Inspection on 19/01/06 for Layden Court Care Home

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 Excellent. 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

Layden Court Care Home 24/10/06

Layden Court Care Home 29/12/04

Layden Court Care Home 29/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Layden Court Care Home All Hallows Drive Maltby Rotherham South Yorkshire S66 8NL Lead Inspector Mike Hamstead Unannounced Inspection 07:30 19 January 2006 th 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 Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Layden Court Care Home Address All Hallows Drive Maltby Rotherham South Yorkshire S66 8NL 01709 812808 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) Tamcare Limited (a wholly owned subsidiary of Four Seasons Health Care Limited) Susan Storey Care Home 89 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (20) Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users within category OP are accommodated on Swallow Wood Unit Service users within category PD(E) are accommodated on Haighmoor Unit Service users within category DE(E) with nursing needs are accommodated on Kiveton Unit Service users within category DE(E) are accommodated on Becks, Thurcroft or Markham Unit One specific service user under the age of 65, named on variation dated 12th November 2004 may reside at the home. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 5 Date of last inspection 17th August 2005 Brief Description of the Service: Layden Court is an 89 bedded care home with nursing, which was purpose built and registered in 1995, and is situated on the outskirts of Maltby, near Rotherham. Residents are accommodated on three floors as follows: The lower ground floor has a 9-bedded residential EMI unit -Markham, for residents who have dementia but no nursing needs. The ground floor has two units for residents in the category of old age: 1. Swallow Wood has 17 beds for residents with general residential needs. 2. Haighmoor has 20 beds for residents requiring general nursing. In addition there are two units on the upper floor offering care to residents with dementia including those with nursing needs. 1.Thurcroft/Becks has 23 beds for residents with EMI residential needs. 2. Kiveton, has 20 beds for residents with EMI nursing needs. The home has pleasant garden areas surrounding it and there is access to the gardens from each floor. There are local shops close by in Maltby, and a bus service operates from the top of the road, close to the home. There is a petrol station/garage close to the home and within walking distance, which has a shop that is regularly used by some residents and staff. The home is part of a group owned by a large healthcare company with other homes in the surrounding area. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the acting care manager and staff on duty, and an examination of the homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection commenced at 07:30 and finished at 15:45, and included talking to members of staff, residents and relatives. What the service does well: What has improved since the last inspection? There has been a general improvement in the care management documentation and recording system, following a review of those residents most at risk to ensure that all residents receive the care appropriate to their needs. Developments are in progress to provide a separate Statement of Purpose for each unit, using the Bradford Dementia Group and a Person Centred Care approach to obtaining residents views, and it is hoped that these views will eventually be included in the Service User Guide. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 7 There has been a reduction in the number of serious falls by residents and fall prevention training is being carried out. Staff training in dealing with residents challenging behaviour has been carried out. Portable appliance testing has been carried out. All health and safety documentation was made available for inspection. 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. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 8 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 Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 9 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): 1. Potential residents/representatives still do not have all the information about the home available to them to enable them to understand and decide whether the services the home provides meets their needs because the views of residents are not included in the Service User Guide. Plans are in place to develop an alternative and more meaningful method of obtaining the views of residents. EVIDENCE: The Statement of Purpose, the Service Users Guide and the last inspection report are available in reception for easy reference, but the views of residents have still not been included in the Service User Guide, nor alternatively has a statement been included in the Service User Guide, that they are available in a separate file for interested parties, in close proximity to the guide. Resident views, obtained as part of the homes quality assurance system, are initially sent to the homes head office for analysis, before being returned to the Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 10 home, in an analysed format, that as has been mentioned before, could be argued does not represent unabridged first hand evidence of their views. The Care Services Director is attempting to provide a separate Statement of Purpose for every unit, using the Bradford Dementia Group and a Person Centred Care approach to obtaining residents views, and it is hoped that these views will eventually be included in the Service User Guide. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. The development of a new care management documentation system has tightened up care recording and this together with a system of individual care audits should improve the overall level of care provided to residents. There has also been an improved liaison with some health professionals that promotes and safeguards the interests of residents. EVIDENCE: The acting care manager has spent time in the general nursing unit in a “hands on” capacity, assessing the staff performance in various areas of care such as bathing and feeding etc, and has also looked at dependency levels and nutritional issues with the objective of finding out those residents most at risk. The acting care manager has also redesigned the current care management documentation system in new care plan folders working towards a person centred approach for all residents, and all staff have been trained in the new system by the acting care manager. The new care plans are now being audited against the Four Seasons standards by the acting care manager and deputy care manager on a random sample basis monthly. