CARE HOME ADULTS 18-65
Leacroft 120 Colchester Road Leicester Leicestershire LE5 2DG Lead Inspector
Kim Cowley Key Unannounced Inspection 9 January 2007 1.00 Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 1 Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 2 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.V319628.R01.S.doc Version 5.2 Page 3 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.V319628.R01.S.doc Version 5.2 Page 4 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) Not available Active Care Partnerships Ltd May Shobowale 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.V319628.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION
Conditions of registration: 1. 2. No person may be admitted to Leacroft 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 Leacroft when 2 persons of category/combined LD(E) or LD(E)/PD(E) are already accommodated within the home. 6th October 2005 Date of last inspection Brief Description of the Service: Leacroft 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. Fees range from £770 to £1300 per week. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key inspection that included a visit to the home and inspection planning. Prior to the home visit, the inspector spent half a day reviewing the last inspection report, and information relating to the home received since that inspection. During the course of the inspection, which lasted four and a half hours, the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means the inspector looked at the care provided to three residents living at the home by meeting or observing them; talking with the staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were inspected. The inspector also met other residents, two nurses in charge, two carers, and the cook. What the service does well:
Leacroft is a well managed home that provides a good all round service to younger adults with learning difficulties. The atmosphere is lively and purposeful and all residents interviewed or observed appeared to be content and settled in the home. During the inspection residents were taking part in a range of activities. Some were out at colleges, or shopping in Leicester. One resident was enjoying a foot spa during an in-house beauty session run by a member of staff. She told the inspector, ‘I love this. It feels really nice.’ Each of the three bungalows was inspected. All were warm, clean, and comfortable. In one bungalow all residents have been photographed professionally and their black and white portraits hang in the corridor. Staff said the residents were proud of these portraits and liked to show them to visitors. The staff team is established and turnover is low so residents benefit from continuity of care. All staff on duty on the day of the inspection were friendly and professional, and appeared to have excellent relationships with the residents they care for. One of the carers described her role to the inspector. She was enthusiastic about her work and knowledgeable about the residents, in particular the one she key works. She commented, ‘I love my job and I feel
Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 7 very well supported by the Manager and the qualified staff.’ One resident said, ‘My key worker is a very good carer.’ Five resident comment cards were returned. These were completed with the support of care staff who identified themselves on the forms. The results showed that all residents interviewed were satisfied with the overall care at Leacroft. What has improved since the last inspection? What they could do better:
The Owning Body has provided a car for resident transport. However some residents cannot use it because they cannot transfer to get in, so they travel by taxi instead. Staff said they thought the home should have a minibus with disabled access that could be used by all the residents. The Owning Body should give consideration to this suggestion. One resident said she did not like weekends because ‘they’re boring and there’s nothing to do’. Staff told the inspector that there were some weekend activities, for example trips out and entertainment, but the programme was not as full as during the week. It is advised that the weekend activity programme is reviewed to see if more activities should be put on for residents who feel they do not have enough to do. Medication records were inspected and the recording of PRN medication was discussed. At present most staff only record when this medication is given. However they should also make a record on the days this medication is not given/needed. It was agreed that the record should be marked ‘F’ (not required) when this occurs. Staff on duty were coping well, but said they would prefer it if the home had a Deputy Manager who could oversee its running while the Manager was not on Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 8 duty, so they would not be taken away from their caring duties. The Owning Body should give consideration to this idea. 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. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 9 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.V319628.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. (Standard 2 was inspected.) EVIDENCE: A good assessment procedure is in place. This is explained to potential residents 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 those who prefer a quieter or livelier environment). All assessments are carried out by the Manager who consults with her staff before making a decision as to whether to offer a place. Potential residents visit the home prior to admission or come for respite care so they can get used to the home. One resident was quoted on their Comments Card as saying, ‘I visited then stayed a few days before I moved in.’ Another was quoted as saying, ‘I visited after my mother and social worker looked the home over.’ Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to the service. Detailed care plans help staff to identify and meet residents’ needs. (Standards 6, 7 and 9 were inspected.) EVIDENCE: Care plans were detailed and comprehensive and contained appropriate risk assessments. Residents’ needs were addressed in full, including their interests, activities, and quality of life. The Manager writes care plans in conjunction with team leaders. Those inspected had been reviewed at least once a month. Good risk assessments were in place. Detailed daily records are kept and used to inform care plans. Nursing needs were 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. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 12 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 DS0000048221.V319628.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to the service. Daily life and social activities enable residents to lead full lives. (Standards 12, 13, 14, 15, 16, and 17 were inspected.) EVIDENCE: The Activities Organiser post is currently vacant and the Owning Body are advertising for a new member of staff to take on this role. Until then staff are carrying on with the activities programme organised by the previous post holder. Since the last inspection the home’s new activities centre has been completed. This is a detached building in the in the grounds of Leacroft which is used every weekday by residents, either individually or in groups. It contains a ‘snoozelem’ (relaxation room), arts and crafts area, computer, and small kitchen where residents do cookery. During the inspection residents were taking part in a range of activities. Some were out at colleges or shopping in Leicester. One resident was enjoying a foot
Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 14 spa during an in-house beauty session run by a member of staff. She told the inspector, ‘I love this. It feels really nice.’ Staff and residents at the home have been holding coffee mornings to raise money for cancer research. Individual records are kept of each resident’s activity programme. This helps staff to discover what they enjoy and benefit from so future activities can be planned. Activities reflect the needs of residents from different cultural backgrounds. For example, Diwali and Eid are celebrated, and trips to Leicester’s Asian shopping areas are organised. The Owning Body has provided a car for resident transport. However some residents cannot use it because they cannot transfer to get in, so they travel by taxi instead. Staff said they thought the home should have a minibus with disabled access that could be used by all the residents. The Owning Body should give consideration to this suggestion. One resident said she did not like weekends because ‘they’re boring and there’s nothing to do’. Staff told the inspector that there were some weekend activities, for example trips out and entertainment, but the programme was not as full as during the week. It is advised that the weekend activity programme is reviewed to see if more activities should be put on for residents who feel they do not have enough to do. Relatives are welcome at the home at any time and are invited to attend meeting with the staff every three months. Staff are still 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 meals are prepared. The home’s parttime cook is currently working full-time while a vacancy in the kitchen is filled. Diabetic, vegetarian, and non-English (including halal) diets are catered for. Care records indicate that good nutrition is a priority in the home. Menus showed a wholesome and varied diet being provided. Lunch served during the inspection consisted of chicken cobbler or tomato pasta, served with new potatoes, carrots and peas, with fruit or yogurt for dessert. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home, and in the wider community, meet residents’ health and personal care needs. (Standards 18, 19, and 20 were inspected.) 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. Qualified nursing staff gives out medication. The Manager oversees medication administration and storage, and delegates some tasks, for example ordering medication, to nursing staff. The home has a new contract pharmacist who carries out inspections, and provides advice and staff training when required as part of their contract. Medication is only administered by nursing staff. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 16 New Department of Health guidance with regard to lancing devices (used for blood tests) was discussed with one of the nurses in charge. She agreed to ensure that the Manager and all staff who take blood were made familiar with the guidance. Medication records were inspected and the recording of PRN medication was discussed. At present most staff only record when this medication is given. However they should also make a record on the days this medication is not given/needed. It was agreed that the record should be marked ‘F’ (not required) when this occurs. The person in charge immediately wrote a reminder for staff and left it in the medication book and also agreed to report this to the Manager who could then remind staff. