Inspection on 01/12/08 for Leazes Hall Care Home

This inspection was carried out on 1st December 2008.

CSCI found this care home to be providing an Good service.

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

Leazes Hall Care Home 20/09/06

Leazes Hall Care Home 01/02/06

Leazes Hall Care Home 29/11/05

Leazes Hall Care Home 25/01/05

Leazes Hall Care Home 26/10/04

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Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Leazes Hall Care Home Leazes Burnopfield Newcastle upon Tyne NE16 6AJ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Alan Baxter     Date: 0 1 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 25 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 25 Information about the care home Name of care home: Address: Leazes Hall Care Home Leazes Burnopfield Newcastle upon Tyne NE16 6AJ 01207271934 P/F01207271934 leazeshall@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Leazes Hall Care Home Limited care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Age Variations: The home may accommodate five individuals aged 45 and upwards. Where necessary the home`s statement of purpose shall reflect any changes in service provision required for this arrangement. Name Individual: The home may accommodate a named individual as set out in a letters to the registered person dated 28 March 2006 which establishes the basis on which the individual`s needs will be met by the home. Where necessary the home`s statement of purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individual, who falls outside the registered category. Date of last inspection Brief description of the care home Leazes Hall is a care home registered to provide care and accommodation, including nursing care, for 50 older people. Up to 20 of these residents may require specialist care due to dementia, and up to 5 may require care due to terminal illness. This terminal illness category was recently added to the home?s registration. The home is owned by Leazes Hall Care Home Ltd. It was opened in 1984, and is housed in an Care Homes for Older People Page 4 of 25 Over 65 0 50 20 0 Brief description of the care home extended and adapted two-storey building. All bedrooms are in single use. There is a passenger lift to the first floor. The home has extensive and pleasant gardens with fine views over the local countryside. Leazes Hall is in Burnhopfield, in northwest County Durham, with village amenities close by. Care Homes for Older People Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means that people using the service experience good quality outcomes. How the inspection was carried out: Before the visit we looked at all the information received about the service since the last inspection on 20th September 2006. We looked at how the service has dealt with any complaints it has recieved. We considered any changes to the way the service is run or managed. We looked at the providers own view of the quality of their service, Care Homes for Older People Page 6 of 25 and asked the views of the people who use the service, by sending out questionnaires. The Visit: an unannounced visit was made to the home on 1st December 2008. During the visit we talked with the people who use the service, relatives, staff, the manager and visitors. We looked at information about the people who live in the home to see how well their needs are being met. We looked at other information which must be kept. We checked that the staff have the knowledge, skills and training to meet the needs of the people they care for. We looked around parts of the building to make sure it was clean, safe and comfortable. We checked what improvements have been made since the last visit to the service. We told the manager/provider what we found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward as recommendations - but only when it is considered that people who use the services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: All assessment documents must be signed and dated, so it is clear what is the most up to date information. The manager has agreed to introduce a different alternative daily for the main meal of the day, lunch. Care Homes for Older People Page 8 of 25 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 25 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Comprehensive assessments of the needs of each new resident are carried out before admission, so the home is sure that it can fully meet those needs. Evidence: The home receives assessments from the referring authority (usually Gateshead) before deciding whether it can meet a persons needs. These assessments are of a good standard, being detailed and comprehensive. In addition, the homes senior staff carry out their own assessment of the persons need, using an appropriate range of assessment tools. Care Homes for Older People Page 11 of 25 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents social and health care needs are set out in detailed care plans, and those needs are clearly being met, including protecting their privacy and dignity. Evidence: There was a good match between the needs of the individual resident identified in assessments and the corresponding care plans. All the care records examined had good quality care plans in place, with sufficient detail to allow staff to give the full care necessary. There was a welcome emphasis on what a resident can do for his or her own self. Most, but not all, care plans were signed and dated. Currently, the manager does a monthly audit of a random sample of care plans, to check the quality. It was agreed to introduce an annual review of each persons care plans, to make sure they are still fully relevant and up to date. There is a good range of health assessments in place. These include assessments of Care Homes for Older People Page 12 of 25 Evidence: skin integrity, nutritional needs and wound care. There was evidence of appropriate referral to community and specialist health professionals. Examples included referrals to dermatologists, ophthalmologists, psych-geriatritions, dietitians and speech and language therapists. Good records of visits to and from health professionals. A local doctor carries out a fortnightly surgery in the home. This has lead to a reduction in the need for hospital admissions. A number of staff are attending a course on tackling health care associated infections, and there was evidence that this has lead to improvements in staff practices in the home (such as not traveling to work in uniform, and replacing bars of soap with liquid soap dispensers. The home is changing its medication system to the Boots mandrex monitored dosage system in the new year. It is anticipated that this will be safer, less time-consuming to use, and will increase the availability of out of hours support from the pharmacist. Medications (including controlled drugs) were being safely stored. The Medication Administration Record (MAR) was generally being well completed. The occasional unexplained gap in the MAR was discussed with the manager. Residents and a relative confirmed that they are treated with respect by staff at all times, and that their privacy and dignity are also protected. The visiting relative said that she could not fault the home at all, and was unhappy with nothing. She said her relative had settled in very well, and very much liked the home. Care Homes for Older People Page 13 of 25 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can choose their own lifestyle, and are provided with social stimulation, access to the local community and an enjoyable diet. Evidence: The homes activities co-ordinator had left without notice three weeks before this inspection. The manager was actively recruiting a replacement, but was aware that the usual daily programme of social activities was not being fully implemented in the short term. There were, however, a number of seasonal activities, such as a carol evening, being organized. A study of the records of activities over the past year showed a reasonably varied activities programme, including bingo, quizzes, games, reminiscence