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Inspection on 16/03/07 for Leabrook House Nursing Home

Also see our care home review for Leabrook House Nursing Home for more information

This inspection was carried out on 16th March 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. Arrangements for pre-admission visits and trial periods are seen by service users and staff as very helpful to settling in to the home. The home has very good assessment procedures and care planning systems in place and service users are confident that their personal needs are understood and can be met. The staff are seen to have excellent relationships with the residents interacting naturally, with empathy and delivering care as the person wishes, achieving a high level of satisfaction and sense of wellbeing amongst the residents. The home gives a high priority to obtaining service users views and demonstrate a commitment and flexibility in adapting services to address wishes where there is consensus. The property is well maintained and kept in good decorative order and in a clean odour free state. The home demonstrates a good commitment to staff training and provide for appropriate levels of formal supervision.

What has improved since the last inspection?

Care records are generally very good and there have been improvement to ensure that care records are updated for those service users who are regularly admitted for respite stays. Bed rail risk assessments is now more comprehensive.

What the care home could do better:

The home maintains up to date statement of purpose and service users guide but this could improve with the inclusion of a date when reviewed, more could be made of the availability of these documents in other formats such as tape, pictures and large print. A comprehensive needs assessment is undertaken during the preadmission period and the assessed needs developed as care plans that are subject to monthly review, the home may find some benefit in further developing the review process by introducing regular full reassessments on a regular basis such as 4-6 monthly. The medicines room was of a comfortable ambient temperature during the inspection, there should be a systematic process of monitoring this and means of preventing overheating from the sun on the window.