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 12 A sample of assessments and plans of care were examined during the case tracking process, to check if the care documentation system provides a safeguard for residents in the home, and the evidence was that they were easier to understand and were comprehensive. Assessment information includes activities of daily living, cognitive abilities, nutrition, social needs and personal preferences, and there are dependency ratings and scores for levels of risk from pressure sores and nutritional needs. Staff try to involve the residents/relatives in the drawing up of plans of care, and this was seen to be in evidence, but where this is not possible, staff record the lack of participation. All residents receive attention to their health needs, and the homes care documentation contains clear evidence of interventions made by nursing and care staff to maintain their health. The case file also contains evidence of the involvement of health care professionals, including GP’s visits and visits from CPN’s and consultant psychiatrist to residents in the homes EMI units. There is a nurse in charge on each nursing unit, who takes responsibility for monitoring the residents needs, which includes monitoring and evaluating pressure area and continence care, which is detailed in their plans of care. Wound assessments are also monitored and recorded. The home has many specialist mattresses in use, and utilises the services of the tissue viability nurse. No residents are (PEG) fed, and all visits to A&E are now undertaken with staff accompaniment, unless a relative can attend at the home or hospital or unless residents are admitted to hospital. The care manager has taken action to address the number of falls in the home, by issuing instructions to staff that there must always be a member of staff present in all the homes communal lounges and dining rooms at all times when residents who are susceptible to falling are present. An accident audit continues to be done by the care manager on a monthly basis to monitor patterns and trends in any falls, and to take any corrective action needed. The acting care manager was able to demonstrate that there had been a significant reduction in the number of falls and this acts to safeguard the health of residents. A training course was taking place on falls prevention at the time of the inspection for both nurses and care staff. Medication arrangements were found to be satisfactory and the inspector saw evidence of the MAR sheets being completed appropriately. The acting care manager has recently acted to make the dispensing of all liquid medication more accurate following her recent medication audit. Staff administering medication including nurses and senior carers undertook an updated training course last year, and this is an ongoing training issue for staff. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 13 The pharmacy that collects the homes medication waste have not yet obtained a Waste Management Licence as required by the NHS contract for community pharmacists introduced from the 1st April 2005, but the inspector was informed that the medication contract is being moved to Boots, who do have the necessary licence. There were many examples of staff interacting with residents on this inspection, and one resident told the inspector that she lived in the “singing unit” and she loved it. Residents were generally clean in dress and appearance, and staff were noted to give attention to this area, thus preserving their dignity. The hairdresser was on site, and it was clear that many residents enjoyed being able to have their hair done on a regular basis. There were a regular number of relatives visiting during the inspection, and one relative was pleased that her mother had been reassessed and had been moved to an alternative unit that was more able to meet her needs. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 14 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, Staff enable residents to maintain appropriate and fulfilling lifestyles both in and outside the home, and the role of the new activities co- ordinator will be to offer an even improved service. Contact with family and friends is encouraged and maintained at all times. EVIDENCE: A new activities co - ordinator, is due to commence work next week whose role will be to organise a range of internal and external recreational activities for residents interest and enjoyment. In addition the activities co-ordinator will be expected to provide each resident with an activities programme on a weekly basis and staff will obtain the residents choices of those activities they would like to participate in. All resident involvement will then be recorded in each residents file as evidence of their involvement, and also separately as an audit trail for the care manager to monitor this important area for residents. There are lots of photographs around the home showing resident/staff involvement in activities generally, and the activities stock room contains an ample supply of materials to maintain this interest for residents in their individual units. The home no longer has the vehicle that was available and based at Layden Court and shared with other homes owned by the company in the surrounding area. Nevertheless, future transport for residents will involve hiring vehicles as Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 15 and when required, and it is hoped to include more external outings, particularly to the coast, in the warmer weather. Many bedrooms are highly personalised with residents’ own belongings and items of memorabilia, demonstrating their choice and control of their lives, and a number of residents choose to spend long periods in their own rooms by choice which is their right. