Inspection on 22/08/05 for 54 Leylands Road

This inspection was carried out on 22nd August 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 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

54 Leylands Road 15/05/07

54 Leylands Road 10/10/06

54 Leylands Road 16/01/06

54 Leylands Road 09/11/04

54 Leylands Road 29/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 54 Leylands Road 54 Leylands Road Burgess Hill West Sussex RH15 8AL Lead Inspector Mr E McLeod Unannounced 22 August 2005 09:30am 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 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 Stationary 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. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 54 Leylands Road Address 54 Leylands Road, Burgess Hill, West Sussex, RH15 8AL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01444 870546 Sussex Oakleaf Housing Association Limited Mr Prabhooraj Unmar Care Home 6 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (MD(E)) - 1 of places Both, Mental disorder, excluding learning disability or dementia (MD) - 6 Both 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9.11.04 Brief Description of the Service: 54 Leylands Road (previously registered as Peppers) is a care home registered for up to six service users in the category of mental disorder (excluding learning disability or dementia), one of whom can be in the category of mental disorder over 65 years of age (excluding learning disability or dementia). 54 Leylands Road is a detached property on two floors in a residential area of Burgess Hill, with nearby bus and train services. The registered provider is Sussex Oakleaf Housing Association Limited, for whom the deputising responsible individual is Ms Tracy Linstead. The registered manager is Mr Prabhooraj Unmar. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was not announced and took place over three and a half hours on the 22nd August 2005. The inspection was arranged to follow up recommendations made at the previous inspection. The inspector interviewed two residents, the registered manager, and the one member of staff on duty who was available. Three sets of care plans, two sets of recruitment records and some policies and procedures were sampled. A tour was made of the communal areas in the home, and one bedroom was seen. The inspector would like to thank everyone who contributed to the inspection. What the service does well: What has improved since the last inspection? There has been some redecoration and re-carpeting since the previous inspection. The garden area has been developed with a gazebo and new planting. A draft policy on dying and death has been provided. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 6 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. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 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 standard(s) 3 The home is able to meet the needs of the residents accommodated. EVIDENCE: The home is registered for six residents, and presently accommodates six residents. There have been no new admissions to the home since 2002. The two residents interviewed believed the home was meeting their needs and aspirations, and this is supported by care planning records seen by the inspector. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 10 The home provides a care plan for each resident which describes the support to be provided and which is regularly updated to reflect changing needs and aspirations. EVIDENCE: Three sets of care plans were sampled by the inspector. There was evidence that residents are being consulted on the content of their care plan, and that care plans are being reviewed on a regular basis. Discussion with staff provided examples of how residents are being assisted to make choices and decisions about their lives, and the role in particular of the key worker in ensuring a resident is supported with their finances and independent living skills. Records of residents’ meetings were seen, which indicated that residents are involved in agreeing house rules, and arranging holidays and menus. The confidentiality policy seen was dated 1995, and therefore does not take into account changes in legislation such as the Data Protection Act and the Freedom of Information Act. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11, 13, 14, 15 Staff support residents to become part of and participate in the local community, and to maintain contact with family, friends and advocates. EVIDENCE: Interviews with residents indicated leisure and sports activities which staff are supporting residents to take part in, and also that staff are supporting residents to maintain contact with family and friends. Both residents interviewed gave examples of outside interests, holidays and trips which staff have assisted in arranging and accompanying them on. Care plans seen, and discussion with staff and residents, indicated a range of ways in which residents are making use of facilities in the local community, including college courses, voluntary work, and involvement with advocacy organisations. Care plans indicated that a number of residents are involved in planning their individual menus, budgeting for this, shopping, and cooking for themselves. Care plans also indicate how residents are being encouraged to further their social skills. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 18, 19, 20, 21 The healthcare and support needs of residents are being met in a planned and consistent way. EVIDENCE: Care plans seen indicate how residents are being involved in agreeing with staff how their personal support and the structure of their day will be provided. Discussion with residents and staff, and a sampling of health care records, show that residents are being supported in having their health care needs met, such as dental care, medication reviews, eating a healthy diet and staying fit. Designated key workers are identified for each resident, and discussion with staff gave examples of how this is ensuring consistency and continuity of support. Medication records, arrangements, and policies and procedures were sampled. The most recent pharmacy inspection report was seen. Records for the receipt, administration and disposal of medications were sampled. Three forms of consent to medication signed by residents were seen. A draft policy dated 21.3.05 on “Dying and Death of Residents” and another on “Bereavement” were seen by the inspector. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 22 Residents are being supported where they wish to make a complaint, and outcomes of complaints are being recorded. EVIDENCE: A complaints policy and procedures are in place. A record of three complaints was seen, which indicated how each complaint had been investigated and the comments from the complainant on the outcome of the complaint. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 24, 25, 27, 28, 30 Residents are living in a homely and comfortable environment, which is clean and well maintained. EVIDENCE: Improvements made to the premises since the previous inspection include the repainting of the hallway and some bedrooms, and the re-carpeting and repainting of the sitting room. There has been new planting and new flower beds introduced into the garden, and vegetable patches have been developed. A gazebo has been erected in the garden. The premises and grounds are being kept in good order. One resident’s bedroom was seen, and he confirmed that he was consulted on the redecorating of the bedroom. The bedroom reflected his hobbies and lifestyle, and had been personalised. The toilets and bathrooms in the home provide privacy, and meet residents’ needs. The main communal areas are the kitchen/dining room, the sitting room, the outside patio and garden, and the conservatory. There is a laundry room which residents are encouraged to make use of. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 14 All areas of the home seen were clean and hygienic, homely, comfortable and brightly decorated. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 36 Residents are being supported by an experienced staff team who are receiving appropriate training. EVIDENCE: Staff rotas were sampled for the week commencing 15.8.05, and a staff training schedule was seen. Discussion with a member of staff indicated that regular supervision is being provided, and that regular staff meetings are taking place. Mr Unmar, registered manager, advised the inspector that Sussex Oakleaf have recently undertaken an assessment of staff training needs. Two sets of recruitment records were sampled by the inspector, which indicated that appropriate interviewing procedures and arrangements for obtaining references and checks on prospective staff are in place. Recruitment records indicated that both new members of staff have appropriate previous experience and training. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40 The views of residents on the service provided are being sought. Consistency of care for residents would be enhanced by the updating of policies and procedures in the home. EVIDENCE: A new form seeking the views of residents on the service provided was seen. Residents are able to express their views on the service at monthly residents’ meetings, and the record of the most recent residents’ meeting was seen by the inspector. Mr Unmar said that a satisfaction survey for relatives, friends, advocates and stakeholders in the community was being developed, but not yet ready. Some of the policies and procedures seen have been recently updated, such as health and safety, and a policy on professional boundaries. A number of policies, such as the policy on confidentiality, do not appear to have been updated in a number of years, and therefore do not take account of changing legislation. 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 17 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 54 Leylands Road Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x 2 2 x x x H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 19 no 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 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 10 Good Practice Recommendations It is recommended that the home’s written policies and procedures on confidentiality should be updated in accordance with the Data Protection Act 1998 and the best interests of service users. It is recommended that policies and procedures should be regularly reviewed to ensure compliance with current legislation including the Care Standards Act. It is recommended that the views of service users, family, friends and stakeholders in the community are sought on how the home is achieving goals for service users. 2. 3. 40 39 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 54 Leylands Road H60-H11 S14663 54 Leylands V236701 220805 Stage 4.doc Version 1.40 Page 21 - 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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