Inspection on 13/03/06 for Leighton House Retirement Home Ltd

This inspection was carried out on 13th March 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 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 Retirement Home... 23/08/06

Leighton House Retirement Home... 29/09/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Leighton House Retirement Home Ltd Leighton House Retirement Home Ltd 170/172 Milkstone Road Deeplish Rochdale Lancashire OL11 1NA Lead Inspector Diane Gaunt Unannounced Inspection 13th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Leighton House Retirement Home Ltd Address Leighton House Retirement Home Ltd 170/172 Milkstone Road Deeplish Rochdale Lancashire OL11 1NA 01706 352075 01706 631416 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) Leighton House Retirement Home Ltd Mrs Anne O`Reilly Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is registered for a maximum of 30 service users to include:up to 30 service users in the category of OP (Older People) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 29th September 2005 Date of last inspection Brief Description of the Service: Leighton House is a care home providing care and accommodation for 30 older people. The home is located approximately 1 mile from the town centre of Rochdale, in an area known as Deeplish. It is close to shops, a post office, and other amenities. Leighton House was opened in 1981. Since 1988 it has been owned by the same provider although registration changed in July 2005 when the provider set up a limited company - Leighton House Retirement Home Ltd. The provider is the responsible individual for the new company and continues his involvement at the home on a day-to-day basis. Leighton House is a 3 storey building with lounge and dining facilities on the ground and first floor. There is also a large basement area which provides a staff room, staff toilet, laundry, drying room, food storage areas, workshop and cleaning storage areas. The area had been modernised and was well maintained. 25 bedrooms are provided, 5 double and 20 singles, of which 2 are ensuite. Bedrooms are provided on the ground, first and second floors. A passenger lift services all levels of the home. The home sits in its own grounds and has a well-maintained garden, which is easily accessible. Adequate parking is available to the front and side of the home. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 7¼ hours. The home had not been told beforehand that the inspector would visit. The inspector looked around the building and looked at paperwork about the running of the home and the care given. In order to find out more about the home the inspector spoke with five residents, three relatives, three senior carers, two care assistants, the cook, a GP, the deputy manager and the responsible individual who is a director of Leighton House Retirement Home Ltd. Three requirements listed at the end of the report had not been fully met since the last inspection. What the service does well: What has improved since the last inspection? More detail had been written in some residents’ plans of care which described what help they needed at the home. Assessments of risk to residents were reviewed more regularly. Staff had been given advice on how best to care for residents who were at risk of falling. All staff had either got an National Vocational Qualification (NVQ) level 2 or 3 award or were in the process of signing up for it. Photographs of staff were kept on staff files. Staff had attended a fire lecture at the home. A 5 yearly electrical installation inspection had been carried out. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 6 Residents safety had been improved as a fireguard had been provided for the ground floor lounge fire and the front door, which is a fire exit, was no longer locked and the key removed. 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 Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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): None of these standards were assessed on this occasion. EVIDENCE: Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Regularly reviewed care plans were in place but were not always accurate or discussed and agreed with residents and/or their relatives, which could result in staff being inconsistent in their approach. Health care needs were met in the main but nutritional assessment was not always accurate, potentially putting the residents at risk. Staff did not always adhere to the home’s medication policies and procedures, potentially putting residents at risk of maladministration. EVIDENCE: Four individual plans of care were inspected and improvement was noted on two which had been thoroughly reviewed and important detail added throughout. The plans encompassed health and social care needs and, in the main, recorded action to be taken to meet the needs, although there were some notable exceptions. For example, information provided in a written assessment by an occupational therapist on the day prior to the admission of one resident had not been transferred onto the care plan; the recorded information was directly contradictory to the OT assessment. Likewise, another care plan did not record communication needs experienced by a resident with significant hearing difficulties. On meeting this resident it was immediately apparent to the inspector that hearing difficulties seriously impacted upon this person’s opportunities for communication. The care plan Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 10 should have addressed this issue, identifying provision which may have assisted the resident. Furthermore, the nutritional risk assessment for this person recorded weight as average for height, inspection of recorded weight showed the resident to be underweight – which was also apparent from observation on meeting her. Assessment completed by the care manager prior to admission identified poor nutritional intake as an issue. As a result of the wrong information being recorded regarding weight a nutritional care plan had not been written, potentially putting the resident’s health at risk. The manager should review the delegation of writing of care plans in order to ensure accurate and detailed plans are written. The inspector was informed that the home were trying to improve their reviewing process by recording more information on the care plan and ensuring each