Inspection on 22/07/05 for Leolyn Care Home

This inspection was carried out on 22nd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Leolyn Care Home 23/01/09

Leolyn Care Home 06/03/07

Leolyn Care Home 17/11/05

Leolyn Care Home 23/11/04

Leolyn Care Home 27/04/04

Leolyn Care Home 10/11/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Leolyn 63 Pevensey Road St Leonards-on-sea East Sussex TN38 0LE Lead Inspector Liz Daniels Unannounced 22 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Leolyn Address 63 Pevensey Road St Leonards-on-sea East Sussex TN38 0LE 01424 422063 01424 718902 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) New Century Care (Leolyn) Limited Mrs Valerie Fowler Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (OP), 34 of places Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users must be aged fifty (50) years or over on admission 2. The maximum number of service users to be accommodated is thirty-four (34) 3. Service users with a physical disability only to be accommodated Date of last inspection 23 November 2004 Brief Description of the Service: Leolyn is a large detached property, situated in a residential area of St. Leonards-On-Sea. It is owned by New Century Care Ltd and provides nursing and personal care for up to 34 residents of an older age. Leolyn is set out over four floors with both a chair lift and a passenger lift to provide access to all floors. There is a large lounge area and a quiet room to provide communal space. Road parking enables easy access for visitors to the Home. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of seven hours, beginning at 10am and finishing at 5pm. The Inspector met with the Registered Manager for Leolyn, the Area Manager for New Century Care and two other members of staff. The Inspector also had a tour of the Home, and met with four residents, relatives and other staff informally before inspecting a range of key records. What the service does well: What has improved since the last 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. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 & 5 Leolyn provides good information for prospective residents and their relatives to make an informed choice about its suitability and are offered the opportunity to be involved as far as is possible in assessments and decisions about admission. The Home has good assessment processes in place for prospective residents. EVIDENCE: The Home has a comprehensive Statement of Purpose and service user guide. When a prospective resident makes an enquiry to the Home, Terms & Conditions are discussed. If admission is requested, an assessment incorporating a Health and/or Social Services assessment whenever possible, is undertaken. Prospective residents are told verbally during their assessment whether or not the Home can meet their needs, although documentation is currently being developed whereby residents will be informed in writing in future. They are offered the opportunity to visit prior to admission: the Manager also endeavours to involve the prospective resident’s relatives as much as is possible. Terms and Conditions are then confirmed on admission to the Home. The Inspector found that the pre-admission assessment documentation for two residents had not been signed and dated. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 8 Two residents when asked, could not recall how much they had been involved in choosing Leolyn prior to their admission and two said they had not visited but their relatives had come on their behalf. The four residents and relative who met with the Inspector are pleased with the Home. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 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 standard(s) 7,8 & 10 The Care Plans reflect the health, personal and social care needs of the residents in general, and are reviewed regularly whereby they remain contemporary. Health care needs appear to be met well. However residents or their representatives should be involved in Care Planning. The Home has good contact with local health services. EVIDENCE: Leolyn provides 24 hour nursing care if required and all the residents have a care plan that reflects their current health and personal care needs. Four care plans were viewed on the day of the inspection; all had been reviewed 1-2 monthly. However they are not all signed by the resident, demonstrating that they may not have been shared with them or their relatives. All the care plans seen included a risk assessment of falls, a nutritional assessment, a dependency assessment and an assessment of tissue viability. Monthly weighing of residents at risk of weight loss or who have a poor dietary intake is prescribed in the care plans and undertaken. Pressure mattresses are used in the Home when required. The Home enables the residents to have access to external health professionals including physiotherapists, chiropodists, opticians and occupational therapists. Staff accompany them to health appointments as needed. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 10 Staff confirmed the importance of promoting privacy and respect when residents are undergoing examinations or personal care. One resident in a double room confirmed that she did not wish to be in a room alone: screens are provided to enable each resident to have privacy as needed. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 The Home recognises the importance of ensuring individual needs are met and endeavours to offer choice and flexibility for the routines of daily living and activities. The menus are varied to provide a balanced diet and specific dietary requests are accommodated. Part used bags of food in the freezer need to be dated when opened. Disposable gloves should be worn to decant dry ingredients from the large storage bins. EVIDENCE: During the Inspection the Inspector found that residents were choosing either to spend time in their room, to sit in the lounge, or to sit in the garden. Residents are encouraged to furnish their own rooms by bringing personal effects with them. They are welcome to have visitors at any time, seeing them in private, in the lounge or in the quiet room. During the inspection the Inspector saw several visitors and had the opportunity to talk with one. He described the Home as ‘good’. A varied programme of activities is organised within the Home. Two of the residents spoken with during the inspection, knew there were activities arranged which they felt welcome to join in with if they wished. They were both enthusiastic about the garden area to walk and sit in. One resident has strong religious beliefs, which she feels unable to discuss and share with staff and other residents in the Home in any depth, but her pastor and church friends are able to visit regularly. A varied, nutritious menu is offered, rotated every four weeks. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 12 The menu does not always include a non-meat alternative, but the chef confirmed that special diets can be accommodated. Food and drinks are available throughout the 24-hour period. All the residents who met with the Inspector described the food as good and varied. They confirmed that they are given the opportunity to choose alternatives to the main meal if they wish. A visitor confirmed that his relative needs a soft diet, and this is provided. The Dining Room is comfortable and welcoming, providing a homely environment. Meals can be taken in the Dining Room, or residents can choose to eat in their rooms. The food preparation area was clean. However large bags of food were found opened but not dated in the freezer. Some dry ingredients are stored in large plastic bins and scooped out as needed. It was recommended that plastic disposable gloves be used to avoid the risk of contamination of the bin contents. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 There is a complaints procedure in the Home which the residents and staff have confidence in. Staff when questioned demonstrated a good understanding of the need to protect Vulnerable Adults and a robust policy is in place to manage this. EVIDENCE: There have been no complaints forwarded to the Commission, since the last Inspection. The Home has a complaints procedure that identifies the timeframes the Home will work to in managing the complaint and the people involved. The staff, when asked, said they are aware of and know how to access the policy. All complaints and the action taken are recorded and the outcomes fed back to the complainant. Two residents and a relative stated that they know they can discuss any concerns they have with the Nurse-incharge for the shift, or the Manager and have confidence that their concerns will be listened to and acted upon. There is a policy for the Protection of Vulnerable Adults. This includes Social Services as the lead agency for investigations and confirms that the local office for the Commission must be informed. Staff, when asked, could identify when to raise any concerns and what action to take. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Leolyn provides homely comfortable accommodation, which is well maintained, with good facilities and access to all floors, for wheelchair users. There are spacious communal areas and the garden has been thoughtfully developed. Equipment, which enables both support and independence, is made available. EVIDENCE: The Home provides spacious accommodation over four floors, with a passenger lift and chair lift to each floor. All areas are accessible for wheelchair users and within the Home there is a range of equipment and aids to assist those with reduced mobility. There is a lounge on the lower ground floor, which naturally divides into two areas: one part is used for television watching and the other provides a quiet area in which to relax with visitors, or read. There is also a quiet room next door: both rooms look out over the garden. A patio area and the garden can be accessed off the lounge. There are raised flowerbeds and a greenhouse to enable residents to be involved with the garden as they wish. The bedrooms all appear homely and comfortable. Residents are encouraged to have their own possessions with them to personalise their rooms. There is a call bell system to ensure assistance as needed. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 15 Cleaning staff are employed at the Home and on the day of Inspection it was found to be free from odours and clean. There is an annual maintenance programme and business plan for the Home, but no dates attached to demonstrate priorities. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 & 30 The health and personal needs of residents are met by a team of nurses and care staff. There is a staff rota in place to cover the 24-hour period and the rotas reflect appropriate numbers and skill mix for the needs of the residents. Safe recruitment checks are in place and the Home offers very good training opportunities for the staff. EVIDENCE: A Registered Nurse leads each shift and is supported by care staff. There is a staff rota in place to cover the 24-hour period but more staff are rostered to be on duty if the dependency of the residents increases. Kitchen, domestic and maintenance staff are also employed. The Manager usually works from Monday to Friday and is supported by the Deputy Manager. The Manager has achieved her NVQ level 4 and the majority of care staff are trained to NVQ level 2. The Home has senior carers who have additional responsibilities including supervision of new staff and helping with their training in personal care. Records indicate that there is comprehensive training in place, some of which is offered within the Company but there is also evidence that staff are accessing external training when appropriate. Staff confirmed that they have monthly supervision sessions and formal appraisals. New staff undertake induction training and staff receive specific training to meet the needs of residents. Three staff files were viewed during the Inspection. All files contained references received prior to appointment and a copy of the Terms & Conditions of employment. Recruitment checks had been applied for. Staff are appointed once a POVA first check is received and then supervised until there is CRB clearance. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36 & 38 The Manager and Deputy Manager demonstrate a commitment to promoting the health and safety of the residents and staff. Feedback from the residents and annual audits are valued as ways of determining the development of the Home. Overall the equipment and environment are well maintained and are safe for clients. However, the Commission must be notified of any death, serious injury or significant event within the Home. EVIDENCE: The Inspector found that Leolyn is managed in a professional way and feedback from the residents and their relatives is welcomed. An annual questionnaire about the Home is circulated to all the residents and their relatives. The comments are collated and a report is published which is available in the Home and for relatives or prospective residents who enquire. Records to promote and protect clients were inspected. Specific audits of the service are undertaken annually. A record of all accidents and the action taken is maintained. The Commission had not been notified of a resident’s admission to hospital in May. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 18 However in general no checks or inspections were found to be outstanding. The last Environmental Health Inspection was on 9th February 2005. It was recommended that the freezer be replaced or repaired which has subsequently been done. There is a contract in place for clinical and household waste management. The water test to exclude the risk of legionella was carried out on 17th November 2004. The Emergency Lighting was last tested on 28th June 2005 and the last Fire Service inspection was on 17th November 2004. Staff had fire training on 6th July 2005 and the last weekly fire alarm test was on 19th July 2005. During the inspection, appropriate equipment for the safe movement and handling of residents was evident and records indicate staff training. Medical equipment is available and used as needed. The Inspector found that equipment in use has been serviced. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x 2 Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? No 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 38.7 Regulation 37(1) (a-g)(2) Requirement The Home must notify the Commission without delay, of the occurrence of death, illness or any significant event. Timescale for action 31st August 2005 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 7.6 15 Good Practice Recommendations The Care Plan should be drawn up with the involvement of the resident, then agreed and signed by the resident whenever capable and/or representative. Bags of food in the freezer should be dated when opened, if part used and disposable gloves used when dry ingredients are decanted from the large food bins. Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 Leolyn H59-H10 S14013 Leolyn V238520 220705 Stage 4.doc Version 1.40 Page 22 - 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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