Inspection on 23/08/06 for Leighton House Retirement Home Ltd

This inspection was carried out on 23rd August 2006.

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 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

Leighton House Retirement Home... 13/03/06

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 09:30 23 August 2006 rd 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.V298166.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. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 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.V298166.R01.S.doc Version 5.2 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. 13th March 2006 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. The home’s Service User Guide advises residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report is available in the reception hall. At the time of this inspection weekly fees were from £321.01p to £348.01p per week, approximately £1386 to £1508 per month. Additional charges were for hairdressing, chiropody, and taxis. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on CSCI records and information provided by people who live at Leighton House, their relatives, professionals who visit the home, the manager and staff at the home. A site visit to Leighton House on 23 August 2006 took place over 9 hours. The home had not been told beforehand when the inspector would visit. The inspector looked around the building and looked at paperwork that had to be kept to show that the home is being run properly. To find out more about the home the inspector spoke with six residents, one senior carer, two carers, the cook, the administrator, the deputy, the manager, the hairdresser and a District Nurse. Questionnaires/ comment cards asking residents, relatives and professional visitors what they thought about the care at Leighton House had been given out a few weeks before the inspection. Three residents, four relatives, District Nurses, a GP and a social worker filled them in and returned them to the CSCI. Their views are included in the report. What the service does well: What has improved since the last inspection? Plans of care describing the care each resident needed were more detailed and were discussed with residents and/or relatives more regularly, although this varied dependent upon which staff member had completed them. Assessments of risk to residents were also updated more regularly. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 6 Staff had improved their record keeping when giving residents medicines and tablets. They also kept medicine trolleys safe by fastening them to the wall. Staff had also had training in the Protection of Vulnerable Adults (POVA) so they knew what to do if they saw any poor practice in the home. More activities, including exercise for residents had been provided but these still did not met all residents’ needs. A lot of electrical work had been undertaken to make sure the home was safe. A new boiler had been installed which had improved the heating system so there was no longer any need to use free standing heaters. 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.V298166.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 Leighton House Retirement Home Ltd DS0000064633.V298166.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents were assessed and given information about the home to help them decide if they wished to live at Leighton House. EVIDENCE: An admission procedure, including the procedure to follow in an emergency was held at the home and was followed. The home’s practice was to visit prospective residents in their own homes or in hospital for assessment prior to admission when a Statement of Purpose and Service User Guide were given to each resident. In an emergency the documents were given on admission and these documents were seen to be available in residents’ rooms. Five residents’ files were inspected with regard to assessment prior to admission, two of these residents had lived at the home for a considerable time and three recently admitted residents had moved in requiring emergency care. All were funded by the Social Services Department (SSD), and care managers had provided full assessments prior to admission. As a result of emergency admission, assessments undertaken by the home had been Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 9 completed on the day of admission rather than prior to admission. The inspector was informed an alternative placement would be sought if the home could not meet the needs of people placed in an emergency. Residents spoken with could not recall the admission process but two residents returning questionnaires said they had received sufficient information about the home before they moved in and this helped them to decide if they wished to live there. Leighton House Retirement Home Ltd DS0000064633.V298166.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provided a good standard of health and personal care for residents although care plans did not always fully reflect this. Residents were treated with respect and their right to privacy upheld. Medication policies and procedures were followed ensuring safe administration of residents’ medicines. EVIDENCE: Five individual plans of care were inspected and improvement was noted in the amount of detail recorded and the involvement of residents or relatives in reviews of care. The plans encompassed health and social care needs and recorded action to be taken to meet the needs, although these would benefit from more detail being recorded. The quality of the information provided on care plans varied dependent upon who had completed them. Some care plans had been reviewed well giving necessary details in each area, others recorded nothing of significance, simply stating ‘no change’. Although staff were all aware of the changing needs of a frail resident whose health had deteriorated a few days before the inspection and were providing the required care to a good standard, this had not been recorded on the care plan. The care plan was however, updated during the inspection with all the necessary detail to Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 11 