Inspection on 15/02/07 for Leawood Manor Residential Home

This inspection was carried out on 15th February 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

Leawood Manor Residential Home 24/03/09

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 Leawood Manor Residential Home Hilton Crescent West Bridgford Nottingham NG2 6HY Lead Inspector Richard Ramsden Key Unannounced Inspection 15th February 2007 09:30 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 Leawood Manor Residential Home DS0000068906.V329602.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. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leawood Manor Residential Home Address Hilton Crescent West Bridgford Nottingham NG2 6HY 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) 0115 8465560 Nottinghamshire County Council Care Home 32 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (16), Old age, not falling within any other of places category (32), Physical disability (5), Physical disability over 65 years of age (16) Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration Numbers and Categories The home is registered to provide personal care for residents of both genders whose primary needs fall within the following categories: Dementia (DE) - 5, Dementia over 65 Years of Age (DE(E)) - 16, Old Age (Not falling in any other category) (OP) - 32, Physical Disability (PD) - 5, Physical Disability Over 65 Years of Age (PD(E)) - 16 Total Number The maximum number of residents to be accommodated at Leawood Manor is 32. No Previous Inspection 2. Date of last inspection Brief Description of the Service: Leawood Manor Care Home is owned and managed by Nottinghamshire County Council Social Services. It is a new purpose built care home for up to 32 older people. The home is divided into four units each with a lounge, dinning room and kitchen area as well as assisted bathing facilities. All bedrooms are for single occupancy they are spacious, with ensuite toilet and shower facilities. The accommodation is provided over two floors with two passenger lifts to assist independent access. There is a parade of shops offering a range of facilities, approximately 150 yards from the home. The weekly accommodation charges for those residents who are self funding is £377.00. There has been no previous inspection at this home since it opened in December 2006. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one day it took approximately 8 hours. It included the inspection of care and other records a discussion with the homes line manager, three team leaders and two members of care staff. The inspector spoke with four residents and one visitor to the home. A partial tour of the building was also completed. Three residents were case tracked, which means that their care plans were examined against the actual care they receive. Prior to completing this visit the inspector assessed the home service history but there had been no issues reported since the home was registered in December 2006. What the service does well: The accommodation at Leawood Manor is new and purpose built. The rooms are large, well decorated and comfortably furnished and there is good natural light throughout the building. Residents stated that they liked their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture ornaments and photographs. A visitor confirmed that she can visit her mother at any time and that staff are always friendly and welcoming. She stated that she is always kept fully informed about her mothers health and welfare. The homes registered manager is experienced. Residents and staff confirmed that the manager is very approachable and that he seeks their views about the way in which the home operates. Residents said that the staff are always friendly and respectful and ensure that their privacy and dignity is maintained at all times. The observed interaction between staff and residents was of a very good standard. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 6 People said that they are generally satisfied with the food provided by the home and confirmed that an alternative will always be provided if they do not want the food suggested on the menu. 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. Leawood Manor Residential Home DS0000068906.V329602.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 Leawood Manor Residential Home DS0000068906.V329602.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. The homes staff ensure that they can meet the assessed needs of prospective residents by obtaining full written assessments prior to their admission to the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents records were assessed as part of this inspection. Two of the records contained preadmission assessments, which had been completed by qualified social workers. The third residents file did not contain a preadmission assessment, however this resident had transferred from another Nottinghamshire County Council Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 9 Social Services Care Home. She had been admitted some considerable time ago and her archive file had temporarily been mislaid. The senior staff stated that residents are never admitted without a preadmission assessment. Leawood Manor does not provide intermediate care. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents individual care plans appear to contain sufficient information to ensure that all staff are aware of what support and assistance each resident requires. Residents’ health care needs are being met. The homes medication systems are well maintained and residents are treated with respect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents care plans were viewed as part of this inspection, the care plans appeared to address the issues highlighted in the residents assessment process. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 11 Two of the care plans had been reviewed and where necessary amended each month. One of the care plans had not been reviewed since November 2006. The senior staff confirmed that this resident’s care had not changed since it was last reviewed. The member of staff was reminded that care plans should be reviewed and where necessary updated at least once each month. Records showed that residents’ health care needs are being appropriately met; this was confirmed by one of the residents spoken with during the visit. A visitor confirmed that she is always kept informed about her mothers health. The homes medication systems have been well managed. One resident administers her own insulin. This medication was stored securely and an appropriate risk assessment had been completed. (This is good practice). The records of receipt and disposal of medication and the homes controlled medication had all been well maintained. All medication was stored safely and staff are regularly recording the temperatures in the refrigerator and the room in which medication is stored. All of the residents spoken with during the inspection said that the staff are always friendly and respectful and that they ensure that their privacy and dignity is maintained at all times. This was also confirmed by one of the relatives spoken with during the inspection. The observed interaction between staff and residents was of a very good standard. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Two residents said that they would like the home to provide more activities and entertainment, however staff have taken steps to provide appropriate stimulation in the near future. People are encouraged maintain contact with family and friends. Where possible residents are encouraged to make decisions about their individual lifestyles but the registered person should ensure that the residents know how to contact local advocates and how to gain access to their personal records. The diet provided for residents is a varied, wholesome and he nutritious. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two of the residents spoken with said that they would like the home to provide more activities and entertainment. Senior staff stated that following the residents meeting on 6th February 2007 staff have produced a programme of Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 13 activities which will commence on 26th of February 2007. The programme of activities includes at least one activity every night of the week and a poster detailing this information was displayed in the home. Church services are held in the home on a monthly basis. It was noted that on two of the three care plans viewed during this inspection details of the residents’ religion had not been recorded. It is essential that this information is recorded to ensure that they are meeting the individual residents religious needs. Residents and one relative confirmed that visitors are made welcome at any time. One resident said that she could see visitors in her bedroom or use one of the communal areas if she wishes to speak to them in private but does not wish to use her bedroom. There has been one residents meeting since the home was registered in December 2006. The home did not have an Access to Records Policy detailing the procedure that staff should follow if a resident or their representative asks to view a residents personal records. There were also no details of how residents could contact local advocates should they want independent advice or support. All of the residents spoken with said that they are satisfied with the meals provided by the home. They confirmed that there is always a choice of food and that if they do not want the meal suggested on the menu an alternative will be provided. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home has a robust accessible complaints procedure and staff are ensuring the residents are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was informed that all residents have been provided with a copy of the homes complaints procedure. This procedure is also displayed on a notice board in one of the main reception areas. The homes complaints records show that the home has received two informal complaints, which appear to have been dealt with appropriately. Residents confirmed that they would contact the manager or any members of senior staff if they had any concerns or complaints. They all believed that their complaints would be taken seriously and dealt with appropriately. There are copies of the local Vulnerable Adults Procedure available in the home. There are also copies of an appropriate Whistle Blowing Policy. The inspector was informed that there have been no allegations of abuse and that Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 15 no staff have been referred for inclusion on the Pova lists since the home was registered in December 2006. The care staff spoken with have received training in safeguarding adults. Leawood Manor Residential Home DS0000068906.V329602.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The new purpose-built accommodation is well planned and maintained to a very good standard. The home was clean, pleasant and hygienic at the time of this visit EVIDENCE: A partial tour of the premises was completed as part of this visit. The wellplanned, purpose-built accommodation has been maintained to a very good standard. The home has good natural light and is well decorated and comfortably furnished throughout. The resident’s bedrooms are large and all have ensuite toilet and shower facilities. People confirmed that they can use their rooms at any time and that Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 17 they were encouraged to personalise them with small items of furniture ornaments photographs etc. The residents said that they are very happy with their bedrooms although one person said that she was concerned that her bedroom may be a little dark when the trees at the back of the home are in full foliage. At the rear of the home there are small-enclosed gardens. The registered person will need to identify how the residents can use these areas when the weather improves. The laundry is large well equipped and has washable wall and floor coverings. At the time of inspection the laundry doors were unlocked and there were no staff in situ. The laundry contained large amounts of cleaning products, this potentially put residents health and safety at risk. The homes line manager stated that the laundry door must be kept locked when there is no staff in situ. A digital lock was fitted to both laundry doors during this inspection. Leawood Manor Residential Home DS0000068906.V329602.