Inspection on 15/02/06 for Leeza Court - Welcome House

This inspection was carried out on 15th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 35 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leeza Court - Welcome House 29/01/07

Leeza Court - Welcome House 20/06/06

Leeza Court - Welcome House 21/09/05

Leeza Court - Welcome House 29/12/04

Leeza Court - Welcome House 01/04/04

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

CARE HOME ADULTS 18-65 Leeza Court - Welcome House Leeza Court 9 London Road Rainham Kent ME8 7RG Lead Inspector Sarah Montgomery Unannounced Inspection 15th February 2006 08:20 Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 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 Leeza Court - Welcome House DS0000031629.V283830.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 Adults 18-65. 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. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Leeza Court - Welcome House Address Leeza Court 9 London Road Rainham Kent ME8 7RG 01634 377667 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) Welcome House Residential Care Homes Vacant Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Leeza Court is a large detached property with accommodation on two floors, offering fourteen single and one double room. The home is located on the main road in Rainham Kent. The home is close to good transport links to the main Medway Towns and has a pub and local shops and facilities nearby. The home benefits from a large rear garden. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by Sarah Montgomery (Regulation Inspector) and John Walker (Regulation Manager). The manager was not available and the inspectors were assisted by an ex member of staff. Service users and staff were spoken with, and records, particularly care plans; risk assessments and the staff rota were inspected. The inspection evidenced major shortfalls in all areas inspected. What the service does well: What has improved since the last inspection? What they could do better: Staffing hours are insufficient to meet the needs of service users. Service users do not have adequate pre assessments, care plans or risk assessments. Staff meetings are very infrequent. Staff training is poor, and staff do not have the skills to competently carry out their duties as described in job descriptions. During the inspection, the inspectors had reason to question the honesty and integrity of staff. The home is not cleaned to a satisfactory standard. The statement of purpose and service user guide do not truly reflect what services are available. Inspectors question the overall management of the home. Leeza Court - Welcome House DS0000031629.V283830.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. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Service users cannot be confident that they have the information they need to make an informed choice about where to live. Prospective service users cannot be sure that their individual aspirations and needs are assessed. EVIDENCE: The service user guide and statement of purpose was inspected. These documents do not provide clarity to service users regarding the purpose of the service, and continue to describe Leeza Court as a service providing respite, short term and longer-term. Standard 1 clearly states; ‘The registered person produces an up-to-date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities, and terms and conditions; and provides each service user with a service users’ guide’. Regulation 6 talks about review of the statement of purpose and service user’s guide and states; ‘The registered person shall keep under review and, where appropriate, revise the statement of purpose and the service users guide’. Information gathered during the inspection through reading care plans, daily notes and the staff rota evidenced that the services spoken of in the service user guide and statement of purpose are ideals the home is hoping to achieve, rather than offering at the present time. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 9 Currently, both documents do not adequately or accurately reflect the services offered at Leeza Court. At the time of inspection the home was critically understaffed and is failing to achieve standards on a daily basis. The statement of purpose and service user guide: documents which serve as a baseline on which individual services are formed, has major shortfalls and consequently impacts on most areas inspected. Information gathered during the inspection indicates that for most service users this home is a long-term placement. There are no systems in place to facilitate service users wishing to gain skills necessary to move into a less dependent placement, and the home cannot evidence documents to support either short-term or respite placements. A file of a service user recently admitted to the home was inspected. Preassessment documentation was very brief and contained several gaps. No provisional care plans were compiled, and the service user’s social history was not completed at all. When questioned, staff had little knowledge about this service user, saying she liked to ‘keep herself to herself’. However, respecting the privacy of a service user is very different to not knowing their care needs and personal aspirations in the first place. Pre-assessment documentation of another service user was inspected. Again, information was very brief, and did not contain sufficient information to enable the home to fully support the service user. On another pre assessment, the reason for referral was given as ‘24hour support needed’. However, once in the home, Welcome House assessed the service user as requiring only 4 hours support per day. It is disappointing to note that this is a recurring theme in all Welcome House homes, with service users assessed as requiring 24hour care by care managers and health care professionals, and then reassessed by the home following admission to requiring significantly less, usually 3 or 4 hours care per day. The Commission question both the validity of these in house assessments, and whether they are shared with all service users representatives. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Service users cannot be sure that their assessed and changing needs and personal goals are reflected in their individual plan. Service users are not adequately supported to take risks as part of an independent lifestyle. EVIDENCE: Several care plans were inspected. All were considered to have major shortfalls. Specifically, care plans were very brief – both in terms of identifying care needs and the type of support required. An example of this is a care plan, which stated the need as ‘monitoring of mood’. The ‘method’ was ‘medication and one to ones’. The detail missing from this (and other) care plans was not considered to be acceptable practice. No record of one to one meetings could be evidenced for this particular service user. When questioned, staff could not indicate how they supported the service user, nor could they outline the support needs of the service user. No care plan existed for a service user assessed as having issues with alcohol. Minimal information was present in a risk assessment, but again, clear guidance for staff was absent. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 11 This minimalist approach to care planning does not meet with either accepted good practice guidelines, or national minimum standards. Staff and service users appear to just ‘get by’, and do not benefit from a clear, consistent and professional approach towards care planning in relation to meeting service users needs and ensuring goals and expectations are met. It was further evidenced during the inspection that service users are not consulted about their care plans or risk assessments. They are written by staff, and the only input from the service user is to sign the finished document. Most care plans and risk assessments were not signed. All risk assessments inspected were inadequate. None described the risk or support in any way that could be considered effective. An example of this is a risk assessment that describes the risk as ‘depression’. The ‘method’ was ‘ staff to give all oral medication due to the service user abusing drugs’. The inspectors noted the failure to firstly address the risks regarding the service user’s depression, and the absence of any risk assessment regarding the alluded to drug abuse. The evidence suggested that this is poor risk assessment practice since there is a minimal recording of what the risks are. When questioned, the staff could not answer how the home was supporting the service user, or how risks for the service user were minimised. The evidence indicated that the home’s risk assessments and care plans were inadequate and that the health and welfare of service users were put at serious risk. The inspection evidenced that staff do not possess the skills or competence to adequately assess, care plan or risk assess service users. Staff training is inadequate and work practice and paperwork evidence that Leeza Court is a home that is failing to meet the needs of service users. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15 and 17. Service users cannot be confident they will have opportunities for personal development, have appropriate family relationships, or will be offered a healthy diet. EVIDENCE: The home displays the organisation’s care philosophy on the notice board. It reads; ‘our care philosophy is to support and encourage all of our residents to lead as normal a life as possible and to reach their full potential. This is achieved by offering guidance and assistance with everyday living skills and by encouraging residents to participate in the planning of their own care. Everyone at Welcome House is respected and treated as an individual and given encouragement and support to develop both personal and social relationships’. No evidence was presented during the inspection to support the above statement. Staff could not demonstrate, either by providing evidence in the form of written documentation (care plans) or by discussing working practice, any area where service users are supported and encouraged, or guided and assisted to reach their full potential and maintain or gain skills in independent living. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 13 Staff admitted to being constrained by staffing numbers. One service user occasionally uses the kitchen to make light snacks. This is an ad hoc arrangement, and, although the service user spoke of moving on to a more independent scheme in the near future, no care plan had been put into place to support the service user in attaining necessary independent living skills. When questioned, staff did not have information regarding the level of skill of the service user, and indicated that the home do not undertake any assessments regarding independent living. Several pre-assessments inspected had many gaps and did not contain sufficient information. Staff were questioned about how a particular service user is supported to maintain contact with family. Staff did not have any knowledge regarding the service user’s family, and had not sought information from the service user regarding their wishes in this area. The inspectors were informed that the menus were fake, and only existed to satisfy inspections. No record of food is kept. There were no fresh vegetables in the home at the time of the inspection and only very small supply of fruit. The home could not evidence any consultation with service users regarding diet. A questionnaire was given to service users in 2005, but no evidence was presented of whether information collated from the questionnaires was acted upon. The home has a budget of £320 per fortnight. This money is for all the needs of the house; food, cleaning materials, and other items. This converts into £1.90 per day per service user, not all of the £1.90 spent on food. The home could not evidence that service users are offered a healthy and nutritious diet. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 20. Service users cannot be sure their emotional health needs are met, or that they receive appropriate care and support regarding administration of medication. EVIDENCE: Prior to the inspection concerns were received by CSCI from health professionals. Some of these concerns were confirmed by the inspection process. For example, evidence obtained during the inspection suggested that the administration of medication in the home did not comply with Standards, and have arranged for a separate pharmaceutical inspection. A service user informed inspectors that staff often drop medication on the floor, handle the tablets, and do not give medication at the right time. Inspectors were informed that the home uses a ‘potting up’ system. This is regarded as unacceptable practice. Tippex was seen on service users MARs sheets. Major shortfalls in care planning and risk assessments indicate that service users emotional needs are not being met, or acknowledged. Staff displayed some indication of the emotional needs of service users, but indicated that lack of time during a shift meant that service users very often were left to their own devices – whether they wanted to or not. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 15 Care notes are not written daily. Staff do not know why this is. Activities are not recorded. Inspectors question how monthly reports can be accurate. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): THESE STANDARDS WERE NOT INSPECTED. EVIDENCE: Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 28 and 30. Service users would benefit from some redecoration and refurbishment to the home. Service users would further benefit if the home were clean. EVIDENCE: A partial tour of the home was undertaken. All communal areas and a few bedrooms were inspected. Overall, the inspectors found the home to be below an acceptable standard of cleanliness, and communal areas were considered shabby and in need of refurbishment. The following was noted; The television lounge had furniture and a carpet which were both fine. In the lounge an unpleasant odour permeated the room. Net curtains on both windows were far too long. In some areas of the room the wallpaper was held up by drawing pins. The ceiling had water damage caused by a recent leak in a bathroom upstairs. A shower room leading off the television lounge was not clean, and had a build up of grime and dirt. The unpleasant odour found in the lounge was also present in this room. There was a communal towel in the shower room. This poses a serious risk to cross infection and staff were advised to remove it. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 18 The dining room and lounge are open plan. Patio doors from this room lead into the smoking room. The patio doors were thick with grime. Walls in the lounge were dirty. Curtains on the patio doors seemed precariously balanced, with the curtain rail looking unsteady. Radiators were not protected and were very hot. Staff could not answer why the television was on the floor. A coffee table in the room had a build up of dust. In the dining end of the room, of the two windows, one had a net curtain on which was far too long, the other had no curtain. Blue tack was on the ceiling, which had been left over from Christmas. Water temperature in the bathrooms was found to be too hot. The home has no thermostatic controls. Sealant around the bath was dirty and stained. There was no covering on the bathroom window. A bedroom was inspected. No linen was on the bed. The service user said it had been like this since the day before. When asked if anyone helped with her room, she answered ‘sometimes’. The inspectors recognise that service users privacy needs to be respected, but would question why service users are not supported in basic tasks. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Service users care is compromised and they are at risk of potential harm due to an inadequate, incompetent, poorly trained staff team. Significant shortfalls in the home’s recruitment practices mean that service users are not protected from harm. EVIDENCE: Inspectors were surprised to note that a recent entry in the staff message book (dated 11/2/06), which read; ‘The rota for next week is not the real one (dummy) because of the long hours on, the DTA comments on them’. The staff member on duty confirmed he had written the message, and that a ‘dummy’ rota was written. Inspectors had already been advised that the menus were ‘fake’, and now were presented with evidence that the home’s rota is also a fake. Given the evidence obtained, the inspectors felt it appropriate to question the honesty and integrity of staff, and further question how the home is being run and managed. Regulation 19(5)(a) states; (5) For the purpose of paragraphs (1) and (4), a person is not fit to work at a care home unless – (a) he is of integrity and good character. The Commission requires the registered provider to evidence he has satisfied himself and Regulation with regard to fitness of employees in relation to their honesty and integrity. Staffing numbers are very low at the home. The home, at present has just 3 members of staff. Welcome House allocate 22 support hours per day Monday Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 20 to Friday, and 14 support hours Saturday and Sunday. The home is registered for 16 service users. At present, there are four vacancies. From information gathered and the observations made during the inspection, staffing is inadequate to meet the present needs of the current service users in the home. Based on figures from the residential forum, this home should have 334.15 support hours per week. The present support hours of 138 per week are significantly less. All service users are reassessed by the home regarding support hours needed during the day. Most service users have been assessed as requiring 4 hours support per day. One service user does not have an assessment, and the inspectors were informed this is because staff disagreed with the formula, and stated to management they would not fill in the assessment. However, the home’s own assessment of care hours needed adds up to 308 hours per week, which is not being adhered to. Welcome House must address these staffing shortfalls as a matter of urgency, and ensure that Leeza Court is appropriately staffed to enable service users to receive the support required. A member of staff from another home was working at Leeza Court. She had been there for 5 days. When questioned about individual service users’ care plans or risk assessments, she could not answer, and informed the inspectors