Inspection on 30/06/09 for Legh House

This inspection was carried out on 30th June 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Legh House 11/12/09

Legh House 25/09/07

Legh House 02/06/06

Legh House 19/12/05

Legh House 19/04/05

Legh House 15/11/04

Legh House 21/05/04

Legh House 11/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Legh House 117 Rylands Lane Wyke Regis Weymouth Dorset DT4 9QB Lead Inspector Ms Sue Hale Key Unannounced Inspection 30th June 2009 09:00 DS0000026835.V375859.R02.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Legh House Address 117 Rylands Lane Wyke Regis Weymouth Dorset DT4 9QB 01305 773663 NO FAX annburt@btconnect.com 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) The Abbeyfield (Weymouth) Society Limited Mrs Ann Burt Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Seventeen (17) in Fifteen (15) single rooms and a suite of two rooms registered as one double. 25th September 2007 Date of last inspection Brief Description of the Service: Legh House is registered to provide care and accommodation for a maximum of 17 people age sixty five and over. The registration is for old age, not falling within any other category. Legh House is a single storey building built into a hill, overlooking Portland harbour. It is situated close to several amenities, including shops, post office, church, GP surgeries and schools. It belongs to the Abbeyfield Society, a registered charity and has been established for many years. The home has a House Committee; however the Executive Committee holds overall responsibility for the management of Abbeyfield (Weymouth) Society. Mrs Ann Burt is the registered manager of the home. The fees for the home are £66 per day for all single rooms with an additional cost for the care suite. Additional charges include hairdressing, chiropody (privately arranged), toiletries and newspapers. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the visit was to inspect relevant key standards and to focus on outcomes for residents. We measure the quality of the service under seven outcome groups and these are individually given a rating of excellent, good, adequate or poor. These ratings are collated to give an overall rating of the service provided by the home. The quality rating for this home is zero stars, poor service The inspection was undertaken over the course of one day by two inspectors. There were 16 people living in the house on the day of the visit. The current fee level ranges from The registered manager completed an annual quality assurance assessment (AQAA) and this is referred to within the body of the report. We spoke to the registered manager, 6 residents and 3 members of staff. We looked at selected residents care files, staff recruitment files and all other documentation relevant to the running of the care home. We also undertook a tour of the premises. We sent out surveys at random to staff, residents, relatives, and health and social care professionals. We received responses from four health and social care professionals, four residents, three members of staff and two relatives. The results have been collated and incorporated into this report. Three of the four residents who completed our survey described themselves as British, Christians and without any disabilities. What the service does well: People have the opportunity to visit the home and spend time there before making a decision about residency. They are provided with written information and their needs fully assessed to make sure they can be met. Residents were involved in their own care planning and reviews and care plans were detailed and covered all assessed needs. Appropriate risk assessments were in place for many residents. People who live in the home were very satisfied with the services they receive. Comments included’ it is my home and I feel loved’, ‘they do everything well’ and they ‘look after us all well like a family’. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 6 Professionals who visit the home commented positively about the service provided including ‘caring, calm environment. In my opinion one of the best residential homes that Ive come across’. Another person commented that Legh House provided’ individualised care and respected residents privacy’. Throughout the visit, staff were seen treating residents with dignity and respect and residents told us that they had confidence in the staff and that they were ‘ very good’ and’ very kind’. The homes activity programme is varied and enjoyed by the residents although many would welcome the opportunity to go out more. Residents’ views sought at regular meetings and there was involved as possible in the running of the home. Clear systems are in place for residents, relatives or anyone involved in peoples care to raise any complaints or concerns. Residents were confident that any concerns or complaints will be listened to and taken seriously. The home was clean and tidy and free from unpleasant odours on the day of the visit. Residents are encouraged to personalise their rooms to reflect their lifestyle and preferences and are able to bring in personal possessions within the space constraints of their private room. One relative commented that Legh House was a caring, happy and safe environment’ and went on to say that’ I am thrilled that we have found such a good care home’. The home maintains if good staffing levels which meet the needs of the residents. The staff team is stable which gives the residents good continuity of care. Recruitment practices for staff were robust to make sure that people who live in the home are protected from the risk of abuse. All new staff complete appropriate in-depth induction training. The majority of staff has achieved qualifications to at least NVQ level II. Policies and procedures are in place in relation to equality and diversity covering both the recruitment and conduct of staff and the way in which the service respects all members of the community and make them welcome in the home. Health and safety is taken seriously to make sure that people who live and work at the home are safe. What has improved since the last inspection? Improvements have been made to the garden and outdoor space. Ongoing maintenance makes sure that the environment is always of a good standard. New furniture has been provided in the conservatory and corridors Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 7 and additional electrical sockets have been fitted to accommodate digital TV boxes so people can receive digital television. What they could do better: 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 8 order line – 0870 240 7535. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 9 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 Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 standard six is not applicable to this service People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not move into the home until their needs are assessed and the home is confident that they can be met. EVIDENCE: The AQAA told us that pre admission assessments are undertaken wherever that prospective resident is living or staying. People considering moving into the home are encouraged to spend time there and given written information before they make a decision about residency. People spoken to do in the inspection confirmed that this was the usual process and some people had visited the home if they were able to. All admissions to the home are on a trial Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 11 basis and reviewed to make sure that the home is suitable and able to meet their needs. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans give clear, detailed information about peoples assessed needs and how these are to be met. Risk assessment practice is inconsistent. Residents have access to medical and healthcare professionals and their health needs are met. People who lived at the home are treated with respect and their right to privacy and dignity is part of the care practice at the home. Improvements are necessary in medication practice to make sure that it is managed safely. EVIDENCE: Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 13 All residents had a care plan and we looked at four plans in detail. Care plans covered all the recommended topics and contained clear detail about individuals care needs and gave clear guidance to staff on how these should be met. Plans are reviewed monthly and updated whenever necessary so that they reflected peoples current needs. It was clear that care plans were discussed with residents and all the ones checked had been signed by residents to say that they agree with the care being provided. All the residents spoken to during the inspection were very satisfied with the care they receive. Appropriate risk assessments were in place in relation to moving and handling, falls, pressure sores and nutrition on three of the four plans looked at. However, the nutritional risk assessments are kept separately to the care plans and were not given to us when we had requested all the information about the individuals to be case tracked, but were provided when we queried why they werent in place On checking these records it was clear that assessments are not in place for all of the people who live at the home. One resident had moved into the home three weeks before the inspection but no risk assessments were in place although there were clear records on file that the person had had two falls at home before they moved in. Daily records were in place on each file looked at; these were generally very task focused and didnt reflect how people spent their time or reflect their well or ill being. These records had not been completed daily on some files looked at. On two care files looked at information had been recorded on the daily record in relation to health care needs but there was no record that this had been followed up, or in one case if the GP had been contacted as recommended. All four of the residents who completed our survey said that they always received the care and support they needed. Three people said staff always listened and acted on what they said and one person said that they usually did. Three members of staff completed our survey, all of whom said they were given up-to-date information about the people that they looked after. Body maps were on file when people had sustained injuries or how pressure sores. These have been used on several occasions in one case for a period over a year and it was difficult to work out which injuries or wounds were current. We saw records that documented some aspects of personal care given to residents including nail care, these records included details of all residents and were not kept in a way that met the requirements of the Data Protection Act 1998. It was evident from looking at records that people have access to health and medical professionals whenever necessary. Appropriate aids and adaptations Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 14 are provided including equipment to reduce the risk of pressure sores. All for of the residents who completed a survey said that they always receive the medical care that they needed. Four professionals completed a survey all said that residents’ health and social needs were always properly monitored and reviewed, three said that the home always sought advice and acted upon it and one person said that the home usually did. One professional commented that ‘I get a very good impression of the care in the house. They always call appropriately. Very personalised care with good atmosphere’. We observed that care staff knocked on residents’ private doors before entering and treated people with respect and courtesy. All four professionals surveyed said that they felt that the service always respected residents’ privacy and dignity. One relative who completed a survey commented that they felt that the home encourages and supports people to be independent as much as they are able to with support available when needed. They went on to comments that when they visited’ Ive always been impressed with the good standards of care and conditions’. We looked at the way that medication is managed in the home. The manager, Mrs Burt told us that only staff that had completed training were authorised to give medication. There was no evidence that their competency to do so was reviewed by the manager, even though issues of concern (as noted below) were evident. Controlled drugs were stored safely and securely and records checked were found to be correct. Records of controlled