Inspection on 11/08/05 for Leafield Residential Care Home

This inspection was carried out on 11th August 2005.

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

Leafield Residential Care Home 24/07/08

Leafield Residential Care Home 16/01/08

Leafield Residential Care Home 12/10/06

Leafield Residential Care Home 18/04/05

Leafield Residential Care Home 10/01/05

Leafield Residential Care Home 17/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Leafield Rest Home 32a Springfield Drive Abingdon Oxfordshire OX14 1JF Lead Inspector Philippa MacMahon Announced 11 August 2005 th 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 Older People. 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. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Leafield Rest Home Address 32a Springfield Drive Abingdon Oxfordshire OX14 1JF 01235 530423 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) leafieldcarehome@aol.com Prashant Brahmbhatt Ruth Bowell Care Home (CRH) 24 Category(ies) of Care Home only (PC) registration, with number of places Old age, not falling within any other category (OP) 24 Dementia - over 65 years of age (DE(E)) 24 Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1: The total number of persons that may be accommodated at any one time must not exceed 24. Date of last inspection 18th April 2005 Brief Description of the Service: Leafield Care Home is situated to the north of Abingdon town centre, within a residential housing estate. The accommodation is provided on two floors and there is anautomatic passenger lift for access. There are 21 single rooms, 5 of which are en-suite, and 1 double room with ensuite facilities. Plans to provide a further 5 en-suite facilities are being progressed at the present time. There are 4 bathrooms, 2 of which are on the 1st floor. The communal areas of the home are spacious and provide a choice of places to sit, or entertain visitors. The grounds are accessible to the residents and offer a pleasant area to wander in safety, or to sit and enjoy the fresh air. The home provides care for older people who are frail and may be mentaly infirm Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place between the hours of 9.30 and 15.30 hours. Much of the inspection was taken up with examining records, policies and procedures, and touring the building. The inspector was able to talk to staff, and to a few residents. The registered manager had previously completed the pre-inspection documentation provided by the commission, and this along with one comment card received from a visiting health care professional were used as part of this inspection. What the service does well: What has improved since the last inspection? What they could do better: The bathroom facilities have still not been improved and little progress has been made in moving this project forward. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 6 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. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. All prospective residents have an assessment of their care needs, and are given sufficient information to make an informed choice about where they choose to live. EVIDENCE: The inspector examined the service users guide and statement of purpose and found them to give sufficient information to enable prospective residents to make an informed choice about where to live. However they are both in need of updating, and review as there were some items such as the name of the commission for social care inspection, which was addressed by its former name. The registered provider explained that these documents were in the process of being updated. The resident’s contracts were not available for inspection. Prospective residents are invited to visit the home with any friends or relatives they would wish to accompany them. The registered manager told the inspector that she carries out all preadmission assessments, and this forms the basis of the care plans. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, Each of the resident’s have a care plan in which their care needs are identified and how these will be met. It is recommended that a review of the care plans should be made in order to clarify the system. The medication system in place is appropriate and safe. EVIDENCE: The inspector examined a sample of care plans and found them to give a good picture of the residents needs although there is a lot of information to read through in order to find the relevant information. The inspector observed a staff handover of care, and it was evident during the course of this communication that the staff have a good understanding of the individual resident’s, their care needs, and how these will be met. The medication system was examined and found to be in good order, and the policy and procedure for medication supported this. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The inspector did not make a judgement about this outcome as none of the outcomes were inspected. EVIDENCE: None of these standards were assessed on this occasion. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18. The home has a complaints system that is in need of updating. It is recommended that as part of the updating of the complaints system it be made explicit within the policy that people may contact the commission for social care inspection at any time. Residents living in the home are protected from abuse. EVIDENCE: The complaints procedure was examined and found to include the previous name of the commission, and not the commission for social care inspection. It was not explicit that people can contact the commission at any time. The registered manager said that any resident wishing to take part in the civil process is encouraged and assisted to do so whether by postal vote or attending the local polling station. All staff as part of their induction programme is made aware of abuse, and the homes policy and procedure in relation to any form of abuse. