Inspection on 07/11/05 for John Calvert Court

This inspection was carried out on 7th November 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 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

John Calvert Court 10/09/07

John Calvert Court 22/06/06

John Calvert Court 26/04/05

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 Leicestershire LE4 0SX Lead Inspector Martin Hefferman Unannounced Inspection 7th November 2005 09:55 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 John Calvert Court DS0000006377.V261412.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. John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service John Calvert Court Address 158 Milton Crescent Beaumont Leys Leicester Leicestershire LE4 0SX 0116 2354933 0116 2352469 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) Leicester Housing Association Lavinia Grace Mann Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number disorder, excluding learning disability or of places dementia (22), Mental Disorder, excluding learning disability or dementia - over 65 years of age (22) John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Previous registration authority. The home is able to admit the four persons of category MD (Mental Disorder) as named in correspondence dated 31 October 2001 as agreed by the previous registration authority. Variation V57595 The home is able to admit the person of category MD (Mental Disorder) as named in registration variation application number V57595, dated 13 October 2003. Variation V44060 The home is able to admit the person of 52 years of age falling in the category MD (Mental Disorder) as named in registration variation application number V44060 dated 09 April 2003. Variation V7898 The home is able to admit the person of category MD (Mental Disorder) as specifically named in registration variation application number V7898 dated 22 June 2004. No person of category MD who is under the age of 50 may be admitted to the home. 26/04/05 2. 3. 4. 5. Date of last inspection Brief Description of the Service: John Calvert Court provides care for twenty-two people aged fifty or over with mental health problems. The home is situated on a modern housing estate within 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 DS0000006377.V261412.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the establishment’s capacity to meet regulatory requirements & minimum standards of practice and focuses on aspects of service provision that need further development. This inspection took place over the course of four hours twenty-five 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 (where appropriate), the care staff and observation of care practices. Four service users were interviewed during the course of this visit. The registered manager facilitated the inspection. NB The term ‘service user’ has been used throughout this report as it is the term in use within the home. What the service does well: What has improved since the last inspection? The home has strengthened its admission procedures by writing to prospective service users to confirm the outcome of the assessment process. The home has strengthened its arrangements for handling medication. The registered manager continues to undertake regular audits in order to identify any issues that need to be addressed. The home has produced a more accessible complaints procedure. John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 6 The registered manager has written to each member of staff enclosing information about the protection of vulnerable adults and reminding them of their responsibilities. The home has obtained the records required by regulation for longer standing members of staff. 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. John Calvert Court DS0000006377.V261412.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 John Calvert Court DS0000006377.V261412.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 Assessment practices are 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 September 2005. Records of that assessment were detailed, covering a range of health and social care needs. The registered manager had written to the service user to assure him that the home would be able to meet his needs (a recommendation from the last inspection). John Calvert Court DS0000006377.V261412.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, 9 & 10 Care planning practices are effective ensuring that staff members have the information they need to meet service users’ needs. Service users are treated with respect and their right to privacy is upheld. Arrangements for the handling of medication have been strengthened. EVIDENCE: The home had completed an individual plan for a service user who had moved to the home during September 2005. This set out his needs in respect of his health and social care. Records indicate that the plan had been reviewed during October. Since the date of the last inspection, the home has changed its medication administration system. The registered manager stated the new system had brought benefits for staff and service users. Records indicate that the manager continues to undertake regular medication audits. She stated that she would investigate a number of omissions contained within records for medication administered since the date of the last audit. John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 10 Service users were treated with respect by the staff on duty at the time of the inspection. Staff members were also mindful of service users’ right to privacy, for example when undertaking personal care tasks. Several service users stated that staff use their preferred form of address and that they knock & wait for a response before entering their rooms. John Calvert Court DS0000006377.V261412.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): 12, 13 & 14 Arrangements for social activities and accessing the local community are well managed. EVIDENCE: Since the date of the last inspection, the home has recruited a part-time activity organiser. Evidence of the wide range of activities undertaken by him with service users was available throughout the home. Service users stated that they enjoy the activities and outings that are provided by the home and by Age Concern who use the home’s activity room three days a week. Specific time is allocated to enable keyworkers to undertake activities with service users on a one-to-one basis. On the day of the inspection, a member of staff accompanied service users on trips to the shops and for lunch out. Service users stated that they are able to maintain contact with their families & friends. They indicated that they could decide when to undertake the various activities of daily living and how to spend their day. Any preferences are recorded in their individual plans. John Calvert Court DS0000006377.V261412.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 Arrangements for responding to allegations of abuse appear to protect service users’ rights. EVIDENCE: Since the date of the last inspection, the home has amended its complaints procedure to make it more accessible. The home’s policies and procedures on the protection of vulnerable adults are covered during the induction of new members of staff. The registered manager stated that she hoped to arrange training for all staff (a recommendation from the last inspection). She reported that in the interim she has written to each member of staff enclosing information about abuse and reminding them of their responsibilities. John Calvert Court DS0000006377.V261412.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 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. John Calvert Court DS0000006377.V261412.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): 28, 29 & 30 Arrangements for the recruitment and training of staff are well managed. EVIDENCE: The registered manager stated that the recent departure of two members of staff has meant that the ratio of those who have completed National Vocational Qualification level 2 (or equivalent) has fallen below 50 . She reported that three members of staff were about to start the award. Records for a recently recruited member of staff indicate that appropriate preemployment checks had taken place. Since the date of the last inspection, the home has obtained the records required by regulation for longer standing members of staff. A recently recruited member of staff had completed the home’s induction programme and was in the process of completing a workbook based on the standards set by Skills for Care (the Training Organisation for Personal Social Services). Records indicate that staff members have received training on a range of issues relevant to their work. John Calvert Court DS0000006377.V261412.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): 31 The home is well managed. EVIDENCE: At the time of the inspection, the registered manager was in the process of completing a level 4 National Vocational Qualification in management and care. Records indicate that the manager and other senior staff have attended relevant training. The home’s compliance with a range of standards inspected on this and previous occasions indicates that it is well managed. John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 16 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 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 17 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. Refer to Standard Good Practice Recommendations John Calvert Court DS0000006377.V261412.R01.S.doc Version 5.0 Page 18 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. 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