Inspection on 26/04/07 for Leighswood Residential Home

This inspection was carried out on 26th April 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Leighswood Residential Home 06/06/06

Leighswood Residential Home 14/11/05

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 Mrs Kathryn Marks Key Unannounced Inspection 26 April 2007 09:00 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.V335387.R01.S.doc Version 5.2 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.V335387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leighswood Residential Home Address 186 Lichfield Road Rushall Walsall West Midlands WS4 1ED 01922 624541 F/P01922 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.V335387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 and over Date of last inspection 9th January 2007 Brief Description of the Service: Leighswood Residential Home is a care home registered to provide accommodation and personal care for 23 people over the age of 55 years with a diagnosis of dementia. Dr.S.S.Gakhal owns Leighswood 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. There are separate lounge and dining facilities with plans to refurbish these areas. There is a small garden to the rear of the rear of the home. Leighswood currently charges service users £354 to £367 per week. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 26/04/07 and covered all of the core standards. The inspection took place over 7 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. A tour of the home took place with the Care Manager and staffs the people living here being involved as they wished whilst walking around. Prior to the inspection visit, survey information has been requested from individuals and their relatives. The inspection included an examination of records, indirect observation, and limited discussion with the people living here although understanding and conversation at times is limited due to dementia. The Care Manager was available throughout the inspection other staff were spoken with whilst working with individuals. Case tracking of three care plans took place. Three staff records were examined and observations were made of interaction with people living here and visitors during daily routines. What the service does well: The homes staffs continue to provide a relaxing environment for all people living here that were seen to be moving freely around the home. There was warm and friendly interaction between staff and People that contributed to the homely feel of Leighswood Care Home. Comments from People and relatives included “I feel safe” “Choice of menu” “Very tasty food and enough to eat” “happy here and enjoy the company” “managers door always open to People living here and visitors” Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 6 “I am not there 24 hours a day but I like to think the person I visit is being well treated and looked after as if I was there. I think the manager is sincere in her work and hope the rest of the staff are, which I believe they are” What has improved since the last inspection? What they could do better: 1.Further develop the assessment process with more detailed holistic information being recorded and ensure that records of assessments are on all individuals files. 2.Ensure choice of food available for breakfast is displayed. 3.Include choice of desserts on lunchtime menu. 4. The bench in the garden damaged by a person living here should be replaced. 5.Consideration should be given to upgrading bathroom no1 due to very low bath that staff can only access from one side and the general deteriation of the décor in this bathroom. 6. An audit of wardrobes should be carried out to ensure they are all secured to the wall. 7. Serious consideration should be given to the provision of a domestic at the weekends to ensure the home remains clean and free from infection. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 7 8. Health and Safety risk assessments for COSH were not available at the home the inspector was told that the General Manager is updating these. Documentation relating to the home should be available in the home at all times. 9. The review of the quality assurance system should be completed. 10. Please ensure that a copy of this report is passed to the Care Manager for staff, People living here and relatives 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. The summary of this inspection report can be made available in other formats on request. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 8 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.V335387.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. Quality in this outcome area is good. This means that information available to People who may consider living here and their relatives is clear and detailed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose and Service users guide provides prospective people with up-to-date details of the services the home has to offer, enabling an informed decision about admission to Leighswood Care Home to be made. All prospective people living here receive an assessment of needs prior to moving into the home to ensure that individual needs can be met. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 10 The care manager visits prospective people in their own homes or current surroundings and individuals have the opportunity to visit the home. Assessment forms where seen and would benefit from being further developed to provide more holistic information. The home does not provide intermediate care. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Health, personal and social care needs of people is well met. The systems for the administration of medication were observed by the inspector to be good with clear arrangements being in place to ensure the medication needs of people living here are well met. EVIDENCE: All People have an individual plan of care that identifies the care and assistance they require. Care plans also contained information relating to the individuals diagnosis, care needs, any specialist intervention and support and assistance required to enable people to live a meaningful life style. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 12 The policy of the home is for people living here to maintain their own GP support wherever practical; otherwise people are registered with the local health care practice. District nursing services are also received at the home as required by individuals. All special needs are identified on the care plan that is reviewed monthly or more frequently if required. Three peoples care plans were case tracked all information relating to them was sampled, accommodation was visited and individuals spoken with. Medication systems were secure and well organised a new medication fridge has been purchased. Medication Administration Sheets sampled were signed up to date. No person is currently self-medicating. Policies and procedures are in place for the management of medication. All senior staff has completed and is certificated in the management of medication. Social contacts of people living here are respected, and an open policy of visiting is promoted, without detracting from a respect for privacy, if so wished. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems in place that indicates that peoples views where possible are sought and acted upon. There was a relaxed and friendly atmosphere with people moving freely around the home. The cook and her staff at the home provide traditional food with a choice at all meals. EVIDENCE: During conversations with people living here and staff it was clearly identified that a relaxed and informal atmosphere existed in which individuals needs were paramount. There is a care assistant with responsibility for organising activities and a variety of events are available. Two People were identified as liking gardening and were able to potter in the garden. (Pull plants up rather than plant them), One person goes out each day in the afternoon. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 14 Relatives the inspector spoke to were very positive in their comments about the care observed at the home and the way their relative was cared for. All People have visitors either families or friends. Choices were available for aspects of daily living. Those people whose bedrooms were visited private space was personalised as individuals and their families wished. Locking devises had been fitted to bedroom doors enabling people who live here to choose whether they locked their door or not. The good standards of catering at Leighswood offered varied traditional meals. However there is a need to include choices available for breakfast and choice of desserts at lunchtime on the menu. Staffs were seen to offer discreet assistance to those who required it at mealtimes. The cook was observed prior to lunch asking people what they would like to eat. People spoken to after lunch said they had enjoyed their meal. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good this judgement has been made using evidence available including a visit to this service. The home has a satisfactory complaints system with some evidence that People living here feel their views are listened to. Regular staff awareness training takes place to protect people from abuse. EVIDENCE: The home has in place a complaints procedure that identifies the practices to be followed in the event of a complaint being made. This procedure was seen and is displayed in the hallway, contained in the Statement of Purpose, Service Users Guide and given to Relatives/People living at the home on admission. Staff training is carried out and has recently included Adult Protection, Pova, and Abuse Awareness. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,26. Quality in this outcome area is good the home provides a homely environment but would benefit from a general painting to freshen up. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The location and layout of the home is suitable for its stated purpose and provides a homely environment for people living here. Observations were made of people wandering freely around and having room to do so. Bathroom as identified with the care manager would benefit from upgrading due to low bath, access being only one side and the general state of the décor in this bathroom. The general manager told the inspector on 01/05/07 that work is due to commence on the bathroom. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 17 Peoples bedrooms visited were personalised as they wished some wardrobes were secured to the wall others were not. It is recommended in this instance that an audit of wardrobes be carried out to ensure all are secured. The home generally was clean and free from offensive odour but due to décor and chipped paintwork the physical environment overall including stairways and corridors would benefit from redecoration to enhance the home. Externally small rear garden with seating and patio area where work is to be carried out to improve the seating space. One of the people living here has damaged a bench it is recommended that this bench be replaced. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good this judgement has been made using available evidence including a visit to this service. Staff on duty at Leighswood Care Home was observed to be competent and satisfactory in number to meet the needs of individuals in their care. Staff morale was observed to be high with the staff team working well together assisting individuals where needed to make choices to improve their quality of life. Appropriate procedures are in place for the recruitment of staff. EVIDENCE: Staffs at this home were very welcoming and friendly creating an atmosphere of openness at Leighswood Care Home. At the time of this unannounced key inspection the inspector identified that staff on duty were as stated on the rota and were sufficient in number to meet the observed needs of people in their care. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 19 Staffs are experienced and were aware of the needs of individuals. Recruitment procedures are in place and prior to commencing employment all staff complete application forms two written references are obtained, Criminal Records Bureau checks and Pova checks are carried out. Regular programme of staff training is in place with records being maintained, individual training records are discussed at supervision. NVQ training is promoted at the home with training being booked for NVQ Level 2/3 for those staff who have not completed. Other training booked is as follows: Challenging behaviour Infection control Diet and Nutrition Fire Training Moving and Handling First Aid and Food Hygiene are all completed and up to date. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good this judgement has been made using available evidence including a visit to this service. The Care Manager is supported by the proprietor in providing clear leadership throughout the home with all staff on duty demonstrating an awareness of their roles and responsibilities to work as a team. EVIDENCE: The Care Manager has been at the home for 6 years and has 20 years experience in care of the elderly. Observations of the staff and the Home’s management, demonstrated that a positive relationship exists throughout the Home. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 21 The general manager to cover all standards and new legislation is currently updating quality assurance systems. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment. The management does not deal with the monies of people living at the home. Staff training programmes included relevant aspects of Health and Safety, first aid, moving and handling and fire training were recorded. All accidents and incidents were recorded for staff and service users, including provisions for Riddor should the need arise. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Service users benefited from competent and accountable management. Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X 2 X 3 X X 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 3 X X 3 Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes 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 OP21 Regulation 23, 2 (n) Requirement The registered provider must ensure that all bathrooms are provided to meet the needs of the service users Timescale for action 25/06/07 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 3 Refer to Standard OP3 OP19 OP19 Good Practice Recommendations More detailed information and assessments to be on all people’s files. Broken garden bench be replaced An audit of wardrobes be carried out to ensure all are DS0000020816.V335387.R01.S.doc Version 5.2 Page 24 Leighswood Residential Home 4 5 6 7 OP27 OP38 OP33 OP32 secured. Consideration to be given to the provision of a domestic at weekends. COSH risk assessments should be kept on site and available to staff. Review of the quality assurance system should be completed. Ensure that a copy of this report is passed to the Care Manager for Staff and people living at the home. Ensure choice of food for breakfast is displayed on the menu. Include choice of desserts on lunchtime menu. 2 OP15 Leighswood Residential Home DS0000020816.V335387.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 - 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!