CARE HOME ADULTS 18-65
Leabrook House Nursing Home 180/181 Leabrook Road Tipton West Midlands DY4 0DY Lead Inspector
Mrs Amanda Hennessy Unannounced Inspection 7th March 2006 09:30 Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 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.V285044.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 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.V285044.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Leabrook House Nursing Home Address 180/181 Leabrook Road Tipton West Midlands DY4 0DY 0121 556 5685 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.V285044.R01.S.doc Version 5.1 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. 8th November 2005 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. Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced Inspection undertaken by one Inspector. The inspection commenced at 09.30 and was of 6 hours duration. This Report is a product of a review of care records, discussions with Residents, the Proprietor, Registered Manager and Staff members and a range of documents/records reflecting the general operation of the Home. High standards of direct care provision and overall management are provided in a friendly and open atmosphere for Residents, who are generally of a high dependency client group. All standards were reviewed at the previous inspection so for additional information on the home the reader should also refer to the inspection report following the inspection on the 8 November 2005. XX requirements were made as a result of this inspection What the service does well: 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. Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 6 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.V285044.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were reviewed in this section during this inspection. EVIDENCE: Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service users who live permanently in the home have a plan of care that reflects their needs, care plans are not always available for service users who are admitted on a short stay basis. EVIDENCE: All permanent service users have a comprehensive plan of care that identifies their needs. Records show that whenever possible either the service user or their representative are involved in planning and evaluating their care. A service user admitted for respite (short stay care) had no care plan available and this service user had also not had their care risk assessments updated. Risk assessments are available for those service users who have bed rails, although require more detail. Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Service users are encouraged and supported to maintain and develop relationships. EVIDENCE: Visitors to the home are made welcome. Service users are encouraged and supported to maintain and develop relationships. Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were assessed in this section during this inspection. EVIDENCE: Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were reviewed in this section during this inspection. EVIDENCE: Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The home is homely, clean, well maintained and is a pleasant place to live. EVIDENCE: The home is homely and pleasantly maintained with good quality furniture and furnishings. There is an ongoing refurbishment programme to ensure that the home is always well maintained. Since the last inspection the lounges, corridors and reception area have had new carpets. All areas of the home seen were clean and free from any offensive odour. There is a full range of specialist equipment for very dependent people the proprietors are now replacing all beds with specialist profiling beds for service users additional comfort. Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 Staff numbers and skill-mix meet the assessed care needs of current service users. Service users benefit from well trained staff who are encouraged and supported to undertake both mandatory and developmental training. EVIDENCE: Staffing numbers and skill-mix meets the care needs of the Service Users. In addition, when judged necessary by the Manager, e.g. periods of peak activity and/or increased dependency, funds are available to increase staffing to meet those needs. Staff are subject to a thorough, and relevant, orientation/induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘simple infection control’. In addition, the Home enjoys an excellent record for the continuing development of Care 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 (53 of Carer Staff) reflects a very positive approach to enabling skills development. Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were assessed in this section during this inspection. EVIDENCE: Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 15 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 x 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 4 33 4 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 16 No 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 OP6 Regulation 15 Requirement Care plans must be available for all service users including those service users admitted for short term care.- This requirement has been addressed. Bed rail risk assessments must be more detailed and reflect all risks to the service user. – This requirement has been addressed. Timescale for action 31/03/06 2 OP6 13(6),15 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Leabrook House Nursing Home DS0000004788.V285044.R01.S.doc Version 5.1 Page 17 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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