she did not know anything about the service users. She had received no induction whatsoever, and did not know even basic information about service users. This is considered to be poor practice. All staff, permanent or temporary must have an induction into the service, and have an awareness of service users and their care plans and risk assessments. Service users spoke to the inspectors openly. One service user informed the inspectors that ‘staff are always arguing with each other and shouting’, while another service user stated that ‘staff are nice and helpful’. Staff meetings are very infrequent. The home have had no staff meetings this year, and conducted just three (April, June and September) in 2005. This is not acceptable, and demonstrates further non-compliance with care home Regulations and standards. Records of supervision indicated that staff are not appropriately supported. Last recorded dates of supervision were in 2004. Staff files inspected were found to be poor and did not meet Regulation. Welcome house has not evidenced they are protecting service users from harm, as they have failed to evidence that appropriate checks are made in relation to references. One member of staff had just one reference from a friend, and two further references from previous employers who refused to comment. In addition current pro forma reference requests sent out by the Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 21 company do not ask sufficiently detailed questions, nor do they insist on formal letterheads or any other indication regarding authenticity of the reference. The notice board in the office had a ‘staff training matrix’. The inspectors consider this matrix to be misleading and inaccurate. For example, it was noted that two members of staff received the following training all on the same day; Induction training, mental health training, medication training, Fire training, Manual handling, managing aggressive behaviour and adult protection. The inspectors believe that by implying staff are trained, or have received training in all these areas, and have done so by being trained in all of the above in just one day, is highly questionable practice. The Commission reminds Welcome House that all training must be by accredited trainers, and that these trainers must be recognised as such by the Commission. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 43 Service users cannot be confident that the home is appropriately and competently managed. EVIDENCE: The manager was not present during the inspection. The evidence obtains suggests that that are serious concerns regarding the overall management of this home. The home does not have enough resources in terms of staffing hours or staff training. The inspection process revealed significant shortfalls in all areas inspected, from the cleanliness of the home, to the provision of appropriate care. The statement of purpose and service user guide is inaccurate and misleading. Services described in these documents are not provided in the home. It could not be evidenced that the holds any staff meetings or offers staff any form of supervision. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 23 Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 1 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 1 27 X 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 1 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 1 12 X 13 X 14 X 15 1 16 X 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 1 X X X X X X X 1 Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 25 No Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 4(1)(a) (b) (c) Requirement Timescale for action 21/04/06 2 YA1 4(2) The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of – (a) a statement of the aims and objectives of the care home; (b) a statement as to the facilities and services which are to be provided by the registered person for service users; and a statement as to the matters listed in Schedule 1. The registered person shall 21/04/06 supply a copy of the statement of purpose to the Commission and shall make a copy of it available on request for inspection by every service user and any representative of a DS0000031629.V283830.R01.S.doc Version 5.1 Page 26 Leeza Court - Welcome House service user. 3 YA1 4(3)(a) 4(3)(b) Nothing in regulation 16(1) 21/04/06 or 23(1) shall require or authorise the registered person to contravene, or not to comply with – (a) any other provision of these Regulations; or the conditions for the time being in force in relation to the registration of the registered person under Part 2 of the Act. The registered person shall 21/04/06 produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (a) a summary of the statement of purpose. (b) The terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees; The registered person shall 21/04/06 produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (c) A standard form of contract for the provision of services and facilities by the registered provider to service users; Version 5.1 Page 27 4 YA1 5(1)(a) 5(1)(b) 5 YA1 5(1)(c) 5(1)(d) Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc 4 YA1 5(1)(e) 5(1)(f) The most recent inspection report; The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (e) (d) 21/04/06 5 YA1 5(2) 6 YA1 5(3) 7 YA1 6(a) 6(b) A summary of the complaints procedure established under regulation 22; (f) The address and telephone number of the Commission. The registered person shall 21/04/06 supply a copy of the service user’s guide to the Commission and each service user. Where a local authority 21/04/06 has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. The registered person shall 21/04/06 – (a) keep under review and, where appropriate, revise the statement of purpose and the service user’s guide; and (b) notify the Commission and service users of any such revision within 28 days. DS0000031629.V283830.R01.S.doc Version 5.1 Page 28 Leeza Court - Welcome House 8 YA2 14(1)(d) The registered person shall not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – 02/04/06 9 YA2 14(1)(a) 14(1)(b) (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The registered person shall 02/04/06 