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, & 18. Staff have a knowledge and an understanding of both complaints and Adult Protection issues that promotes the protection of residents, and the acting care manager has taken positive steps to improve the overall management of the home. EVIDENCE: There is a complaints procedure that is on display and the complaints log is well organised and contains all information relating to each of the complaints. There has been one anonymous complaint and one concern raised since the August 2005 unannounced inspection. The complaint has been investigated, and the concern has been referred to the companies Human Resources section for advice and action. A notice board displays information about local support groups and services that will provide advocacy. There is also an Adult Protection and WhistleBlowing Procedure, that includes definitions, indicators of abuse and ways to detect abuse, and there are procedures to follow in the event of abuse towards residents, staff or visitors. A meeting was held on the 9th December 2005 with the homes senior management and the newly appointed acting care manager to discuss CSCI concerns about the increasing number of complaints that had been made throughout last year, some having been referred to Adult Protection. A further concern was that despite addressing this matter with the registered care Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 17 manager on the 17th August 2005 at the unannounced inspection that complaints had still been received . Eight complaints had been received between the 29th December 2004 (unannounced inspection) and 17th August 2005 (last inspection) 5 being referred to Adult Protection, and another 3 complaints had been made since the last inspection 1 being referred to Adult Protection. An analysis of the issues involved in these complaints suggested that they were wide ranging, and a number related to nursing issues and inadequate and inconsistent recording to the homes documentation. Another common denominator however was the allegation of there being insufficient staffing on duty, or an inadequate deployment of staff that protected the safety of residents leading to an above average number of residents falling because they have been left unattended. There had been one occasion when a resident was able to leave the building without staff supervision sustaining a serious injury to her leg in a fall down a steep banking. These matters were discussed with the care manager at the August 2005 inspection, and assurances were given that steps had been taken to address the issues involved. The inspector was informed that instructions had been issued to staff that there must always be a member of staff present in all the homes communal lounges at all times when residents who are susceptible to falling are present, but this was found not to be the case on the inspection when residents were seen to be left unattended in some areas of the home. Discussions with Senior staff on a visit to the home on the 28th October 2005, also revealed their concerns about shortages of staff on many occasions, and residents being got up in a morning and being taken to the dining room where there was no supervision until breakfast was served leaving them in potential danger of falling etc. The conclusions of the 9th December 2005 meeting were that all the matters had been addressed and staff were looking forward to a complaint free period in the future. A CSCI monitoring visit to the home on the 5th January 2006 revealed that the acting care manager had taken positive steps to improve the overall management of the home as found on this inspection. Residents have opportunities to vote at local and national elections, and some residents exercise this choice via postal votes as they did at last years general election. Staff confirmed that a number of residents present challenging behaviours, and suitable training for staff has been arranged, to ensure that residents are dealt with appropriately in such circumstances. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 18 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, 25, & 26. There has been some redecoration and refurbishment maintaining the upkeep of the furnishings and fabric of the premises, and a more general refurbishment is being planned. Resident accommodation is personalised and homely, and the home is clean and odour free which contributes to the residents overall health and safety. Further attention needs to be paid to the heating problems and the wedged doors. EVIDENCE: The home is in a relatively good state of decorative order and has an ongoing redecoration programme. Since the last inspection the curtains have been replaced in the Thurcroft lounge, and Becks has been repainted, and new curtains and co-ordinating bed linen have been obtained. The acting care manager is to cost and arrange a refurbishment plan for the home over a 6 – 12 month period. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 19 Residents individual rooms are now subject to a weekly audit to ensure all equipment is in good working order and the décor is in a satisfactory condition in an effort to maintain satisfactory standards for residents. Each unit has a lounge, dining room and small sitting room. The standard for space requirements is met, and all lounges are well presented. Lounges on the different units have various styles. The quiet lounges are not in frequent use but are open and available for residents and their families to use. All bedrooms have en-suite toilets with wash hand basin and storage, and there is an assisted bathing facility and shower on each unit. Additional toilets are situated near communal areas. One bathroom on Swallowood is still being used for storage as it is stated that it is underused as a bathroom, and the acting care manager’s review of the bathing needs for residents accommodated near to this facility has concluded that existing bathing facilities are adequate for the number of residents. There were two doors wedged open against Fire Service advice, one a dining room door in Thurcroft and Becks that was wedged open with a saucer, the other a residents bedrooms that was propped open using a traditional wooden wedge. Some staff complained that temperatures in the upper floor units of Kiveton and Thurcroft /Becks continue to be unpredictable, and the homes maintenance man confirmed that despite a recent review by the contractors the home is still too warm. The acting care manager was surprised at the staff comments, and said that health and safety meetings are held, but this issue has not been brought up by staff. The home was generally clean and tidy throughout, and staff work hard to remove all odours and provide a clean and hygienic home for residents. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30. Staffing levels must reflect the assessed needs of residents at all times, and residents must be protected at all times by a stable and competent staff team in sufficient numbers and suitably trained. Staff training in NVQ must enable residents to feel assured that that they are in safe hands at all times. EVIDENCE: The acting care manager deploys staff according to the different dependency levels of residents as follows and as agreed by the staffing notice issued by the Social Services inspection unit in RMBC prior to the introduction of the NCSC in 2002. 