Inspection on 16/02/06 for Leaze Court

This inspection was carried out on 16th February 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 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

Leaze Court 27/04/09

Leaze Court 18/07/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Leaze The Leaze Hillside South Brent Devon TQ10 9AY Lead Inspector Graham Thomas Announced Inspection 16th February 2006 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 The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Leaze Address The Leaze Hillside South Brent Devon TQ10 9AY 01364 73267 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) Sally Brazier Steven Richard Dyke Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (21) The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection following registration of new owners on 01/11/05 Brief Description of the Service: Ms Brazier and Mr Dyke took ownership of the home on 1st November 2005 and registered as Providers under a partnership arrangement. The home is now part of a group of loosely affiliated companies and partnerships collectively known as “The Court Group”. This group has a number of homes in the Torbay and South Hams areas of Devon and promotes a corporate identity and ethos. Leaze Court is a detached property set in its own landscaped grounds in the South Hams village of South Brent on the edge of Dartmoor. The home provides personal care for up to 21 older persons of both sexes, some of whom may have dementia and/or physical disabilities. Accommodation is provided on two floors with access via a stair lift. Individual accommodation mostly comprises single rooms some of which have en suite toilets and baths. Residents benefit from large attractive gardens. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this inspection, the Inspector spoke individually with ten service users and spent time with others in groups. Two staff were spoken with as well as the interim manager, acting manager and Ms. Brazier, the Registered Provider. A visiting District Nurse was interviewed. A pre-inspection questionnaire completed by the acting manager was reviewed. The Inspector also examined five feedback cards completed by service users and friends / relatives. A tour of the premises was conducted. A sample of care plans and other records concerning the running of the home were examined. Systems concerning the use of medication were inspected. What the service does well: What has improved since the last inspection? What they could do better: Recruitment procedures must include all the required pre-employment checks. Verbal references for staff must be recorded. A quality assurance system should be implemented and developed. A Legionella assessment is required. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 the following standard(s): 3 and 6 Prospective service users can feel confident that the home will properly assess whether it can meet their needs before they are admitted. EVIDENCE: The care plan files of recently admitted residents demonstrated that assessments had been carried out prior to admission. This was supplemented by further assessment after admission. Individual service users stated that they had received confirmation that the home would be able to meet their needs prior to admission. Leaze Court does not admit service users whose needs if solely for intermediate care The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Service users receive satisfactory personal, social and health care in a manner which is appropriately respectful of individual dignity. EVIDENCE: Each service user has a detailed, individual plan of care which sets out personal social and healthcare needs. The plans sampled included assessment and referral information, individual guidance for staff, risk assessments and sections for visiting Doctors’ and Nurses’ notes. Details of the Care Programme Approach were seen on some files. All had been recently reviewed and were signed by the service user. Healthcare needs were discussed with individual service users. All felt that they had access the medical services they needed and some commented positively on the promptness with which these needs were addressed. Care plans showed that service users receive both the routine and specialist treatments they require. Files showed evidence of hearing and sight testing, chiropody, access to the GP as well as more specialist consultations with, for example the specialist falls nurse. A visiting District Nurse commented positively on the healthcare provided at the home. She stated that staff were prompt in referring clinical issues for her attention and followed recommended treatment The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 10 regimes. Staff, she felt, were alert to changes in individual health and managed eating drinking and toileting very well. A monitored dosage system is used for the administration of medicines which are securely stored in a locked cupboard. Examination of a sample of medicines administration records showed them to be accurate and up-to-date. At the time of inspection there were no homely remedies in use. Secure storage is in place for controlled drugs and a register is kept for recording their administration. Systems are in place for recording the receipt of all medicines and the return of those not used. The acting manager stated that staff training had been booked with an external training provider. During the inspection, some service users chose to enjoy the privacy of their own rooms whilst others socialised in communal areas. Individual service users confirmed that medical consultations take place in their own rooms. Staff were observed knocking on doors before entering and treating service users with respect. Those with whom the Inspector spoke, felt that staff were respectful and upheld and promoted their dignity in matters of personal care. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Service users can feel confident that the home will enable them to pursue a lifestyle which matches their expectations and preferences. EVIDENCE: During the inspection, service users followed their own, individual routines which appeared to be flexibly accommodated by the home and its staff. A regular Communion service was held during the inspection which a number of service users attended. Another service user described how her religious needs were met by trips with friends to a local church organisation. A weekly events and recreation programme has been introduced on five afternoons per week. This includes table top games, arts and crafts and film afternoons. A minibus is available for group trips such as a recent one to the local garden centre. One service user’s interest in garden birds has been promoted by the provision of a feeding table and bird feeders. All the service users with whom service users spoke confirmed that the home maintains flexible visiting arrangements and that visiting friends and relatives receive a warm welcome. Examination of care plans and discussion with individual service users demonstrated that choice and autonomy are promoted and upheld in matters of daily activity and routine, diet, friendships and the management of personal The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 12 affairs. All individual rooms incorporated a range of personal possessions including furniture as well as portable and decorative items. The home’s dining room has been redecorated and refurnished to create a light and airy dining area. Those service users who wish to take meals in their rooms are able to do so. Service users commented positively on the quantity, quality and choice of the food. A varied menu is provided with adaptations for those with particular dietary needs which are recorded in individual plans. Minutes of a residents’ meeting showed menu suggestions made by service users. Jugs of water were available in individual and communal areas and drinks are regularly served throughout the day. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Adequate systems are in place to ensure service users can appropriately exercise their right to complain and are protected from abuse. EVIDENCE: Policies and procedures concerning complaints and the protection of vulnerable adults from abuse are in place. The Registered Provider stated that no complaints had been received at the time of inspection though a recording system is in place should any arise. Staff had received some awareness training in adult protection and had seen a locally produced “No Secrets” video. Minutes of the first residents’ meeting, held before the inspection, show that complaints and abuse issues had been discussed with service users and the complaints procedure had been described. The acting manager stated that, other than immediate cash amounts, service users finances were managed by relatives, friends or other representatives. Understanding and managing challenging behaviour forms part of the Court Group’s routine training schedule. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Leaze Court provides a homely, safe and comfortable living environment for service users. EVIDENCE: Since the Registered Providers took ownership in November 2005 a number of improvements have been made to the home’s environment. An entrance to the lounge has been re-sited to improve the appearance and access to the lounge areas. The hallway and lounges have been re-carpeted and re-furnished. The lounges have been rearranged to provide a distinct quiet area. The dining room has been redecorated and re-furnished. This forms part of a wider planned programme of refurbishment, improvement and renewal which was discussed with the Registered Provider. Risk assessments have been produced in respect of remaining uncovered radiators and hand basins without hot water safety valves. The Registered Provider stated that radiator covers and hot water valves were to be fitted as part of the programme of refurbishment. In discussion, service users welcomed the recent improvements and felt that the accommodation was homely, comfortable and met their needs. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 15 On inspection, the home was found to be clean throughout and free from offensive odours. The home’s laundry benefits from a new industrial type washer with a sluicing facility and two new dryers. Staff were seen using aprons and gloves. Health and safety, infection control and moving and handling training are part of an ongoing staff training schedule The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Service users are supported by adequately trained and supervised staff. However recruitment practice does not offer adequate protection to service users. EVIDENCE: Staffing for the home comprises eight care assistants, two “duty officers” (senior carers), two general assistants, a cook and the acting manager. All work 24 hours per week. There have been several appointments since the present registration to reduce a previous over-reliance on agency staff. Night cover is provided by one staff member sleeping-in and another who remains awake. The staff group encompasses a variety of age and experience. Currently, two care staff hold an NVQ qualification at level 2 or above and another four are in the process of completing the course. Another two staff are due to enrol in the near future. Induction training is provided using the framework of a commercially available training package linked to national training standards. Individual training needs are identified through regular staff supervision and recorded in individual staff training records. The Court Group provides a rolling training schedule in health and safety topics and others relevant to the service user group. Copies of the schedule were seen during the inspection. The home’s recruitment procedure includes a formal application, request for two references and an interview. Checks regarding criminal records (CRB) and the national list of staff referred under the Protection of Vulnerable Adults (POVA) procedures had not been completed for all new staff. The Registered The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 17 Provider stated that CRB checks had been applied for and, where required, POVA First checks would be sought immediately. In some cases, references had been followed up verbally but this had not been recorded. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Leaze Court is being generally well managed through a period of change. Improvements are require in quality assurance and health and safety systems. EVIDENCE: After taking over the home, the Registered Providers appointed an interim manager from another part of the Court Group. Two weeks prior to the inspection an acting manager was appointed whose intention is to apply for registration in the near future. The acting manager has many years experience of working in the home as a senior carer under the previous Registered Provider. She is currently undertaking an NVQ level 4 / Registered Manager’s Award. As yet, a quality assurance system for the home has yet to be developed though service users’ views have been canvassed through a residents’ meeting. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 19 The acting manager stated that service users’ financial affairs are managed by relatives, friends or other representatives. Small amounts of cash are administered in the home and securely stored. Records relating to this cash included receipts and were found to be in order on inspection. Care plans included inventories of individual possessions. The staff training schedule included training in health and safety topics such as first aid, fire safety, moving and handling. A fire log book was examined which showed up-to date checks on fire safety equipment and recent training for staff. A recent independent gas safety check had been undertaken. Testing of electrical personal appliances had been conducted. A Legionella assessment is awaited. The acting manager stated that the return of some maintenance records was awaited following the current Providers’ purchase of the home. Environmental risk assessments were seen including those for uncovered radiators and unregulated wash basin hot taps. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 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 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Not applicable 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 OP29 Regulation 19 Requirement Where staff are employed prior to the completion of a CRB check, the Registered Providers must ensure a POVA First check is completed. Such staff must not have unsupervised access to service users in or outside the premises. The name of the responsible supervisor must be recorded for each shift. Where references for prospective staff are taken verbally, these must be recorded in writing. Timescale for action 21/02/06 2 OP29 19 21/02/06 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 OP31 OP33 Good Practice Recommendations A manager who is in day to day control of the home should apply to the Commission for Registration The Registered Providers should develop and implement a quality assurance system which takes account of the views of service users and other stakeholders. This should form DS0000065905.V276015.R01.S.doc Version 5.1 Page 22 The Leaze 3 OP38 the basis of an annual development plan for the home. A Legionella assessment should be conducted. The Leaze DS0000065905.V276015.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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