Inspection on 29/09/05 for Leighton House Retirement Home Ltd

This inspection was carried out on 29th September 2005.

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... 13/03/06

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 29th September 2005 08:30 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.V250617.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 Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 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.V250617.R01.S.doc Version 5.0 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. 09 February 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.V250617.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken over a period of 6½ hours. The inspector spoke with four residents, two relatives, a District Nurse, two care assistants, two senior carers, the deputy and the registered manager. Care practice was observed and records looked at. Comment cards asking residents and visitors what they thought about the care at Leighton House had been given out a few weeks before the inspection. Eight residents and nine relatives filled the cards in and returned them to CSCI. Their opinions are also included in the report. Requirements listed at the end of the report include one that had not been fully met since the last inspection. What the service does well: What has improved since the last inspection? Medication systems had been improved to make sure staff followed policies and procedures, completed records correctly, and assessed to make sure those residents keeping their own tablets and medicine were OK to do so. The menu had been changed to include more of residents’ favourite meals and the home was keeping a record of residents’ food choices again. The home was quickly contacting the Commission for Social Care Inspection (CSCI) to tell them of important events affecting residents. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 6 Action was being taken to improve the heating system at the home on the day of the inspection. 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.V250617.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 Retirement Home Ltd DS0000064633.V250617.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): 3. Standard 6 is not applicable. The home could not be sure they could meet prospective residents needs prior to their admission as care management assessments were not always up to date and staff from Leighton House didn’t visit to assess people prior to admission. EVIDENCE: The majority of residents were funded by the Social Services Department (SSD) and care managers had provided information about each. However, inspection of 3 files showed that in two instances the information provided was over 6 months out of date on admission. It was the policy of the home for the manager or deputy to visit prospective residents in their own homes or in hospital for assessment prior to admission. However, the inspector was advised they had not done so for any of the current resident group as they had all needed to be admitted quickly. With regard to emergency admissions, information from placing agencies was requested but not always received prior to admission. Assessment was undertaken on admission and the manager stated that she would request an alternative placement if the home could not meet the person’s needs. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 9 Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 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 and 10. Care plans were regularly reviewed to ensure care provided met changing needs. With minor exceptions, health care needs were appropriately met on an ongoing basis. Residents were treated with respect and their right to privacy upheld. EVIDENCE: Four individual plans of care were inspected. They encompassed health and social care needs and recorded action to be taken to meet the needs. Care plans recorded GP, District Nurse and CPN involvement but there were some omissions with regard to health care e.g. mental health needs; record of a fall and consequent risk assessment; need for glasses; outcome of continence assessment; management strategies with regard to weight loss. Where risk assessments were held, they were regularly reviewed, but were not always signed by the resident and/or their relative. The plans had been regularly reviewed by staff on a monthly basis and evidence of resident or relative involvement was seen. Relatives and some residents interviewed recalled discussion with the staff about meeting of their care needs. Those returning comment cards considered they were appropriately consulted and kept informed with regard to the residents’ care and well-being. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 11 Pressure care aids were provided and none of the residents had pressure sores. The District Nurse considered that staff contacted them appropriately and followed all the advice they gave. Residents said the home called their GP when they needed them and 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. In one instance the GP had been called to a resident who regularly fell, but the advice had not been taken from the falls co-ordinator. Staff interviewed said they were given sufficient information on handover to provide appropriate care for residents. Armchair exercises were arranged by staff and individual exercises encouraged for those who had had medical advice to do so. 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. Relatives commented that observation during their regular visits to the home indicated staff treated residents with respect and upheld their dignity. Privacy screens were provided in double rooms. Safety locks were fitted to bedroom doors. With the exception of a recently admitted resident those interviewed had keys to their bedroom doors. Lockable space with keys was provided. Those interviewed and returning comment cards were satisfied with the overall care provided. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 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): None of these standards were assessed. EVIDENCE: Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse, although a minority of staff were in need of training 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 on admission. It had also been posted on each bedroom door. Residents, relatives and staff interviewed were familiar with it as were the nine relatives returning completed comment cards. A complaints book was available but did not record any complaints since the last inspection. The CSCI had received no complaints during this period either. Residents and relatives spoken with said they knew to see the manager or deputy if they wished to raise a matter of concern. A procedure for responding to allegations of abuse was 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 but some were not entirely clear about the different types of abuse. Not all staff had received POVA training, although arrangements were in place for the manager and deputy to attend a course run by Rochdale SSD. Residents interviewed and those returning comment cards said they felt safe living at Leighton House. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed. EVIDENCE: Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 15 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, 29 and 30. Residents’ needs were met by an appropriate number and skill mix of staff. Failure to take up Criminal Record Bureau (CRB) checks prior to employment of some staff put residents at risk. Training was provided on an ongoing basis and the majority of staff were trained and competent to do their jobs. 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 ‘very good’, ‘pleasant and helpful’, relatives considered them to be ‘friendly and helpful’. All staff completed induction training and the majority of carers had successfully completed or were taking NVQ level 2. However, 4 staff who had been employed at the home for some time had taken neither NVQ level 2 nor SkillsforCare foundation training. Comment regarding health and safety training is made in the management and administration section below. A training matrix was provided but was not up to date, it was therefore difficult to establish whether staff had received 3 days training per year. Staff interviewed said the home was pro-active in establishing their training needs and providing identified training. Inspection of three staff files showed that the most recently recruited staff member had taken up employment prior to a Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) check having been received. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 16 Another file showed that the home had accepted a CRB check taken by another employer despite the worker having had a gap in employment since the check was taken. Only one of the staff files inspected had a recent photograph of the staff member, another did not have documentary evidence of completed training. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 and 38 Leighton House was adequately managed by an experienced person who was fit to be in charge and supervised staff well. Whilst health and safety of residents and staff was generally promoted, two practices at the home put residents at risk. 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 regularly 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. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 18 Staff were regularly supervised on a formal basis by senior staff and commented positively on the process, considering it gave them an opportunity to discuss their work and identify training needs. In addition to formal supervision, the provision of senior staff working alongside carers throughout their shift ensured day to day supervision of their work. Two new staff and a number of long serving staff had not completed all the necessary health and safety training. Discussion and inspection of records further showed that health and safety training was in need of updating for a number of staff. This included food hygiene, first aid (to ensure one person per shift had completed the training), and infection control. Fire precaution checks and drills were undertaken on a regular basis in keeping with GM Fire Officer’s recommendations. Induction included fire training but the annual fire lecture for all staff was overdue. Building, fire and COSHH risk assessments were written as required. With the exception of the 5 yearly electrical installations inspection, regular maintenance checks were undertaken in line with legislation. Two health and safety hazards were noted during the inspection. An electric fire was in use without a fireguard. The fire casing was very hot to touch. Staff turned the fire off immediately this was brought to their attention. The door leading to the front door fire exit was locked and the key had been removed. Staff immediately unlocked the door once this was raised with them. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 19 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X 1 Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 20 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 OP8 Regulation 12 Requirement Risk assessment and management strategies must be recorded, agreed and reviewed with regard to falls, nutrition and weight monitoring. (Original timescale: 31.03.2005) All health needs must be recorded on care plans along with action to be taken. All staff must receive training in Protection of Vulnerable Adults Procedures. Staff must not be employed without a Criminal Records Bureau check undertaken by the home. A recent photograph and documentary evidence of qualifications must be held for each staff member. Care staff must complete foundation training. Health and safety training must be provided for all staff and updated as required. All staff must attend an annual fire lecture. A 5 yearly electrical installations inspection must be undertaken. DS0000064633.V250617.R01.S.doc Timescale for action 30/11/05 2. 3. 4. OP8 OP18 OP29 12 13 19 30/11/05 30/11/05 29/09/05 5. OP29 19 Sch 2 30/11/05 6. 7. 8. 9. OP30 OP38 OP38 OP38 18 13 & 18 23 23 31/12/05 31/12/05 30/11/05 30/11/05 Leighton House Retirement Home Ltd Version 5.0 Page 21 10. OP38 13 11. OP38 23 A fireguard must be provided for the electric fire in the ground floor lounge or the fire must be taken out of use. The door leading to the front door fire exit must remain unlocked. 31/10/05 29/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP10 Good Practice Recommendations The falls co-ordinator should be contacted with regard to residents who regularly fall. Door keys should be offered to residents on admission unless risk assessment indicates otherwise. Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Leighton House Retirement Home Ltd DS0000064633.V250617.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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