Inspection on 06/10/05 for Leacroft

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Leacroft 24/01/08

Leacroft 09/01/07

Leacroft 03/08/05

Leacroft 28/09/04

Leacroft 26/04/04

Leacroft 06/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Leacroft 120 Colchester Road Leicester Leicestershire LE5 2DG Lead Inspector Kim Cowley Unannounced Inspection 12:30p 6 October 2005 th Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 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 Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 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. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leacroft Address 120 Colchester Road Leicester Leicestershire LE5 2DG 0116 2461425 0116 2768662 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) Active Care Partnerships Limited Position Vacant Care Home 19 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (2), Physical disability (19), of places Physical disability over 65 years of age (2) Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person may be admitted to the home who falls within category PD or PD(E) unless that person also falls within LD or LD(E) i.e.. dual disability. No person who falls within category LD(E) or LD(E)/PD(E) may be admitted to the home when 2 persons of category/combined LD(E) or LD(E)/PD(E) are already accommodated within the home. 05.06.05 Date of last inspection 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 (Cherry Tree, Pine View, and Sandalwood) 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 DS0000048221.V256282.R01.S.doc Version 5.0 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. When undertaking inspections the Commission for Social Care Inspection (CSCI) focuses on the outcomes for residents living in a home. In order to do this, the inspector ‘case tracked’ three residents. This means the inspector checked their care records and was met with them. In addition the inspector talked to the Acting Manager, two of the carers, and a relative. Further care and other records were examined and the premises were toured. Two Requirements and one Recommendation were made. What the service does well: What has improved since the last inspection? What they could do better: The carpet in the music room in Sandalwood needs replacing. The home has now been without a Registered Manager for 10 months. This situation must be rectified and a suitable candidate put forward to CSCI by 5 December 2005. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 6 The Environmental Health Officer visited on 26.07.05 and recommended improvements to the kitchen. These should be carried out. 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 DS0000048221.V256282.R01.S.doc Version 5.0 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 Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 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 the following standard(s): 2 A good procedure is in place to ensure residents’ needs are fully assessed prior to admission. EVIDENCE: A good assessment procedure is in place. This is explained to potential residents and their representatives verbally, and they are shown pictures of the home. The assessment considers which unit might be suitable for a new resident as each caters for a different type of resident, for example quieter or livelier. The Acting Manager said ‘It’s important that we accommodate the right sort of resident and we have refused people in the past who we didn’t think would fit in.’ The home does not cater for residents with severe challenging behaviour. Potential residents visit the home prior to admission or come for respite care so they can get used to the home. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These Standards were inspected at the last inspection on 5.06.05. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: These Standards were inspected at the last inspection on 5.06.05. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 11 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): 18, 19, 20 Care plans give clear instructions to staff about how to deliver personal care. Residents’ health care needs are met by nursing staff at the home and health professionals in the wider community. Medication is properly managed and administered. EVIDENCE: Care plans explain how residents like their personal care to be given. Residents who cannot verbalise use body language to indicate choices, for example in deciding whether they want a bath or a shower. The home employs some general nurses who provide basic nursing care to residents. District Nurses give advice where necessary. Local GPs, opticians and dentists provide services to the home. Records showed residents making progress, for example by increasing their mobility. Qualified nursing staff gives out medication. The Acting Manger audits medication supplies and records every month and carries out spot checks. Staff are trained in-house. Records showed that any issues are promptly addressed. The home’s contract pharmacist regularly inspects the arrangements for medication and provides additional staff training. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These Standards were inspected at the last inspection on 5.06.05. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 13 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 premises are mostly homely, comfortable and safe, although the carpet in the music room in Sandalwood should be replaced. EVIDENCE: The premises were briefly toured and most areas were found to be warm and clean with a reasonable standard of decoration. However the carpet in the music room in Sandalwood is in need of replacement as it is worn and stained. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: These Standards were inspected at the last inspection on 5.06.05. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 15 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): 37, 39, 42 The home is well run, but to meet legal requirements a Registered Manager must be appointed. Staff strive to involve residents, or their relatives, in all decisions made about the home. The kitchen is in need of some improvement with regard to health and safety. EVIDENCE: The home is still without a Registered Manager. This must be rectified in order for the home to meet Regulations. The home is well run by the Acting Manager who has worked hard to provide a stable environment for both residents and staff. She is committed to putting residents’ interests first. The home is non-institutional with a relaxed environment. Residents are encouraged to make choices about their meals, activities, and their personal care. Relatives are also consulted where appropriate. For Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 16 example, residents/relatives have recently been asked to make decisions about flu jabs. Monthly staff meetings are held where health and safety is reviewed. A Fire Risk Assessment is in place, dated 4.05.05. The Environmental Health Officer visited on 26.07.05 and recommended improvements to the kitchen. The Acting Manager said the Owners are considering totally refurbishing this room. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 17 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 2 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leacroft Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 X DS0000048221.V256282.R01.S.doc Version 5.0 Page 18 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 05/01/06 1 24 16(2)(c) The carpet in the music room in Sandalwood must be replaced. The home has now been without a Registered Manager for 10 months. This situation must be rectified and a suitable candidate put forward to CSCI. 2 37 8 05/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 42 Good Practice Recommendations The improvements to the kitchen recommended by the Environmental Health Officer should be carried out. Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office 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 © 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 Leacroft DS0000048221.V256282.R01.S.doc Version 5.0 Page 20 - 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. 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