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. The home provides a safe, well-maintained clean environment. The baths provided are not readily accessible and plans are in place to replace these. It is recommended that the registered manager should inform the inspector in writing when the work is completed. The flooring at the entrance to the conservatory could in the inspectors view be a trip hazard to the residents. It is a requirement that the hole in the flooring must be made good. EVIDENCE: The inspector made a tour of the whole building and overall found that the home is cleaned to a high standard, well maintained, and homely touches have been added such as attractive bedding and curtains. Some new pictures are also being purchased. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 13 One of the resident’s rooms had an unpleasant smell, and the registered manager said that this was an ongoing problem, even though they made every effort to mop up spillages, as soon as possible and shampooed the carpet daily. The manager is discussing this with the provider to seek a solution to the problem. One of the bathrooms on the ground floor is not easily accessible using a mobile hoist and a number of staff spoke to the inspector and each raised this as a difficult problem and that the residents are not able to have a relaxing pleasant experience in having a bath. This issue was raised at the last inspection and it was said that this was to be replaced. Discussion with the registered provider and manager revealed that it is in progress, and would be completed within the next 2 months. The flooring at the entrance to the communal sitting room in the conservatory is in a poor state of repair where there is a hole developing underneath the carpet in the main walkway to the room. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29.30. The home is staffed appropriately on all shifts to meet the needs of the resident’s. The homes recruitment procedures in place are satisfactory, and it is a requirement that the registered provider must inform the inspector as soon as he is in receipt of the missing criminal records bureau checks. EVIDENCE: The inspector examined the staff rosters provided and the most recent one and found that there were sufficient numbers and skill mix of staff on each shift. Staff records were examined and overall found to be in good order with all the necessary documentation in place in accordance with the homes recruitment policy and practices. However there was a number of staff that did not have clearance from the criminal records bureau. The registered provider admitted that he had failed to send off the completed application forms and that he had now sent them to the bureau and was waiting for their return. Protection of vulnerable adults first checks with the Home office had been made on each of these staff. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37,38. The home is well managed. The resident’s cash for small transactions is kept in an appropriate and safe manner. It is a good practice recommendation that when monies are received from relatives for safe keeping, that they should be asked to countersign the receipt as having given the money. All staff will eventually receive formal supervision as the system is rolled out. There are good systems in place for the keeping of records required by regulation. It is commendable that most of the care staff holds current first aid appointed persons certificates. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 16 EVIDENCE: The registered manager is half way to completing her registered manager award. Staff and residents spoken to, and observations made by the inspector all amounted to there being evidence of strong leadership and good management of the home. There is no quality assurance system in place at the present time. The home does not manage the resident’s money, but small amounts are kept in individual plastic “pockets” with receipts and a record of the money held and every transaction made. These are kept in the homes safe and were examined by the inspector. A good practice recommendation has been made. The registered manager has started the process of carrying out formal staff supervision, and is planning to roll it out across the organisation. Those records made available for inspection were found to be in good order complete, and appropriately stored. All members of staff receive mandatory training in fire safety, moving and handling and food hygiene. Most of the care staff possess the appointed person first aid certificate, which means that there is at least one qualified first aid worker on each shift. The front door has been fitted with a keypad type of lock for the safety and security of the resident’s. Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 2 2 3 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 2 3 1 x 2 2 3 4 Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 18 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 19 Regulation 23(2)(B) Requirement It is a requirement that the hole in the flooring at the entrance to the conservatory must be made good. It is a requirement that the registered provider must inform the inspector as soon as he is in receipt of the missing criminal records bureau checks. Timescale for action 25.8.05 2. 29 19(5)(d) 30.9.05 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. 2. 3. 4. Refer to Standard 7 16 21 35 Good Practice Recommendations It is recommended that a review of the care plans should be made in order to clarify the system. It is recommended that it is made explicit within the complaints policy that people may contact the commission for social care inspection at any time. It is recommended that the registered manager should inform the inspector in writing when the work to improve the bathrooms is completed. It is a good practice recommendation that when monies are received from relatives for safe keeping, that they should be asked to countersign the receipt as having given the money. H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 19 Leafield Rest Home Leafield Rest Home H57_H08_S13103_Leafield _V234318_110805_Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Burgner House 4630 Kingsgate Oxford Business Park (South) Cowley, Oxford, OX4 2SU 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. 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