drugs were kept in a home-made book. It was evident that there were gaps in recording and several occasions when the medication administration record (MAR) charts had not been signed to say that medication had been given as prescribed. The recording that prescribed creams and ointments had been given was poor. Some residents are prescribed medication as required (PRN) but there was no rationale in place giving guidance to staff in what circumstances the medication was to be given, the dosage, the length of time between medication and the maximum dose to be given within 24 hours. It was evident from checking the MAR charts that on some occasions medication had been allowed to run out. Monthly medication audits are undertaken by two senior members of staff and these are signed by Mrs Burt. However, there was no evidence of any action taken by Mrs Burt in relation to the above issues which should have been picked up and addressed as part of the management auditing processes. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the 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 routines of the home are flexible to suit the choices and preferences of people who live there. People are very satisfied with a range of activities available in the home but would welcome more opportunity to go out. Visitors to the home are made welcome unable to visit at any time. Residents are satisfied with the standard and variety of food available. EVIDENCE: All the residents spoken to told us that they were able to get up and go to bed at times to suit themselves with staff offering assistance when needed. A hairdresser visits the home regularly and there is a weekly trolley service enabling service users to make small purchases. The care staff arrange Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 16 activities. On the day of the inspection nine residents were in the lounge singing with staff. We observed that the atmosphere was relaxed and enjoyed by both residents and staff. The home has an activities programme that the AQAA told us included Scrabble, bingo, art and craft work, skittles and singalongs. The library service visits monthly and one resident place the piano for the enjoyment of other people in the lounge. Residents have the opportunity to continue with their religious worship with clergy visiting the home and some people being supported to attend a local church. All residents spoken to on the day of the visit said that they enjoyed the activities but the majority would like more opportunities to go out of the home on trips. For residents who completed a survey said that that was always activities arranged that they could take part in. one resident who completed our survey when asked what the home could do better that they would like ‘more outings please’. One member of staff who completed our survey when asked what they thought the home could do better said’ taking them out more (residents)’. The homes notice board in the dining room was displaying the previous days date when we arrived and this had not been changed when we checked in the afternoon. The home has two cats and one resident has birds in her room. Residents spoken to confirmed that their visitors are always made welcome and able to visit at any time. Two relatives completed our survey one of whom said that the home always helps their relative keep in touch and they were kept up-to-date about any change in circumstances. One response was blank in relation to these two questions. The menu is not displayed for residents to see. Staff told us that residents are asked in the morning what they would like for lunch and tea. The main meal is available at lunchtime with two choices and a lighter meal is served at teatime. The majority of residents have breakfast in their private rooms which consist of a choice of cereals, fruit juice, grapefruit, prunes and toast. Residents are not offered the choice of a cooked breakfast. Four residents completed our survey one person said they always like the meals at the home, two people said that they usually did and one person said that they sometimes did. Comments made on the day included’ the food is very good’ and’ there is always a choice’. Residents have a cake on their birthday. The cook told us that a choice of vegetables is served at the main meal every day. They told us that they were aware of how to enrich food for those at nutritional risk but that they have no current good practice guidance about this. We observed that there were sufficient food stocks and a good range of good quality fresh, frozen, dried and tinned goods available. Appropriate food safety records were in place. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to make sure that people are able to raise concerns with confidence. Adult protection procedures at the home are poor and do not protect people who live there. EVIDENCE: The home has a complaints policy and procedure which met the national minimum standards and included the contact details of external agencies. Neither the Commission nor the home had received any complaints or concerns. All the people spoken to on the day of the visit were confident that they could raise any concerns or complaints with the registered manager and that they would be listened to and taken seriously. Four people completed our survey and they all said that they knew how to make a complaint if they had any problems and confirmed that they all knew who to speak to informally if they wanted to. There has been a recent adult protection investigation at the home. The training matrix supplied by Mrs Burt showed that all staff has completed Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 18 training in adult protection. The homes adult protection policy states that’ care staff have a duty to report concerns about abuse’ but during the investigation it became clear that several staff were aware of the issues and had not reported it to the manager or any external agencies. The homes policy also states that ‘if the matter is serious’ suspension would be considered the normal course of action to follow’. Mrs Burt reported the allegation to Social Services and the Commission but appeared unaware of the homes policy in relation to suspension of staff accused of abuse. The member of staff concerned was only