Inspection on 03/05/06 for George Hythe House

This inspection was carried out on 3rd May 2006.

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

George Hythe House 02/09/09

George Hythe House 06/09/07

George Hythe House 30/01/06

George Hythe House 13/12/05

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 Beaumont Leys Leicester Leicestershire LE4 1HA Lead Inspector Ruth Wood Unannounced Inspection 3rd May 2006 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.V290063.R01.S.doc Version 5.1 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.V290063.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service George Hythe House Address 1 Croft Road Beaumont Leys Leicester Leicestershire LE4 1HA 0116 2350944 0116 2366560 lqhaltd@talk21.com www.leicesterquakerhousing.com Leicester Quaker Housing Association 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) 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.V290063.R01.S.doc Version 5.1 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. 23rd January 2006 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, dementia 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 of 10 rooms, each having its own dining room and kitchen. One of the existing wings primarily accommodates people with dementia. Outside there is a garden with seating areas. Current fee levels at the home range from £269 to £480 per week. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9:30am and 3:45pm on a weekday. The Registered Manager was on annual leave, which limited access to some documents relating to staff recruitment. The care needs and experiences of three residents were focussed on in detail; this included an examination of their care records, discussion with them, their key workers and in one case their commissioning social worker together with direct and indirect observation of staff interaction and care of these residents. Discussion was also held with other residents about the home’s food and activity programme and with two residents who had been living at the home for a relatively short period about the admission procedures. Two staff members were interviewed about their experience of the recruitment, induction and training process and discussion was also held with the home’s ‘shift leader’. A partial tour of the home was conducted focussing on communal areas and a limited number of residents’ bedrooms. What the service does well: What has improved since the last inspection? All risk assessments relating to health and safety within the home have been reviewed together with the Control of Substances Hazardous to Health (COSH) assessment. A new nutritional assessment has been introduced which helps catering and care staff to identify and monitor residents’ nutritional needs. Finally a new pagoda has been bought and installed in the garden. Several residents commented that they were waiting for an improvement in the weather so they could sit in the garden. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 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. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 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.V290063.R01.S.doc Version 5.1 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 Quality in this outcome area is good. Residents needs are fully assessed prior to them moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The assessment process was discussed with two residents who had recently moved into the home, one directly from hospital and one from their own home. The former stated that the home’s manager and another senior staff member had visited them at the hospital and asked them about their care needs. The latter stated that the manager had asked them about their needs when they arrived at the home and had also discussed these with their daughter. Staff confirmed that usually the senior staff member and a senior staff member would make an initially assessment of need prior to admission. The four service users’ files examined contained a copy of this assessment which was holistic in nature covering physical and mental health as well as care needs and included a biographical assessment. This home does not offer intermediate care therefore Standard 6 is not applicable. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 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): 7,8,9,10 Quality in this outcome area is good. Residents are treated with respect, their health and medication needs are well met and care plans accurately reflect assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans of three case tracked residents were examined in detail and information contained in them was verified through discussion with residents, care staff and in one case with the commissioning social worker. In addition direct and indirect observation of care staff ‘s response to residents needs was made. Plans outlined physical and mental health needs as well as current interests of residents and any religious and cultural needs. (The needs of one resident arising from their membership of a particular church were clearly noted). The commissioning social worker said she felt the care plan to be ‘very relevant’ and said she was also impressed by the knowledge displayed by the key worker of the resident’s needs. Key workers of two of the case tracked residents were interviewed and both displayed a high level of familiarity with residents’ needs that corresponded with the information in the care plan. All plans showed documentary evidence of regular review (usually monthly) and contained risk assessments pertinent to individual residents. The responses taken to some of the identified risks may benefit from a more comprehensive approach; following one case tracked resident’s fall in the toilet consideration George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 10 was not given to modifications to the physical environment of that area. This was discussed with staff members and the risk assessment re-evaluated. Health care needs continue to be well met by the home with the local GP holding a regular surgery at the home every Wednesday. Health care appointments are documented separately and examination of these and discussion with residents indicated that optical, chiropody and district nurse services were also regularly available. The lunchtime medication round was observed and good practice was in place with medication administration records being fully and accurately completed and the trolley being securely locked when not attended. Thirteen care staff (including all seniors) are currently undertaking a National Vocational Qualification level 2 in the safe handling of medicines. Observation indicated that residents were treated with respect