Inspection on 08/01/07 for Leaholme

This inspection was carried out on 8th January 2007.

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

Leaholme 13/12/08

Leaholme 26/09/05

Leaholme 11/05/05

Leaholme 09/11/04

Leaholme 09/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Leaholme 8 Springfield Road Leicester Leicestershire LE2 3BA Lead Inspector Susan Lewis Key Unannounced Inspection 10:00 8th January 2007 X10015.doc Version 1.40 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 Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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 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 DS0000006440.V324901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leaholme Address 8 Springfield Road Leicester Leicestershire LE2 3BA 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) 0116 270 2665 0116 270 2667 www.yourhealth.ltd.uk Your Health Ltd Vacant 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 DS0000006440.V324901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration. Date of last inspection 26th September 2005 Brief Description of the Service: The fees for 2006/07 are £350-£420. The latest inspection report can be found in the reception area of the home. 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. The bedrooms on the first and second floor 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 level 2. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and observing staff in their practice. The inspection was unannounced and took place over 6 hours one Tuesday in January 2007, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ records were inspected and residents and a selection of staff on duty as well as visiting health care professionals were spoken with. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, including comment cards received from residents, accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: Residents live in a small care environment where they are able to exercise control over their day-to-day life. Staff are well trained and provide individual care that meets the identified needs of residents. Meals are appetising and nutritious and residents are able to choose where they eat their meals. Comments received both in the pre inspection information and from speaking with residents during the inspection provided evidence that residents felt that they were well cared for. ‘Anyone who is not happy here must be very hard to please’. ‘People are very nice here’. ‘I consider myself very lucky to have found this home’ Assessments are carried out for all residents and provide good information to create a care plan from. Care plans are simple and straight forward for staff to gather the information they need to provide care to each resident. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents do not move into the home without having their needs assessed and assured that these will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident had a detailed assessment carried out at either the point of admission or before. The assessments were comprehensive and covered all aspects of the residents’ life; it was also signed by the resident. This information then went on to inform the care plans and looked at long-term outcomes for the resident ensuring that the carers maintained residents independence for as long as possible. Intermediate care is not provided at this service. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Individual plans address residents needs and risks. There health care needs are met and they are treated with privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed for the purpose of this inspection. Each plan was created in a structured way so it was clear for the reader, what was the assessed need and what was the plan of care to meet that need, this meant that it was an simple document to gather the necessary information that carers would need to ensure residents received the correct care. Staff spoken with confirmed that they found the care plans useful and straightforward to use. Each need that was identified also looked at identified risks to the resident and what action the carer needed to take to minimise that risk, including risk of falls and moving and handling concerns. There was evidence that plans were reviewed regularly but there was no evidence that residents were involved. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 10 The Registered Person must ensure that where practicable that residents are involved in the review of their care plans. Residents spoken with said that they saw a doctor when they needed to and some residents said that as the practice was only across the road they went over with a carer if they needed to see a doctor. This supports residents to remain part of the community as well as ensuring their medical needs are met. Plans viewed showed that where residents were considered to be at risk of developing pressure sores then appropriate risk assessments were carried out with liaison with the district nurse and equipment was obtained. On the morning of the inspection residents were taking part in an exercise class and residents spoken with later said that this was a regular event, which they enjoyed. Evidence was seen that residents weight is monitored this is used not only to ensure that residents nutritional intake is maintain but also informs the moving and handling risk assessment, providing the staff with the information to maintain the residents safety as well as their own. Evidence was seen that residents are supported to see a chiropodist as well as an optician and dentist; this maintains the residents’ health and well being. Medication was stored appropriately; policies and procedures for medication maintained the safety of residents and ensured that they received their medication at appropriate times during the day. Only trained staff administer medication and residents confirmed that staff stay with them whilst they take their medication. The records seen were kept appropriately ensuring that an audit could be made of medication received into the home, administered to residents and any medication returned to the pharmacy. Therefore residents’ safety is maintained. Residents spoken with said that they always wore their own clothes and that they were laundered regularly to a good standard. During the inspection staff were heard to speak to residents politely and supporting them in providing care in a respectful manner. Staff were also observed knocking on residents bedroom doors before entering. Residents spoken with confirmed that’ ‘People are very nice here’. ‘The people looking after me are very good and I consider myself to be very lucky to be here’. ‘The staff are kind and treat us very well’. Throughout the day residents were observed as being well groomed and clean. This shows that residents’ dignity is maintained by staff care. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Lifestyle choices and opportunities for leisure activities are varied and appropriate. Residents feel respected and encouraged to be part of the local community. A healthy diet is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From evidence received prior to the inspection there are a variety of activities provided within the home. Residents also confirmed that they were offered different activities during the week. ‘We have various activities, like a film show in the week. At Christmas we had a Pantomime and party. We also have books from the library that are changed regularly and I really like those’. Currently there is no visiting priest to the home, however when asked the residents said they were ‘not bothered’. All residents said that they liked the routine in the home they were able to spend the day as they wished, they could get up and go to bed when they wanted to. If they wanted to have their meal in their bedroom they could, residents spoken with said that they understood that all residents had their Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 12 breakfast in their bedrooms because they wanted to. Staff spoken with also confirmed this. Residents said that they were able to see residents when they wanted, and were able to see them in private. Residents confirmed that they were able to bring personal possessions in to their bedrooms and this was confirmed during the partial tour of the bedrooms. Residents spoken with said they felt able to make decisions about their life and felt in control. Residents spoken with were positive about the meals and said that they were given variety and that they were well cooked. Residents said ‘If you feel hungry at any time staff will get you something’. ‘Meals are good couldn’t be better’. ‘The food is good and you get a choice’. ‘It is nice well cooked I enjoy it all’. The menu identified a choice of hot meal most days and the manager confirmed that if a resident did not like the meal offered then an alternative would be given. Staff spoken with who prepared meals understood nutrition and the importance of variety as well as providing meals to residents who had special needs such as diabetes. The dining room is spacious and pleasant with views over the grounds. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents are aware of how to make their views known. Staff protect residents and procedures are in place for staff to follow. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From evidence received prior to the inspection the home had not received nay complaints since the last inspection. The Commission also not received any complaints. Residents spoken with all knew who to raise any complaints or concerns with and felt confident that the acting manager would deal with any problems. From training records it was clear that all staff had received Adult Abuse Awareness training. In discussion with staff they were clear about their responsibilities to protect residents and what they should do if they suspected abuse. Residents spoken with said that they felt safe and staff were kind and treated them well. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. A homely environment is provided, which is mostly clean, comfortable and safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the partial tour of the building it was clear that although the home was currently in a safe condition, the home was tired and in need of redecoration in some identified areas. In discussion with the Responsible Person she was aware that the home needed to be refurbished and was drawing up a programme for 2007. It is recommended that the Registered Person provide the Commission with a timescale for the intended redecoration. The external grounds were maintained with good access if residents wished to use it in the better weather Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 15 Overall the home was clean and in the extension to the main building this was still in good condition. Residents spoken with said that they liked their bedrooms. The Registered Person must ensure that the home is maintained to minimise any potential risk to residents. The home was generally clean and no odours were noted during the inspection. Residents spoken with said that their bedrooms were always clean. Staff spoken with were aware of the importance of infection control and maintaining good personal hygiene to minimise risk of cross infection amongst residents. At a previous inspection it had been commented that there was no cleaner employed at the home. The cleaner that had been employed had recently left after an extended period of sick leave and evidence that a new cleaner has been employed was seen. This has meant however that some areas of cleaning have not been done and a number of cobwebs were noted around the home. As this does not imminently place residents at risk it is recommended that the Registered Person ensure that these areas are cleaned as soon as possible. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 16 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Staff are clear about their roles and staffing ratios meet the needs of residents, procedures are in place to ensure recruitment practices protect residents. Staff are trained and competent to do their job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with said that they felt that there were enough staff on duty and that they didn’t feel that they had to wait too long before someone came when they needed help. Staff spoken with said that they felt that there were enough staff available to ensure that residents were well looked after. From information received prior to the inspection it was evident that very few staff had NVQ Level 2 training. In discussion with staff it was confirmed that training is supported and that some staff are currently undergoing NVQ training. This means that the target of 50 NVQ trained staff should be met and residents will be cared for by staff competent to do so. Staff recruitment files were seen and were well put together with information available to evidence that Criminal Records Bureau checks were carried out prior to a staff member starting work and that two references were also obtained. This ensures that only staff suitable to work with vulnerable people are employed. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 17 Staff confirmed that they receive induction training when they start work and that they are provided with training regularly and mandatory training is updated regularly. Evidence was seen that shows what staff have done what training and when it needs to be renewed. This is good practice. This means that staff are provided with the skills to support residents safely and residents benefit from well trained staff. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The overall management of the service safeguards the best interests of residents. Residents’ views and comments are valued and health and safety is promoted within the environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently a new acting manager in post and as yet has not applied to be registered as a ‘fit person’ with the Commission. The Registered Person must ensure that the Commission receives an application to register a manager at the earliest opportunity. A customer satisfaction survey was seen, however it was not dated and so did not show whether residents were regularly asked their opinion of the service Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 19 they receive. Residents also confirmed that they are able to attend Residents Meetings. It is recommended that when questionnaires are sent to residents and/or family that they be dated and that the information is used to inform the action plan for the coming year. Residents spoken with said that they felt able to comment on the service they receive. Residents money is stored safely and from pre inspection information received the manager does not act as appointee for any resident. Records are kept to show that residents are protected from financial abuse. From information received prior to the inspection it is clear that the manager informs the Commission if any incident occurs that may affect the well being of the resident. Accidents are recorded, but currently they are stored on individual residents files. It is recommended that the Registered Person store copies centrally to enable an audit of all accidents to take place at regular intervals. Staff receive all mandatory training and regular updates ensuring not only residents safety but their own is maintained. The fire officer’s last visit was May 2006 and no requirements were set at that visit. This evidence was received with the pre inspection information. Evidence was also seen that the fire alarm is tested weekly. The Environmental Health Officer’s last visit was April 2006 and no requirements were left. This evidence was received with the pre inspection information. All other maintenance checks have been done to ensure that residents live in a safe environment. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 3 Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2)(b)(c) Requirement The Registered Person shall keep the residents plan under review and where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users plan. Residents should be involved where possible with the review of their care plans. The Registered Person must ensure that the manager is fit to manage a care home. An application to register the manager as a fit person must be made to the Commission by no later than the timescale set. Timescale for action 01/03/07 2 OP31 9 (2)(b) 31/01/07 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 OP19 Good Practice Recommendations The Registered Person provides a timescale as to when she intends to redecorate the home. DS0000006440.V324901.R01.S.doc Version 5.2 Page 22 Leaholme 2 3 4 5 OP26 OP28 OP33 OP38 The Registered Person ensures that the identified areas where cobwebs were noted are cleaned as soon as possible. The Registered Person ensures that a minimum ratio 0f 50 of NVQ level 2 trained staff within the home. Where residents take part in customer satisfaction surveys it would assist with recording the data if the surveys were dated. It would improve auditing of accident records if copies were kept centrally as well as the copy currently held on the residents file. Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Leaholme DS0000006440.V324901.R01.S.doc Version 5.2 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. 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