Inspection on 13/06/05 for Leighton House

This inspection was carried out on 13th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Leighton House 30/04/07

Leighton House 14/11/05

Leighton House 22/11/04

Leighton House 10/08/04

Leighton House 26/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Leighton House 59 Burgh Heath Road Epsom Surrey KT17 4NB Lead Inspector Mrs M McHugh Announced Inspection 13 June 2005 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 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. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leighton House Address 59 Burgh Heath Road, Epsom, Surrey. KT17 4NB 01372 720908 01372 813991 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Azher Hashmi Mrs Eileen Spacey CRH (N) 26 Category(ies) of Old age, not falling within any other category registration, with number (OP) 26. of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 6. Dementia - over 65 years of age (DE(E)) 6. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Of the 26 residents accommodated, up to 6 may fall within the category of either MD(E) or DE(E). In respect of this service, Service Users may be admitted from the age of 60 years and over. Date of last inspection 22 November 2004 Brief Description of the Service: Leighton House is a large detached property that has been converted to provide accommodation for twenty-six service users. The home is located in a residential area of Epsom. Access to shops, church, public transport and other local services is short distance from the home. However, the home is situated on the top of a hill and this can cause some difficulty for service users especially those who use a wheelchair. Accommodation is provided over two floors with twenty single and three shared bedrooms. Eighteen of these rooms are provided with en-suite facilities. There is a passenger lift access to the first floor. The home provides two lounges, a dining room and a large garden and patio area. The home has car-parking facilities at the front of the house.The main office and some staff accommodation are provided on the top floor. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over seven and a half hours. A tour of the premises was undertaken and staff and care records were sampled during the day. Staff were spoken with during the course of their duties and five of the twenty-six residents were spoken to in depth. A number of other residents were spoken with in passing or during the lunchtime meal. The inspector received comment cards back from eleven residents, seven relatives/visitors, two visiting GP and one from a care manager. What the service does well: What has improved since the last inspection? Since the last inspection the home has redecorated a number of areas in the home, including the corridors and many bedrooms. New furniture has been purchased for the lounge areas and some new high/low beds were purchased for residents. It was pleasing to note that the home has covered all the radiators in the home within the agreed timescale. The statement of purpose has been updated to include the increase in numbers of residents following the building work and extension to the home. Staff files have also been updated and those sampled during the inspection contained all the information as required by legislation. The owner showed the inspector that specialist training is to be provided to all staff to ensure that they are able to provide even more specialised care to all the residents in the home. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 standard(s) 1, 2, 3, 4, 5 Residents have access to information about the home to enable them to make an informed choice about the service. This includes information about the level of needs the home can cater for and any specialist equipment available. Contracts were in place for all residents. People are invited to visit the home prior to making a decision about admission to the home. EVIDENCE: The home’s brochure, statement of purpose and residents guide was available and contained information about the home, activities, meals, staff and more. The brochure and statement of purpose have recently been updated to include the increased number of residents the home can now admit and to include the structural changes to the home. The statement of purpose needs to be amended further to include the sizes of the bedrooms provided. The home should update the residents guide to incorporate these changes. Resident’s files sampled contained contracts between the home and the resident and/or the funding authority. These contracts included the room that the person was to occupy and information about any additional costs that are Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 9 not covered in weekly fees. There was also terms and conditions of residence in each file that was signed by the resident or their representative. All residents are assessed by the home or by the social services care team prior to admission. The resident then has a comprehensive admission assessment completed which looks at physical, emotional, social, health and nutritional needs. These are reviewed as part of the care planning process each month. Any needs that are identified as requiring specialist equipment are provided through the home or the occupational therapist. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 standard(s) 7, 8, 9and 10 The resident’s health, personal and social needs were documented in the care plan and their health care needs were being met. The medication was administered in the correct manner, however records were not accurately completed. Overall, issues of privacy or dignity were promoted, however the home needs to consider some feedback from two residents following a survey of views. EVIDENCE: The care plans sampled were comprehensive and contained the individual risk assessments and relevant action plans as well. All plans were reviewed on a monthly basis by staff and the reviews stated the reason for changes or no changes to the care plans. This was good practice and staff were commended. The daily notes were completed during the day, however these could be more informative about the individual’s care needs met during the day, what activities they participated in, meals taken and emotional needs assessed. The tick boxes for care needs were completed ensuring that information was documented, but again these could be modified to include additional information such as assisted wash given. The home has some additional paperwork that is used for residents who are poorly or remain in bed and this Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 11 includes turning charts, fluid balance charts and mouth care records. This was seen as good practice. Records of external professional’s visits were viewed and showed that the GP, optician and chiropodist make regular contact in the home. Residents stated that they see the GP as required. Medication records were viewed and no gaps were noted in record sheets and the staff were using the symbols on the record sheets, however there was not always a clear and accurate record of why a medication was not administered to a resident. A number of residents receive certain medications as they require them and good practice would be that there are guidelines in place to assist staff to be able to assess when a medication is or is not required. This should be done with the GP and/or Community psychiatric nurse’s input. A random count of controlled drugs was carried out and these tallied with the amounts in the register. No issues of privacy or dignity were brought to the inspector’s attention during the inspection process and staff were observed to be knocking on bedroom doors and calling residents by their preferred form of address. Although comment cards received back from residents, one stated that their privacy was not respected and one stated that it was sometimes respected. These residents did not comment further on the day of the inspection. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 standard(s) 15 The mealtime was well managed and no negative comments were received about the quality or quantity of the food provided. EVIDENCE: Although activities was not looked into in detail during this inspection, it must be noted that seven out of eleven comment cards received back from residents stated that the home sometimes provides suitable activities. The four other comment cards stated that they felt suitable activities were provided. The home offers two sittings for mealtimes, with those residents requiring assistance having one sitting and those residents who do not require assistance the other sitting. This was so that anyone requiring assistance did not feel rushed or uncomfortable during their mealtime. One resident commented that they did not like the food but all other residents spoken with during the day stated that the food was of a satisfactory standard. The dining room is nicely set out with flowers on the tables and a view out of the window. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 standard(s) 16, 17 and 18 Residents and relatives are aware of the complaints procedures and residents legal rights were protected. Procedures were in place in respect of the protection of vulnerable adults and training and induction was available for staff. EVIDENCE: The complaints procedure also contains contact information about the Commission and the local Ombudsman. The manager stated that the home has not received any complaints in the last twelve months. Residents stated that they would talk to a member of staff, the manager or the owner if they had a complaint. One comment card out of eighteen received back from residents and relatives/visitors stated that they were unaware of the home’s complaints procedure. The registered manager stated that residents were asked if they would like to vote in the elections in May, all were registered on the electoral role and a number of residents did choose to make a postal vote. It was pleasing to hear from staff on duty that they had received training in the protection of vulnerable adults, were aware of the whistle blowing policy and would use the knowledge they have been taught to prevent abuse from occurring in the home. The procedure was discussed with the manager and it is recommended that she reviews the policy to ensure there is a full understanding on her part of the actions that should be taken that are in line with the local multi agency procedures. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The home is safe, well maintained, provides comfortable communal areas and residents have bedrooms to suit their needs. The home has sufficient heating, ventilation, lighting and is clean and free from malodours EVIDENCE: All areas of the home were well maintained and there is a rolling redecoration plan in place. A number of the communal areas, including corridors have been redecorated over the last year, many bedrooms have been redecorated and new furniture has been purchased for the lounges. All the radiators now have covers in place as required and the registered provider stated that the lighting on the ground floor is due to be upgraded to ensure this meets with legislation. The communal areas consist of two lounges and a large dining room. There is a large patio outside with an enclosed garden. Residents bedrooms were decorated to varying degrees depending on what they brought into the home with them and what they wanted put in their bedrooms. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 15 The registered provider stated that the home has recently purchased a new hoist for a resident, as none of the hoists available in the home were suitable. The home has built a new entrance with a wheelchair ramp leading up to the front door and this is now undercover as well. During the inspection, a contractor arrived to provide a quote on changing the conservatory/lounge doors (leading to the garden), into a door that does not require a wheelchair ramp. The home was clean and free from any offensive odours on the day of the inspection. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The staffing levels in the home are satisfactory to meet the needs of the current residents. Staff files sampled contained all the relevant information as required by legislation. Staff are trained to do their jobs, however the home needs to continue to work on their NVQ (National Vocational Qualification) training needs. EVIDENCE: Information taken from the resident’s questionnaires stated that six residents felt they were well cared for, five felt they were sometimes well cared for, eight stated that staff treated them well and three said that staff do not treat them well. Seven of the nine comment cards received back from relatives/visitors stated that in their opinion, the home was sufficiently staffed and two felt it was not. On the day of the inspection there were staff seen around the home at all times and residents were not seen to be unattended at any stage. It was concluded that the staffing levels were satisfactory to meet the current residents needs. Some staff files were sampled and contained all the information as required by legislation. A list of criminal record bureau checks for the staff was taken by the inspector. Mandatory staff training is in place and up to date with fire training, food hygiene, manual handling, health & safety and protection from abuse. Staff spoken to on the day of the inspection stated that the staff team worked well together and there was good staff moral. They also stated that induction training was done and that they were often offered training courses to attend. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 17 Two staff members are currently doing their NVQ level 2 qualification training and one staff member is due to complete their NVQ level 3 training shortly. This is only three out of eleven care staff on or completed a NVQ level 2 or above qualification. By the end of 2005 the home needs to meet a target of 50 of staff with a NVQ level 2 or above qualification. A requirement was made in this respect. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35, 36, 37 and 38 Residents benefit from the ethos and management approach of the home, which is run in the residents best interests. The health, safety and welfare of all in the home is promoted EVIDENCE: The home is generally well run and staff and residents were observed to respond positively towards the registered manager and the registered provider. Staff stated that there is good staff morale and everyone works well together as a team. Staff meetings are held monthly with trained staff and senior carers and any information is passed down to the rest of the team through the minutes of the meetings or by the senior staff. The home’s business plan is still in progress from the last inspection and the provider stated that he is busy working on next year’s plan. The home has met all of their targets set out in the business plan, which was pleasing to see. The Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 19 provider manages the petty cash for some residents and these records were sampled and found to be up to date and comprehensive. At the end of each month the resident’s representative is sent an invoice of the person’s expenditure, (for example; hairdresser, physiotherapist) and this is then paid back to the home. The home’s accounts are dealt with by an accountant. The manager stated that staff have regular informal supervision sessions with her and other senior members of staff. However there was no written evidence of this taking place. All staff need to receive at least six sessions of formal supervision each year. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 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 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x 3 3 2 3 2 Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 21 Yes 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 OP 1 Regulation 4(1)(c), Schedule 1 6(a) 17(1)(a), Schedule 3(m) Requirement The statement of purpose must include all the information as set out in Schedule 1, including bedroom sizes. The service users/residents guide must be updated. The home must ensure that the standard risk assessments, including nutrition, are correctly completed. All assessments must be reviewed to ensure the information provided presents a clear picture of each resident. Clear records must be kept of medication administered to service users. This must demonstrate who prepared and administered the medication to the resident. The registered person must provide an action plan to CSCI detailing how the home plans to meet the target of 50 staff with a NVQ level 2 qualification by the end of 2005 All staff must receive at least six sessions of formal supervision each year and records of this supervision must be kept. The registered person must submit a plan of how the home intends to Timescale for action 04/07/05 2. 3. OP 1 OP 8 04/07/05 27/06/05 4. OP 9 13(2) 14/06/05 5. OP 28 18(1)(c) 11/07/05 6. OP 36 18(2)(a) 11/07/05 Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 22 meet this Standard. 7. OP 38 13(4) The home must put in place a risk assessment for any resident who has their bedroom door propped open and must ensure that furniture is not used to do this. This is a health and safety hazard. 15/06/05 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. 2. 3. Refer to Standard OP 7 OP 9 OP 18 Good Practice Recommendations The daily notes could be expanded to include more information about the resident and the care provided to them. The home should obtain guidelines from the GP, detailing when as required medication is to be administered. The registered manager should take time to review the protection of of vulnerable adults procedure as set out in the Local Multi-agency procedures. Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Leighton House H58 H09 s13333 Leighton House v223833 130605 Stage 4 ann.doc Version 1.30 Page 24 - 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!