by staff and enjoyed an open friendly relationship with each other. Residents described the staff as ‘kind’ and ‘friendly’; one resident also commented “they’re alright here, some are better than others but they’re alright.” George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 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): 12,13,14,15 Quality in this outcome area is good. Residents have a good lifestyle which includes nutritious and enjoyable meals and the opportunity to make some choices although this area of care could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home routinely offers a varied programme of activities and outings; a copy of the programme is circulated to all residents and one is also displayed on the dining room notice board in each wing. Activities taking place in May included a sing- a – long, music and movement, a scrabble competition and a film show. A boat trip and an outing to a garden centre had also been arranged. Pictures displayed in the home also evidenced the art and craft activities that take place. The home has a dedicated activities organiser who from many positive comments was clearly held in high esteem with residents, “She’s lovely!” However the organiser was on annual leave during the week of the inspection and many residents commented on this, “It’s good when she’s here, there’s plenty to do but it’s boring now, we just sit around.” No activities took place during the period of the inspection and although television, newspapers and books were available the majority of residents either sat quietly or slept until tea was served. This is an area that needs addressing as clearly residents have become used to a certain level of stimulation and this is clearly not being continued during the organiser’s absence. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 12 Discussion with several residents indicated that relatives are free to visit at any time and social events are also arranged to which relatives are invited. Daily records also noted when relatives had visited or had been contacted to pass on information about a resident’s care. Several residents were spoken with in their bedrooms; all of these were highly personalised and contained personal possessions brought from home. Some residents said that they chose to spend the majority of their time in their room whereas other residents said that they liked to go down to the communal lounge. Similarly some residents chose to attend all activities and go out on all trips offered, “I like to get out and about.” Whereas other residents said that they preferred their own company. It was observed that two residents were left in their wheelchairs for a considerable length of time following their return from lunch (over two hours). During conversation one resident said that they would like to sit in an ordinary chair. This was brought to the attention of staff and the resident’s choice was accommodated. Staff should ensure that where appropriate all residents are offered the choice of sitting in an ordinary chair rather than being left in their wheelchairs for extended periods. One resident in the main lounge was seated on a pressure pad which triggered an alarm when they stood up. Although this was successful in alerting staff to respond quickly to assist him, the noise clearly disturbed other residents. Investigation should be made as whether an alternative way of meeting this resident’s needs can be found. All residents spoke very highly of the home’s food saying that they really looked forward to meals and that the food was “very nice”, “lovely” and that there was “always plenty of choice”. Menu records were examined and discussion was held with the home’s catering manager. Menus showed that for the main meal of the day two main choices were offered (including one vegetarian option) or if residents preferred they could have an omelette, jacket potato and filling or soup. Homemade cakes are routinely available for afternoon tea and residents are offered a selection of items such as cake, biscuits, crisps and fresh fruit together with drinks in the evening. A new nutritional screening tool was introduced in the home in January following the catering manager’s attendance at a training course run by Leicestershire Health’s dietetic Service. The catering manager completes this when residents first come to live at the home and at the same time finds out about their likes and dislikes. The catering manager said that she monitored residents’ menu choices and if for example she noted that a resident was consistently choosing soup she would bring this to the attention of care staff. She would also examine ways of making choices more ‘nutrient rich’ for those residents with a small appetite. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 13 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): 16,18 Quality in this outcome area is good. Residents’ complaints are listened to and systems are in place to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are formal and informal mechanisms allowing residents to raise concerns about the service. The complaints procedure is clearly displayed on the Wing notice boards and residents spoken with said if they were not happy with anything they would tell their key worker or the manager. Residents also have the opportunity to raise concerns at regular (usually monthly) Wing meetings. Minutes of these were seen and two residents concerns were clearly noted. Discussion with the Wing’s team leader indicated that these concerns had been addressed; it is suggested that a record be kept of any action taken to concerns raised by residents at these meetings. Staff are aware of policies relating to the protection of residents from abuse and the manager recently demonstrated awareness of the area policy in this area by taking appropriate action following a concern raised by staff members George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome area is good. Residents live in a clean, comfortable and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All communal areas of the home were visited, together with four residents’ bedrooms. All areas were generally clean and tidy and appropriately furnished. The catering manager is in charge of maintaining hygiene within the kitchen and is implementing new government guidance ‘Food Safety – Better Business’. This includes checks on all areas on a daily basis and regular ‘deep cleans’. There are clear policies within the home relating to caring for any residents who may be MRSA positive. Staff questioned about these policies displayed good knowledge and were able to outline the procedures that should be followed. Hot water temperatures are tested on a weekly basis by the home’s maintenance man who also is responsible for ongoing repairs to the home; records are kept of both tests and repairs. A new pagoda has been recently purchased for the garden and it is hoped this will be put to good use when the weather improves. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 15 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): 27,28,29,30 Quality in this outcome area is good. Residents’ needs are met by adequate numbers of competent staff. Some areas of recruitment practice still need improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were six care staff members on duty during the morning shift and five during the afternoon shift. Generally at least two of these staff are allocated to the Wing whose residents have higher dependency needs due to their dementia. The staff rota showed that there are routinely five or six members of staff on duty during day shifts plus a care team leader. There are two waking night staff plus one staff member that ‘sleeps in’ at the home. In addition the home employs contract domestic workers, dedicated catering and kitchen staff and two domestic/care support workers who as their name suggests undertake both domestic and caring duties. Discussion with staff and examination of training programmes indicated that all staff have access to regular and relevant training including a programme of induction when first starting work at the home. Currently training is taking place in food hygiene and safe handling of medicines. Staff have completed recent training in dementia care and moving and handling. Several staff have achieved National Vocational Qualifications (NVQ) in care at level 2 and are seeking to move on to level 3. The home’s cook is soon to complete her level NVQ 2 catering qualification. Staff recruitment records were not available for inspection as the Registered Manager was on annual leave. The senior member of staff on duty said that all George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 16 staff working at the home had a current criminal records bureau check in place and that they could not work at the home until this had been processed. Discussion with a recently appointed member of staff indicated that this procedure had been followed. Discussions with this and other members of staff suggested that the recruitment process was through. Candidates for employment are asked to complete an application form, give the names of two referees and attend for interview with the Manager and another senior staff member. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 17 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): 31,33,35,38 Quality in this outcome area is good. The Registered Manager is competent and ensures that the home is run in the best interests of residents and that good health and safety standards are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager was on annual leave on the day of inspection but has several years experience of managing care and has recently completed the Registered Manager’s Award. She undertakes relevant training on a regular basis and maintains regular contact with the Commission through notifications of significant events, requests for guidance and shares information about changes to training or practice within the home. Residents’ views are sought informally in general discussion and more formally in Wing meetings. A suggestion box is also in place in the main lounge although the senior staff member on duty stated that to her knowledge no suggestions had been received. An open day and other social events are held for relatives and the senior staff member stated that the most recent of these George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 18 had resulted in “a lot of feedback”. It is recommended that a more formal system to record consultation with residents and relatives be introduced that includes the action taken in response to any concerns or suggestions. The home should also consider ways in which it may consult with other stakeholders such as commissioners and medical practitioners. Maintenance records were examined which demonstrated that gas servicing, portable electrical appliance testing, lift and hoist servicing were all up to date. The home’s Control of Substances Hazardous to Health (COSH) assessment was updated in March 2006 and all risk assessments relating to safe working practices were also updated at this time. All staff are currently undergoing training in Food hygiene and have also recently received updated training in moving and handling. Records stated that fifteen staff members have received training in first aid including all shift/team leaders. The families of two case tracked residents administered the finances for their relatives and arrangements for this were documented in care plans. The Housing Association’s Financial Assistant outlined the systems in place for the management of resident’s finances during the inspection held on 23 January 2006. Some residents hold money in an account held centrally by the Housing Association and choose to receive their personal allowance in cash on a weekly basis. Full records are kept of all transactions and these are subject to internal and external audit on a quarterly basis. There has been no indication that these arrangements have been modified during the three months. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 19 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The responses taken to some identified risks may benefit from a more comprehensive approach than that currently taken, particularly in response to residents who have experienced a fall. Arrangements for the continuation of activities should be made for when the Activities Organiser is on leave. Staff should ensure that where appropriate all residents are offered the choice of sitting in an ordinary chair rather than being left in their wheelchairs. An alternative, less intrusive way of meeting the resident’s needs who currently uses an alarmed pressure pad should be considered as the current system is particularly disturbing to other residents. A more formal system to record consultation with residents and relatives should be introduced that includes the action taken in response to any concerns or suggestions. The home should also consider ways in DS0000006386.V290063.R01.S.doc Version 5.1 Page 21 2 3 4 OP12 OP14 OP14 5 OP33 George Hythe House which it may consult with other stakeholders such as commissioners and medical practitioners. George Hythe House DS0000006386.V290063.R01.S.doc Version 5.1 Page 22 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.V290063.R01.S.doc Version 5.1 Page 23 - 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. 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