Inspection on 13/12/05 for George Hythe House

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

George Hythe House 02/09/09

George Hythe House 06/09/07

George Hythe House 03/05/06

George Hythe House 30/01/06

George Hythe House 19/04/05

George Hythe House 06/10/04

George Hythe House 22/04/04

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

CARE HOMES FOR OLDER PEOPLE George Hythe House 1 Croft Road Bennion Road Leicester Leicestershire LE4 1HA Lead Inspector Ruth Wood Unannounced Inspection 13th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service George Hythe House Address 1 Croft Road Bennion Road Leicester Leicestershire LE4 1HA 0116 2350944 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) www.leicesterquakerhousing.com Leicester Quaker Housing Association Mrs Jeannette Evelyn Ewens Care Home 41 Category(ies) of Dementia - over 65 years of age (31), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (31), Old age, not falling within any other category (41), Physical disability over 65 years of age (41) George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person to be admitted in categories MD(E) or DE(E) when 31 persons in total of these categories/combined categories are already accommodated. 19 April 2005 Date of last inspection Brief Description of the Service: George Hythe House provides a service for 41 older people, some of whom have mental health needs and/or physical disabilities. The home was purpose built in 1993 and is owned and managed by the Leicester Quaker Housing Association. The home has 41 single rooms, all of which have en-suite facilities. The accommodation is on two floors, serviced by a shaft lift. There is a large communal lounge on the ground floor and a smaller lounge with attached dining and kitchen facilities on the first floor. The latter is used primarily as the focus for activity sessions. The Home is divided into four wings, each having its own dining room and kitchen. Outside there is a garden with seating areas. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place on a weekday between 9.30am and 3pm. The majority of key Standards were assessed at the Announced Inspection earlier in the year; health and safety practice and administration of residents’ finances will be further assessed at an additional Inspection in the New Year. Discussion was held with eight residents, three relatives, team leaders, care assistants and ancillary staff. Care and daily records were examined. Care practice was directly and indirectly observed. Three of the fourteen Requirements made at the previous Inspection remain outstanding and seven new Requirements were made together with one Recommendation. What the service does well: What has improved since the last inspection? What they could do better: Improvements are required in some aspects of assessment, care planning and daily records and the Registered Manager must ensure that the Commission is notified of all incidents affecting the well being of residents. Although the home was generally clean, tidy and in good repair the carpet in one resident’s bedroom was badly stained and must be cleaned or replaced. As at the previous Inspection water temperatures were excessive in some residents’ bedrooms placing them at risk of scalding. Staff still seemed unaware of their ongoing responsibility to monitor the temperature of water and inform the Registered Manager if temperatures reach a dangerous level. Staff also need further information about the home’s whistle blowing policy, particularly the role of the Commission as the regulating body who can act on concerns if an appropriate response is not given by the home’s management. Strategies should also be considered as to how staff respond to visitors to the front door to avoid them waiting outside for excessive periods. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 6 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. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 7 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 George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Improvement is needed in one area of assessment. EVIDENCE: The care records of four residents were examined; all contained the home’s assessment of need, together with copies of social workers’ Community Care Assessments. A recently admitted resident said that the Manager and another member of staff had visited them in their home before they moved in, to discuss their needs and “see if I was suitable.” Discussion between Team Leaders demonstrated however that an assessment had not been completed with regards to this resident’s medication needs, specifically in relation to their wish to continue to self-administer. This must be completed and should form part of the assessment of all residents. Intermediate care is not offered therefore Standard 6 is not applicable. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Residents’ health and medication needs are met but care plans do not always accurately reflect residents’ current needs. EVIDENCE: Four residents’ care plans were examined. One resident’s care plan had not been recently updated and did not accurately reflect their current observed and reported needs/care following deterioration in their health. It was difficult to follow the care received by another resident as Daily Records were not in date order and entries had been made in several places. Several entries also stated, “All care needs met” without stating what care had been given. This entry appeared six days in succession on the seventh day the resident was admitted to hospital. It was difficult to track therefore if the care given had been appropriate. Another resident’s daily report sheet was not dated. Some care plan ‘reviews’ summarised the major events that had taken place in the resident’s life during the proceeding month but did not expressly state the changes made to the actual plan of care as a result of these. Care plans now contain pressure area risk assessments together with information on how to manage that risk. The G.P. visited during the Inspection and saw several residents. Residents’ files contained documentary evidence of George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 10 the involvement of Consultant Psychiatrists, Physiotherapists and other health professionals such as Dentists and Opticians where appropriate. Discussion with Team Leaders and examination of care records did not indicate what action had been taken in response to a Requirement made at the previous Inspection that a strategy be developed to improve practice in relation to prevention of falls. Part of the morning medication round was observed and this was conducted appropriately. Medication records were accurate and medication was stored appropriately. