This inspection was carried out on 8th February 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.
CARE HOME ADULTS 18-65
Leonard Cheshire Home Mickley Hall Mickley Lane Totley Rise Sheffield South Yorkshire S17 4HE Lead Inspector
Rob Curr Unannounced Inspection 09:00 8 February 2006
th Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 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 Leonard Cheshire Home DS0000021792.V268382.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 Adults 18-65. 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. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Leonard Cheshire Home Address 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) Mickley Hall Mickley Lane Totley Rise Sheffield South Yorkshire S17 4HE 0114 236 9952/3 0114 262 0234 Leonard Cheshire Mrs Irene Gwendoline Webster Care Home 40 Category(ies) of Physical disability (40) registration, with number of places Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: The Leonard Cheshire organisation work with disabled people throughout the world. It offers support and campaigns for the rights of peole living with disabilites. Mickley Hall is one of their residential services. It offers long term support for 40 adults with a physical disability. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection began at 9.00 a.m. and lasted 5 hours. All but four of the key standards were inspected during the last inspection therefore progress on requirements and recommendations made during recent visits to the home were assessed. The inspector was escorted on a partial tour of the home. A variety of policies, procedures, and records were checked. The Manager was present during the inspection. The inspector discussed practice at the home with her and other staff. One service user was particularly helpful during the inspection process. He was willing to discuss his experience and life style at the home. The manager and staff were extremely helpful and assisted the inspector throughout the visit. What the service does well: What has improved since the last inspection?
The team as a whole have worked hard to maintain and enhance the service delivery. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 6 There have been further improvements to the environment and facilities. Specialist equipment is now fully operational and staff have had the appropriate training to use the equipment. The communal kitchen area had been fully refurbished to a high standard. The abilities of the people using this had been recognised therefore all the facilities and equipment was fully accessible, offering service users an opportunity to develop skills. The refurbishment and decorating plan was on target and a variety of improvements had been completed. The recommendation that 50 of the care staff team are qualified to National Vocational Qualification (NVQ) level 2 in care has almost been achieved. 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. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. All service users had an individual contract. EVIDENCE: All the service users’ files contained a copy of their ‘Terms and Conditions of Residence’. The service user and or their representative had signed these. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 8. All of the above key standards were checked and met during the last inspection. EVIDENCE: The service users that met with the inspector expressed their views in relation to being involved in the management of the service. They said that they had regular service user meetings. These were an opportunity to identify their needs and wishes. They said that they staff were ‘very supportive’ and that they could ‘depend on the staff to promote their independence’. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 14. All of the above standards (11-17) were checked and met during the last inspection. However, systems need to be in place for when service user’s choices were restricted. EVIDENCE: The service users said that all the social needs were highlighted in their ‘care plans’. One person said that the staff team encourage him to contribute to his family life and enhance relationships. The manager said the service users were accessing educational and leisure activities were this was identified. The service users were about to review the service user guide to make it more ‘user friendly’. There were occasions when the use of the computers and Internet access had been monitored. The manager and inspector discussed the need for a clear recording system that highlighted the reasons and benefits when service user’s use of the Internet is restricted.
Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. The information within the care plans was very clear. Health care was monitored and care plans were reviewed. This ensured the well-being of the service users. A range of health care professionals worked within the home to assist in meeting the needs of the service users. Service users could choose their GP and could see them in private so that their privacy and dignity was respected. All medication administered was signed for. EVIDENCE: The care plans were checked. They were comprehensive and contained detail of the action required by staff to meet the service users needs. The plans contained records of health assessments such as moving and handling. The service users said that their health needs were met. One service user said that he was ‘very happy’ with the care they received and that he had a named ‘key-worker’.
Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 12 Medication Administration Records (MAR) were checked. Staff had signed to indicate that medication had been administered. Staff were observed respecting service users privacy by knocking on bedroom doors before entering and closing bathroom and toilet doors when in use. During the lunchtime meal, staff were seen and heard treating service users kindly and respectfully. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Service users views are listened to. EVIDENCE: The service users explained to the inspector how they are supported to make their feelings known. One service user said that he was encouraged to ‘speak out’ at service users meetings. All the service users said that they ‘felt safe’ and that they had confidence in the manager and the support team. There were some outstanding issues in relation to an adult protection investigation. This needed to be expedited by the manager. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users live in a homely and comfortable environment. The identified refurbishment programme was maintained. EVIDENCE: The service users clearly enjoy their living space. They talked with a positive attitude about all refurbishment work that had improved their home. The outside area is generally tidier and well kept. Specialist equipment is now fully operational and staff have had the appropriate training to use the equipment. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Service users are protected by a robust recruitment practice and comprehensive training plan. EVIDENCE: Pre-employment vetting is undertaken thoroughly. All staff members had an appropriate CRB disclosure. A group of staff were currently undertaking National Vocation Qualification (NVQ level 2 & 3) in direct care. Staff confirmed that they received more than 3 days paid training each year. The training co-ordinator maintains comprehensive records and a training matrix that enables the manager to monitor the training needs of the staff. The recommendation that 50 of the care staff team are qualified to National Vocational Qualification (NVQ) level 2 in care has almost been achieved. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41 and 43. The service users informed the inspector that the organisation constantly monitors the service. EVIDENCE: Service users said that they have ‘every confidence’ in the manager and her staff team. The organisation undertakes monthly monitoring visits. This is reported to the local office of the CSCI. These reports reflect that the organisation is proactive at identifying good practice within the service and developing any areas that are found to be lacking. Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 2 X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 X X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Leonard Cheshire Home Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 X 3 DS0000021792.V268382.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 Good Practice Recommendations Standard YA16YA14YA7 Any sanctions imposed with regard to service users ‘activities’ should be recorded appropriately. Taking into account: • Details of activity/behaviour leading up to the use of the sanction • Description of the sanction used • Time date and location of sanction • Name of person/persons imposing the sanction • Effectiveness and consequences of the sanction YA23 YA35 YA37 The manager must expedite the outcome of the identified adult protection procedures instigated recently. Continue the plan to ensure that 50 of all care staff has a qualification of NVQ level 2 or equivalent. The Registered Manager should continue to achieve a management qualification equivalent to NVQ level 4.
DS0000021792.V268382.R01.S.doc Version 5.0 Page 19 2 3 4 Leonard Cheshire Home Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Leonard Cheshire Home DS0000021792.V268382.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