give staff good guidance. Care plans and were supported by daily record sheets which recorded good detail of care monitoring. Staff interviewed said they were given sufficient information on handover to provide appropriate care for residents. Risk assessments were in place and were reviewed along with care plans. Residents were weighed regularly and appropriate action taken when necessary. Staff had received input from a dietician with regard to the MUST nutritional assessment tool – the tool had not been implemented but the dietician’s advice was being followed in respect of one frail resident. Food/fluid charts were in use and staff were closely monitoring the resident’s needs. Care plans recorded GP, District Nurse and CPN involvement. Care managers, relatives, GP and District Nurses returning comment cards were all satisfied with the overall care provided at Leighton House, although one relative commented that the ‘little things’ were sometimes overlooked and gave an example of staff serving the resident with sugared tea when they had been advised the residents did not like sugar. Residents spoken with and completing questionnaires were also satisfied and made comments such as ‘they do a good job all round’ and ‘I am happy, relaxed and well cared for’. The hairdresser who visited the home weekly said that residents were always clean and appeared well cared for. None of the residents had pressure sores at the time of the inspection. Pressure care aids were provided and used as necessary. Turning charts were used appropriately. District Nurses considered staff communicated clearly with them and demonstrated a clear understanding of residents’ needs. Staff alerted District Nurses as necessary and followed their advice. 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 visited the home to offer advice as necessary. Staff were providing more opportunities for regular exercise in that weekly chair exercises had been introduced and some residents went out with staff for a walk or to the local shops. During the good weather residents had also had the opportunity to walk in the grounds. Medication policies and procedures were available within the home. The senior carer responsible for medication was monitoring their correct implementation. Improvement was noted in that controlled drugs were correctly administered and recorded; receipt entries were made for medicines supplied for all respite residents who were not included in the monitored dosage system; handwritten transcription was signed, checked and counter-signed; and both medication trolleys were kept secured to the walls. Records of medication administration were up-to-date and no errors were noted. The medication Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 12 storage was orderly and returns were recorded and held securely until the pharmacist collected them, which was on a monthly basis. None of the residents self-administered their medication at the time of inspection. Residents spoken with were happy with the arrangements in place. Residents returning comment cards and those interviewed considered their privacy and dignity was respected at the home. Staff interviewed were able to describe good practice in this area. Privacy screens were provided in double rooms. Lockable space was provided and safety locks were fitted to bedroom doors. Further comment regarding the locks is made in the environment section below. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Provision of social activities and integration into community life satisfied the majority but not all resident’s social and recreational interests. Visiting arrangements at the home were informal and family and friends were encouraged to maintain contact promoting personal relationships. A wholesome, nutritiously balanced and appealing diet was provided in pleasing surroundings at times convenient to residents. EVIDENCE: The number of activities provided for residents had increased since the last inspection but were still not provided on a daily basis. A variety of musical entertainment was provided by visiting performers and residents spoken with enjoyed these sessions. The frequency of the entertainment varied, they were generally twice per month. Other activities held over the last four months included trips out for a meal, to see a musical show, and to a local beauty spot. A barbeque had also been held at the home and had been attended by relatives and friends. Resident feedback regarding the provision of activities at the home varied – two said there were usually enough activities going on, one person said there were sometimes enough and one person asked if activities could be more Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 14 often. One resident interviewed also said ‘there was not a lot going on’, although three said they were ‘happy enough watching TV and sitting out in the good weather’. TVs were on in each of the lounges throughout the day. There was evidence from discussion with staff and residents that staff took individual residents out to the shops or for a drink on occasion and played dominoes and cards with those who wished to join in. One resident said they would like to do this more often. They also sometimes sat with residents and chatted whilst providing a hand massage. Chair exercises had been introduced by a new member of staff who was also looking to see what other activities could be introduced. Improvement was noted in the amount of information recorded about residents’ past interests and its use when planning individual activities. Staff need to continue to develop this process. The home had an open visiting policy and relatives returning comments cards said they were made to feel welcome. Residents could see their visitors wherever they wished, either in the lounges, dining rooms (outside of mealtimes) or their bedrooms. Residents went out with relatives as and when they wished and staff assisted them in preparing for these trips. Religious services were not held at the home, although representatives of two Christian faiths visited residents regularly to serve communion and offer prayers. Residents spoken with were happy with these arrangements. 