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,15 Residents are able to exercise choice in their diet, which is wholesome, nutritionally well balanced and served in pleasant surroundings. EVIDENCE: Discussion was held with the assistant cook and menu records were examined. An assessment is made of each resident’s dietary needs and preferences and this informs the choices available on the menu sheets. A vegetarian option is available each day and the menu features plenty of fresh fruit and vegetables. A special choice of menu is available for people with diabetes. A full range of food, including cooked breakfast, is available each morning and four choices of food are offered for tea. Meals are served in the four Wing dining rooms, which are light and airy and attractively furnished. Residents and their relatives spoke positively about the food in the home. Residents have the opportunity to bring personal possessions in to the home; all residents’ rooms visited were highly personalised. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 A greater awareness of the whistle blowing policy is required to fully ensure residents’ protection. EVIDENCE: Whistle blowing was discussed with three individual staff members. None were aware of the role of the Commission for Social Care Inspection should any concerns about the welfare of residents fail to be acted upon by the home. This should be clarified. This Standard was fully assessed at the previous Inspection. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in a comfortable and clean environment although excessive water temperatures compromise residents’ safety. EVIDENCE: Sample water temperatures were taken in residents’ bedrooms in all Wings. Water temperatures were excessive in Wings 1,2 and 5 ranging from 52.4°C to 65°C. An Immediate Requirement was made that water temperatures be made safe (43°C or below at delivery) and a plumber was arranged for later that day. The home was decorated for Christmas and appeared festive and welcoming. In-house cleaning staff and contract cleaners were cleaning bedrooms and communal areas during the Inspection. The home was generally clean and tidy although the carpet in one bedroom visited was badly stained and required cleaning or replacing. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The number of staff on duty meets residents’ needs. EVIDENCE: On the day of Inspection there was a Team Leader on duty during the early and late shift with one member of care staff being on duty in each Wing and two additional domestic/care support workers on duty between the four Wings. Contract cleaners, laundry assistants and catering staff were on duty in addition to care staff. During the afternoon shift one Team Leader was on duty with four care staff. The rota showed that on the late shift on Sunday 18th December there was one Team Leader and three care staff on duty. All staff appeared very busy throughout the Inspection and it was noted that it took five minutes for a staff member to come to the front door when the Inspector arrived. Relatives visiting later in the morning had a similar experience. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Improvements are needed in aspects of health and safety to ensure the welfare of residents. EVIDENCE: Standards 35 and 38 will be fully assessed at an additional visit before the end of the Inspection Year. Following a successful fit person interview the Manager Jeanette Ewens was registered on 06/10/05. Ms Ewens has sufficient relevant experience but is still to complete her Registered Manager’s Award. The Registered Manager was not on duty during this Inspection. Hot water temperatures were excessive in three of the five Wings (see Standard 19 for details) neither was there any evidence that temperatures were regularly monitored or that staff were aware of their responsibilities in doing this. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 16 A resident’s recent admission to hospital with a serious illness was not notified to CSCI as required under Regulation 37. A notification of this incident must be forwarded and all senior staff reminded of their responsibilities in this area. George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 1 George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 13 Requirement The medication needs of the recently admitted resident must be assessed. The assessment must include a risk assessment for self-administration of medication. A copy of the assessment must be forwarded to CSCI. Assessment of medication needs must form part of the preadmission assessment. The care plan of the identified resident must be updated to accurately reflect their current needs. All care plans must accurately reflect residents’ current needs and must therefore be updated when there are significant changes in care. Daily records must be entered and stored sequentially to ensure that changes in residents’ needs can be identified and met. Staff must specify care given to service users (rather than using terms such as “All care needs met.”) to enable delivery of care to be accurately monitored. DS0000006386.V255031.R01.S.doc Timescale for action 20/12/05 2. 3 OP3 OP7 13 15 13/12/05 16/12/05 4. OP7 15 13/01/05 5. OP7 15 16/12/05 6. OP7 15 23/12/05 George Hythe House Version 5.0 Page 19 7. OP8 13 8. OP18 13 9. 10 OP26 OP38 16 37 The Registered Manager must provide documentary evidence of the measures taken to reduce the risk of falls for residents identified as being at risk. The Registered Manager must ensure that all staff are aware of their responsibilities under the homes whistle blowing policy and the role of CSCI within this. The carpet in the identified bedroom must be cleaned or replaced A report of the admission of the identified resident to hospital must be forwarded to CSCI. Senior staff must be reminded of their responsibilities in this area. The valves that regulate water temperature must be serviced to ensure that the temperature does not exceed 43 degrees centigrade. Staff must be made aware of the potential danger from hot water and report any increase in water temperatures to the senior staff member on duty. Water temperatures should be regularly monitored. 21/01/06 13/01/06 21/01/06 23/12/05 10. OP38 13 16/12/05 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 Refer to Standard OP27 Good Practice Recommendations Strategies should also be considered as to how staff respond to visitors at the front door to avoid them waiting outside for excessive periods. DS0000006386.V255031.R01.S.doc Version 5.0 Page 20 George Hythe House George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 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 George Hythe House DS0000006386.V255031.R01.S.doc Version 5.0 Page 22 - 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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