Inspection on 26/04/05 for John Calvert Court

This inspection was carried out on 26th April 2005.

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

Other inspections for this house

John Calvert Court 10/09/07

John Calvert Court 22/06/06

John Calvert Court 07/11/05

John Calvert Court 25/01/05

John Calvert Court 24/08/04

John Calvert Court 16/03/04

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

CARE HOMES FOR OLDER PEOPLE John Calvert Court 158 Milton Crescent Beaumont Leys Leicester LE4 0SX Lead Inspector Martin Hefferman Unannounced 26 April 2005 09:30 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 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. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service John Calvert Court Address 158 Milton Crescent Beaumont Leys Leicester LE4 0SX 0116 2354933 0116 2352469 john.court@l-h-a.co.org Leicester Housing Association 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) Lavinia Mann Care Home 22 Category(ies) of Dementia - over 65 (22), Mental Disorder - over registration, with number 65 (22) of places John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To admit the person of 52 years of age falling in the category MD (Mental Disorder) named in variation application number 44060 dated 09/04/03. To admit the four persons of category MD named in correspondence dated 31/10/01 as agreed by the previous registration authority. To admit the person of category MD named in variation application number 57595 dated 13/10/03. To admit the person of category MD named in variation application number 7898 dated 22/06/04. Date of last inspection 25/01/05 Brief Description of the Service: John Calvert Court is registered to provide care for twenty-two older people with dementia or mental disorder. The home is situated on a modern housing estate within easy reach of a range of facilities. Service user accommodation is situated on the ground floor. There are eighteen single and two double rooms. All of the bedrooms have en suite facilities. In addition to their rooms, service users have access to two sitting rooms (both of which have kitchenettes), a dining room / conservatory, an activities room and a well-maintained garden. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of six hours twenty minutes. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Two of the service users who were chosen for the purposes of case tracking chose not to speak to the inspector on this occasion. Three service users and a visiting healthcare professional were interviewed during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home could strengthen its admission procedures further by confirming in writing the outcome of the assessment process to the prospective service user. The home must pay particular attention to its arrangements for the administration of medication as any shortfalls in this area could have a detrimental affect upon the health of service users. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 6 The home could strengthen its arrangements for the protection of service users’ rights by ensuring that staff members receive up-to-date training regarding the protection of vulnerable adults. Staff records must be kept at the home to enable the Commission to verify that recruitment practices protect service users. NB The term ‘service user’ has been used throughout this report as it is the term in use within the home. 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. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 standard(s) 3 & 6 Assessment practices are very thorough, ensuring that prospective service users’ needs are identified prior to their admission. EVIDENCE: The home had completed its own assessment of a service user who had moved in during February 2005. Records of that assessment were detailed, covering a wide range of health and social care needs. Copies of a Care Programme Approach assessment and care plan were also available for inspection. Records indicate that the prospective service user had been involved in the assessment process. The registered manager stated that she had assured the service user that the home would be able to meet her needs. A recommendation has been made that the home should confirm this assurance in writing. The home does not provide intermediate care. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 standard(s) 7, 8 & 9 Individual plans are clear and comprehensive, providing staff with the information they need to satisfactorily meet service users’ needs. Arrangements for the handling of medication provide an adequate level of protection for service users. EVIDENCE: The individual plans that were inspected set out service users’ needs in respect of their health and social care. Records indicate that they have been reviewed on a monthly basis. The home had completed a risk assessment for each of the service users whose records were inspected. Any risks that had been identified were addressed in the service user’s individual plan. Records indicate that staff members are monitoring service users’ healthcare needs and involving external agencies when appropriate. Staff members advocated on behalf of a service user on the day of the inspection to ensure that he received the health care he required. Whilst records of the receipt and disposal of medication met relevant requirements, administration records contained two omissions. Records indicate that on two occasions during March 2005 medication had been administered to the wrong service user. Staff on duty at the time had taken John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 10 appropriate action. The registered manager stated that she had investigated both incidents and had recommended a change to the administration system to prevent further occurrences. Since the date of the last inspection, the registered manager has started to undertake regular medication audits. The home has previously been commended for the introduction of a form to enable it to monitor the use of ‘as required’ medication. A contract pharmacist inspected medication arrangements at the home on 12th January 2005. He also provided training for staff. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 standard(s) 12 & 15 Arrangements for social activities and the provision of meals are well managed with the result that both appear to meet service users’ expectations. EVIDENCE: Service users stated that they enjoy the activities and outings that are provided by care staff and by staff employed by Age Concern. The latter use the home’s activity room three days a week. The home is in the process of recruiting a part-time activity organiser. A communion service takes place every month. Service users stated that they enjoy the meals that are provided. A choice of meals is displayed on a notice board in the dining room. Records indicate that service users receive a varied and nutritious diet. Individual plans contain details of any particular dietary requirements and likes or dislikes. A dietician is involved in the care of individual service users. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 standard(s) 16 & 18 Arrangements for dealing with complaints and responding to allegations of abuse mostly support the protection of service users’ rights. EVIDENCE: Service users stated that they felt that their views are listened to and acted upon. Minutes of Residents’ Meetings confirmed that action had been taken as a result of service users’ comments. The complaints procedure is displayed in various places around the home and includes information about local advocacy services. The registered manager agreed to update copies of the procedure that refer to the previous regulatory authority. The home has a copy of the local multi-agency policy and procedures for the protection of vulnerable adults. It also has written policies on abuse, restraint, handling service users’ money and whistle blowing. The registered manager stated that these policies were covered during the induction of each new member of staff. A recommendation has been made that all staff receive upto-date training on the protection of vulnerable adults. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 standard(s) 19, 20 & 26 The standard of the accommodation is satisfactory providing service users with comfortable surroundings in which to live. EVIDENCE: The areas of the home that were inspected were decorated and furnished to a satisfactory standard. They were clean and free from offensive odours. Service users have access to two sitting rooms (both of which have kitchenettes), a dining room / conservatory, an activities room and a wellmaintained garden. A number of service users have furnished their rooms with their own possessions. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staff members are deployed in sufficient numbers to meet service users’ needs. EVIDENCE: Staffing levels on the day of the inspection complied with the requirements set by the previous regulatory authority. Records were available for recently recruited staff members. One reference appeared to have been completed over the phone. The registered manager investigated the issue and found that it had been the result of an error. She stated that she would ensure that a written reference was obtained. Some of the records required by regulation were not available for longer standing members of staff. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 38 The home’s current working practices support the protection of service users’ interests. EVIDENCE: The home has published the findings of a service user survey completed in October 2004. The findings indicate that overall service users’ needs are being met. The registered manager stated that she is in the process of following up any issues that have been identified as a result of the survey. Service user meetings provide a further opportunity for people to comment upon the running of the home. The home maintains records of any money it handles on behalf of service users. The records that were inspected had been signed by two members of staff. Since the date of the last inspection, a member of staff has started to undertake regular ‘spot checks’ to ensure that the records are correct. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 16 The members of care staff whose records were inspected had received training in first aid, health & safety and moving & handling. Records indicate that fire tests and drills have been completed at the required frequency. John Calvert Court C51 S6377 John Calvert Court V221943 260405.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 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 x x 3 John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement The registered person must ensure that arrangements for the administration of medication protect service users. The registered person must ensure that all of the records required by regulation are held at the home. Previous timescales of 31/12/04 & 31/03/05 were not met. Timescale for action With effect from 26/04/05 30/06/05 2. 29 17 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. Refer to Standard 3 18 Good Practice Recommendations It is recommended that the home write to prospective service users to confirm the outcome of the assessment process. It is recommended that staff members receive up-to-date training on the protection of vulnerable adults. John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 19 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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 John Calvert Court C51 S6377 John Calvert Court V221943 260405.doc Version 1.30 Page 20 - 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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