Inspection on 19/01/06 for Horse Leaze (7)

This inspection was carried out on 19th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Horse Leaze (7) 30/11/07

Horse Leaze (7) 25/05/06

Horse Leaze (7) 29/07/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Horse Leaze (7) 7 Horse Leaze Beckton London E6 6WJ Lead Inspector Lea Alexander Unannounced Inspection 19 January 2006 11:30 th Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 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 Horse Leaze (7) DS0000063910.V274222.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 Adults 18-65. 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. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Horse Leaze (7) Address 7 Horse Leaze Beckton London E6 6WJ 020 7473 1945 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.heritagecare.co.uk Heritage Care Warren Spencer Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2005 Brief Description of the Service: 7 Horse Leaze is a care home for adults with mental health support needs. Since the last inspection Heritage Care have taken over as the Registered Provider from English Churches Housing. As Heritage Care were previously providing day to day staffing and management of the home this change has not been disruptive to service users. The home is a single storey building located within a residential area of Beckton. There are bus routes and the Docklands Light Railway is accessible nearby. The home aims to provide a supportive environment within which service users can develop confidence, dignity and personal responsibility. Each service user has their own bedroom and access to communal lounge, dining, kitchen and bathroom facilities. The home has four male and two female service users in residence. The home is culturally reflective of the local community with service users from African Caribbean, Asian, Irish and White British backgrounds. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors third inspection of this home. The Inspection was carried out over the course of half a day and its main focus was to review the progress made with the 11 requirements made at a previous inspection on the 29th July 2005. The Inspector met with the Registered Manager on the day of the inspection and spoke with them by phone on the 20th January 2006 to clarify some issues arising from the inspection. Five service users met privately with the Inspector. Service users personal files were inspected, as were other relevant documents. The Inspector also toured the homes premises and five service users showed the Inspector their bedrooms. What the service does well: What has improved since the last inspection? Some service users individual plans are reviewed ever six months or as service users needs change. The home has developed its practise and potential risks identified within the individual plan are subject to risk assessment, including self-medication. Items stored in the hallway that were potential trip hazards have been removed, and WC’s were noted to be generally cleaner. Horse Leaze (7) DS0000063910.V274222.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. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 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 the following standard(s): 2. All service users within the home benefit from an assessment of their needs. EVIDENCE: The home has had no new admissions since the last inspection on the 29th July 2005. The Inspector sampled the personal file of the most recently admitted service user and noted that an individual plan had been developed by the home in line with the requirements of the previous inspection. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 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 the following standard(s): 6 & 9. The home produces individual service plans and risk assessments that appropriately reflect service users needs, however the home should develop its practise to ensure that individual plans are reviewed and updated at least every six months. EVIDENCE: The registered manager advised the Inspector that the home was in the process of reviewing and updating care plans. The Inspector sampled three service users personal files and their individual plans. The individual plan for one service user was dated August 2004, with a review of this recorded as having taken place in August 2005. The individual plan n for a second service user had been drafted in July 2004 with reviews and evaluations occurring in October 2004 and July 2005. Additional plans to address changes in need were recorded as having occurred in December 2005. The Inspector noted that service users plans generally contained sufficient information and addressed areas of need such as mobility, personal care, selfmedication and managing finances. Standardised risk assessments had been completed for service users including safe access to cleaning materials and Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 10 access to kitchen knives. Annotations on these assessments suggest that they had been reviewed annually in 2003, 2004 and 2005. In addition individual risk assessments had been completed regarding particular needs identified in the individual plan. An example of this was the development and review of a risk assessment regarding a service user keeping paracetomol in their room. In response to a requirement made by the previous inspection, the Inspector noted that a risk assessment had been completed for a service user who is self medicating. The service users spoken to by the Inspector expressed a range of views about what is was like to live in the home. Some thought it was “okay” and others felt that they were “happy”. All the service users expressed the view that staff were “very helpful” and “very good”, and that they were “well looked after”. Key standard 7 was not inspected on this occasion. It was inspected on the 29th July 2005 and assessed as met. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 11 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 the following standard(s): Previous inspections have evidenced that the home is able to identify and meet the lifestyle needs of service users. EVIDENCE: These standards were not inspected on this occasion. Key standards 12, 13, 15, 16 & 17 were inspected on the 29th July 2005 and assessed as met. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 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 the following standard(s): 20. Whilst the homes Medication Administration Records and practises are in order, other lists of medication do not tally. A care plan and risk assessment continue to be required for the service user who periodically misses their medication. EVIDENCE: The Inspector viewed the medication records and compared the medication actually available against the list recorded on the Medication Administration Record (MAR). These were found to be in order as the medication actually available did tally with the MAR. The Inspector did however note that service users personal files contained lists of medication, and that these had not always been updated to accurately reflect the current medication being taken. For one service user the list of medication recorded on the dossett box was out of date but the contents did correspond with the current MAR. Medication Administration Records had been comprehensively completed with no gaps or omissions. The previous inspection had noted that one service user was recorded as having missed medication on six occasions in a four-month period. As a result a requirement to address this issue in the individual plan and a risk assessment had been made. On this occasion the Inspector noted that the Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 13 service user had missed medication on seven occasions in a three-month period, and that no individual plan or risk assessment had been developed to address this. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 22 & 23. Complaints and adult protection investigations have not been appropriately recorded. Details of the investigation, actions taken and outcome of an adult protection investigation have not been notified to relevant parties. EVIDENCE: The previous inspection had required the home to comprehensively record details of complaint investigations, actions taken and the outcome. The Inspector viewed the homes complaints log and noted that one entry had been made since the last inspection. This indicated that a service user had made allegations of physical abuse against staff members. In accordance with the homes procedure the allegations had been reported to the responsible individual, and a memorandum in the complaints log indicates that they carried out an investigation and concluded the allegations were unfounded. However, the Inspector noted that there was no copy of the details of the investigation, and no notifications of the allegations, the investigation or the outcome had been made to the Commission for Social Care Inspection or other agencies as required by the homes policy and in accordance with local multi agency adult protection procedures. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 24, 27, 29 & 30. The home would benefit from a planned redecoration of service users bedrooms and the bath and shower facilities should be refurbished in line with service users needs. EVIDENCE: The Inspector toured the homes premises. These comprise of a communal lounge diner with doors to a large garden with patioed area. This space was homely and comfortable with a formal dining table and chairs and a range of sofas and comfortable chairs in the lounge area. The lounge has a satellite TV, video player, a choice of videos and a stereo. A new kitchen has been installed and the room redecorated and new flooring fitted. The home has a separate laundry room that houses an industrial type washing machine and tumble dryer. The Inspector noted that the floorboards in the laundry entrance were loose and that the lino on top of them was splitting and curling up, causing a potential trip hazard. The staff office is located to the front of the property, adjacent to the front door. The Inspector noted that the laminate flooring was very worn and requires replacing. Each service user has their own bedroom and several service users showed the Inspector their bedrooms. These contained a sink, wardrobe, bed, chair and Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 16 chest of draws. Service users have been able to personalise their rooms by bringing in extra furniture where space permits, hanging pictures and photographs on the walls, and choosing how they would like their rooms decorated. The Inspector noted that a number of repairs and maintenance issues were required in service users bedrooms. One service user whose room was visited smelt strongly of stale body odour, and the smell was also very noticeable in the communal corridor area outside of their room. The home must develop a strategy and individual plans to address this. Another service user had a picture frame with broken glass hung on their wall, which represents a health and safety risk. The headboard in another service users room was badly stained, and their curtains not properly hung. The Inspector noted that service users bedrooms would benefit from redecoration as the walls were marked and stained. A previous inspection had recommended that service users sinks be fitted with a light. The manager advised that these had been obtained but were not yet in working order. The Inspector noted that the bedroom of a service user with continence issues was well maintained with no evidence of odour. The home has one bathroom with a tub and no toilet, an adapted shower room with WC and hand basin, and a toilet with hand basin. The previous inspection had identified that service users prefer to use the shower room and that the large bathroom is not really used. During this inspection it was noted that the bathroom appears to be mainly used as a storage area. The previous inspection had required the home to facilitate occupational therapy bathing assessments for each service users to identify their needs and then refurbish the current bathroom to address these. The manager advised the Inspector that a verbal request for this assessment had been, but no assessments had yet taken place. The Inspector is of the view that the shower room and separate WC have badly stained flooring and would benefit from general refurbishment. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 17 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34. Personnel information required by inspection is not available within the home. EVIDENCE: The home is part of the Heritage Care organisation and implements the corporate recruitment policy. A centralised personnel department carries out staff’s recruitment, and they retain recruitment records such as references. The registered manager advised that information regarding recruitment is not available in the home. The Inspector discussed with the manager the need for a summary sheet of personnel information required by regulation to be completed by the personnel office and held within the home where it can be made available for inspection. Key standards 32 and 35 were not inspected on this occasion. They were inspected on the 29th July 2005 and assessed as met. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Service users benefit from a generally well run home, however, to develop the quality of the service restated requirements should be addressed with priority. EVIDENCE: The registered manager has been in post for approximately 3 years and will complete their NVQ level studies this year. The Inspector noted that a number of requirements had been restated over several inspections, these include reviewing all service users individual plans at least six monthly or as their needs change, and obtaining occupational therapy assessments for each service user and then developing and implementing a programme to refurbish the current bathroom and shower room provision. The registered manager must ensure that the changes required by regulation are implemented as part of the homes quality assurance process. At the previous inspection the home had been required to securely store all potentially hazardous cleaning materials, and the Inspector noted that this had been complied with. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 19 An inspection of the homes fridges and freezers indicated that all opened processed or prepared foods were appropriately labelled with start dates. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 20 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 2 X X 3 X Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 21 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 YA6 Regulation 15 Requirement Individual service user plans must be reviewed at least every six months or more frequently if service user needs change. This is a restated requirement. Previous targets of the 01/11/04, 01/03/05 and 29/10/05 were not met. 2. YA20 13 The home must develop its medication administration practise. (1) The list of medications taken by service users must match the medications recorded on the MAR, or be annotated to indicate a medical review resulting in stoppage. The home must ensure that service users are supported to comply with their medication and that needs associated with this are included in the service Version 5.1 Page 22 Timescale for action 31/03/06 31/03/06 (2) Horse Leaze (7) DS0000063910.V274222.R01.S.doc user plan and are risk assessed. These are restated requirements. The previous target of the 29/10/05 was not met. 3. YA22 22 The complaints log must adequately record details of the complaint investigation, any action taken and the outcome. This is a restated requirement, the previous target of the 29/10/05 was not met. 4. YA23 13 Allegations of the abuse of service users must be notified and investigated in accordance with the homes adult protection policy and local multi agency adult protection procedures. Details of the investigation referred to in the main body of this report must be forwarded to the Commission for Social Care Inspection and other appropriate agencies. 5. YA24 23 The following maintenance issues must be addressed: (1) The broken picture frame hung in one service users bedroom must be removed. The soiled headboard in one service users room should be cleaned. The curtains in this service users bedroom should also be properly hung. The laundry floor should be repaired and the lino replaced. Version 5.1 Page 23 31/03/06 24/02/06 31/03/06 (2) (3) Horse Leaze (7) DS0000063910.V274222.R01.S.doc (4) A programme of redecoration for service users bedrooms should be developed and implemented. The flooring in the staff office should be replaced. 30/06/06 (5) 6. YA27 23 The home should refurbish the under utilised bathroom in line with occupational therapy assessments required under Standard 29. A programme of refurbishment and redecoration should be developed and implemented for the shower room and WC. This is a restated requirement. The previous target of the 29/10/05 was not met. 7. YA29 23 Occupational therapy assessments must be completed for each service users bathing needs, and identified aids obtained. This is a restated requirement. The previous target of the 29/10/05 was not met. 31/03/06 8. YA30 16 The home must ensure that service users bedrooms and communal areas are free from offensive odours. A summary of information of the personnel information required by regulation must be completed and be available in the home for inspection. The registered manager must DS0000063910.V274222.R01.S.doc 31/03/06 9. YA34 7, 9, 19 & Sch 2 31/03/06 10. YA39 24 31/03/06 Page 24 Horse Leaze (7) Version 5.1 ensure that requirements are progressed within the specified timescales and any difficulties with compliance fully recorded. 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 YA26 Good Practice Recommendations The home should consider providing lights over the sink area in service users rooms. This is a restated recommendation. Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Horse Leaze (7) DS0000063910.V274222.R01.S.doc Version 5.1 Page 26 - 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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