suspended following further consultation with the Commission. It was clear from records looked at that when the manager became aware of the issues that although they were reported they were not taken seriously. We are unable to include any further details due to the serious and confidential nature of the allegation. Three members of staff completed our survey and they all said that they knew what to do if there were any concerns raised (please refer to notes above). One relative who completed our survey said they knew how to make a complaint and one person said that they didnt. Four health and social care professionals who completed a survey said that the home always responded appropriately if any concerns are being raised. The home has an adult protection policy and a copy of the locally agreed Dorset wide policies and procedures. A whistle blowing policy was in place but did not include the contact details of Public Concern at Work or the current contact details of the Care Quality Commission. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the 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 provides a good standard of accommodation that is personalised to reflect individuals s choices and preferences. Infection control measures are in place but need to improve to reduce the risk to residents and staff. EVIDENCE: The home was clean and tidy and free from unpleasant odours on the day of the visit. All the residents spoken to confirmed that this was usual and that they were satisfied with the standards of the environment that they live in. Residents are encouraged and supported to personalise their private room and Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 20 are able to bring in their own belongings including furniture. Rooms are refurbished when they become vacant. The home has plans to extend the building to provide some en suite facilities. Four residents completed our survey and they all said the home was always fresh and clean. One professional surveyed commented that Legh House’ provides a homely atmosphere’. One resident commented that they would like to have ‘a visit is room where friends and relatives could come and stay for a short period’. The rear garden of the home is very well maintained and provides a lovely accessible patio area as well as the garden. Good-quality outdoor furniture is provided residents are unable to help in the garden if they want to the support provided if necessary. One resident commented that ‘the garden is beautiful, I didnt think I would be lucky enough to come here’. The home has an ongoing maintenance programme to make sure that standards are maintained. There are 15 single rooms with level access. One self-contained care suite, which may be used by two people choosing to share, is accessible by two steps. The suite has its own bathroom with a wet room including shower basin and WC. The remaining bathroom facilities are communal, comprising of an assisted bath and wc, a walk-in shower and wc, a conventional bath and wc and a separate wc. There is a separate sluice room. To the rear of the premises there is a spacious dining/sitting room leading through to a conservatory. There are scenic views of Portland Harbour from the dining room. The communal bathrooms, toilets and shower room were all clean and tidy. Protective clothing including aprons and vinyl and latex gloves were available for staff. However, not all bins were foot operated, antibacterial hand wash was not available in all areas and in one bathroom a cloth towel was in place. In one bathroom a list of all residents and their allocated time for having a bath was on display. We observed that in a shower room a cleaning product was not stored securely. There is a separate laundry and sluice room. The door to the laundry had no signage and neither room were lockable. Items are transported to the laundry in an appropriate way. Laundry from the kitchen is washed in a separate machine in the staff room. The home uses dissolvable laundry sacks to avoid double handling of soiled items and the commercial washing machine has a sluicing cycle. The floor is nonporous and there were paper towels available for staff to wash their hands. However, there was no foot operated bin for waste, no antibacterial hand wash and we saw dirty washing left on the floor contrary to good practice. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels were appropriate to the needs of the residents. Residents had confidence in the staff that looked after them. The training programme ensures staff have the appropriate skills and knowledge to meet residents’ needs. Recruitment processes of staff are robust but volunteer recruitment is poor. EVIDENCE: A staff rota was in place, detailed staffs designation and this demonstrated that there was enough staff on duty to meet the needs of residents. Two members of staff are awake during the night shift. The home employs appropriate numbers of domestic staff. The registered manager told us that the staff team and stable and that there were no problems in recruiting staff when vacancies occur. The home does not use agency staff. Four residents completed our survey three of whom said there was always staff available when they needed them and one said that the usually was. Three members of staff completed our survey one of whom said there was always Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 22 enough staff available to meet residents’ needs, one said they usually was and one said there sometimes was enough staff. one member of staff when asked what the home could do better commented that’ an extra care in the mornings’ would be useful as ‘ it is always busy in the morning ‘.All the staff survey said they felt that they always had enough support, experience and knowledge to meet peoples needs. We looked at the recruitment files of two members of staff who had started work at the home since the last inspection. All the required documentation had been obtained before they had started work at the home. Staff receive terms and conditions of employment after they have completed a probationary period but are not given their own copy of the General Social Care Council code of conduct. We also looked at the recruitment file of a volunteer which included a satisfactory CRB disclosure. Whilst