care need was thoroughly considered and changes recorded. There was some evidence of this on file. Residents and/or relatives should be routinely involved in this process to ensure they are given the care they need and want. Care plans recorded GP, District Nurse and CPN involvement and were seen to have improved with regard to regularly reviewed risk assessments, although there was no evidence that these had been discussed and agreed with the resident and/or their relative. None of the residents had pressure sores at the time of the inspection. Pressure care aids were provided and used as necessary. The GP and residents spoken with considered staff contacted GPs appropriately and followed advice given. The services of opticians, dentists, chiropodist and audiologist were accessed either at the home or in the community as and when necessary. Residents were assessed for continence aids as required and the falls co-ordinator had visited the home to offer advice since the last inspection. Staff interviewed said they were given sufficient information on handover to provide appropriate care for residents. Residents were not offered the opportunity for regular exercise, although staff sometimes took one or two residents out for a walk. Those interviewed were satisfied with the overall care provided. Medication policies and procedures were available within the home and had been reviewed following inspection by a CSCI pharmacist inspector in February 2005. None of the residents self-administered their medication, although one person was prompted to apply cream and this intervention was appropriately recorded. Residents spoken with were happy with the arrangements in place. Trained carers administered medication but there was evidence they did not always follow the agreed policies and procedures. Records of medication administration were generally up-to-date, but errors were noted e.g. recording Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 11 of administration of medication which had run out and therefore not been administered; poor recording of administration of one resident’s controlled drugs and evidence that staff regularly did not count remaining tablets. Receipt entries were not made for medicines supplied for all respite residents who were not included in the monitored dosage system. Hand-written transcription on administration records was not always signed, checked and countersigned. The medication storage was orderly and was secure on the 1st floor where the locked trolley was fastened to the wall. The ground floor trolley was less secure as the wall fastening had not been used. Eye drops were held in a small fridge. Returns were collected by the pharmacist on a monthly basis. There were no items awaiting return at the time of the inspection. The manager would be advised to monitor administration of medication on a regular basis and provide additional training for those who do not adhere to the homes’ policies and procedures. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 and 15 Social activities were provided but residents would benefit from an increase in both individual and group activities. Visiting arrangements at the home were informal and family and friends were encouraged to maintain contact promoting personal relationships. Residents were able to exercise choice and control over their lives. A wholesome appealing diet was provided in pleasing surroundings at times convenient to residents. EVIDENCE: Provision of social activities was limited. A variety of musical entertainment was provided by external performers and one such activity took place on the day of the inspection. The frequency of the entertainment varied, in February there had been three sessions but they were generally twice per month. Residents said they enjoyed this activity. Other activities were not planned and the deputy commented that a number of residents did not wish to be involved in them. Staff sometimes sat with residents and chatted whilst providing a hand massage. A reflexologist used to visit the home but had left the area. Likewise, residents had enjoyed regular sessions with Active Minds but they no longer offered a service to the home. On the day of the inspection a visitor and a carer played card games with residents, one resident spoken with said staff also played dominoes or draughts with them on occasion. TVs were on in each of the lounges throughout the day. Some but not all care plans inspected recorded some of the residents’ past interests but recorded information was limited and had not been used to introduce appropriate Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 13 activities. Staff interviewed considered more activities could be provided for both groups and individuals. The home had an open visiting policy and relatives interviewed said they were made to feel welcome and ‘at home’. They were always offered a hot drink and biscuits during their visit. Residents could see their visitors wherever they wished, either in the lounges, dining rooms (outside of mealtimes) or their bedrooms. One visitor was seen enjoying a game of cards with a group of residents during her visit. Residents went out with relatives as and when they wished and staff assisted them in preparing for these trips. Staff occasionally took residents out for a walk to local shops. Following consultation at a residents meeting, the home had two trips planned for April. Religious services were not held at the home, although representatives of two Christian faiths visited residents regularly to serve communion and offer prayers. A resident commented upon how much they had enjoyed a carol concert held at the home at Christmas time. The choices residents made each day varied, dependent upon their mental frailty but residents who were able generally chose what time to get up, go to bed, what clothes to wear, what to eat, where to spend their day and whether or not to participate in activities. There was evidence of each of these choices being made on the day of inspection. The home held information about an advocacy contact (CareAware) and a poster giving information about the service had been displayed but recently removed. It was agreed this would be displayed again for resident/relative information. None of the residents managed their own money, having passed the responsibility to relatives, solicitors or the manager. All those spoken with were happy with the