CARE HOME ADULTS 18-65
Leacroft 120 Colchester Road Leicester Leicestershire LE5 2DG Lead Inspector
Kim Cowley Unannounced 3 August 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Leacroft Address 120 Colchester Road Leicester Leicestershire LE5 2DG 0116 2461425 0116 2768662 leacroft.schealthcare.co.uk Active Care Partnerships Limited 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) Vacant Care home with nursing 19 Category(ies) of LD Learning disability (19) registration, with number LD(E) Learning disability - over 65 (2) of places PD Physical disability (19) PD(E) Physical disability - over 65 (2) Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 28.09.04 Brief Description of the Service: Leacroft (previously known as Colchester Court) is registered to provide care with nursing to nineteen residents with learning disabilities, some of whom also have physically disabilities. The home is divided into three adjoining bungalows, each with its own dining room, lounges, and kitchenette. There is a central kitchen, where main meals are prepared, and a reception area. All areas are wheelchair accessible, and secure private gardens surround the property. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on a weekday. The inspector met with four residents, the Acting Manager, and two of the care staff. The premised were toured. Care records were examined. There were no requirements outstanding from the last inspection, and no new requirements were made. The Activities Organiser and Acting Manager are commended for the positive impact they are having on the home. What the service does well: What has improved since the last inspection?
The home has just appointed a new Activities Organiser who works 32 hours per week. Although this worker has only recently taken up her post, a comprehensive activities programme is already in place. The Acting Manager
Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 6 said ‘Our residents want to go out and they want to do more in the home. That’s why we’re so pleased to have our own Activities Organiser. We hope this will lead to a change in the culture of the home with residents becoming more active and more involved in the local community.’ The Activities Organiser is commended for the work she is doing in the home. A redecoration and refurbishment programme is in progress, and staff say the environment is substantially improved. The Acting Manager, who is an RGN, is an enthusiastic and motivated professional who is determined to run a ‘user-led home’. Over the last few months staff at Leacroft have faced change and uncertainty. The majority of problems have now been resolved and the home appears to be entering a period of stability. The Acting Manager has a clear vision about the future of the home that includes many more activities for service users, with staff enabling them to get out and about more, try new things, and grow in independence. The Acting Manager is instrumental in helping to bring about this change of culture in the home and is commended for her role. 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. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards will be inspected at the next inspection. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 9 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 standard(s) 6,7,9 Care plans are comprehensive and regularly reviewed. Good risk assessments are in place. Residents are offered alternatives and encouraged to make choices. The key worker system is effective and gives residents the opportunity to have intensive one-to-one support from specific members of staff. EVIDENCE: The Acting Manager writes care plans in conjunction with team leaders. Four were inspected. They were comprehensive and had been reviewed at least once a month. Good risk assessments are in place. Detailed daily records are kept and these are used to inform care plans. Nursing needs are clearly set out. Care staff are expected to regularly refer to care plans so they can keep up with each resident’s progress. Care records showed that residents are encouraged to make decisions about their daily lives. Alternatives offered and choices made are recorded. One resident sits with her key worker and takes part in the recording and review of her care plan. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 10 All residents have key workers. Their responsibilities include getting to know the residents, finding out their likes and dislikes, and encouraging them to develop interests and take part in activities. All records inspected were well kept and organised, with information easily accessible. Information on residents is kept securely in accordance with the Data Protection Act. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 11 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 standard(s) 12,13,15,16,17 The Activities Organiser is a welcome new addition to the home and is already having a positive impact on residents’ lives. A lively programme of activities is in place. EVIDENCE: The home has just appointed a new Activities Organiser who works 32 hours per week. Although this worker has only recently taken up her post, a comprehensive activities programme is already in place. The Acting Manager said ‘Our residents want to go out and they want to do more in the home. That’s why we’re so please to have our own Activities Organiser. We hope this will lead to a change in the culture of the home with residents becoming more active and more involved in the local community.’ The Activities Organiser has already developed a good relationship with the residents. The inspector observed that residents’ faces lit up when she came into the room. She has a small office in one of the bungalows and residents are welcome to come and go while she works. She is in the process of talking to
Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 12 residents and their families/friends/key workers to find out what they’d like to do and where they’d like to go. Activities in the last two weeks have included: • cinema trip • country walk • boat trip on Rutland Water • pub lunch • visit to arboretum • aromatherapy • pottery class • night club The Activities Organiser is commended for the positive impact she is having on the home. For transport the home has a car, which some staff are insured to drive, and there is a minibus on order. Relatives meeting are held approximately every three months. The home has recently held an open day for residents and their families/friends. Wine, soft drinks and food was served. The Acting Manager said attendance was good and a similar event is being planned. Staff are in the process of introducing advocates and befrienders to the home. It is hoped that residents who have little or no family contact will be able to have an advocate/befriender to support them and oversee their personal finances. Residents are encouraged to develop daily living skills. Most are able to do small jobs in the home supported by their key workers. For example, some take their laundry to the laundry room and collect it when it has been laundered. Others vacuum with the staff and make hot drinks under supervision. The home has a central kitchen where the home’s cooks (one full-time and one part-time) prepare the main meals. Diabetic and non-English diets are catered for. Care records indicate that good nutrition is a priority in the home. Menus show a wholesome and varied diet being provided. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 13 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 standard(s) EVIDENCE: These Standards will be inspected at the next inspection. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 14 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 standard(s) 22,23 Residents are listened to and staff encourage them to express any concerns they may have. Staff know how to protect residents from abuse. EVIDENCE: The Acting Manager said the majority of residents are able to let staff know if they are unhappy about something. She said ‘For example, if they don’t like a particular meal they’ll tell us, or they’ll push it away.’ Care records set out residents’ likes and dislikes. Key workers work to build up relationships of trust with residents and encourage them to express any anxieties they might have. The home has a written complaints procedure, which meets minimum standards. Policies and procedures are in place to protect residents from abuse, and the staff on duty were familiar with these. All staff, including ancillary staff, have the opportunity to undertake adult protection training. So far 17 members of staff have completed this training course. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 15 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 standard(s) 24, 30 The premises are homely and well equipped and are being continually improved. All areas inspected were clean, fresh and tidy. EVIDENCE: The home, which was purpose-built in 1991, is in the middle of a substantial redecoration and refurbishment programme. Most of the work is being done by the full-time handyman The premises are divided into three bungalows: Cherry Tree, Pine View, and Sandalwood. Each caters for residents with slightly different needs, for example, one of the bungalows is for residents who prefer a quieter environment. Those bedrooms inspected were individually decorated and furnished. The home is well equipped for residents with reduced mobility with a range of aids and adaptations, including Parker baths and hoists. Some of the bedrooms are quite large and suitable for wheelchair users. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 16 A part-time cleaner is employed and takes responsibility for the bathrooms and kitchens and other ‘heavier’ aspects of cleaning. Care staff do the rest of the cleaning, encouraging residents to help where possible. All areas inspected were clean, fresh and tidy. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 An enthusiastic and professional Acting Manager currently runs the home. Care is provided by a good mix of experienced and qualified staff from a range of different backgrounds. Staff are appropriately trained and supervised. Recruitment policies and procedures are generally good although one improvement is needed. EVIDENCE: The Acting Manager, who is an RGN, was in charge of the home on the day of inspection. She is an enthusiastic and motivated professional who is determined to run a ‘user-led home’. Over the past few months staff at Leacroft have faced change and uncertainty. The majority of problems have now been resolved and the home appears to be entering a period of stability. The Acting Manager has a clear vision about the future of the home that includes many more activities for service users, with staff enabling them to get out and about more, try new things, and grow in independence. The new Acting Mananger is instrumental in helping to bring about this change of culture in the home and is commended for her work. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 18 The home employs ten team leaders, all of whom are qualified nurses from a general, learning disability, or mental health background. This skills mix enables good holistic care to be offered. Some residents have ongoing nursing needs and these can be met in the home along with their social care needs. Approximately 30 support workers are employed and records show the majority are experienced and well trained. The home has a full-time handyperson, a full- and part-time cook, and a parttime cleaner. A full-time administrator is based in a office near the entrance to the home. She was observed to get on well with residents and to offer a warm welcome to all visitors. Four staff files were inspected and were generally of a good standard. A checklist is in place to ensure all the necessary documentation and checks are carried out. One member of staff (who was employed prior to the Acting Manager taking up her post) did not have a reference from their most recent employer. This was discussed with the Acting Manager who agreed that this was not acceptable, and that in future applicants’ most recent employers would always be approached. It is recommended that policies and procedure are put in place to ensure this happens. An extensive training programme for staff is in operation. Weekly staff meeting are held. A new programme of staff supervision was started this year. All staff have already had one supervision session, and it is intended that they will all have a second one by the end of the year. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards will be inspected at the next inspection. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 4 3 3 3 Standard No 31 32 33 34 35 36 Score 3 4 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Leacroft Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 21 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. 1. 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. Refer to Standard 34 Good Practice Recommendations Policies and procedures must be put in place to ensure that a reference is always obtained from a job applicant’s most recent employer. Leacroft C51 C01 S48221 Leacroft V222669 030805 STAGE 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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