sessions, dominos etc. There was also evidence of a lot of individual contacts being made with residents, and a simple social assessment of their likes and dislikes, hobbies and interests, has been carried out. There have been a number of themed nights, such as a Geordie night, and a broth and stotty night, which have proved popular. Staff also use old local photographs to Care Homes for Older People Page 14 of 25 Evidence: engage with the residents. Each month, there is a visiting entertainer. The home encourages residents family and friends to visit (though residents prefer no visitors at meal times). The manager operates an open door policy, and relatives confirmed that she is available to talk to on demand. There is lots of written information about the home, including inspection reports, available in the entrance lobby. Residents are encouraged to be as independent as possible, and to make their own decisions about how they spend their time. They may bring in items of furniture and other possessions, to make them feel at home. They may have a telephone in their room, if they so wish, and can spend as much time in their room as they want. Information on how to make a complaint is displayed in the home, and information about how to contact an independent advocate has recently been displayed. Residents have nutritional assessments carried out, and staff weigh residents weekly, to make sure that any weight loss is picked up quickly. There is a four week menu, with an emphasis on traditional cooking. A cooked breakfast is available daily. Although there is a list of alternatives (including omelet, jacket potato, sandwiches, and cheese or beans on toast) to the main meal, it was recommended that an alternative main meal is offered daily, to improve choice and variety. Residents suggestions regarding the menu are listened to and acted upon. Meals were seen to be unhurried, and to be taken at each individual residents own pace, with help given, where needed. Snacks and drinks are available throughout the day. Care Homes for Older People Page 15 of 25 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home takes any complaints very seriously, and responds appropriately to any concerns. It protects its residents from abuse. Evidence: The home has recorded one complaint in the past year. This was an issue about the catering. It was responded to, promptly and positively, and remedial action was taken immediately to resolve the issue. In discussion with the manager, it was agreed that the scope of the complaints book would be widened to include comments, compliments and other feedback. A recent safeguarding issue was discussed at length with the manager. The local social services office had complimented the home in writing about its response to this issue. The manager was able to demonstrate that she had recently updated the homes policy on responding to and reporting any allegations of suspected abuse. The new system is in line with current good practice guidelines and local authority policies. Care Homes for Older People Page 16 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents enjoy a safe, comfortable, pleasant and well maintained environment, with high standards of hygiene. Evidence: The home has an ongoing programme of redecoration and refurbishment. The next major project over the coming year is the replacement of all the armchairs in the home. The manager reported that she gets very good support from the providers, who respond positively when told of any improvements, repairs or replacements that are needed. The building is kept in a very pleasant and attractive condition. The standard of domestic work is obviously high, and odour control was generally very good. Communal area carpets were being cleaned when the inspector arrived, unannounced, in the home. Domestic and care staff take their responsibilities for the control of infection very seriously, and implement carefully what they are learning on a current course. Care Homes for Older People Page 17 of 25 Care Homes for Older People Page 18 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are protected and their well-being enhanced by the good staffing levels in the home, by the good staff training programme, and by the high proportion of qualified staff. Evidence: Staff rosters show that the home is well-staffed, often in excess of the minimum required staffing levels. There is an exceptionally high proportion of qualified staff in the home. Thirty-nine of the 43 care staff hold National Vocational Qualification (NVQ) level 2 in care; of these, 24 have gone on to achieve NVQ level 3; and no less than 14 care staff are working towards NVQ level 4 (which is normally achieved only by managers). This is very good practice. Staff recruitment is taken seriously, and all the necessary evidence (such as written references, full employment history, Criminal Record Bureau checks etc.) is collected before a new staff member is appointed. New staff receive appropriate and detailed induction training. Care Homes for Older People Page 19 of 25 Evidence: Staff receive supervision at the required frequency of at least six times each year, as well as an annual appraisal of their performance by the homes manager. Staff training is given a high priority in the home. All staff are given the training required by legislation (mandatory training), with refresher courses as necessary. The individual needs of residents are also addressed in staff training. Examples of such training include stoma care, MRSA,diabetes and insulin, challenging behaviors, entoral feeding, care of aging skin, mental health awareness and oral health promotion. Care Homes for Older People Page 20 of 25 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well-managed, and the residents are protected by the quality systems, staff supervision practices, financial systems and good health and safety systems. Evidence: The manager is well-qualified and is experienced in the care of older people. She is a qualified nurse, and holds an appropriate management qualification. There are a range of quality assurance systems, including monthly care plan, kitchen and maintenance audits. Comments sheets are available to residents and their families. There is a six monthly survey of residents views and a separate survey for relatives. Results of these surveys are collated and published, and there was evidence that the resulting feedback is taken seriously by the manager, and any concerns identified are quickly addressed. The manager also operates an open-door policy for residents and relatives. This was seen to operate during this inspection. Care Homes for Older People Page 21 of 25 Evidence: Residents finances are properly accounted for, with two staff signatures for each transaction, and receipts kept. Random spot checks of three accounts found the records to be accurate. Staff receive formal one-to-one supervision at the required regularity (a minimum of six times per year) and also receive an annual appraisal of their performance from the manager. The health and safety of residents, staff and visitors is taken seriously. Health and safety training is given to new staff as part of their induction, and updated as part of their ongoing mandatory training. Those staff working towards NVQ level 4 also receive more advanced training in this area. staff also receive all the areas of training required by law, including fire safety, moving and handling, first aid, food hygiene and infection control. Servicing and maintenance documentation was up to date, as were the necessary checks and tests of fire safety equipment and systems. The accident book was also up to date, and recorded in good detail. Care Homes for Older People Page 22 of 25 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 15 It is recommended that a second choice is available to residents for the main meal of the day, to increase their choice, and the variety of their diet. Care Homes for Older People Page 24 of 25 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 25 of 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!