Inspection on 07/11/06 for Leahyrst Care Home

This inspection was carried out on 7th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Leahyrst Care Home 10/11/08

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Leahyrst Care Home 20 Upperthorpe Sheffield South Yorkshire S6 3NA Lead Inspector Michael O`Neil Key Unannounced Inspection 7th November 2006 09:45 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 Leahyrst Care Home DS0000068204.V318357.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. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leahyrst Care Home Address 20 Upperthorpe Sheffield South Yorkshire S6 3NA 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) 0114 230 9988 0114 273 0441 None Silver Healthcare Limited Ms Jane Anne Brindley Care Home 41 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (30), Mental disorder, excluding learning of places disability or dementia (32), Old age, not falling within any other category (9) Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All 32 of the DE beds can be MD instead. 30 of the DE beds are for people 65 years and over. Date of last inspection 4th January 2006 Brief Description of the Service: Leahyrst is situated in the Upperthorpe area of Sheffield close to local shops, other amenities and the tram and bus routes. The building is purpose built and has three floors accommodating service users who require dementia and general personal care. The home is registered for 41 places. A variety of communal seating and dining areas are provided. The home has a sufficient number of baths, toilets and showers. A commercial type laundry serves the home and kitchen.35 bedrooms are single, and 3 bedrooms are double. Six of the single rooms have en-suite toilets. The home is accessible to service users, ramps and a lift are available, and aids and adaptations are in place. The home has a pleasant enclosed garden. Car parking is available. The individual persons owning Leahyrst remained unchanged, however, a limited company took over the ownership of the home in October 2006. The manager confirmed that the range of monthly fees from 7th November 2006 were £340 - £375 per week. Additional charges included hairdressing, newspapers and private chiropody. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Mike O’Neil and Stuart Hannay regulation inspectors. This inspection took place between the hours of 9:45 am and 3:45 pm. Carol Golightly, deputy manager, was present during the inspection. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 4 staff, 3 relatives and 10 residents. One inspector spent a period of time sitting with a group of residents in a lounge. The inspector was able to observe the residents experiences of living in the home and their interactions with each other and the staff. The inspectors wish to thank the staff, relatives and residents for their time, friendliness and co-operation throughout the inspection process. A copy of the previous inspection report was available in the office of the home. The deputy manager said that this was made readily available to enquirers. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. What the service does well: Service users and their relatives said that they felt that the health and personal care needs were being met. Some service users were not able to say whether they felt that they were being well cared for; these service users were well-dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. An inspector saw staff consistently treating service users in respectful and friendly way. The inspector observed staff generally interact very well with the service users. Simple activities arranged by staff such as putting on a music DVD whilst the service users had a cup of tea and a biscuit had a really positive affect on the service users well being/mood. Service users said that their visitors were made to feel very welcome and could visit at any reasonable time. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 6 The significant majority of service users, who were able to clearly say, said that they were consulted about their care and involved in decisions about their lives. The significant majority of service users said that the food provided was ‘good’ or ‘very good’. The environment within the home was well maintained and generally clean providing a comfortable, safe environment for residents. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Staff and service users interviewed said that the manager was approachable and would take any of their concerns seriously. The 3 relatives interviewed echoed this opinion. They felt that the interests of the service users and their opinions were valued at the home. What has improved since the last inspection? What they could do better: The care plans need to contain clear guidance for staff on what to do if a service user required assistance with transferring or mobilising. A clearer and safer procedure is needed when staff return medication back to the pharmacy. Efforts must be increased to eradicate all unpleasant smells around the home. Staff must receive more practical based manual handling training. The hot water temperature in the home must be controlled at a safe temperature to make sure that residents’ safety is not put at risk. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 7 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. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 8 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 Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 9 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. This judgement has been made using available evidence including a visit to this service. Residents’ assessments prior to admission took place. These enabled staff to be aware of residents needs to ensure that they could be met. EVIDENCE: Three care plans were checked and these contained assessments of the service users’ needs. The assessments were formulated into a plan of care for each person. Five service users interviewed said that the staff were able to meet their personal and healthcare needs. Some service users were not able to say if their needs were being met, however they looked well-cared for and settled at the home. Three relatives interviewed confirmed that they felt the needs of their relative were being met. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 10 Staff had undertaken training relating to the needs of the service users. The home does not provide intermediate care. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 11 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. This judgement has been made using available evidence including a visit to this service. The service users health, social and personal care needs were well documented in the care plans meaning that the resident’s needs could be met. However the moving and handling requirements for one resident was not adequately documented. The lack of this detail may provide a risk of injury to the residents or staff. Service users said that they felt that their health and personal care needs were being met. Three relatives interviewed confirmed that they felt the needs of their relative were being met. Some medication practices were inadequate and provided a health and safety risk. Service users privacy and dignity was maintained. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each service user had a care plan that described what their needs were and what action staff could take to meet these needs. Three of these were checked in detail. Two of the plans reflected what the service users had said about the care that they needed; one of the people had not been able to say what help she required but there was a care plan based on information obtained from other professionals and her family. The care plans contained records of any contacts with other healthcare professionals, including dentists, chiropodists, opticians, GPs and district nurses. The care plans had been regularly reviewed and monitored by the staff. Service users said that they felt that their health and personal care needs were being met. Some service users were not able to say whether they felt that they were being well cared for; these service users were well-dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. Three relatives interviewed confirmed that they felt the needs of their relative were being met. The care plans did contain manual handling assessments but there was no clear guidance for staff on what to do if a service user required assistance with transferring or mobilising. Medicines were securely stored around the home in locked cupboards. The inspector observed a staff member dispense medication to residents in a safe and hygienic way. Staff said they had received medication training. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. The procedure to return medication back to the pharmacy was not adequate. Individual tablets that service users had refused to take were put in a pot and locked in the controlled drug cabinet. A record of these drugs was made, however the drugs had not been returned to pharmacy for over 4 months. Previous similar drug returns to pharmacy had not been recorded anywhere. When these inadequacies were highlighted to the deputy manager she immediately returned the medication to pharmacy and spoke to them about safer future procedures. All the service users and relatives spoken with said that the staff were respectful and friendly. They commented on the hardworking and kind nature of the staff team. An inspector saw staff consistently treating service users in respectful and friendly way. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 13 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. This judgement has been made using available evidence including a visit to this service. Residents had a choice of lifestyle within the home and they were able to maintain contact with family and friends ensuring that they continue to be involved in community life. Meals served at the home were of a good quality and offered choice to ensure residents receive a healthy balanced diet. EVIDENCE: The home had a record of activities provided, including ‘chair aerobics, watching old films and discussing them, hair and beauty sessions, quizzes, bingo and dominoes’. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 14 The inspector observed staff generally interact very well with the service users. Simple activities arranged by staff such as putting on a music DVD whilst the service users had a cup of tea and a biscuit had a really positive affect on the service users well being/mood. However, most of the service users and their relatives felt that there had not been sufficient activities in recent months due to reduced staffing levels on regular occasions. The deputy manager said that this had been made worse by short-term sickness on the part of some staff and staff holidays. She felt that the impact of this had been softened as the home had six vacant rooms. The activities record reflected that the activities provided since August had largely been limited to ‘chair aerobics’ which not all the service users were able to be involved in. Service users said that their visitors were made to feel very welcome and could visit at any reasonable time. Three relatives, who were visiting on the day, confirmed this. The significant majority of service users, who were able to clearly say, said that they were consulted about their care and involved in decisions about their lives. The significant majority of service users said that the food provided was ‘good’ or ‘very good’. One person thought that the food was ‘adequate’. There were nutritional risk assessments in the care plans and special diets were provided where necessary. One mealtime was observed. The atmosphere was relaxed, the tables were pleasantly set and the service users were given a choice of food. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. Complaints procedures are in place to enable residents and service users to feel confident that any concerns they voice will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure residents are protected from abuse. EVIDENCE: The home had a complaints procedure which included all the required information on how service users or their relatives could make complaints. It contained information on how to contact the CSCI if necessary. Service users and their relatives said that they would have no hesitation in raising concerns with the manager or any of the staff. No complaints had been received at the home since the last inspection and there had been no complaints made to the CSCI. Staff interviewed had received training on adult protection and were aware that there were procedures in place to report any concerns. There was regular staff training on adult protection. Staff were aware of their duty to report any concerns immediately. There were no adult protection issues ongoing at the home. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 16 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, 21, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Refurbishment and investment in the homes environment has continued. The environment within the home was well maintained and generally clean providing a comfortable, safe environment for residents. EVIDENCE: A check was made of the environment, including all the communal areas and at least three bedrooms on each floor. The bedrooms were pleasantly decorated, clean, tidy and highly personalised. The bedding, carpets and furniture were of a good standard. Since the last inspection a refurbishment of the home has occurred. Lounge/corridors have been redecorated and carpets have been replaced. This has markedly improved the aesthetics of these areas. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 17 There was a strong smell of urine in one bedroom – the home were aware of this and were taking measures to eradicate this. Service users spoken with said that they were happy with their rooms. Keys had been provided for service users who wanted them and had been assessed as being able to manage one safely. The communal areas on each floor were clean and pleasantly decorated with suitable furniture for service users. There were designated smoking areas in the home. Toilets and bathrooms were clean and tidy. Suitable hoists had been provided in some bathrooms and there were walk-in bathing/showering facilities available. The home had a record of repairs and improvements made at the home. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. Staff were employed in sufficient numbers to meet the residents health and physical needs. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. Staff have completed training that ensures these staff have the competences to meet the residents needs. Staff undertook induction training to ensure they had the skills needed to carry out their duties. EVIDENCE: The staff signing-in books and the rotas were checked. These indicated that whilst the staffing numbers were generally sufficient to meet the physical and personal care needs of the service users, short-term sickness and holiday cover has had an impact on the activities at the home. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 19 Staff interviewed had received a range of training relating to the needs of the service users and new staff had had a full induction. More than 50 of the care staff had achieved NVQ Level II. The recruitment records of 2 recently employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. POVA checks had been made. A CRB check had been obtained for one of the staff members. The second staff member had a clear CRB check from her previous employment and the home had applied for an updated one. There was a training and development plan for the staff. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Staff interviewed said that when they started work they received induction training in the first two months of their employment. A staff file checked identified that a member of staff had received induction training when they commenced work at Leahyrst. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. There was a positive style of management in the home. This would have a positive affect on the quality of the service the residents receive. Some of the homes policies and procedures did not fully promote the health, safety and welfare of residents and staff. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home’s manager has achieved NVQ level IV in Management and Care. She has experience in working at a senior management level with this group of service users. Staff and service users interviewed said that she was approachable and would take any of their concerns seriously. This opinion was echoed by the 3 relatives interviewed. They felt that the interests of the service users and their opinions were valued at the home. The owners have visited the home on a monthly basis to monitor progress and had provided a written report. The staff make regular audits of different aspects of the service at the home. Spending monies were managed for some of the service users. There were receipts for all transactions made on their behalf and clear records were kept. The building was generally safe with no obvious hazards, however the hot water in the sink in one bathroom was noted to be well above 43° C. This was checked using the home’s thermometer. The home’s major systems had been checked and services on a regular basis, including the fire alarm system, the lifts and the electrical and nurse call systems. There had been regular staff training on fire safety and the alarm tests had been completed every week. Regular fire drills had taken place. Staff had undertaken manual-handling training using a video but it was felt that more practical, updated training was needed to ensure that staff could safely mobilise and transfer service users. Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 22 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 X X 2 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 3 X 3 X 3 X X 2 Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 12,13,15 Requirement Resident care plans must detail clear guidance for staff on what to do if the resident required assistance with transferring or mobilising. Arrangements must be made for the safe disposal of medicines. (Part completed at the time of inspection) Staffing levels must be sufficient to ensure that service users social interests can be met. All parts of the home must be kept clean and free from offensive odours. The hot water temperatures in areas where service users have access must be adjusted to ensure they are close to 43 degrees centigrade. Staff must receive manual handling training that is more practical, to ensure that staff can safely mobilise and transfer service users. Timescale for action 01/12/06 2. OP9 13 01/12/06 3. 4. 5. OP12 16,18 16 13 01/02/07 01/02/07 01/12/06 OP26 OP38 6. OP38 18,19 01/04/07 Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 24 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 Leahyrst Care Home DS0000068204.V318357.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Leahyrst Care Home DS0000068204.V318357.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. 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