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 these choices being made on the day of inspection. Residents had all received postal votes for the May elections and some had chosen to use them. The home held information about an advocacy contact (CareAware) and a poster giving information about the service was displayed 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. Menus had been developed since staff at the home had training from a dietician. It was pleasing to note that a wide variety of fresh fruit was regularly provided – both as snacks, in milk shakes and as part of the menu’d meals. Milk puddings were offered more frequently and stodgy desserts had been reduced. Food served during the inspection looked and tasted appetising. It was hot when served. Residents were seen to enjoy the food and were heard to make positive comment. They described the food as Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 15 ‘fine’ and ‘very good’, one resident said that menus had improved and there was more variation now – particularly at teatime. Those returning questionnaires said they always liked the food and one said they ate ‘very well’. In order to continue improvement the cook was going to attend a course to learn more about menu planning and nutritional needs of older people in care homes. Discussion with her reflected her enthusiasm and eagerness to provide residents with good nutritious food which they enjoyed. The cook was knowledgeable about residents likes and dislikes and had been pro-active in providing a suitable diet for a frail resident. She 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. Diabetic and soft diets were provided as required. Staff were seen to give appropriate assistance to those needing it. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse and the majority of staff had been trained to ensure their full understanding of the procedures. EVIDENCE: The home had a complaints procedure. It was included in the Service User Guide, a copy of which was given to each resident prior to or on admission. The procedure had also been posted on each bedroom door. Feedback from residents and relatives showed that they knew about the complaints procedure and who they should speak to. A complaints book was available and recorded two complaints made by the same person. The registered representative of Leighton Home Retirement Home Ltd had informed the CSCI of the complaints and was in the process of responding to them. The CSCI had received no complaints since the last inspection. A procedure for responding to allegations of abuse and a whisteblowing policy were available, as was the Rochdale Inter-agency Protection of Vulnerable Adults (POVA) procedure. Appropriate reporting and recording procedures were in place. Staff spoken with understood the importance of reporting malpractice. Four staff had not attended POVA training, three of them had completed NVQ level 2 which addressed the area. The fourth person had only been in post for 3 days. The manager said that training would be arranged as Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 17 part of the home’s rolling programme. safe living at Leighton House. Residents interviewed said they felt Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 18 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, 24 and 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The decor and cleanliness throughout the home was generally to a good standard and it was evident that Leighton House Retirement Homes Ltd was committed to improving the environment for residents. Infection control practices were satisfactory. EVIDENCE: A tour of the building confirmed that the home was safe, comfortable and well maintained. 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. 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. A bedroom was being decorated at the time of the inspection. Since the last inspection a new boiler has been fitted and appeared to have Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 19 resolved the central heating problems although it was too warm on the day of inspection to fully assess this. Work had been undertaken to the electrical wiring at the home and an approved electrician had certified its safety. A gardener was employed and grounds were seen to be safe, tidy and accessible. Residents said they enjoyed sitting outside in the good weather. A large gazebo had been provided for those who preferred to sit in the shade. The Environmental Health Department and 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. However, bedroom door locks were problematic in that they automatically locked when doors were closed. Despite previous recommendation, bedroom door keys were not routinely given to residents and as only two residents had keys to their doors the locks restricted the majority of residents’ free access to their rooms. None of the care plans inspected on this occasion recorded risk assessments or the residents wish not to have a key. The majority of residents and relatives considered the home was always kept fresh and clean. However, feedback from one resident questionnaire indicated that the area near to the lift door was not always thoroughly cleaned. This was noted to be the case but with this exception the home was seen to be clean throughout. The manager said she would address the matter with the domestic the day after the inspection. Although feedback from one person had indicated there was a malodour in the first floor lounge, this was not observed and the only malodour was confined to two individual bedrooms. The inspector was informed the carpets in these rooms were shampooed on a regular basis but had not been cleaned that day. An infection control policy was in place and staff spoken with described safe infection control practice. Disposable gloves and colour coded aprons were provided for staff use when assisting with personal care and serving food. Liquid soap and paper towels were provided in communal areas. Communal soap was noted in one bathroom but removed during the inspection. 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. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Residents spoken with said there were no problems with the laundry. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Sufficient staff were employed to meet residents needs. The majority of staff were trained and competent to do their jobs, practice with regard to preemployment checks was being changed to ensure protection of residents. 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 ‘super’, and ‘very good’. Those returning comment cards said they were always ready to listen and very good at responding immediately. Inspection of three staff files showed that the home had improved their practice with regard to employing staff prior to receipt of adequate checks. Those appointed since the last inspection had a Protection of Vulnerable Adults 1st (POVA) check as well as a Criminal Records Bureau (CRB) check having been taken by their last employer. They were also supervised during their initial employment. However, CRB checks applied for by the home had not been received and gaps in employment were not always explored and an explanation recorded prior to employment. Following discussion the manager and deputy planned to change their practice in order to fully safeguard residents. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 21 TOPSS induction training was in place and completed within appropriate timescales. All carers had also been issued with a list of foundation training standards against which they were recording their competence. The manager was advised about changes to Skills for Care Common Induction Standards and agreed to implement them from September 2006. The full range of health and safety training was provided on a rolling programme. Inspection of the training matrix showed that although the majority of care staff had completed all the necessary health and safety training at recommended intervals, some had not. The manager must monitor the training matrix and ensure those in need of training or refresher courses attend when necessary in order to keep abreast of current practice. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leighton House was adequately managed by a qualified, experienced person who was fit to be in charge and supervised staff well. Health, safety and welfare of residents and staff was promoted for their protection. EVIDENCE: The registered manager is an experienced carer and manager. She had successfully completed her NVQ Level 4 in care and Registered Manager’s Award, as had the deputy. The manager and senior staff undertook additional training to keep abreast of issues. The manager had a job description, and met with the responsible individual of the home on a regular basis. Lines of accountability were clear. As part of her role the manager ensured staff were regularly supervised and had ‘job chats’ which were recorded. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 23 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. Feedback on the home was actively sought during quarterly resident meetings. Staff meetings used to be held quarterly but more recently had been held approximately every six months. Formal care plan reviews with residents and relatives were held. Relative/resident questionnaires were circulated annually, they had not been circulated since the last inspection. A business plan for 2004 – 2006 was in place and was reviewed by the responsible individual. Inspection showed that the majority of tasks identified had been achieved. In order to reflect the company’s response to feedback, the responsible individual may wish to include in the business plan areas identified in the next round of completed resident/relative questionnaires. The home acted as appointee for three residents. They also managed personal monies handed to them by relatives for residents’ use. Records in relation to one resident were inspected and seen to be in order. 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. Since the last inspection the manager had contacted a legal advocate to explore what action the home could take to enable residents to 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. Fire precaution checks and drills were undertaken on a regular basis in keeping with GM Fire Officer’s recommendations. Fire training was provided, as were regular drills. Building, fire and COSHH risk assessments were written as required and regular maintenance checks undertaken. At the time of this visit the annual gas inspection was overdue but this was addressed immediately after the inspection. Electrical work required by the 5 yearly electrical installations inspection had been undertaken since the last inspection. Inspection of the Accident Book showed that accidents were appropriately recorded but in one instance in respect of a respite resident had not been reported to Environmental Health Officers or CSCI. Neither had a small outbreak of diarrhoea and vomiting been reported although the home had taken appropriate and effective action to manage and control the situation. Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 25 No 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 OP30 Regulation 18 Requirement The manager must monitor the training matrix and ensure those in need of training or refresher courses attend when necessary in order to keep abreast of current practice. Timescale for action 31/12/06 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 ensure that all staff members responsible for completing care plans update them as necessary and record sufficient detail when they are reviewed. A programme of suitable activities including 1 : 1 and group activities should be planned, implemented and monitored to ensure each person’s social, cultural, and recreational needs are met. 2 OP12 Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 26 3 OP24 Bedroom door locks should be replaced with suitable safety locks and all residents given a key unless risk assessment suggests otherwise. The manager should inform CSCI and other relevant agencies of notifiable occurrences. 4 OP37 Leighton House Retirement Home Ltd DS0000064633.V298166.R01.S.doc Version 5.2 Page 27 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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