1. Markham Unit - 1Snr and 1carer = 2 for 9 EMI residential residents. 2. Swallowood Unit - 1Snr and 1 carer =2 for 17 Older people residents. 3. Haighmoor Unit – 1RGN and 3 carers = 4 for 20 Older people with nursing needs. 4. Kiveton Unit – 1RMN/RGN and 3 carers =4 for 20 EMI older persons with nursing needs. 5. Thurcroft/Becks Unit – 1Snr and 3 carers = 4 for 23 EMI residential residents. The situation found on this inspection was that staffing levels were in accordance with the above requirements with the exception that there were 3 carers, but no Senior in Thurcroft and Becks, for a reduced number of 13 residents out of 23 beds, with the Senior in Markham unit assisting to do the Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 21 medication. In addition there was a nurse and 2 carers in Haighmoor for 15 residents instead of a registered 20 nursing residents, and a member of agency staff was used for the afternoon shift. The inspector was informed that there is usually an interchange of care staff between Swallowood and Markham units to cover for sickness etc, and this is generally satisfactory, but is not always the case because of a refusal by a member of staff to assist in this way. The inspector learned that this matter is being dealt with via the homes disciplinary procedures. There were 68 residents in total with many staff working a long day shift, by choice, and the acting care manager is monitoring the dependency levels of residents to ensure that a sufficient number of staff are deployed on duty. There is a recruitment and selection procedure and a number of staff files were checked from people employed since the last inspection, and found to be satisfactory. One reference is now checked verbally, for verification of its authenticity to strengthen the protection of residents. Enrolment for NVQ training continues, but the requirement to have 50 of staff trained to NVQ level 2 by 2005 has not been met. The company has started to take positive steps to remedy this situation that it is hoped will be resolved as soon as possible. The deputy manager continues to undertake a full review of the training needs of the staff team and has a clear plan of what is to be achieved this year. Each member of staff has an individual training record. Some POVA training by the Regional Manager took place last year, and also training on wound care and palliative care for staff in order to meet the assessed needs of residents. Further training on palliative care is currently ongoing. The Four Seasons induction pack is in use for new starters and a supervisor is allocated within the unit they are working on. Statutory training is ongoing with the acting care manager taking appropriate action to ensure that all staff attend this training to enable them to meet the assessed needs of residents. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 22 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, 32, 36, & 38. Residents continue to benefit from a home that is generally run well and in their best interests, but attention must be paid to ensuring that all staff receive formal supervision at least six times per year. EVIDENCE: The registered care manager is currently on maternity leave and the home is being run by a peripatetic acting care manager Julie Dakin with many years of experience in the care sector and 2 years experience with Four Seasons. Ms Dakin commenced working at Layden Court in November 2005. There is a deputy care manager who is based on Kiveton Unit who works with the acting care manager in managing a comparatively very large home registered for 89 beds. The registered care manager is due back at work in Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 23 May 2006 and was working towards completing the Registered Managers Award, before her maternity leave. Staff were willing to offer their views that the acting care manager manages the home in an open and inclusive manner, is always approachable, and that their views receive attention, when given both formally and informally. Supervision is being carried out for all staff, but a random sample revealed that some staff are not receiving supervision at least 6 times per year. The home operates a delegated system to ensure all staff receive supervision in line with the standard, and this clearly needs attention in the protection of residents interests. Accident records are being maintained, and other health and safety requirements are being met as follows: 1. The fire records were satisfactorily recorded and the home has a fire risk assessment that is to be shown to the Fire Officer. 2. The portable appliance testing was carried out in September 2005. 3. The shaft lifts had a “Thorough Examination“on the 23rd August 2005. 4. The lifting equipment was tested in November 2005. 5. Legionella testing was carried out on the 10th October 2005. 6. The gas boiler was serviced on the 3rd November 2005. 7. The electrical hard wiring is still within the 5 year retesting date. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 24 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 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 x x x x x 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 x x x 2 x 3 Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4 Requirement The registered person must ensure that the view of residents are obtained and included in the Service User Guide. The registered person must ensure that doors are not wedged against Fire Service advice. The registered person must reassess ways of alleviating the heating problems in two of the units in the home. The registered person must ensure that adequate staffing levels are maintained at all times The registered person should ensure that a minimum ratio of 50 trained members of staff NVQ Level 2 or equivalent is achieved as soon as possible. The registered person must ensure that all staff receive formal supervision of at least 6 times per year. Timescale for action 31/03/06 2. OP19 23 31/01/06 3. OP25 23 31/03/06 4. 5. OP27 OP28 18 18 31/01/06 30/06/06 6. OP36 18 31/01/06 Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 26 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 OP31 Good Practice Recommendations The registered person should ensure that the registered care manager achieves a relevant management qualification as soon as possible. Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Layden Court Care Home DS0000003082.V277060.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!