not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (a) needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) the registered person has obtained a copy of the assessment; The registered person shall not provided accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (c) there has been appropriate consultation regarding the assessment with the service user or a representative of the DS0000031629.V283830.R01.S.doc 10 YA2 14(1)(c) 02/04/06 Leeza Court - Welcome House Version 5.1 Page 29 service user; 11 YA6 15(1) Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. The registered person shall – (a) make the service user’s plan available to the service user; (b) keep the service user’s plan under review; The registered person shall (c) where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service user’s plan; and (d) notify the service user of any such revision. The registered person shall ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service DS0000031629.V283830.R01.S.doc 02/04/06 12 YA6 15(2)(a) 15(2)(b) 02/04/06 13 YA6 15(2)(c) 15(2)(d) 02/04/06 14 YA6 12(1)(a) 12(1)(b) 02/04/06 Leeza Court - Welcome House Version 5.1 Page 30 15 YA9 13(4)(b) 13(4)(c) 16 YA11 12(1)(b) 17 YA15 16(2)(m) 18 YA17 16(2)(i) users; to make proper provision for the care, and where appropriate, treatment, education and supervision of service users. The registered person shall ensure that – (b)any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person shall ensure that the care home is conducted so as – (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The registered person shall having regard to the size of the care home and the number and needs of service users – (m) consult service users about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit, or maintain contact or communicate with, their families and friends. The registered person shall having regard to the size of the care home and the number and needs of service users – DS0000031629.V283830.R01.S.doc 19/03/06 02/04/06 19/03/06 19/03/06 Leeza Court - Welcome House Version 5.1 Page 31 19 YA19 12(1)(a) 12(1)(b) 20 YA19 12(2) 21 YA19 12(3) 22 YA28 23(2)(h) (i) provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may be reasonably required by service users. The registered person shall ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service users; to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The registered person shall so far as is practicable enable service users to make decisions with respect to the care they are to receive and their health and welfare. The registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feeling. The registered person shall having regard to the number and needs of the service users ensure that – (h) the communal space provided for service users is suitable for the provision of social, cultural and religious activities appropriate to the DS0000031629.V283830.R01.S.doc 19/03/06 19/03/06 19/03/06 02/04/06 Leeza Court - Welcome House Version 5.1 Page 32 23 YA30 16(2)(j) 24 YA30 16(2)(k) 25 YA30 23(2)(d) 26 YA32 12(5)(b) 27 YA32 19(5)(a) 28 YA32 19(5)(b) circumstances of service users; The registered person shall having regard to the size of the care home and the number and needs of service users – (j) after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home; The registered person shall having regard to the number and needs of the service users ensure that – (k) keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste. The registered person shall having regard to the number and needs of the service users ensure that – (d) All parts of the care home are kept clean and reasonably decorated. The registered provider and registered manager shall, in relation to the conduct of the care home – (b) encourage and assist staff to maintain good personal and professional relationships with service users. For the purposes of paragraphs (1) and (4), a person is not fit to work at a care home unless – (a) he is of integrity and good character. For the purposes of DS0000031629.V283830.R01.S.doc 19/03/06 19/03/06 19/03/06 19/03/06 19/03/06 19/03/06 Page 33 Leeza Court - Welcome House Version 5.1 29 YA33 18(1)(a) 30 YA34 19(4)a, 19(4)b 19(4)c paragraphs (1) and (4), a person is not fit to work at a care home unless – (b) he has qualifications suitable to the work that he is to perform, and the skills and experience necessary for such work. The registered person 31/03/06 shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person shall 17/03/06 not allow a person to whom paragraph (2) applies to work at the care home in a position to which paragraph (3) applies, unless – (a) the person is fit to work at the care home; (b) the employer has obtained in respect of that person the information and documents specified in – (i) paragraphs 1 to 7 of Schedule 2; and has confirmed in writing to the registered person that he DS0000031629.V283830.R01.S.doc Version 5.1 Page 34 Leeza Court - Welcome House 31 YA35 18(1)c(i) 18(1)c(ii) 32 YA36 18(2) 33 YA43 10(1) has done so; and (c) the employer is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person, and has confirmed in writing to the registered person that he is so satisfied. 21/04/06 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users – (c)ensure that the persons employed by the registered person to work at the care home receive – (i) training appropriate to the work they are to perform; and suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. The registered person shall 21/04/06 ensure that persons working at the care home are appropriately supervised. The registered provider 19/03/06 and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the home (as the DS0000031629.V283830.R01.S.doc Version 5.1 Page 35 Leeza Court - Welcome House case may be) with sufficient care, competence and skill. 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 Refer to Standard YA33 Good Practice Recommendations Regular staff meetings take place (minimum six per year) and are recorded and actioned. Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 36 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Leeza Court - Welcome House DS0000031629.V283830.R01.S.doc Version 5.1 Page 37 - 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. 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