Inspection on 02/06/05 for Crown House

This inspection was carried out on 2nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Crown House 05/09/06

Crown House 10/11/05

Crown House 11/01/05

Crown House 18/08/04

Crown House 24/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOME ADULTS 18-65 Ayeesha-Raj 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU Lead Inspector Jo Vyas Unannounced 2 June 2005 2:00pm nd 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. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ayeesha-Raj Address 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU 01509 413667 01509 413667 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) Cherre Residential Care Ltd Vacant Care Home 20 Category(ies) of LD Learning disability (20) registration, with number of places Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 3rd March 2005 Brief Description of the Service: Ayeesha Rajj is registered to provide care for twenty adults with learning disabilities. Formally known as David Leslie it was bought by Cherre Residential Care Ltd. in April this year. This company also owns a further two homes in the Leicester area. The home is situated on the main road running through Mountsorrel. It is located close to the centre of the village and has good access to public transport services into Leicester and Loughborough. The original house, a large detached property, has been extended to provide three shared and fourteen single bedrooms. It has three lounge areas, all of which are located on the ground floor. The garage has been converted into a games area for service users. There is off road parking for staff and visitors. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and three quarter hours and was carried out as part of the annual plan of inspection. Planning for this inspection included reviewing details of concerns raised by residents and the Registered Person prior to this scheduled inspection. The inspection focused primarily on those standards related to issues raised. Some aspects of the concerns raised have led to disciplinary action taken by the Registered Person against a member of staff. During the inspection, a resident gave the inspector a tour of the premises and staff and care records were inspected. Five care files were viewed. The inspector spoke to and observed the practice of four staff and most of the residents living in the home. At this time, no questionnaires have been received from residents, relatives or staff who use or work for the service. The inspector has also not received a pre-inspection questionnaire. What the service does well: What has improved since the last inspection? The home is under new ownership and this has had a significant effect on the residents and staff. Residents have been upset by some of the changes and some staff have left. However, residents and staff at the time of the inspection said they were happy with the changes in the home. It is difficult to assess improvement as the new owner, Cherre Residential Care Ltd., has only owned the home for two months but the Registered Person is confident that the home will significantly improve over the next six months. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 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. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 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 Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 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) 2 Prospective residents’ needs and aspirations are fully assessed therefore their care needs can be met once they move into the home. EVIDENCE: • All residents’ files viewed had a full assessment completed by a social worker in consultation with relatives and carers. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 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, 9 The individual needs and choices of residents are not fully addressed therefore this potentially puts residents at risk. EVIDENCE: • • Five care plans were viewed. Care plans were found not to be comprehensive and did not cover all care needs for residents. The advice and guidance for the specialist needs of one resident was not sufficient for staff to carry out procedures safely. The Registered Person has requested via a recent review, clear written guidance and training for staff. Five staff have been trained since the meeting but the Registered Person has requested that more staff are trained. The Registered Person is still awaiting the guidance requested. Residents the inspector spoke to are aware of their care plans and know who their keyworker is. The Registered Person stated that residents had attended two resident meetings since she has bought the home. Residents the inspector spoke to confirmed this. The meeting minutes could not be found at the time of the inspection. Risk assessments are in the process of being written. They are currently not comprehensive and do not cover all risks for residents. D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 10 • • • Ayeesha-Raj 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, 12, 13, 14, 16, 17 Currently, staffing levels and attitudes inhibit choice for residents in daily living activities. Staff offered minimal communication with residents, which resulted in an inflexible service and could potentially lead to residents’ needs being overlooked. EVIDENCE: • • • • • Residents access the local community, some independently. One resident told the inspector she likes to go into Leicester city centre. Some residents access day care provision. One resident complained about being bored as she said there is not enough staff on duty to take residents out. Staffing levels are three staff every morning and evening shift for sixteen residents. Another resident said he would like to go out shopping and to have a pint. He also said he visits Glebe House every Tuesday and enjoys cooking in the home. He also helps to dry the pots. Staff were observed offering choices of meals to residents at teatime. Two choices were offered but staff made alternatives if residents didn’t want what was offered. D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 11 Ayeesha-Raj • • • • • • Staff stated that the menu had been discussed with residents and changed as a result. Staff appeared task focused and reactionary, interacting with residents only when the need arose. The inspector observed interaction between staff and residents and on some occasions this was positive but on others there was minimal communication. The Registered Person was observed interacting positively with residents, using appropriate communication in the form of Makaton, showing interest in their day and discussing future plans with them. Residents were looking forward to a disco the home was holding for them later that evening. The garage has been converted into a games room and is also where residents smoke. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 12 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) 19 The healthcare needs of residents are identified and met. EVIDENCE: • • All residents are registered with a GP and have access to the appropriate healthcare professionals as required. Healthcare visits are recorded in the residents’ daily notes. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 13 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 Currently, the inspector is not satisfied that the home responds to complaints and concerns effectively and therefore is unable to ensure that residents’ views are listened to and acted upon. EVIDENCE: • Some residents wrote a letter of concern to the Commission for Social Care Inspection about some of the changes the home was undergoing as a result of the change in provider. These were the areas of concern raised by a resident during a conversation with the inspector: The home’s name has changed – she wanted it to remain ‘David Leslie’ as this was what she was used to. The menu – she said that it had been changed without consultation and she can’t make her own choices now. Short-staffed – she said that there used to be four or five staff on duty and now there is only three and therefore its boring as they can’t go out as much. These issues are being addressed separately. Staff stated that the home does have a record of complaints but they were unable to access them. • • Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 14 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, 26, 27, 28, 30 Ayeesha Rajj is homely, clean and comfortable but residents are at risk from some health and safety issues. EVIDENCE: • During a tour of the premises the inspector found; fire exits in two bedrooms, which does make it difficult for those residents to secure their belongings, as these rooms can’t be locked. The Registered Person stated that she is looking into the matter; the flooring for the downstairs bathroom is rucked and is therefore, a trip hazard; a chair is blocking the fire exit in room 12; the ramps into the home and a walk-in shower room are very steep making it difficult for a resident with a physical disability to access; a resident stated that a hand drier in the walk-in shower room was switched off as it is sparking when switched on; the sink in room 21 is old and grubby; some bedroom furniture is in need of replacement as old and broken. The Registered Person stated that a list has been made of furniture that needs replacing; the aerial in room 21 was broken therefore the TV did not have a clear picture and there was no lid on the kitchen bin. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 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) 33, 35 Support to residents is inadequate as the staff team is not cohesive or effective which resulted in an inflexible service and could potentially lead to residents’ needs being overlooked. EVIDENCE: • The Registered Person stated that a number of the original staff team have left the home. The inspector met new staff and staff who have worked at the home for a number of years. Both were positive about the change in management. The Registered Person was concerned that residents need continuity and consistency and therefore saw established staff as being key to this aswell as ensuring staff receive appropriate training and support. Residents stated that they liked the staff and that the new management listened to them. The rota demonstrated a consistent staffing level of three staff for the morning and evening shifts and at night, one waking and one sleeping staff. The number of staff appeared to ensure that all the tasks for the shift were accomplished and residents in most need were given priority. The Registered Person stated that she has put some training in place and is planning further training to take place so that staff are skilled at being able to meet the needs of the residents. D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 16 • • • Ayeesha-Raj 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) 37, 42 The current manager has a clear sense of direction and leadership, however this has yet to impact fully on staff custom and practice. EVIDENCE: • • • • The home does not currently have a Registered Manager but is being managed by the Registered Person, Hema Patel. The inspector saw examples of good and poor practice, staff being unclear about what is expected of them and inconsistent quality of recording. The home has a recently updated fire risk assessment and fire checks are completed as required. The inspector noted that one resident had a number of falls logged in the incident book but these were not recorded in the accident book. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 17 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 3 x x x Standard No 22 23 ENVIRONMENT Score 1 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 3 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 1 2 Standard No 31 32 33 34 35 36 Score x x 1 x 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ayeesha-Raj Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 1 x D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 18 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. 2. 3. Standard 6 9 16, 17 and 35 37 Regulation 15 13 12 Requirement The care plans must cover all aspects of the health and welfare needs of residents. Risk assessments must cover all potential risks to residents. The Registered Person must evidence staff training and support systems to ensure good practise. The Registered Person must put forward to the Commission for Social Care Inspection, a suitably qualified and experienced person to register as manager. The floor covering in the downstairs bathroom must be made safe. The chair in room 12 must not block the fire escape. Risk assessments must be completed for the identified resident who struggles to access the home and the downstairs shower room as ramps are very steep. The hand drier in the downstairs shower room must be repaired or replaced. The wash hand basin in room 21 must be replaced. Timescale for action 30/07/05 30/07/05 With immediate effect. 30/07/05 4. 8 5. 6. 7. 24 24 9, 24, 42 23 23 13, 23 30/06/05 With immediate effect. 30/06/05 8. 9. 24 24 23 23 30/06/05 30/12/05 Page 19 Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 10. 11. 12. 13. 14. 24 24 42 22 33 23 23 23 22 18 The TV aerial in room 21 must be reaired or replaced. The kitchen bin must have a suitably fitted lid. Records must be accurate and up to date. staff must have access to the record of complaints. The Registered Person must review staffing levels to ensure residents needs are met. 30/09/05 30/06/05 30/06/05 30/06/05 30/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 35 Good Practice Recommendations The Registered Person should look at team building exercises for the staff. Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE15 1SX 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 Ayeesha-Raj D C51 C01 63000 Ayeesha-Raj V231421 020605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!