Inspection on 06/06/06 for Leighswood Residential Home

This inspection was carried out on 6th June 2006.

CSCI 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 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 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 Mandy Beck Key Unannounced Inspection 6th June 2006 09:00 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.V298463.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.V298463.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 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.V298463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 55 and over Date of last inspection 14th November 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. There is a small garden to the rear of the rear of the home. Leighswood currently charges service users £343.64 per week with an additional £12.98 for a room with en suite facilities. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place between 0900 hours and 1530 hours. The judgements and requirements made in this report are as a result of information supplied to the Commission for Social Care Inspection by the registered manager, talking to service users and relatives. Service users and staff files were also seen to ensure required standards are being met. A tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: The registered provider must begin to upgrade the environment, there are chairs, beds and other furnishings which now need replacing. The bathroom on the first floor is not easily accessible for use by the disabled or those service users who need close assistance. Relatives have commented “the walls could be brighter”, “there could be some memory boards and large clocks”. The garden is not easily accessible for service users there is insufficient seating for service users, the patio is uneven and poses a trip hazard and there is a large amount of unused equipment that needs to be removed. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 6 Care planning systems need to be improved to ensure that all service user needs are included and a management plan is formulated. 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.V298463.R01.S.doc Version 5.2 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.V298463.R01.S.doc Version 5.2 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): 2,3,4,5 Service users do receive a contract of terms when they enter the home. Their needs are fully assessed before admission to the home. All service users are encouraged to spend a trial day before agreeing to stay at Leighswood. Staff are receiving appropriate training to meet the needs of service users. EVIDENCE: Service users receive a contract of terms and conditions of residency, these must be updated to ensure that service users rights are protected against potentially unfair terms. The manager visits all service users in their own home prior to admission to complete an assessment of need. Service users are encouraged to spend a day at the home to ensure that they like what they see and feel that it is the right place for them. The manager will write to all service users informing them that the home and care staff will be able to meet their needs. All staff have received basic training in dementia care and are to be enrolled on accredited dementia training course in the near future. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 All service users have an individual plan that details the care and assistance they require. Every attempt is made by care staff to ensure service users have access to health care professionals should their needs require it. Medication is generally administered in a safe manner that protects service users well being. Service user are treated with dignity and respect at all times by all members of staff. EVIDENCE: All service users have an individual plan that informs them and care staff of the needs they have and how they will be met whilst they stay at the home. Service user files were seen and generally were completed. One service user had recently been admitted to the home on a temporary basis there had been no paper work completed for them. The manager must ensure that even if service users are admitted on a temporary basis they must have care plans that details their care needs and these must be documented in order for the home to be able to demonstrate they are meeting service user needs. There was evidence that service users have access to community health services such as dentistry, opticians, chiropody and community mental health Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 11 nursing service. Each service user has a risk assessment to determine whether they are at risk of developing pressure sores and if they need assistance with moving and handling. Currently the home does not have a falls risk assessment and does not screen service users upon admission for nutritional needs, the manager must address this to show that all needs have been assessed and acted upon. It was also noted that service users who have specific needs such as behaviour that challenges, diabetes and constipation had no management plan this must be done to ensure the well being of those service users and to give staff clear instruction on how to deal with these issues. Relatives spoken to were very complimentary about care staff and the way in which they look after their relatives commenting “they look after them here you know, if ever they need the hospital they go and quickly”. “I have complete peace of mind knowing she’s here I have no worries at all”. Medication is generally administered in a safe manner, only staff that have completed accredited training in safe handling of medicines administering medication. There are robust systems in place for ordering, receipt and return of medication. The manager must ensure that Medicine Administration Record sheets do not indicate “as required”, all medicines must have a specific dose and frequency of administration to reduce the risk of errors occurring. The home does not have a fridge for the specific storage of medicines, this must be addressed. The current arrangement is unsatisfactory, medicines are being stored in the kitchen fridge which the service users have access to when they make drinks, this means if service users have access to the fridge they also have access to the medicines stored within it. During the inspection staff were seen to be courteous to all service users and spoke to them in a polite manner. They were seen to be knocking on doors before they entered service users bedrooms and toilets. All service users receive their mail unopened and staff will assist as necessary. Service users are addressed in terms they prefer and all were seen to be clean and dressed appropriately. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Service users are encouraged to make choices about the activities they take part in, the food they eat and the visitors they receive. Meals provided are appealing and are served at times convenient to the service users. EVIDENCE: Service users have access to an activity organiser twice a month, she visits the home and encourages those who want to participate to do music and movement. The service users have recently replanted the flower beds at the front of the home and on the day of inspection were attempting to weed the beds on the patio area, some service users commented “the garden could be better, if they’d get us plants we’d do it, we like it”. A number of the service users attend day centres during the week this helps them to maintain links with the community and their friends. The home operates an open visiting policy but does prefer visitors not to arrive at mealtimes as this tends to unsettle the service users and distracts them from eating at times. The home must provide details of advocacy services for all service users so that they have the opportunity to contact if they wish. Service users are Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 13 encouraged to bring their personal possessions into the home with them with prior agreement from the manager. Currently the home does not have a cook and care staff are taking it in turns to do this duty. On the day of inspection service users were seen to be enjoying their meals, they looked appealing and were of generous sizes. All service users are offered a choice of meal and the home provides a menu on a four weekly rota. Hot and cold drinks are available as needed, service users are encouraged to use the kitchen themselves to make drinks and small snacks under supervision of staff. The care staff do their best to make mealtimes a relaxing affair which can be challenging at times because of some of the behaviour the service users display. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 14 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 responds positively to all concerns and complaints and service users can feel sure that their views will be acted upon and taken seriously. Staff have undertaken training to help them safeguard service users welfare and rights. EVIDENCE: The home has a detailed complaints procedure which is well promoted. All of the relatives spoken to said they knew who to complain to if they were unhappy about any aspect of care. “we never have to but Linda will sort it out if needed”. The home has not received any complaints since the last inspection in November 2005. Most of the staff have received some training in adult protection and there are plans to provide more training for those staff that need it. The home has been involved in one adult protection investigation recently and it dealt with the matter promptly and in full cooperation with the protection agencies and social services. The homes policies ensure that all staff know how to report any practice that they feel is inappropriate and know that this will be investigated. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 15 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): 19,20,21,22,24,25,26 The environment is in need of improvement to ensure that it provides a homely environment for service users. The outdoor communal space needs to be improved to ensure that all service users can access it if they wish to. EVIDENCE: The environment is in need of upgrade and the provision of new furnishing and equipment to ensure that service users need for comfort is being met. A tour of the premises revealed that some beds were broken, mattresses were stained and bedding was of poor quality with lumpy pillows and quilts. The home has an institutional feel to it and service users must be consulted about the use of lino in their bedrooms and their decisions must be documented. The rubber mats must be removed as some have perished and others have an odour despite regular cleaning. Flooring in toilets must be reassessed, because some areas are stained and have lifted, and appropriate action taken. Easy chairs in the day rooms need repair or replacement some of the chairs seen were ripped and others had the varnish worn off. Relatives have also Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 16 commented “that walls could be brighter”, “needs brightening up”, “memory boards and extra large clocks would be a good idea”. Service users do have limited access to the garden at the rear of the home however the ramps and patio are uneven and in some places pose a trip hazard to service users. There is insufficient seating for all service users in the garden and service users commented “if they buy the flowers we will plant them I like weeding”, “ I don’t go out much”. Service users do not use the bathroom on the first floor as they find it difficult to access; this room is currently being used as staff toilet. Since the last inspection the home has taken delivery and installation of a sluice disinfector this means that all commode pots are being cleaned at a temperature that will help minimise the risk of cross infection. The laundry is small but has the necessary equipment to wash service users clothing with a sluicing cycle to ensure that disinfection standards are met. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There is sufficient staff on duty to meet the needs of the service users. Staff are generally recruited in a safe manner. All staff are receiving training to give them the skills they need to do their jobs. EVIDENCE: There are sufficient numbers of staff on duty 24 hours a day these are appropriate to the needs of the service users. All staff have an individual training record and the numbers of staff who have completed their NVQ level 2 meets the minimum requirement. In addition to this some staff have completed their NVQ level 3. The manager has enrolled staff on additional training to supplement the knowledge and skills they already have. Recruitment and selection is generally of a good standard and staff files were seen to ensure that all necessary checks had been completed. Although one staff file showed that a member of staff had commenced employment without a CRB disclosure or POVA first. This was bought to the managers attention during the inspection and steps to rectify the situation put into place. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The home is run in the best interests of the service users, the manager demonstrates good leadership skills and service users benefit from consistency. The home continues to monitor it’s performance and the quality of the service it provides. The home does not manage any service users monies. Generally the safety and well being of service users and staff is promoted. EVIDENCE: The home continues to be led by an enthusiastic and well qualified manager, since the last inspection Linda has completed her Registered Managers Award. The home actively seeks the views of relatives and other interested parties in order to review the service it is providing. This is pleasing to see but needs to be developed further so that the results of surveys are published and action plans for improvement can be drawn up, this demonstrates the home’s commitment to continuous improvement. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 19 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. Certification of a range of servicing and annual inspections undertaken of all utilities and equipment in the home are maintained and up to date this was based on information provided in the pre inspection questionnaire completed by the manager. Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 20 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 2 2 X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b)(c) Requirement Timescale for action 01/08/06 2 OP4 18(1)(c) (i) Conditions and terms of residency must be reviewed using guidance from the Office of Fair Trading 2003 All staff must undertake 01/09/06 accredited dementia care training, All staff must undertake training in “behaviour that challenges” All care staff must receive training in care planning and documentation All service user plans must include a risk assessment for the prevention of falls The manager must demonstrate service user involvement in the review of their care. All staff must receive training in risk management All service users must have a nutritional screening completed upon admission There must be individual 3 OP7 18 (1) 15 (2) sch 3 (m) 01/09/06 4 OP8 17(1)(a) sch 3 (m) 01/08/06 Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 22 5 OP9 13 (2) management plans for those service users who display behaviour that challenges, and for those service users who have physical ailments that need to be addressed, i.e. diabetes and constipation Medicines must be prescribed with a dose and frequency of administration not “as directed” The registered provider must supply a fridge specifically for the safe storage of medicines All staff must receive training in adult abuse awareness that includes adult protection procedures A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and implemented with records kept. A copy of the programme with dates for completion must be forwarded to the CSCI The registered provider must make accessible the outdoor space for all service users and designed to meet the needs of service users with dementia. The patio must be made even. There must be sufficient seating for all service users in the garden. The old dining chairs must be disposed of. The unused equipment stored at the end of the garden must be disposed of. The ripped easy chair in the conservatory must be repaired 01/07/06 7 OP18 13 (6) 01/09/06 8 OP19 23,2 (b) (c) 30/06/06 9 OP20 23, 2 (o) 01/08/06 Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 23 10 OP21 12 OP24 or replaced The registered provider must ensure that all bathrooms are provided to meet the needs of the service users 16, (2)(c ) The registered provider must: 23, 2 (n) Replace every service users quilt and pillows Repair or replace those beds that are broken. Replace mattresses and bed bases that are stained or torn 01/09/06 01/07/06 13 13 OP25 OP25 23, (2) (b) 23 (2) (b) The registered provider must repair or replace the rotten window in the male toilet. The registered provider must address those sealed units that are in need of repair or replacement (room 1). Radiator cabinets but be secured to the walls No staff must be employed without appropriate checks. Any staff commencing employment with only POVAfirst check must be risk assessed and work with a dedicated supervisor at all times until the CRB disclosure is available. Copy of the risk assessment and duty rota indicating the supervisor must be forwarded to the CSCI The registered manager must ensure that the results of the service user and relatives surveys and provide an action plan for improvement. 12/06/06 30/06/06 15 OP29 19, sch 2 06/06/06 16 OP33 24 01/08/06 Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Leighswood Residential Home DS0000020816.V298463.R01.S.doc Version 5.2 Page 25 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.V298463.R01.S.doc Version 5.2 Page 26 - 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. 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