arrangements in place. Menus inspected were seen to provide a nutritious and varied diet over a 3 week period. Two hot choices of meal were served each lunchtime and 3 or more choices at teatime, although these were not always recorded. A milk pudding was served each day for one dessert, an alternative was also served but tended to be of less nutritional value e.g. sponge and custard or pie. The cook may wish to reduce the number of stodgy desserts when next reviewing the menu. Fresh fruit was occasionally served as a dessert e.g. bananas and custard, apple crumble, but was also cut up and offered as a snack in the afternoon. Food served during the inspection was sampled, it looked, smelt and tasted appetising. It was hot when served. Residents were seen to enjoy the food and were heard to make positive comment. The cook was informed if a resident did not eat their meal and their intake was monitored, with a lighter choice being offered to tempt the resident if necessary. Residents spoken with said the food was very good and that there was plenty of it, one resident said a good selection was offered. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 14 Diabetic and soft diets were provided as required. Staff gave appropriate assistance to those needing it although it was noted they did not all sit beside residents whilst assisting. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 A well-maintained environment was provided but residents’ safety was compromised by slow response to identified electrical defects. The home was clean, pleasant and hygienic. EVIDENCE: A tour of the building confirmed that the home was well maintained and clean. Ramped access was provided to the home and an internal passenger lift and handrails in corridors ensured residents could move about the home with ease. Residents and relatives spoke positively about the cleanliness, one relative described the home as ‘spotlessly clean’. Planned maintenance and renewal was operated, and a handyman was employed to ensure small repairs were addressed quickly. The home was kept in good decorative order and furnishings and fittings were renewed as necessary. At the last inspection problems were being experienced with the central heating system. There had been improvement but temperatures in some bedrooms were significantly below 21°on the day of inspection. Staff had been monitoring the temperatures and providing additional heating when necessary. Risk assessments relating to the use of free standing radiators Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 17 were not written. The inspector was informed there were plans to drain the system and provide an additional boiler during the summer months. In need of more urgent attention was the electrical wiring at the home which, on inspection had some serious defects. The responsible individual had booked an electrician to do the work, but an immediate requirement notice was served to ensure the work was undertaken speedily. A gardener was employed and grounds were seen to be safe, tidy and accessible. Residents said they looked forward to sitting outside in the good weather. The Environmental Health Department had undertaken a food and health and safety inspection in December 2005. No requirements or recommendations were made. Greater Manchester Fire Officers had not visited since the last inspection. Residents spoken with were pleased with their individual rooms and there was evidence they had brought in a number of personal possessions to make them feel more homely. All bedrooms were fitted with door locks and lockable storage space to ensure resident’s valuables were kept safe. Staff had a master key, which could be used to gain access in an emergency. Despite previous recommendation, bedroom door keys were not routinely given to residents and one person interviewed expressed a wish to have a key. Some, but not all care plans recorded the residents wish not to have a key. An infection control policy was in place and staff spoken with described safe infection control practice. Malodour in the home was confined to one individual bedroom, the inspector was informed the carpet in this room was shampooed on a regular basis. The manager may wish to review cleaning materials used or employ the services of an industrial cleaner. Disposable gloves and colour coded aprons were provided for staff use when assisting with personal care and serving food. Liquid soap was provided throughout the home but paper towels were not. Staff interviewed said they had purchased alcohol based cleaning gel to offer further infection control protection. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry was sited in the basement away from the food preparation area and was seen to be clean and orderly. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Feedback from relatives indicated that laundry did get mixed up on occasion and one commented the person she visited sometimes had on other residents’ clothes. This was raised with the deputy who said she would attend to the matter. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Sufficient staff were employed to meet residents needs. The majority of staff were trained and competent to do their jobs. Failure to take up Criminal Record Bureau (CRB) checks and two written references prior to employment put residents at risk. EVIDENCE: Inspection of four weeks rotas showed sufficient staff were provided to meet the needs of residents. Feedback from staff, residents and relatives supported the view that there were enough staff on duty each shift to meet residents’ needs. Observation on the day of inspection provided further evidence. Residents spoke well of staff describing them as ‘grand’, and ‘really nice people’, relatives considered them to be welcoming and ‘really good’. One relative commented on their positive attitude and willingness to listen and act upon feedback. All staff had completed induction training, 8 had achieved NVQ level 2 and 3 had NVQ level 3. In addition, 6 were taking NVQ level 2 training and 2 were awaiting an appointment to sign up for the course. Three further carers were taking NVQ level 3. On completion of this training, all care staff will have an NVQ qualification. In addition to this, all staff had been given a list of foundation training standards against which they were recording their competence. The full range of health and safety training was provided on a rolling programme and most staff had up to date training in this area. The main exception was with regard to health and safety training, an outstanding requirement is in place. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 19 Staff interviewed said the home was pro-active in establishing their training needs and providing identified training. Inspection of three staff files showed that staff had taken up employment prior to a Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) check having been received. In addition, one file showed that current references were not taken up for a new employee. This person had worked at the home previously but had gaps in their service since that employment. An immediate requirement was made on the day of inspection to make sure staff were not appointed without these checks in future. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 The home had some quality assurance systems for seeking the views of residents and their relatives but these were not always used to plan the service. Residents’ monies were held safely and securely and administered efficiently but were not managed to the maximum benefit for residents. EVIDENCE: The home had the Investors in People (IIP)Award which had been renewed in December 2005, the assessor had been satisfied beyond any doubt that the home continued to meet the IIP standard. An annual business plan was also in place and was reviewed by the responsible individual. Feedback on the home was actively sought during quarterly resident meetings. Staff meetings used to be held quarterly but there had been a 7 month gap between the last two. Staff supervision was held, but again not as frequently as in the past. Formal reviews with residents and relatives were not regularly held. Relative/resident questionnaires were used on an annual basis but the feedback was not used to advise annual planning. Staff interviewed said that both the registered provider and manager were easily accessible and open to suggestions should Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 21 they wish to raise anything. Relatives said the manager and deputy were approachable if they wished to raise matters and staff were always open to suggestions for change. Their views were not actively sought however. A newsletter was written by the responsible individual and circulated to residents, relatives and staff periodically. Action to implement requirements identified in CSCI reports was not always taken within agreed timescales. The home acted as appointee for five residents and agent for one. They also managed personal monies handed to them by relatives for residents’ use. Records in relation to four residents were inspected and were seen to be in order. However, the recording of incomings, outgoings and minus amounts were not always clear and the manager may wish to review the present recording process. Receipts were held for each transaction and records were externally audited by an accountant. Residents’ monies were held in a residents’ bank account but this was not interest bearing. As some large sums were held for residents, the manager should consider how they could receive interest to their individual savings as advised by Department of Works and Pensions and CSCI. Residents spoken with said they were able to access their monies via the office whenever they needed to. Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 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 X 17 X 18 X 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X X Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 23 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 OP7 Regulation 15 Requirement Care plans must be detailed, accurate, agreed and reviewed with residents and/or relatives The manager must monitor staff administration of medication to ensure: • MAR sheets and CD book are accurately completed • A signed record is kept of receipt of all medication • Medication trolleys are secured to the wall All staff must receive training in Protection of Vulnerable Adults Procedures. (Previous timescale of 30/11/05 not met) A satisfactory heating system must be provided and in the interim. Risk assessments relating to the use of free standing radiators must be written and regularly reviewed for each resident. Staff must not be employed prior to receipt of a satisfactory Criminal Records Bureau check DS0000064633.V269877.R01.S.doc Timescale for action 30/04/06 2 OP9 13 30/04/06 3. OP18 13 31/05/06 4 OP19 23 31/08/06 5 OP19 13 30/04/06 6 OP29 19 13/03/06 Leighton House Retirement Home Ltd Version 5.1 Page 24 undertaken by the home (Previous timescale of 29/09/05 not met) and two written references. 7 OP38 13 & 18 Health and safety training must be provided for all staff. (Previous timescale of 31/12/05 not met) All category 1 defects identified in the 5 yearly electrical inspection must be addressed. All other defects identified in the 5 yearly electrical inspection must be addressed. 31/05/06 8 OP38 23 31/03/06 9 OP38 23 21/04/06 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. Refer to Standard OP7 Good Practice Recommendations The manager should review the delegation of writing of care plans in order to ensure accurate and detailed plans are written. Staff should provide residents with regular opportunity for exercise both in and outside of the home. Hand-transcription on medication administration records should be signed, checked and countersigned. Additional training should be provided for those staff who do not adhere to the home’s policies and procedures. Door keys should be offered to residents on admission unless risk assessment indicates otherwise. A programme of suitable activities including 1 : 1 and group activities should be planned, implemented and montiored to ensure each person’s social, cultural, and recreational needs are met. DS0000064633.V269877.R01.S.doc Version 5.1 Page 25 2 3 4 5. 6 OP8 OP9 OP9 OP10 OP12 Leighton House Retirement Home Ltd 7 OP26 That paper towels are provided in all communal areas and for staff use in rooms where they assist with personal care. The manager should consider how residents could receive interest to their individual savings as advised by Department of Works and Pensions and CSCI. 8 OP35 Leighton House Retirement Home Ltd DS0000064633.V269877.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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