the volunteer policy and the AQAA says that they will be recruited in the same way as permanent staff and will be offered regular supervision there was no evidence of this on the volunteer file checked. References had not been obtained, there was no record of the proof of identity of the individual, that they had been supervised or had received appropriate training. The two new members of staff were undertaking the Skills for Care common induction standards in line with good practice. Three members of staff completed their survey all of whom said that they were offered training that was relevant, up-to-date and help them meet the needs of individual residents. one members have commented that’ I have up-to-date training and support when needed’. The AQAA told us that nineteen out of twenty two care staff had achieved qualifications to a least NVQ two or above. However, the training matrix supplied by Mrs Burt told us that only seventeen staff had achieved these qualifications. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36, 37 and 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is poorly managed with staff unsupervised and a lack of effective management audit systems. Residents’ personal finances are managed appropriately. Quality assurance systems are in place to seek the views of residents and inform the homes improvement plans. Health and safety is taken seriously and well managed to make sure that people who live and work at Leigh house are safe. EVIDENCE: Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 24 The home is operated by Abbeyfield and there is a management team who regularly visit the home and carry out independent checks on the service. Mrs Ann Burt is the registered manager and is in day to day control. Mrs Burt has achieved qualifications at NVQ level IV in management and care. The registered manager completed and returned the AQAA as required in a timely manner. Please refer to outcome group four, complaints and protection for greater detail about management concerns. The rating in this outcome group takes into account the concerns detailed in outcome group four. The home uses surveys and meetings to seek the views of residents and visitors to the home. Responses to surveys are collated and show satisfaction levels in most areas. The home has a continuous improvement plan which is used to record the outcome of the surveys and the action being taken. Three health and social care professionals who completed a survey said that they thought that the homes manager and staff always had the right skills and experience to meet residents’ needs. one member of staff who completed our survey commented that the manager was’ always helpful and available’, with another member of staff say in that the’ managers door is always open’. The home has a range of policies and procedures relating to equality and diversity covering both the recruitment of staff and the way the home is run to make sure that all members of the community are made welcome and an individuals rights to make different lifestyle choices is respected. We looked at the way that residents personal finances are managed by the home. It was suggested to the registered manager that the term personal allowance was used rather than pocket money (as used in the AQAA). The AQAA told us that a policy in relation to the management of residents’ finances was in place, dated April 2008, but on the day of the inspection it was not available. We checked the personal allowances of four residents and all were found to be correct. Records were well-kept with two signatures of staff to every transaction. There was no evidence that financial records were independently audited. The AQAA told us that ‘all staff are supervised however as yet the home is not yet able to be at the stage where six written formal records of supervision have been achieved’. On the day of the inspection it was clear that there were no formal supervision systems in place .We were shown brief notes made by Ann Burt in a communication book which recorded some issues raised with some members of staff but she confirmed that there was no supervision policy and that some individuals have never received formal supervision of their Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 25 practice. The training matrix showed that neither Mrs Burt nor any senior staff had undertaken training in supervision. The way in which this information was recorded was not in line with the requirements of the Data Protection Act. Three members of staff completed our survey two of whom said they met regularly with the registered manager one of whom said they sometimes did. The communication book noted several incidents of poor practice by staff and incidents of disagreements and tension between staff but there was no evidence that this had been investigated or addressed by Mrs Burt. One member of staff case tracked had a reference from a previous employer stating that they required supervision. There was a reference in the communication book to a complaint from members of staff about this person but there was no evidence that Mrs Burt had taken it seriously, investigated it or provided the person with formal supervision. There had been three residents meeting since the last inspection with all residents invited to attend a minutes taken. All residents spoken to during the inspection told us that they were able to speak freely at these meetings. There had been three staff meeting since the last inspection with minutes taken and available to staff. Information recorded included personal information about individual residents that should have been recorded on their individual care plans. An accident book was used by staff to record any injuries or accidents that occur to residents. We checked entries against care plan daily records and these were all found to be correct. However, two entries looked at recorded injuries but there was no record of what treatment if any had been given. From talking to Mrs Burt and checking records it was evident that deaths had occurred at the home that had not been reported to the Commission and that people had been admitted to hospital following accidents but these had also not been reported to us in line with the Regulations. We looked at the homes communication book and noted an entry in April 2009 recording and medication error. This had not been reported to the commission in line with the requirements of the regulations. The homes insurance certificate on display had expired on 31 December 2008 which the registered manager was unaware of. We requested that the current certificate was faxed from the organisations head office. The homes registration certificate was displayed. The AQAA told us that all the equipment in the home is serviced and maintained to make sure that it is safe to use. Policies and procedures were in place in relation to health and safety to make sure that people who live and work in the home are protected from the risk of harm. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 26 We saw records that showed that the fire alarm and fire safety equipment is regularly tested and serviced by an external contractor. The emergency lighting had been serviced but there was no record that it was tested monthly to make sure it was in working order. Mrs Burt told us that all staff have completed mandatory training. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 2 3 1 1 2 Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 28 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 OP8 Regulation 13(4)( c ) Requirement The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This refers to falls risk assessment. To identify risks and put in place control measures to reduce the risk of re-occurrence. 2 OP9 13 (2) The registered person shall make 30/08/09 arrangements with recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (This relates to the lack of rationale for PRN medications, medications running out, gaps in MAR sheets and prescribed creams not being administered). This is to make sure that medication practice is safe. 3 OP9 37 The registered person shall give DS0000026835.V375859.R02.S.doc Timescale for action 30/08/09 30/08/09 Page 29 Legh House Version 5.2 notice to the commission without delay of the occurrence of any event in the care home which adversely affect the well-being or safety of any service user. This relates to medication errors. To make sure that medication is administered safely. 4 OP18 13 (6) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. To make sure that people who live in the home are safe and then the allegations received are taken seriously. 5 OP36 18 (2) The registered person shall ensure that persons working at the care home are appropriately supervised. This is to make sure that the care practice of individuals is monitored and reviewed and staff are offered appropriate support. 6 OP38 37 (1) (a) ( c ) The registered person shall give notice to the commission without delay of the occurrence of the death of any service user, including the circumstances of his death. The registered person shall give notice to the commission without delay of the occurrence of any serious injury to a service user. To make sure the commission is informed without delay in line Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 30 30/08/09 30/08/09 30/08/09 with the regulations. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP8 Good Practice Recommendations Daily records should be completed daily and should be more person centred. Urgent consideration should be given to using a new body map every time someone sustains an injury or pressure sore. Risk assessments should be completed on admission and reviewed and updated regularly as necessary. (This includes nutritional risk assessments). Serious consideration should be given to keeping nutritional risk assessments in residents care plans. Serious consideration should be given to purchasing an appropriate controlled drugs register. The notice board giving details of the date should be updated every day so that it is accurate. The registered manager should consult with service users about their wishes to have the opportunity to out of the home more. Consideration should be given to displaying the menu. Current good practice guidance should be obtained on the nutritional needs of older people. The whistle blowing policy should include the contact details of public concern at work and the current contact details of the Care Quality Commission. All bins in communal bathrooms, toilets and the laundry DS0000026835.V375859.R02.S.doc Version 5.2 Page 31 3 OP8 4 5 6 7 OP8 OP9 OP12 OP12 8 9 10 OP15 OP15 OP18 11 OP26 Legh House should be foot operated to reduce the risk of cross infection. 12 OP26 Antibacterial hand wash should be available in all communal toilets, bathrooms and the laundry. Bars of soap should not be used in communal toilets. 13 14 OP26 OP26 Cloth towels should not be in communal bathrooms or toilets to reduce the risk of cross infection. The door to the sluice and laundry should be kept locked at all times. The door to the laundry should have signage on it. Dirty washing should not be left on the floor of the laundry. 15 16 17 OP29 OP35 OP36 All staff should be given their own copy of the General Social Care Council code of conduct. Personal allowance records should be regularly audited. A supervision policy that meets the national minimum standards should be developed as soon as practicable. All staff should receive formal supervision at least six times a year in line with the national minimum standards. Staff should be given their own copy of supervision records. 18 19 OP36 OP37 The registered manager should undertake training in how to undertake formal supervision. All records should be constructed and maintained in line with the requirements of the Data Protection Act 1998. This includes bathing records, staff meeting minutes, records of personal care, the diary/communication book and staff supervision. All cleaning products should be stored securely. Emergency lighting should be tested monthly to make sure it is in working order. 20 21 OP38 OP38 Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 32 22 OP38 The accident book should record any treatment given to service users. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 33 Care Quality Commission South West Citygate Gallowgate Newcastle uponTyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Legh House DS0000026835.V375859.R02.S.doc Version 5.2 Page 34 - 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!