CARE HOMES FOR OLDER PEOPLE
Leazes Hall Care Home Leazes Hall Care Home Leazes Burnopfield Newcastle upon Tyne NE16 6AJ Lead Inspector
Gavin Purdon Unannounced Inspection 1st February 2006 10:30 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 Leazes Hall Care Home DS0000054486.V275674.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. Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Leazes Hall Care Home Address Leazes Hall Care Home Leazes Burnopfield Newcastle upon Tyne NE16 6AJ 01207 271934 01207 271934 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) Leazes Hall Care Home Limited Mrs Linda Tupman Care Home 50 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (50) of places Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: 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 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. Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced, started at 10:30 am and finished at 3:50 pm. The inspection included discussion with residents, discussion with the manager and one of the home’s owners, discussions with nursing staff, and with the home’s cleaning, laundry and maintenance staff. The public, private, and service areas of the home were looked at, and a range of records seen, covering medication, staff recruitment and training, residents’ finances, health and safety checks, equipment servicing, fire drills and fire training. What the service does well: What has improved since the last inspection?
Any required or recommended improvements made by the CSCI are followed up by the home. Required improvements to staff personnel files, highlighted in the last inspection, had been made. Since the last inspection Leazes Hall has received Investors in People status. This is a nationally recognized award for
Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 6 businesses who can demonstrate that they provide an all round quality service, that is well managed, clear about what it wants to achieve, and listens to its staff and its customers. 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. Leazes Hall Care Home DS0000054486.V275674.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 Leazes Hall Care Home DS0000054486.V275674.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): Not assessed on this occasion. EVIDENCE: Leazes Hall Care Home DS0000054486.V275674.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): 9. Residents’ health, comfort, and welfare, are protected by the home’s arrangements for receiving, storing, administering, and disposing of medication. EVIDENCE: Resident’s medication was given out at lunchtime by qualified staff. This was done in an efficient and friendly way. Residents receiving medication were given it in a discrete and reassuring manner. Nursing staff explained how medication was safely stored and properly disposed off and showed what equipment was used and what records were kept to protect residents. Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 10 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): Not assessed on this occasion. EVIDENCE: Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 11 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): Not assessed on this occasion. EVIDENCE: Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 12 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 & 26. Residents live in a safe and well-kept home. Residents’ health, comfort, and dignity are protected by the good standards of hygiene and cleanliness in the home. EVIDENCE: Residents said that they liked how well kept the home was, and appreciated the effort that staff put into keeping it that way. They thought Leazes Hall was a nice place to live. Records and schedules were seen for the general upkeep of the home and for the maintenance of essential services and equipment. These showed that there is an organized and thorough approach to keeping the home safe and pleasant for residents. The manager explained how everyday practices, equipment, and training, made sure that the home was clean and hygienic.
Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 13 4 support staff were interviewed, from the home’s maintenance, domestic, and the laundry services. All of them gave a very good account of how they ensured residents’ health and safety in their everyday work, but also how they did that in a flexible and sensitive way that was comfortable and convenient for the people living at the home. On the day of the unannounced inspection the home looked well cared for and was odour free. Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 14 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, 28, 29, 30. Residents benefit from the good staffing levels and good teamwork in the home, and from the attention of skilled staff. Residents’ safety and wellbeing are protected by the level of training and qualifications achieved by the workforce of the home. The home’s recruitment and selection procedures protect the residents of the home from unsuitable job applicants. Residents benefit from a workforce whose skills are maintained by a continuing schedule of training and development. EVIDENCE: On mornings to mid afternoons the home has 10 or 11 care staff. Mid afternoons to mid evenings the home has 9 care staff, with 3 to 4 on night duty. These are supported by activity, catering, laundry, domestic, and, maintenance staff. This exceeds the minimum expectations of the national standard for the care of 50 older people. The high levels of satisfaction expressed by residents about their care and the pleasantness of their surroundings are linked to these generous basic arrangements. Of the home’s 39 care assistants, 30 hold the NVQ 2 or 3 qualifications in care, which is well above the 50 by December 2005 quota set out in the national
Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 15 standard. This high level of training achievement contributes to the good quality of care enjoyed by residents. The personnel records seen, of recently recruited staff, showed an improved standard for the recording of identity checks. The staff appraisal and training files seen showed that a good clear plan is followed in the training and development of staff, so that they all continue to meet the needs of residents in a well informed and skilful way. The home has recently obtained the Investors in People award, which requires businesses to demonstrate well-developed links between the training of its staff, and the success of the business, and the satisfaction of its customers. Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 16 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, & 38. Residents benefit from living in a home with a mature, modern, well informed, and well designed, approach to managing their care and accommodation. Residents benefit from the home checking that good standards of care are provided, and that residents are happy with their care. The home has financial procedures to ensure that money kept for residents and spent on their behalf is well recorded and accounted for. Residents are protected by the home’s arrangements for ensuring safe working practices. EVIDENCE: As well as having nursing qualifications, the manager holds the additional management qualifications expected by the national standard. Care and
Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 17 management are both well-developed features of the homes and this benefits its staff and its residents. The home has recently obtained the Investors in People award, which requires businesses to demonstrate well-developed links between the aims of the business, its conduct, and the satisfaction of its customers. The home has particularly well developed arrangements for gathering views from relatives and residents, and using these to build up a picture of care in the home, which it then publishes. Records of money kept and spent on behalf of residents were looked at. These records were up to date, accurate, and complete. The home is safety conscious, and this benefits residents. Staff are well trained in health and safety matters. The home maintains schedules of checks, servicing, and repair. Clear and detailed records of these activities are kept. Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Leazes Hall Care Home DS0000054486.V275674.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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