Inspection on 14/11/05 for Leighswood Residential Home

This inspection was carried out on 14th November 2005.

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

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

Other inspections for this house

Leighswood Residential Home 26/04/07

Leighswood Residential Home 06/06/06

Leighswood Residential Home 10/03/05

Leighswood Residential Home 17/11/04

Leighswood Residential Home 29/04/04

Leighswood Residential Home 29/03/04

Leighswood Residential Home 08/08/03

Leighswood Residential Home 27/08/02

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

CARE HOMES FOR OLDER PEOPLE Leighswood Residential Home 186 Lichfield Road Rushall Walsall West Midlands WS4 1ED Lead Inspector Richard Eaves Unannounced Inspection 14th November 2005 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leighswood Residential Home Address 186 Lichfield Road Rushall Walsall West Midlands WS4 1ED 01922 624541 01922 624541 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) Quality Homes (UK) Limited Mrs Lynne Shirley Care Home 23 Category(ies) of Dementia (23) registration, with number of places Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 and over Date of last inspection 23rd May 2005 Brief Description of the Service: Leighswood is a care home providing accommodation and personal care for 22 people over the age of 55 years with a diagnosis of dementia. It is owned by Dr. S.S. Gakhal along with two further homes in the area. The home is located in Rushall, within easy access of the local amenities and is a bus ride away from the centre of Walsall. The home was initially registered in 1986 and is a detached two-storey property. There are 15 single occupancy rooms with 4 double rooms, 9 of the single rooms have en-suite facilities. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by one inspector over one day. The focus of the inspection was on the delivery of care and included case tracking. The inspector had opportunity to speak with all the service users and those able to communicate were positive regarding life at the home and they all appeared content. There was a relaxed atmosphere among service users and staff. The inspection also included a tour of the building, meeting with service users and inspection of records. What the service does well: What has improved since the last inspection? Care planning is good overall and identifies problems and needs to be addressed well and has been expanded to direct staff more specifically clearly identifying each action required to address the need. The use of processed foods and frozen vegetables has been reduced and make up a much smaller part of the menu. The provision and range of fresh fruit has been improved. The supply of full cream milk has been increased provides a good source of nourishment useful in the care of elderly frail people. Hot water management has been objectively assessed and appropriate controls, monitoring and servicing implemented. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4 The homes Statement of Purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. The staff group are stable well established and collectively have the knowledge and skills to meet the assessed needs of current service users. EVIDENCE: The Statement of Purpose and service user guide were reviewed and updated at the start of this year and meet the requirements listed in the regulation and schedule 1 of Regulations. All residents’ files include a contract and a letter of confirmation that service users needs can be met by the service. Assessments are undertaken by the manager prior to acceptance for admission and takes account of the community care assessed needs. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. All service users are registered with a GP and the district nursing service visits on request. The chiropodist visits every 8 weeks, annual ophthalmic checks are arranged. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 10 Medication arrangements are good using a monitored dose system supplied by 8pm chemist. Staff receive accredited training prior to being included to administer medicines. Staff were observed to interact well with service users in a respectful manner, use preferred terms of address and are sensitive to protecting the service users dignity in dress, toileting and cleanliness. Service users needs and wishes at the time of dying are assessed fully at the time of their admission. The manager advised that a recent death of a service user the home were able to help and support the service user and family to stay at the home as was their wish. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The home provides well-organised and varied social and recreational activities that provide interest and pleasure for the residents. Visitors are welcome and help to keep service users interested in the wider community Many aspects of care evidences that service users exercise choice and control over their lives. The meals at Leighswood are good, offering both choice and variety. EVIDENCE: The home provides a wide range of dementia appropriate activities within and outside of the home on a twice a day basis, with inputs from external leaders offering keep fit exercise and craft activities. Summer activities have included trips to the safari park, a canal trip and a visit to the theatre. The service users choose the trips they would like at regular meetings. In house activities include music and movement, singalongs, current favourites being music of the 40’s and 50’s. Recent crafts have been making flower basket arrangements and decorative table mats. A Christmas party away from the home has been planned. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 12 Three service users took a holiday during September at Blackpool in association with other homes in the group. The home has open visiting and many families play an active role in the life of the home. Service users and their families produce a personal profile which identifies those aspect of lifestyle that are important and hold memories, it also identifies long held likes and dislikes and staff find it useful in getting to know the individual. The 4-week rotating menu provides for a nutritious diet and choice, take up by individual service users is monitored and recorded. Cooked options are available at breakfast, lunch and high tea and snacks are available at all times. Previously observed high use of processed foods has been addressed and now provides a much smaller proportion of the menu, which also now includes the high tea. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 The home has a satisfactory complaints policy and service users supporters can be confident that their views will be listened to and acted upon. Staff have all undertaken adult protection training with social services preparing them to uphold the welfare and rights of the service users. EVIDENCE: The home has a detailed complaints procedure which is well promoted by way of notices and the service users guide. No complaints have been received in recent times. All staff have attended adult protection training provided by the local social services and also through NVQ training which all staff have either completed or are currently undertaken. At the completion of the electoral roll recently 7 service users applied for postal votes for the coming year. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 The home provides a good standard of décor, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The bedrooms have bathrooms in close proximity for the convenience of service users and some have en-suite. The home is clean, free from odours and hygienic. EVIDENCE: Since the inspection in May the home has refurbished the dining room and replaced the tables and chairs. A new call system has been installed and some additional smoke detectors fitted. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 15 On the day of inspection the home was clean and free from offensive odours. The decoration is in good condition having been undertaken recently, the bedrooms and communal rooms have been redecorated to a good standard and are comfortably furnished to provide a homely environment. Records are kept which detail routine maintenance, monitoring of services and the environment, an inspection of these show them to up to date and within the safe range. A further decoration programme is due to commence and will complete the repaired ceilings damaged by a roof leak, which has been repaired. The manager advises that a sluice disinfector has been obtained and is due to be plumbed in. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 Staff are enthusiastic and well trained and committed to maximising the service users quality of life. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: The rotas confirm that numbers across the 24hour period are appropriate to the needs of service users. The ancillary services provide a full 7-day service. The standard of 50 of care staff being trained to NVQ level 2 standard has been exceeded and continues to be increased. All staff have an individual training record and a training matrix of mandatory and other regular training required. Recruitment and selection are completed to a good standard and includes all necessary checks such as CRB and POVA. Staff files also show that two references are obtained and a record kept of the interview. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance, which includes seeking the views of service users and their families. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 18 EVIDENCE: The home is led by an experienced and well qualified manager. The home is currently engaged in a survey of service users satisfaction and previously the March survey results were positive with very good levels of satisfaction. Other quality monitoring is undertaken and the area manager undertakes monthly regulation 26 inspections. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in health and safety and fire safety. A fire risk assessment was available and this is subject to review as changes occur. Certification of a range of servicing and annual inspections undertaken of all utilities and equipment in the home are maintained and up to date. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 19 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 20 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 OP26 Regulation 13(3) Requirement A sluicing disinfector must be fitted to reduce risk of potential infection to service users and staff. Timescale 31/08/05 not met. Timescale for action 31/12/05 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 OP21 Good Practice Recommendations The registered person is advised to consider increasing the provision of assisted bathing facilities. Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Leighswood Residential Home DS0000020816.V264714.R01.S.doc Version 5.0 Page 22 - 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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