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence including a visit to this service. Residents are listened to, and staff know how to tell if they are unhappy about any aspects of their care. (Standards 22 and 23 were inspected.) EVIDENCE: Care records set out residents’ likes and dislikes. Key workers 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. One resident’s Comment Card showed that although they would be unable to make a complaint themselves, their next of kin would be able to complain on their behalf should the need arise. Another Comment Card identified that the resident in question would be able to complain verbally if necessary. Policies and procedures are in place to protect residents from abuse, and the staff on duty were familiar with these. All staff, including ancillary workers, have the opportunity to undertake adult protection training and the majority of staff have done so. The safeguarding procedure was discussed with one of the carers. She was clear and knowledgeable about her responsibilities should abuse be suspected and knew exactly what to do and who to go to. This is commended. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is safe and well maintained. (Standards 24 and 30 were inspected.) EVIDENCE: Each of the three bungalows was inspected. All were warm, clean, and comfortable. In one bungalow all residents have been photographed professionally and their black and white portraits hang in the corridor. Staff said the residents were proud of these portraits and liked to show them to visitors. The premises are subject to on-going improvement. Since the last inspection the kitchen has been re-tiled and partially re-furbished, with further improvement work planned. Leacroft DS0000048221.V319628.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Friendly, professional and well-trained staff meets residents’ needs. (Standards 32, 34 and 35 were inspected.) EVIDENCE: The home employs eight 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 20 support workers are employed and records showed the majority are experienced and well trained. The home has a full-time handyperson, a full-time cook, and a part-time cleaner. A full-time administrator is based in an office near the entrance to the home and provides a warm welcome to visitors. The staff team is established and turnover is low so residents benefit from continuity of care. All the staff on duty on the day of the inspection were friendly and professional, and appeared to have excellent relationships with the residents they care for. Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 20 One of the carers described her role to the inspector. She was enthusiastic about her work and knowledgeable about the residents, in particular the one she key works. She commented, ‘I love my job and I feel very well supported by the Manager and the qualified staff.’ One resident said, ‘My key worker is a very good carer.’ Staff files were inspected and found to be well organised and complete. Each contains a checklist to ensure all the necessary documentation has been obtained, and checks are carried to help to ensure residents are safeguarded. An extensive training programme for staff is in operation. Since the last inspection staff have attended courses in First Aid, Fire Safety, Manual Handling, Health and Safety, Food Hygiene, and Epilepsy. Sixty-five per cent of staff are qualified to NVQ Level 2 or above. All staff have formal supervision and attend staff meetings. Inductions are overseen by the nursing staff. Leacroft DS0000048221.V319628.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 good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe and well managed. (Standards 37, 39, and 42 were inspected.) EVIDENCE: Since the last inspection a Registered Manager has been appointed. She is an experienced, qualified nurse, and worked in the home prior to her promotion. She was away on a training course during the inspection. Staff on duty were coping well, but said they would prefer it if the home had a Deputy Manager who could oversee its running while the Manager was not on duty, so they would not be taken away from their caring duties. The Owning Body should give consideration to this idea. All the staff on duty praised their new Manager and their comments included: ‘She is very accessible to staff and residents.’ ‘May is a supportive Manager. She is understanding and flexible when I have family commitments.’
Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 22 ‘She delegates some tasks to us so we gain in experience.’ ‘May understands the importance of work/life balance.’ ‘Since I began work at the home the Manager has encouraged me to go on training courses.’ An Operations Manager oversees the running of the home. Monthly Regulation 26 monitoring visits are carried out. During these visits staff, relatives, and residents are interviewed, the environments is inspected, and records are examined. A report is compiled and sent to CSCI every month. Reports received showed that the Operations Manager takes a supportive and proactive approach and focuses on the well being of residents and staff. Records showed that the health, welfare and safety of residents and staff is a priority in the home. Appropriate checks and servicing of equipment has been carried out, as has consultation with the Fire Department and the home’s Environmental Health Officer. Leacroft DS0000048221.V319628.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 X 2 3 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 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X Leacroft DS0000048221.V319628.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. Refer to Standard Good Practice Recommendations Leacroft DS0000048221.V319628.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Leacroft DS0000048221.V319628.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
