Inspection on 14/11/05 for Leighton House

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 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 13/06/05

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 Mavis Clahar Unannounced Inspection 14th November 2005 09:45 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 Leighton House DS0000013333.V266588.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. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leighton House Address 59 Burgh Heath Road Epsom Surrey KT17 4NB 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) 01372 720908 01372 813991 Mr Azher Hashmi Mrs Eileen Spacey Care Home 26 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (26) Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 13th June 2005 Date of last inspection 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 DS0000013333.V266588.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care Inspection year March 2005 to April 2006. It is recommended that both reports be reviewed in order to get a fuller understanding of the way the home meets the National Minimum Standards for younger Adults. This unannounced inspection took place on the 14th November 2005, the home having received an announced inspection on the 13th June 2005. This was the first visit by the inspector to the home and the staff, service users and management made the inspector very welcome. The first part of the inspection was spent with the manager, explaining the process of the inspection, reviewing the requirements from the last inspection, discussing care issues and staff training needs. The Owner joined the discussions at approximately 10:30am. The second part of the inspection was spent speaking with service users and available care workers, touring the home and giving feed back to the manager on the findings of the inspection. There were no visitors to the home during the time the inspector toured the home. What the service does well: What has improved since the last inspection? The home has now employed a Trainer to ensure carers have up to date and current training to meet the assessed and social needs of the service users. Leighton House DS0000013333.V266588.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. Leighton House DS0000013333.V266588.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 Leighton House DS0000013333.V266588.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 The information about the home contained in the service users guide is too disjointed. EVIDENCE: The information in the service users guide does not conform to the requirements contained in Schedule 2 of the amended Care Homes Regulations 2001. The requirement issued on this standard stands. Leighton House DS0000013333.V266588.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): 89 The health care needs of the service users are well met. No service user at this home is risked assessed as capable of self administering their medication. EVIDENCE: Random review of service users care notes, and speaking with service users and their carers demonstrated that service users needs are well met. Some of the comments made by service users are “I am well looked after here” “The nurses are kind to me”. “ I am asked what I want to wear today”. “The food is good and plentiful, I get enough to drink”. None of the service users is risked assessed as capable to manage their medication. All medication is administered by registered nurses based on the NMC guidelines of Safe administration of medicines. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 10 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 Service users enjoy a life style suitable to their abilities. They have regular contact with their family and the community, based on their choices. EVIDENCE: The activity coordinator is at the home for five days per week, and activities are planned for service users to suit their abilities. Some service users are able to go out with their relatives, and they enjoy these visits. The R?C Priest visits as needed, but the deaconess offer communion to service users once per week. The C/E Vicar visits once per month on Thursdays to have service for the service users. Some service users have their own Vicars come to visit with them. Service users visitors can book a meal at the home with their relatives. Visiting is open and visitors are always made welcome in this home. The service users told the inspector they are able to make choices as to their meals, clothing for the day and whether or not they have breakfast in their bedroom or dining room. , Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 11 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 17 18 These standards were assessed on the last inspection. EVIDENCE: For information on these standards please refer to the report of 13th June 2005. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 12 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 23 24 25 These standards were assessed on the last inspection EVIDENCE: For information on these standard please refer to the report of 13th June 2005. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 13 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 These standards were assessed on the last inspection EVIDENCE: For information on these standards please refer to the report of 13th june 2005. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 14 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): 33 Service users are given the opportunity to speak with service users in private. EVIDENCE: On this unannounced inspection the manager introduced the inspector to the service users individually. The inspector observed that the manager withdrew from the service users bedrooms allowing the inspector and service user to speak in private. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 15 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 16 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 OP1 Regulation 4(1)(c), Sch 1 Requirement The statement of purpose must include all the information as set out in Schedule 1, including bedroom sizes. Timescales of 04/07/05 not met Timescale for action 14/01/06 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 OP7 OP9 OP28 Good Practice Recommendations The daily notes could be expanded to include more social 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 manager to have the training record and matrix DS0000013333.V266588.R01.S.doc Version 5.0 Page 17 Leighton House 4 OP28 available for easy management of staff training needs and for inspection. Care workers should be made to take responsibility for completing their induction programme as they are shown a task. Leighton House DS0000013333.V266588.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Surrey Area Office 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 DS0000013333.V266588.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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