CARE HOMES FOR OLDER PEOPLE
Leaholme 8 Springfield Road Leicester Leicestershire LE2 3BA Lead Inspector
Helen Abel Announced 11 May 2005, 10:00am
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. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Leaholme Address 8 Springfield Road Leicester Leicestershire LE2 3BA 0116 270 2665 0116 270 2667 leaholme.co.uk Your Health Ltd 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) Mrs Amanda S Johnson Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17) Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 9th of November 2004 Brief Description of the Service: Leaholme is registered to accommodate up to seventeen older people and older people with physical disability.There are thirteen single rooms and two double rooms. The home is part of a national company called Your Health Limited. Leaholme is a large, detached three-story Victorian house. The home is situated in a quiet tree-line road, which runs off a busy main road. The home is ten-minute bus journey from the city centre and close to the railway station.The home is clean bright, with comfortable furniture and décor to match. There is a separate dining room and two large lounges. Bedrooms are accessible via the passenger lift. There is a large mature garden at the rear of the property, which continues at the side and to the front of the home. The garden is accessible via a gradual slope and ramp for service users requiring the use of walking aids. The home has a stable compliment of staff, some having worked at the home for many years. A number of staff have commenced the National Vocational Qualifications levels 2. The Registered Manager is completing NVQ level 4 – Registered Manager Award. The home promotes on-going training for all the staff. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours and was an announced inspection. The Registered Manager was present throughout the inspection. A full tour of the building took place with care records, policies and procedures inspected. Three service users were spoken with. What the service does well:
It was evident that service users care plans and risk assessments are comprehensive and include detailed information around all aspects of care. There is a good emphasise on organising social and religious activities to match service users individual needs and choices. Meals are nutritious and balanced and served in a pleasant dining area overlooking the garden. The home offers a clear complaints procedure in the Service User Guide and a copy is displayed. Service users confirmed they felt comfortable and confident they could raise any complaints with the Registered Manager or staff group. Individual service users accommodation was very clean and comfortable with service users possessions around them. Service users are able to see whom they want to see. The home offers an “open house” policy on visiting hours so that family members and friends can come and visit at any time. The grounds outside were well maintained and kept tidy safe and attractive. The staff group are able to meet the individual needs of service users. Staff are trained and competent to do their jobs. The staff group are currently working towards National Vocational Qualifications in care and management levels 2,3, and 4. This ensures staff fulfil the aims of the home and meet the changing needs of service users. A relative /visitors comment card returned to the Regulatory Inspector confirmed, “I feel that the standard of care is very good and that this should be noted”. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 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 Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 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) 1,3,5 Written information is available to prospective service users to make an informed choice around living at Leaholme. Assessments take place for all new service users before they enter the home. Trial visits are available for prospective service users with relatives able to visit and assess the suitability of the home. EVIDENCE: The Service User Guide is well presented with a range of information available for prospective service users, but needs some updating. The Registered Manager agreed to do this. Copies of past inspection reports were available in the foyer. A new service user had an assessment undertaken by the Registered Manager around six weeks before admission. This was not dated or signed. It is recommended assessments be dated upon their completion and signed by the prospective service users and Registered Manager. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 9 Trail visits are offered for a full day at no charge. A new service user came straight into the home from outside of Leicestershire and is on a four- week trial admission period. Her family members visited the home previously to make their own assessment and immediately requested a place. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 10 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 Care plans are good and set out individual’s health, personal and social care needs. Service users health care needs are fully met. Medication management is generally good with improvement around service users self-medicating to be met. EVIDENCE: Care plans were very comprehensive including detailed information around all aspects of care. Risk assessments were in place for a range of risks, prevention of falls, self-administration of medicine and smoking. It is recommended risk assessments are also undertaken for the safe use of bed rails to safe guard service users. Daily records of services users care are made twice a day. Care plans are regularly reviewed. Health care records are recorded in detail for individual service users. Service users have access to hearing and sight tests and appropriate aids, according to need. A service user new to the home is in the process of registering with a local GP. The Registered Manager confirmed the Registered Providers is looking to obtain sit-down scales. This type of weighing scale would allow less mobile service users to be safely weighed and monitored.
Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 11 Two service users self-administer medication with a risk assessment framework in place. One of these service user medication was not kept secure. The Registered Manager agreed to arrange a lockable space in which to store medication. The medication area was organised and maintained well with senior staff trained in medication management. It was agreed with the Registered Manager she would arrange for the medication cabinet chain attattched to wall, to be further secured. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 12 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) 12,13,15 There is a good emphasise on organising social and religious activities to match service users individual needs and choices. Every effort to maintain contact with family and friends and the local community is made. Meals are balanced and served in pleasant surroundings. EVIDENCE: The Exercise Person was due to come in the morning of the inspection but had cancelled the exercise session with the service users. The hairdresser was present and was arranging small groups of service users hair in a communal lounge. Trips to the local shops, garden centres, walks around the home’s garden are arranged for service users. One of the service users enjoys knitting, reading and crocheting. All the materials required were arranged around her seating area. One service user was observed busy weeding in the garden. A new service user reported still getting to know the other service users but was looking forward to a game of scrabble. A range of board games are available in the dining room. Service users are able to see whom they want to see. The home offers an “open house” policy on visiting hours so that family members and friends can come and visit at any time. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 13 A varied and nutritionally balanced choice of meals is offered. A cooked breakfast is available upon request. A hot lunch was observed being served to service users in the dining room. The day’s menu was on display on a chalkboard. The dining room was attractively set out with small groups of tables and chairs. Staff took time to explain and serve food from individual food dishes to individual plates. Many the service users choose to have a tray brought to their room with breakfast and tea. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 14 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) 16,18 Complaints procedures are evident in the home and meet this Standard. Policies and procedures around Abuse safeguard service users. EVIDENCE: The home offers a clear complaints procedure in the Service User Guide and a copy is displayed. It is recommended the complaints procedure is updated and a copy be displayed prominently in the main foyer. Service users confirmed they felt comfortable and confident they could raise any complaints with the Regisited Manager or staff group. Policies and procedures were examined and safe guard service users from harm. Information around the revised Multi Agency Adult Procedures were passed to the Registered Manager. This document builds upon existing adult protection procedures and further safe guards service users. Training round Protecting Adults has not been offered to staff in the home. For good practice it is recommended Protecting Adults training be provided on a regular basis to raise staff awareness. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 15 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, 24,25 Environmental Health requirements have not been met and potentially put people at risk. Individual accommodation was clean and comfortable with service users possessions around them. EVIDENCE: A dedicated maintenance manager and heath and safety manager are employed by the Registered Providers and responsible for their designated areas of work. Any maintenance work identified by the Registered Manager are detailed in a weekly Managers Report and presented to the Responsible Individual. The work is then carried out. A fire risk assessment and periodic fire checks are in order. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 16 The extractor fan in the kitchen area was not working. A kitchen window was left open for ventilation. Natural ventilation is normally not suitable for commercial kitchens. The kitchen must have mechanical ventilation. The kitchen extractor fan must be maintained in good repair and condition. Advice was sought from Environmental Health on this issue following on the inspection. Requirements are still outstanding from the Environmental Health’s visit on the 28th September 2004. The Registered Manager will be raising this further with the home’s health and safety manager. The grounds outside were well maintained and kept tidy safe and attractive. Four individual rooms were viewed and appeared clean and comfortable with all the required furnishings. One service user had brought her soft furnishings and chest of drawers with her. One service users floor had wide sticky tape covering trailing flexes around a doorway and part of the room. It is recommended a permanent safety alternative be sought. Another service user was allowed to smoke in his room (as part of his risk assessment) and had all his personal effects around his chair and table. A service user asked for his talking clock to be re-set, as it was not accurate. The Registered Manager agreed to look into this Hot water temperatures for service users areas were set at 43.c this is acceptable and prevents risks from scalding. Radiators were set at low temperatures. The kitchen hot water was also set at 43.c. To prevent risks from Legionella water must be stored at a temperature of at least 60.c and distributed at 50.c minimum. Advice was sought from Environmental Health on this issue following on the inspection Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 17 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) 27,30 The staff group are able to meet the individual needs of service users. Staff are trained and competent to do their jobs. EVIDENCE: The core staff group have been working at the home for a long time. Staff left in charge of the home are 21 and over. Service users confirmed they were happy with care received and spoke positively of their key workers and the Registered Manager. The company employs a training manager. Together, the Registered Manager and individual staff plan their training. The staff group are currently working towards National Vocational Qualifications in care and management level 2,3, and 4. This ensures staff fulfil the aims of the home and meet the changing needs of service users. It was agreed with the Registered Manager the cook updates her skills with food hygiene training. Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 18 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) 33,38 The home is run in the best interest of service users. Insufficient safety checks are in place to promote and protect the health, safety and welfare of service users and staff. EVIDENCE: The Registered Manager has produced questionnaires to measure service users views on life at the home. This is part of the quality monitoring systems. It is recommended any feedback the home acts on, for individual service users are recorded on the service users care plan. Make available a copy of the report on the findings of the quality assurance to CSCI. Seven service users comment cards and one relative/visitor’s card were returned to the CSCI. A service user commented, “Here in this home we are all very well cared for and I have no reason to complain about anything”.
Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 19 All health and safety checks are undertaken by the Registered Manager and designated staff. There are shortfalls as indicated in the body of the report to prevent risks from legionnella and providing appropriate ventilation in the food preparation area. See Standards 19 and 25. Information around managing asbestos and current legislation was passed to the Registered Manager to be reviewed. All health and safety policies and procedures are in the process of being updated. Leaholme C51 S6440 Leaholme V220428 110505.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 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 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 x x x x 3 2 x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 2 Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 21 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 Requirement The kitchen must have mechanical ventilation. The kitchen extractor fan must be maintained in good repair and condition. Food Safety(General Food Hygiene Regulation 1995) To prevent risks from Legionella water must be stored at a temperature of at least 60.c and distributed at 50.c minimum. Timescale for action 30th June 2005 2. 25 13 30th June 2005 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 3 7 9 16 Good Practice Recommendations It is recommended assessments are dated upon their completion and signed by the prospective service user and Registered Manager. It is recommended risk assessments are undertaken for the safe use of bed rails. The Registered Manager to arrange a lockable space in which to store medication for an identified service user that self-medicates. It is recommended the complaints procedure be updated and a copy displayed prominately in the main foyer.
C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 22 Leaholme 5. 6. 7. 18 19 33 For good practice it is recommended Protecting Adults training is provided on a regular basis to raise staff awareness. One service users room floor had wide sticky tape covering trailing flexes around a doorway and part of the room. It is recommended a permanent safety alternative is sought. Quality monitoring systems. It is recommended any feedback the home acts on, for individual service users is recorded on the service users care plan; Make aviable a copy of the report on the findings of the quality assurance to CSCI. (Outstanding from the 9th Novemeber 2004 inspection). Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 23 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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 Leaholme C51 S6440 Leaholme V220428 110505.doc Version 1.30 Page 24 - 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!