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): 27,28,29,30. There is sufficient staff to meet the assessed needs of the residents. The manager has taken steps to improve staff training but the registered person must ensure that staff do not assist residents to use a hoist to assist their mobility, until staff have received appropriate training. The homes recruitment policies and practices support and protect residents but the staff personnel records do not contain the required information. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota provided on the day of this inspection showed that there is sufficient staff employed to meet the assessed needs of the current residents. The manager has identified that there are some gaps in the staff training and has arranged for all staff with to re-complete their Skills for Living courses. (This is good practice). Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 19 The two members of staff spoken with during this inspection both stated that they had never received any training on how to safely to assist residents’ who need a hoist to assist their mobility. An immediate requirement was left at the home stating that staff must not use a hoist to assist residents’ mobility until they have received appropriate training. The personal records of two members of staff were assessed as part of this visit. The records did not include written references, application forms or details of Criminal Records Bureau Clearance. The written references and the application forms were faxed through to the home during the inspection and were satisfactory. However at the time the senior staff could not provide any evidence that these members of staff had received satisfactory Criminal Records Bureau Clearance. Both members of staff were spoken with during the inspection one person confirmed that she had applied for her CRB check but confirmed that she had never received a copy of the completed clearance form. The second member of staff stated that as far as she was aware she had never completed the CRB clearance forms. The day after the inspection staff at Leawood Manor were able to provide the date that the staffs CRB clearance had been received and the appropriate reference numbers. Staff records as detailed in Schedule 4 of the Care Homes Regulations as amended by the Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 must be kept in the home for inspection. Alternatively with the agreement of CSCI relevant details can be recorded on a pro forma (validated by the registered provider or manager). A copy of the pro forma has been provided to the homes line manager. Leawood Manor Residential Home DS0000068906.V329602.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): 31,33,35,38. The homes manager is very well qualified and experienced. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. Where checked the health and safety of residents and staff are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes registered manager is well qualified and experienced. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 21 Residents and staff said that the manager is very approachable and that he seeks their views about the way in which the home is run. Quality monitoring systems are in place, which will enable residents and stakeholders in the community to express their views about the services, provided by the home. The manager will produce an individual business plan for the home based on the information gathered from the completed quality assurance questionnaires. The records of residence finances were checked at random and were well maintained. All of the residents who were asked said that they were happy with the way their finances are managed. The records of items handed in for safekeeping were well maintained. The aspects of health and safety, assessed as part of this visit had been satisfactorily maintained. It was recommended that a fire drill be completed in the near future to ensure that staff are aware of the procedures they must follow, should a fire occur in this new building. Leawood Manor Residential Home DS0000068906.V329602.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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP14 Regulation Data Protection Act 1998. Requirement Timescale for action 02/03/07 2. OP29 17 (2) Schedule 2 (6) 3. OP30 13 (5) It is required that the registered person provides an Access to Records Policy which informs residents, their representatives & staff of the procedure they must follow if a resident or their representative requests to see a residents personal records. 02/03/07 It is required that the records specified in Schedule 2 (6) of the Care Homes Regulations as amended by the Care Standards Act 2000 (Miscellaneous Amendments) Regulations 2005 are kept within the home. Alternately with the agreement of CSCI the relevant details can be recorded on a pro forma (copy supplied to the homes line manager). The information on the pro forma would have to be validated by the registered person or the registered manager. It is required that that staff do 15/02/07 not use a hoist to assist residents with their mobility until they have received appropriate training. NOTE An immediate DS0000068906.V329602.R01.S.doc Version 5.2 Leawood Manor Residential Home Page 24 requirement was left at the home on the day of inspection. The registered person has informed CSCI that this requirement had been instituted. 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. Refer to Standard OP14 OP38 Good Practice Recommendations It is recommended that the registered person provide information for the residents on how they can contact an independent advocate who will act on their behalf. It is recommended that the registered person institute a fire drill within the home to ensure that staff will know how to respond if there is a fire in these new premises. Leawood Manor Residential Home DS0000068906.V329602.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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