Inspection on 20/04/05 for Larks Leas

This inspection was carried out on 20th April 2005.

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

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

Other inspections for this house

Larks Leas 12/11/07

Larks Leas 31/10/06

Larks Leas 29/09/05

Larks Leas 26/11/04

Larks Leas 03/08/04

Larks Leas 05/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Larks Leas Milldown Road Blandford Dorset DT11 7DE Lead Inspector Debra Jones Unannounced 20th April 2005 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. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Larks Leas Address Milldown Road Blandford Dorset DT11 7DE 01258 452777 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) Castle Farm Care Ltd Mrs Andrea Falconer CRH - Care Home only 24 Category(ies) of OP - Old Age, not falling within any other registration, with number category - (24) of places Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 24 in 20 single and 2 double bedrooms. The rooms acceptable for double occupancy are 6, 7 or 12. Date of last inspection 26th November 2004 Brief Description of the Service: Larks Leas currently cares for 22 older people (capacity 24) in a detached property on a main road approximately half a mile from the centre of Blandford where there are shops, a post office and churches. Larks Leas is also close to a GP surgery. The home is on two floors and there are two passenger lifts. There is a variety of aids and adaptations around the building to allow residents to move about more independently. All 22 rooms are used as single rooms although the home is registered to accommodate a maximum of 24 people in twenty single and two double rooms. Some bedrooms have direct access to the rear terrace and patio areas. All but one room have en suite toilet facilities. There are additional communal bathroom and toilet faciltiies on the ground and first floors. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours and was the first of the two anticipated inspections this year. The two recommendations and requirements made at the last inspection were followed up to see if the home had made any progress towards meeting them. The Inspector looked around most of the building and at a number of records. The manager, ten of the 22 residents (current number) and 2 members of staff were spoken to. What the service does well: What has improved since the last inspection? The building works to extend the home have been completed and all the new rooms have been occupied. The home has continued to function at the high standard that has been noted at previous inspections. The home has, and is, addressing shortfalls in paperwork and is well on the way to total compliance with the standards set by the Department of Health. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 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. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.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 Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.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) 1,3,4 and 5. 6 is not applicable to this home. The home provides prospective residents with details of the services the home provides enabling them to make an informed decision about going to live at the home. The home has a good admissions procedure. Prospective residents and / or their representatives are welcome to visit the home to decide if the home suits them. The home makes an assessment, based on information collected, that informs their decision to offer a place. This process ensures that only service users whose needs can be met by the home are offered places there. EVIDENCE: The home has recently rewritten the service user guide/ statement of purpose. This was done when the building works were complete and the home increased the number of residents they could accommodate. The guide contains all the information referred to in the regulations and standard and provides residents with all they need to know to inform their decision to move to the home. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 9 Prospective residents are given a copy of this when the pre admission assessment takes place. All files sampled contained a thorough pre admission assessment. Written confirmation of the offer of a particular room in the home is sent to residents assessed as suitable to move to the home. Residents spoke of how the manager had visited them to carry out the assessment. Residents also talked of how they, or their relatives had come to see the home before they moved there. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 10 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 and 10 There is an excellent care planning system in place to make sure that staff have the information they need to meet the needs of the residents. The health needs of the residents are also well met with evidence of good support from community professionals – such as GPs and District Nurses. Residents confirmed that they felt treated with respect and that their right to privacy is upheld. EVIDENCE: Files sampled contained excellent care plans, which laid out clearly the needs of the residents. The plans were clear about what the residents could do for themselves, what they needed help with and what staff needed to discretely monitor. The need to ensure dignity and respect privacy came through strongly. Care plans are backed up by good risk assessments and the action to be taken where risk was identified was clear. Daily notes form the bridge between the care plan and the actual care delivered and these were well written and informative. Care records also showed the interventions of community professionals. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 11 Residents spoken to could not fault the care they were given and spoke very highly of the staff at the home, describing them as ‘so kind’ ‘treating us as the intelligent people we are’ ‘working to a very high standard’ and ‘always cheerful and chatty’. Residents confirmed that they felt treated with respect and that their privacy was respected. Staff always knock before entering rooms and residents said that they were treated ‘as individuals’ and as ‘grown ups’. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 12 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) 13,14 and 15 Residents’ lives are enriched by the high degree of choice they are able to exercise in their daily lives at the home. The meals in this home are very good offering both choice and variety and are served in a pleasant environment. EVIDENCE: Residents talked of their families, of how often they visited and of the trips they went on with them. Residents said that visitors were welcome to come at any time. The manager talked of how residents could invite friends / family for meals at the home, with some notice to the chef. The visitors’ book confirmed the number and range of visitors to the home. Residents spoken to were very in control of their lives, within the limitations of a group environment. They talked of how they chose where they spent their days, what they did, what possessions they had around them, who they saw and what they ate. All residents spoke very highly of the food – in terms of quality, quantity and presentation. They praised the chefs, saying ‘they know our tastes’ and ‘we don’t think we are ever hungry!’ The Inspector had lunch at the home and agreed with residents. The roast chicken meal was delicious and came with a wide range of vegetables, all well Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 13 cooked. Residents are offered meal choices the day before. As vegetables are served separately residents are in control of what they have and how much. A bowl of fresh fruit was available in the lounge area. Appropriate food records are kept. Residents said they could have meals where it suited them. The home has a pleasant dining room, overlooking the garden that residents can eat in if they wish. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 14 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 The home has a complaints system and evidence showed that complaints are handled objectively and concerns raised are taken seriously. EVIDENCE: The home has a complaints policy / procedure that is included in the information given to residents. It states that complaints should be taken up with the home and if the complainant is not satisfied then they can take up concerns with the Commission. Residents should be able to bring their concerns to the Commission’s attention at any time. An example was seen of a complaint by a relative that was made and of how the home had responded. The response was thorough in content and met the home’s own timescale for replying. Residents have regular monthly meetings and are able to raise anything they wish to. Residents spoken to said that they were confident that if they had any concerns they would raise them with the manager or staff and that they would be listened to and that they would put things right for them. ‘They try their best to make you happy.’ Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 15 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) 19,20,21,22,23,24,25 and 26. Larks Leas is an excellent facility managing to create environment that is homely, comfortable and at the same time safe for the residents living there and for anyone visiting. Bedrooms are well decorated, well furnished and personalised to suit the residents. Adequate communal facilities are available to meet the number and needs of the current residents and the home is kept clean and smelling pleasant altogether enhancing the daily life of residents. EVIDENCE: The ‘garden suite’ was completed last year and added 8 new bedrooms and new communal areas to the home. All furniture and furnishings in the new suite are brand new and of a very high standard. The older part of the home is well decorated and it is obvious that the management of the home consider that their residents deserve the best that can be provided. The manager described plans for further redecoration and refurbishment and furniture replacement. Work to the garden is yet to be completed and following consultation with residents a bowling green at the end of the garden is going to be created. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 16 Lounge and dining areas are well and comfortably furnished. In the newly built part of the home a quiet area has been created which all residents can use and some residents said they enjoyed using. There are a number of communal bathing areas in the home. All but one room have en suite facilities. Some residents who use wheelchairs have larger en suites making them far easier to use and contribute to them managing more independently and retaining privacy and dignity. Aids and adaptations are available throughout the home and some residents with particular needs have their own personal equipment to assist with their independence. Adjustable beds are in place for those who need them. Residents are able to personalise their rooms with furniture and general belongings. Although the home has 3 bedrooms large enough to share, all rooms are currently only used as single rooms. There are two passenger lifts in the home, enabling easy access to both floors and for residents who use wheelchairs to have bedrooms on the upper level. There are emergency alarm bells throughout the home. Where two residents have been identified as being at high risk of falling they have been equipped with pendants they can wear at all times which would allow them to summon help wherever they were. The home was clean and there were no unpleasant odours. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 17 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 and 29 Sufficient staff are employed and deployed throughout the day and night to ensure that the needs of residents are met. Recruitment practices ensure that residents are protected from the risk of unsuitable staff working at the home. Evidence must be kept of the POVA 1st checks (see below). EVIDENCE: Duty rosters are kept that demonstrate that appropriate staff numbers are on duty at all times. 3 care staff are on duty between 7am and 2pm. During the busiest period between 9 am and midday another member of staff is on duty. Three staff are on duty between 3pm and 10pm. Two members of staff are on duty overnight. There are always experienced members of staff on each shift, with most shifts including a member of the management team. The manager is additional to these numbers as are the domestic and kitchen staff. The manager talked confidently about the recruitment procedures at the home and was knowledgeable about the recent changes that have come with the introduction of the Protection of Vulnerable Adults list. Well-ordered files are kept that demonstrate the recruitment process in action. Currently the home does not keep the confirmations of POVA 1st checks (allowing employers to start workers whilst waiting for full Criminal Records Bureau (CRB) disclosures to arrive. The written recruitment procedure does not reflect the extent of the checks being undertaken by the home. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 18 The manager was advised to obtain a copy of a Home Office publication ‘Comprehensive guidance for United Kingdom employers on changes to the law on preventing illegal working’ – and to make sure that the recruitment procedure is in line with the guidance in this document. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 19 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) 31, 32 and 37 The home is well organised and the care and contentment of residents is at the heart of the daily management and running of the home. EVIDENCE: Mrs Falconer, who has a nursing and management background, manages the home. Residents described her as having very high standards and staff commented on her good organisational skills. Mrs Falconer takes a very active part in home life and works closely with her senior staff who, in turn, lead in the delivery of care and in housekeeping duties. Mrs Falconer also has a designated deputy and it is always clear who is in charge at any time in the home. Regular meetings take place between Mrs Falconer and her senior staff, with the wider staff group and with residents. Notes are kept of these meetings and demonstrate the open channels of communication throughout the home. Residents talked of the meetings they attended and of the contribution they Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 20 had made and the issues they raised. A suggestion box is located in the hallway giving an alternative way to make views known. Annual anonymous questionnaires are circulated in the summer to further discover what people think about the home. The Responsible Person for the company that owns the home – Mr Russell Wilson - regularly visits the home and attends some meetings. No records are made of these visits. The manager and staff spoke highly of the way in which Mr Wilson supported the ongoing improvement agenda at the home. Records were available as requested. Photographs have not yet been taken of all residents. Accidents are well recorded. Some are excellent in that they are explicit as to how staff came across accidents e.g. responding to call bells, responding to cries for help etc, and ideally all records would be as informative. Analysis of such records would provide the home with important information as to the effectiveness of the emergency systems in operation. A health and safety audit of the premises has been completed. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 21 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 3 x 2 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 4 4 4 3 3 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 2 x x 3 4 x x x x 2 x Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 22 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 37 Regulation 26 Requirement The Registered Provider must visit the home at least once a month and provide a written report of this visit to the Commission. (Timescale of 4/9/04 and 1/1/05 not met) The home must have a photograph of all residents. Timescale for action 1/6/05 2. 37 17 1/6/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 16 29 29 Good Practice Recommendations When next reviewed the complaints procedure to be amended to say that residents may complain to the Commission at any time. Evidence of POVA 1st checks and CRBs to be kept on all individual staff members files. Recruitment procedure to be updated to reflect rigorous pre employment checks and compared with the latest Home Office guidance in respect of the employment of foreign nationals and updated if necessary. Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole, Dorset BH17 0NF 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 Larks Leas D55 S55591 Larks Leas V220437 200405 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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