed. The manager was unable to clarify the current situation but carers confirmed that the heel boot was not being used. Following this inspection we were told that the community nursing team were no longer recommending the previous care regime (i.e wearing the boot) and therefore there appeared to be no concern that care needs were not being The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 14 met. However, the evident confusion in the records did not give us confidence that needs would always be known and acted on appropriately. In relation to another person we saw a Waterlow risk assessment regarding pressure care dated 08/10/09. This score was already high however staff had not completed the information about weight which would have increased the score further. Another tool indicated no risk to pressure sore damage but staff were using a pressure relieving cushion and the community nurse had requested a pressure relieving mattress. We saw no care plan regarding pressure prevention. Comments from a relative at a review were included with the documentation we saw. The person was said to be really pleased with the care my *** is getting. She is well looked after and the staff are wonderful, nothing is too much trouble for them. Her medical care is better here than she has ever received. One member of staff told us that, at the time of our visit, there was nobody who needed to use the hoist. We were told that the hoist over the bath is used. We highlighted a potential risk to male residents due to the design of the seat on the bath hoist. This risk was taken on board by the member of staff concerned. Following the last inspection the registered person’s needed to make improvements in the management, recording and administration of medication. We recognised within the previous report that our concerns, at that time, were being taken seriously and an action plan was devised and sent to us. On assessing medication during this visit we saw significant improvement. We found MAR (Medication Administration Record) sheets to be completed and up to date. We saw that random audits of the records had taken place. At the time of this inspection four members of staff were permitted to administer medication. Handwritten entries on the MAR sheets had the necessary two signatures. We audited some antibiotics all three of these balanced correctly. A stock of anticoagulant tablets also balanced correctly. We also audited some painkillers however these did not balance as we found two tablets to be missing. Both the manager and deputy manager were disappointed that we found this one area when it appeared a mistake in recording had occurred following the improvements they had make in medication management during the previous 12 months. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 15 One member of staff wrote on our questionnaire ‘The Leys always puts the residents first, the care here is excellent.’ Another member of staff wrote ‘All our residents have excellent care and are extremely well looked after.’ Although we overheard a number of staff referring to residents as ‘sweetheart’ we observed staff being caring and considerate. Generally staff were polite and courteous to residents. During our discussions with residents nobody brought to our attention any concerns or worries. Residents were suitably attired taking into account gender, culture and weather conditions. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People using the 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 offers opportunity to take part in some activities. Meal times are relaxed and people like the food provided. EVIDENCE: During this inspection there was a discussion regarding the home having advertised for an activities coordinator. Staff members, as well as management, told us that an advert for a coordinator was unsuccessful and since then debates had taken place within the home as to whether a specific person should be appointed or whether, with additional staff, activities should continue to form part of each carer’s duties. We received some conflicting information regarding whether staff have the availability or not to undertake activities. One carer told us that over the previous fortnight there had only been one day when no activity was provided. Somebody else said that activities are provided when staff have the time and that this may be once or twice a week. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 17 A member of staff told us that they join residents and encourage people to take part in quiz programmes on the television. Another member of staff told us that activities include basket making and using musical instruments. Information about proposed activities was on display showing for example reminiscence and cards on a Tuesday and exercises to music and sing a long on Wednesday. During our visit we saw staff interacting with residents. Photographs were on display of a St. Patricks Day party which took place during March 2009. The home was preparing for a Halloween party A white board in the lounge showed the date and weather conditions, this information can assist people in their daily orientation. During our previous visit we were able to talk to a visiting retired vicar. The Service User’s Guide confirms that the rector from a local church visits every four weeks. We are not aware of any restrictions regarding when people are able to visit relatives and friends residing at The Leys. The AQAA states that family and friends are encouraged to visit. Staff told us about the food provided in the care home. One member of staff wrote ‘We do a wide choice of food for the residents and cater for diabetics and vegetarians, food is fresh and they enjoy it very much.’ During our inspection a member of staff described the food as very good. Upon the AQAA the registered manager wrote ‘There is a varied choice of meals which are nutritious, cooked fresh on the premises and have been given four star rating from Ev (Environmental) Health Bromsgrove DC (District Council) The dry store contained small tins of items such as baked beans, spaghetti, macaroni cheese, tuna and salmon. Having these items demonstrates that these items are made available to people should they so request them. A menu board was on display just outside the dining room. The board contained some pictorial images as well as the menu in writing. We were told by the manager that further pictures are going to be obtained. On the day of our first visit the lunch time meal consisted of steak and onions, gravy, cauliflower, peas and carrots. An alternative of vegetable and macaroni bake was available. While residents were eating we noticed that staff withdrew from the dining to allow residents to enjoy their food. Residents we spoke to told us that they had enjoyed their meal. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to make a complaint and can be confident that their concerns would be listened to. People are safeguarded from the risk of harm or abuse because staff have sufficient knowledge about the procedures they should follow. EVIDENCE: Copies of a leaflet entitled ‘The Leys Values Your Views. If you have any Comments, Compliments or Complaints we want to hear them were available in the hall. The leaflet suggests that complaints should go to the manager or deputy in the first instance. The information about the regulator is incorrect and needs to be amended. Despite the comments about the leaflet it is nevertheless encouraging that the service has such information freely available for people to write their comments upon. A small letter box is available for people to use to deposit their comments. The recently reviewed Service User’s Guide contains information about complaints and gives details of CQC and our postal address in the West Midlands. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 19 Staff confirmed within the questionnaire that they know what to do if somebody has a concern about the home. The AQAA states that the service has received no complaints during the 12 months leading up to completing the document. This was confirmed by the registered manager during our inspection. The commission have not received any concerns or complaints about the service provided at The Leys since our last inspection. During our visit people told us that they would speak to the registered manager if they had any complaints. People appeared confident that their concerns would be listened to. On the AQAA the manager wrote that people have the right to vote if they wish in local or government elections and that they are given a choice about how they wish to do it. The Service User’s Guide included information about an advocacy service in Redditch. Since our last inspection the registered manager brought to our attention a potential safeguarding incident which was alleged to have occurred while the individual concerned was in the care of others. We discussed safeguarding with a member of staff who had a good understanding of the term. The staff member told us that she would report any incidents to the registered manager, the provider and the commission. Another member of staff said the police may need to be involved in certain cases. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well maintained and comfortable environment. Some improvements to systems regarding health and safety will assist in ensuring that people are safeguarded against any potential hazards. EVIDENCE: The home has sixteen single and two double bedrooms. Eight of the single bedrooms and both of the double bedrooms have en-suite facilities. Bedrooms are provided on both the ground and first floor. A passenger lift is provided to afford ease of access between the two floors in addition to a central staircase. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 21 The home has a bathroom on the first floor, a wet room on the ground floor and three communal toilets on both floors. The wet room is new since our last inspection; the registered manager believes this facility to be an improvement as it assists staff meet additional care needs. Sit on scales are kept within the wet room to help staff weigh people. The home is set in two and a half acres of garden which are well maintained. Car parking is available at the front of the building. During our last inspection we were informed by a range of people that improvements to the environment had taken place since the new provider took ownership of the home. Improvements have continued to take place for example a number of new windows replacing ones highlighted as needing attention, the repainting of the fire escape and work to the roof and guttering. The entrance foyer remains a popular place for people to sit and watch the comings and goings in the home and general goings on. The dining room is a pleasant area for people to have their meals. The lighting and decoration in this area continue to be in good order. As previously reported the main lounge is well maintained and pleasant. A large flat screen television is provided in the lounge. A conservatory leading off from the lounge provides an addition seating area which looks over the extensive garden. We viewed a number of bedrooms. It was evident that people living at The Leys are able to bring in personal items which are familiar to them such as photographs and items of furniture. Some of the furniture provided by the home is in need of replacement as it appears tired. We did however see one bedroom with new furniture in, which was very pleasant. The wardrobe in this room was not secured to the wall. We saw a cupboard which contained new matching bed linen. The radiators we saw were covered to prevent accidental scalding. Pipe work leading to a radiator in the hall way was either not covered or had a covering coming away from it. Pipes carrying hot water need to be risk assessed to ensure that potential risks are identified and strategies or action implemented to reduce these risks. People told us that they have found the home to be clean and tidy. One person wrote on behalf of a resident ‘My room is always clean and tidy, towels are always changed.’ Another relative wrote ‘Home is very clean. Clothes are always clean and ironed.’ Hand wash gel dispensers are located near the main entrance door and the kitchen. Visitors are requested the use gel on arriving at the home to assist within infection control procedures. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 22 We noticed that a cleaning cupboard in the sluice was left unlocked for a lengthy period of time. The registered manager was able to give us an account for this happening however as the fire door to the sluice was also propped open for a period of time this presented a risk to the health and safety of residents. Earlier during this inspection a bottle of toilet cleaner, a spray, a hard surface cleaner and a floor cleaner described as an irritant were found left in a corridor. These items were removed once they were brought to the attention off the registered manager. Information regarding some newly replaced windows and the restrictors fitted to these windows is included elsewhere within this report. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a staff group which is well trained. People are protected by good recruitment procedures. EVIDENCE: When we asked what the home does well one relative wrote Everything everyone is very kind. Another person wrote very caring, approachable and able staff. On a survey, completed by a relative on behalf of a resident, we were told The staff are always friendly and helpful and always there to listen to me. During this inspection we were informed that the morning shift is covered by either 3 or 4 carers. We viewed some recent rotas. As a result of the home having a vacancy for cook the deputy manager and senior have been covering that role, therefore removing them from their other duties. We were told that the deputy manager had worked as cook 6 days per week for the previous 4 weeks. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 24 The rota showed that on a couple of occasions a member of staff had worked a late shift followed by a night shift. This would be a total of 16 hours continual working which could be hazardous and potentially place people at risk. We also noted an occasion when a member of staff worked 8 consecutive days without a day off. Within the AQAA the registered manager wrote that ‘Staffing levels for each shift are adequate for the number of residents.’ We asked staff in our questionnaire whether there are enough staff to meet the individual needs of people using the service. The vast majority answered ‘sometimes’. Staff told us that they need more staff to do activities with people and to meet care needs. Staff stated that a senior is always on duty but that staffing levels are sometimes low when people are either on holiday or off sick. At the start of this inspection the registered manager, a senior carer and a care assistant were on duty. In addition was the deputy manager, working as cook, and a domestic. We were told that care staff would be undertaking laundry duties and activities as well as meeting the other identified care needs of residents. We were told that agency staff have at times been used. Prior to any agency staff working in the home the registered manager obtained documentary prove that people were suitably checked by the agency concerned. We saw a letter from one agency which stated ‘All of our care assistants are fully referenced, have a current CRB (Criminal Records Bureau (checks)) and are fully trained.’ The manager held copies of the CRB disclosure on staff they had used. The manager told us that they would have used agency personnel for catering duties but they could not obtain anybody with a CRB. We were assured that at no time had the home used agency staff to cover the senior role as well as a care assistant post at the same time. The rota showed that either a housekeeper or domestic are on duty each morning and both the housekeeper and the domestic work on a Tuesday and Thursday morning. Domestic cover occasional happens during the afternoon. We were told of plans to employee an evening kitchen assistant. Having a member of staff covering the evening will provide care staff with additional time as they currently have to undertake this role. A clerk works two days per week to provide additional administrative support to the manager and her deputy. We viewed the records regarding a new cook. Two written references were held as was a PoVA (Protection of Vulnerable Adults) first. At the time of our visit the manager was awaiting the CRB. We were informed that further documents were awaited in relation to a new carer prior to her commencing duties. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 25 The registered manager wrote in the AQAA that the home is ‘committed to NVQ training which over 50 of staff have achieved.’ Out of the current establishment of care staff all but two have complete National Vocational Training. All the senior carers have a level 3 NVQ and the deputy manager has a level 4. These figures are in excess of the National Minimum Standards and are commendable. On the AQAA the registered manager wrote that staff receive training in equality and diversity. Details of training were seen including a timetable of training that had recently occurred or been planned for the future. Recent training had included health and safety, food safety and risk assessments. Infection control training needed to be re arranged as the trainer was unwell. On the day of our visit moving and handling training took place. Forthcoming training includes emergency first aid, bereavement, Mental Capacity Act and Deprivation of Liberty. Training on dignity in care was carried out in July 2009. We were also told of a forthcoming visit regarding dementia training entitled ‘The Emotional Journey.’ The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is managed in the best interests of people living there. People could have greater confidence in the service once risk management and quality assurance systems are implemented or improved. EVIDENCE: The registered manager of the home is experienced and has achieved the Registered Managers Award (RMA). This award is a level 4 NVQ (National Vocational Qualification) in management. During this inspection we were told that an assessor for the NVQ level 4 in care was due to visit. As well as The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 27 undertaking an NVQ level 4 in care the registered manager is also working towards a diploma in dementia care. Staff told us in our survey that the manager gives support and meets with them to discuss how they are working. Staff told us that they receive supervision in line with the National Minimum Standards. The current certificate of registration was on display in the entrance hall. Prior to this inspection we requested the completion of an Annual Quality Assurance Assessment. This document was returned to us and was fully completed. We previously found that a quality assurance manual was available however, it had not been used. Results of a previous