CARE HOME ADULTS 18-65 Leabrook House Nursing Home 180/181 Leabrook Road Tipton West Midlands DY4 0DY Lead Inspector Mr Richard Eaves Unannounced Inspection 16th March 2007 09:00 Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 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 Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leabrook House Nursing Home Address 180/181 Leabrook Road Tipton West Midlands DY4 0DY 0121 556 5685 F/P 0121 556 5685 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) Mrs Veronica Lovell Mr James William Lovell Julia Handley Care Home 31 Category(ies) of Learning disability over 65 years of age (3), registration, with number Mental disorder, excluding learning disability or of places dementia (4), Physical disability (24), Physical disability over 65 years of age (23) Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 3 LD(E), 4 MD, 24 PD, 23 PD(E) Up to 10 day care places for LD/PD One service user in the category LD(E) may be under 65 years of age and also be DE and will remain until such time that the service user reaches the age of 65 or the placement is terminated. Date of last inspection Brief Description of the Service: Leabrook House is situated on the Tipton/Wednesbury border, close to the towns of West Bromwich, Walsall, and Wolverhampton. It is within easy reach of several motorway/main road networks, with good availability of public transport. The Home offers 31 single occupancy rooms, most of which have en-suite toilet facilities, with some benefiting from the addition of an en-suite shower. There are a range of services and facilities available to Service Users including:entertainment and recreational activities, various aids and adaptations, complimentary and relaxation therapies, a swimming/hydrotherapy pool and an excellent catering service. The Home also provides a 10 place day-care facility for younger adults with specific nursing needs. The current scale of charges are £440 to £1400 each week. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the inspections during November 2005 and March 2006, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, comment card responses from service users and relatives and records held at the home. The inspection involved a full tour of the property including, a number of bedrooms, the communal rooms and service areas and provided an opportunity to speak with most of the service users. What the service does well: The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. Arrangements for pre-admission visits and trial periods are seen by service users and staff as very helpful to settling in to the home. The home has very good assessment procedures and care planning systems in place and service users are confident that their personal needs are understood and can be met. The staff are seen to have excellent relationships with the residents interacting naturally, with empathy and delivering care as the person wishes, achieving a high level of satisfaction and sense of wellbeing amongst the residents. The home gives a high priority to obtaining service users views and demonstrate a commitment and flexibility in adapting services to address wishes where there is consensus. The property is well maintained and kept in good decorative order and in a clean odour free state. The home demonstrates a good commitment to staff training and provide for appropriate levels of formal supervision. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 6 What has improved since the last 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. The summary of this inspection report can be made available in other formats on request. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 - 5 Quality in this outcome area is excellent The home’s statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and trial the home before committing themselves to staying at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 9 The home’s statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and receive a full work up provided by the home before committing themselves to staying at the home. Evidence from 4 randomly selected case files, discussions with Residents and their Relatives showed the assessment process to be comprehensive. The assessed needs are reviewed as part of the care plan review process. The home may consider if any benefit may be derived from occasional review of the whole assessment process. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent Care needs are comprehensively identified in Care Plans and the necessary directions of actions required to ensure that service users care needs are fully met and health is promoted. Care Plans are regularly reviewed and revised as necessary. Service users are fully involved in all aspects of life at the home and are supported to make decisions for themselves and encouraged to be as independent as possible, even though this may mean taking risks. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many of the Residents at Leabrook House have very complex nursing and general care needs. A random sampling of 4 Case files were case tracked and showed related Care Planning documentation to be well organised, current, clearly written and comprehensively encompassed the range of ‘care areas’ necessary to ensure the delivery of care appropriate to the needs of each Resident. One service user was noted to have had a rash on admission and Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 11 received treatment for this but no care plan was seen, a further service user was receiving a daily medication but no care plan identified this. (Thyroxine). Good contingency plans are available for conditions such as epilepsy that may have serious side effects. Care Plans evidence that Residents are closely involved in decisions regarding their lifestyle some spoken with were able to confirm this. The Home has developed a comprehensive set of individual and generic risk assessments, including; pressure area relief, nutrition, bed rail use and bedroom door locks, these were seen to be reviewed on a regular basis. Families say of the care provided “X is always clean, well dressed and smells sweet”, “ X loves it there, everyone has time for him, the standards of care are excellent”, “they give the best care they can. Help them to manage their situation as best they can”, “X has come on very well since she’s been there. She has opened up a lot as she was very quiet and would not speak to anyone now she is very open and I am pleased with this, the staff take very good care of the residents”, “the home has everything that my son could wish for, I couldn’t wish for a better place, the home is the best place, my son has improved since he has been there. He couldn’t communicate but he can now with his eyes and hands and that’s down to the carers”. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent Staff support service users to access opportunities for their personal development and health promotion. The involvement of family and friends is encouraged in agreement with the service users wishes. The home provides a varied social and recreational activity programme that provides interest and pleasure for service users. Meals at the home are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation and discussion with Management and Residents showed routines to be flexible to suit the needs of individuals. An open visiting policy is operated with Relatives/Friends being encouraged to become involved in the service delivery, visitors spoken with confirmed this and that they were comfortable with this. Some service users frequently travels to neighbouring townships independently using electric chair or public transport. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 13 There is strong evidence of support for service users wishing to engage with the local community e.g. theme nights, trips out using the Home’s mini-buses, progressive mobility, a visit to the ballet planned for this week, visiting entertainers, twice weekly religious services, plus activities focussed on the individual, which include shopping trips, visits to the local pub, use of complementary therapy and ‘relaxation’ rooms. There is a multi-week rotational menu in operation, which includes choice at the three main meals; supper is included on the menu. Lunch was served during the inspection and the meal appeared appetising, tasty and nutritious and enjoyed by all. Fresh fruit and vegetables are available daily. In discussion with a number of service users they said the food was “very good”, “ I really enjoy the meals here”, and all wished to communicate how much they appreciate the range and quality of food provided at the Home. Service users comments about activities were positive, “I am taken out to the shops, go to the seaside and Zoo and a lot of places”, “We have communion service every two weeks, I enjoy this”, “ X likes to listen to music from Iraq”, “I enjoy trips out i.e. seaside, country runs”, “there are in-house activities and out in the community, I am very happy here”. Of the meals they said, “ My food preferences are not easy, but there is always alternatives to menu, Chef is very good at meeting my needs”, “the food is a very High Standard”. A visitor said “ It gives a good homely environment and visiting at any hour is not a problem, I think the staff are very friendly, they always seem to know what is going on, I don’t have to wait to see a particular member of staff if I need some information regarding my father”. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 – 20. Quality in this outcome area is excellent Service users are assisted to maximise their independence and control over their lives and staff respect their privacy and dignity and give support to achieve this. Healthcare needs are well documented and are compiled with the input of the individual service user. The care plans give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 15 The home routines are flexible although service users are encouraged to accommodate meal times and medication regimes within their personal routines they are generally encouraged to make independent choices. The Home operates a ‘named nurse system’ with specific responsibilities for particular individuals. Registered General Nurses, and Registered Nurses for People with Learning Disability, provide nursing care within the Home, with external specialists used as needed. Generally, the manner in which Staff meet Residents’ complex nursing care needs is to be commended. One relative specifically said “the GP is excellent”. Service users have their physical, emotional and mental health needs met and the care plans evidence general practitioner and other health care professionals input. A local chemist provides medication and the pharmacist provides advice as required and provides a report of quarterly inspection. Currently no service users are assessed as able to self administer and control their own medications. At the time of the inspection none of the service users were administering their own medication and there were no controlled drugs. Arrangements for the receipt, storage, administration, recording and disposal of medicines comply with the homes policy and this standard. The manager may wish to check how the medication room temperature is best monitored and maintained below 25°c. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Staff demonstrate excellent knowledge and understanding of adult protection issues which contributes to an environment that is safe from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear and concise Complaints Procedure is displayed in the main hallway, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details, no complaints have been received in the previous year. Information relating to the use of advocacy services is also displayed. Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. Staff training files indicated that Staff had received training in respect of these Policies. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent The Home provides a comfortable, attractive, safe and ‘homely’ place to live. Specialist equipment, consistent with the needs of the Residents and the demands of tasks carried out by care staff, is available to facilitate the provision of care. The home is clean, hygienic and free from odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building including an inspection of some bedrooms that the inspector was invited to see were found to be mostly nicely personalised and included some items of own furniture. There are several lounge/sitting and dining areas offering a variety of size and outlook. Furniture in lounge and dining areas are of good order and present a ‘domestic’ ambience. The specialist equipment, available to facilitate provision of care, e.g. hoists, wheelchairs, stand-aids, appeared to be in good working order, is consistent with the needs of Service Users, and the demands of tasks carried out by Care Staff. The Home has a full range of maintenance contracts in place, and an on-going refurbishment/redecoration programme. Most of the Residents Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 18 present with very high levels of dependency and, as part of this, many have unavoidable problems with continence. It is a measure of Home’s success in managing these issues that the general ambience of the Home is clearly one of freshness and cleanliness, for which all Staff involved are to be commended. The home was clean and hygienic in all areas. The laundry is equipped with washing machines with sluice and disinfection programmes that meet standards. A sluicing disinfector is available but is rarely required to meet the hygiene needs of the service users. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 – 36. Quality in this outcome area is excellent Staff are clear as to their individual roles and responsibilities and are enthusiastic, sufficient in numbers, well trained, supportive and committed to maximising the service users quality of life. The recruitment practices, staff training and supervision all contribute to ensuring service users benefit from the skills and knowledge of the staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix is of a high standard and enables a high quality service provision meeting the care needs of the Service Users. The Manager is authorised to exceed routine staff numbers for periods of peak activity and/or increased dependency. A sample of staff files were viewed and show that recruitment procedures are completed to a good standard with appropriate checks of Personal Identification Number and Criminal Record Bureau in place. Job descriptions appeared satisfactory for roles and support the underlying values of the home. Staff are subject to a thorough, and relevant, orientation/induction Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 20 programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘infection control’. In addition, the Home enjoys an excellent record for the continuing development of staff, and supporting staff in undertaking appropriate training based on a well-structured plan for determining individual training needs. The current level of NVQ Level 2 attainment is 66 of carer staff with many holding higher qualification and Learning Disability Award Framework accredited training, which reflects a very positive approach to enabling skills development. Staff files contain a record of the supervisions that are undertaken and planned to provide at least 6 meetings each year. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities. The managers approach is open and positive and develops positive relationships amongst service users and with staff. The home regularly reviews its performance which includes seeking the views of service users and their families. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is an experienced registered nurse with an NVQ level 4 management qualification and has also achieved the Registered Managers Award, other senior staff also hold NVQ4. The manager is well regarded and liked by the service users and staff alike and this is apparent from the Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 22 comment cards and in speaking with service users and staff as well as observing the interactions over the day. The manager undertakes regular surveys of service users views and uses the findings to influence and improve the delivery of care. Since the previous inspection a survey undertaken during 2006 had an 82 response these findings have been written up in report form. Comments received include: “a particular feature has always been the excellent attitude of staff”, “staff treat every resident with respect”, “relationships with residents is brilliant”, “happy and friendly home”, “the staff are exceptional”. Many other comments were received and all very positive, a similar response was received by the Commission the responses being included throughout the body of this report. Documentation was seen of a full range of servicing, maintenance and regular monitoring of services and equipment is undertaken, staff receive training in health and safety and first aid. Monitoring of hot water is good and records show that the standard of 43°c is achieved consistently, anti scald testing and legionella prevention are also undertaken. Fire safety including tests, staff training and equipment maintenance were seen to be up to date. Records of all accidents are recorded, using data protection compliant documentation and reported as necessary. Induction and foundation training is provided to Skills for Care standards. Overall the premises were observed to be well managed to meet safety requirements. Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 4 4 4 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 X 4 4 3 X X 4 X Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 24 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. 1. 2. Refer to Standard YA1 YA2 Good Practice Recommendations The Statement of Purpose and Service Users Guide while observed to be up to date should include the date of the last review and the availability of other formats stated. The assessment of needs process is comprehensive and needs are reviewed monthly along with the care plans, it would be beneficial to regularly review the whole assessment process. Monitoring of the medicines room temperature should be undertaken in a systematic way and means taken to prevent heat ingress from the sun. 3. YA20 Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Leabrook House Nursing Home DS0000004788.V338674.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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