survey, March 2008 were at that time on display. During this visit we were informed that a new format was devised and that comment cards were distributed. A few of these have been returned however these have not as yet been collated. The registered provider of the service visits regularly and seemed to be known by residents. Regular reports are written by the provider on his findings when he visits regarding the conduct of the home and any comments he receives. No other quality assurance systems are in place within The Leys as a tool to assess the quality of the service provided. When we last visited the home we enquired whether money was held on behalf of people residing in the home. We became aware of some money held however we were informed that no records were kept. During this inspection we did not assess the storage arrangements however we were told that other than money no valuables were held. We viewed the records and checked the balance held for four people. It was clear that improvement had taken place. Although significantly improved and records held are sufficient to protect both residents and staff further improvements could take place regarding the design of the forms to make them more user friendly. The Service Users Guide states ‘We can hold up to £50.00 per resident in the safe’ one of the amounts we checked was slightly over this limit. Personal effects are insured to a limit of £1,000 per resident however people are recommended, within the service users guide, to check the exact cover provided against individual items. Some policies and procedures were in need of reviewing when we last visited. The AQAA stated that policies and procedures are in place and that they were last reviewed during April 2009. It was evident that a review of these important procedures had taken place. We did however note some old procedures displayed around the home, some of these were different versions The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 28 of the same procedure which could cause confusion amongst staff. The jewellery policy stated that staff should not wear any jewellery to work with the exception of engagement and weddings rings etc, discreet earrings and watch. We saw staff wearing items in excess of this policy. Certain items of jewellery can potentially cause injury such as skin tears as well as harbour infections. The registered manager is aware of the requirement to inform us of certain events regarding the well being of residents. We are not aware of any incidents within the home when we were not suitably informed in a timely manner. The registered manager confirmed that the evacuation plan for the home in the event of an emergency was still in place. We previously commented upon the good arrangements made regarding the availability of transport and alternative accommodation should The Leys become unsuitable following an emergency such as fire or flood. We viewed the fire safety records. These were generally in satisfactory order. The testing of the fire alarm is carried out on the vast majority of weeks and it is done in sequential order around the break glass points in the home. Records suggested that the last monthly check of the fire fighting equipment was done in July (this inspection was done in October). We saw other records and these suggested that checks had not taken place recently such as water temperatures and window restrictors. We saw another record which showed maintenance carried out such as changing bulbs and unblocking toilets. Within these records we saw reference to ‘water check’. The information within this record was not sufficiently detailed to show what the check had entailed. A certificate dated September 2009 following the testing of water against the presence of the legionella bacteria was seen. This did not indicate any concerns or problems needing to be addressed. Records suggested that the testing of equipment used for lifting people is serviced on an annual basis. The company who had previously undertaken the test were found to have gone into liquidation when the provider contacted people during this inspection and no records regarding The Leys could be found by the company who had taken over. Guidance from the Health and Safety Executive (HSE) regarding the servicing of hoisting equipment states that ‘The Lifting Operations and Lifting Equipment Regulations 1998 require that personal lifting equipment (hoists and lifts for people) are thoroughly examined every six months unless a separate thorough examination scheme is devised by a competent person.’ The seat over the bath hoist has holes in the seat to allow drainage; these holes can however be a potential hazard from some residents which needs to be taken into account when bathing takes place. We The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 29 were told that a piece of lift equipment in one en-suite bathroom is not used but is serviced. Since our last visit the registered provider has replaced some windows on the first floor. We previously commented on the restrictors on some of these old windows as they could be fully opened with ease. The new windows have restrictors fitted however, as we were able to demonstrate to the registered manager, these could be over ridden and as a result a risk of people managing to either accidentally or deliberately fall to the ground existed. The registered manager undertook to address this shortfall as she was not aware that the risk remained. We did not view records regarding the electrical testing of portable equipment however we noticed that the plug on the large television stated that the next testing is due October 2010. The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 30 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 31 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 A review of care plan documentation should take place to support good practice and evidence the care given to people living in the home. A risk assessment of the window restrictors and hot water pipes should be undertaken and any necessary action to ensure their resident’s safety should be taken. 2. OP38 The Leys DS0000071685.V377937.R01.S.doc Version 5.3 Page 32 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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 © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. 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