Inspection on 11/05/05 for Leonard Cheshire Of Gloucestershire

This inspection was carried out on 11th May 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

Leonard Cheshire Of... 12/09/07

Leonard Cheshire Of... 15/05/06

Leonard Cheshire Of... 11/12/05

Leonard Cheshire Of... 25/11/04

Leonard Cheshire Of... 18/06/04

Leonard Cheshire Of... 07/01/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOME ADULTS 18-65 Leonard Cheshire of Gloucestershire Charlton Lane Leckhampton Cheltenham Glos GL53 9HD Lead Inspector Lynne Bennett Unannounced 11&12 May 2005 8.30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leonard Cheshire of Gloucestershire Address Charlton Lane Leckhampton Cheltenham Gloucestershire GL53 9HD 01242 512569 01242 253264 glos@cent.leonard-cheshire.org.uk Leonard Cheshire 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) Mr Gareth Jones Care Home 36 Category(ies) of PD - Physical Disability - Both (36) registration, with number OP - Older People - Both (2) of places Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th November 2004 Brief Description of the Service: Leonard Cheshire of Gloucestershire provides residential and nursing care for people with a physical disability. The home is owned and managed by The Leonard Cheshire Foundation. The home is located in Leckhampton, not far from Cheltenham town centre, and close to local facilities and amenities. The home was purpose built some 13 years ago, providing a main building divided into five lodges for six people, communal spaces, offices and a hydrotherapy pool, a sensory room and a physiotherapy room. There are six bungalows that enable service users to have greater independence but also retain some support from staff. The home has four mini buses and a car; service users also use local taxis and the community transport system. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in May 2005. The inspection on the first day involved two inspectors and on the second day one inspector was present. The inspectors spent time talking to people living at the home and staff who were on duty. Documents examined included care plans, medication records, staff files, training records and off duty schedules. A tour of the premises was conducted. The inspectors were present during a fire drill and one inspector observed the medication round. What the service does well: What has improved since the last inspection? Service users are being involved in the running of the home, in decision making and taking responsibility for tasks such as reception and interviewing staff. People living at the home are enjoying being more involved in these processes. Medication procedures have substantially improved. Staff administering medication use medication trolleys and were observed following medication procedures. The gardens are being well maintained and improvements to patios and paths are underway. A sensory room has been provided and a sensory garden is planned. Leonard Cheshire of Gloucestershire Version 1.30 Page 6 D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc 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 of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 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 standard(s) 1,2,3,4 and 5 The Statement of Purpose and Service User Guide do not reflect the diversity of needs being supported at the home providing prospective people moving to the home with a false impression of the services provided by the home. A thorough admissions process is in place providing prospective people with the opportunity to make an informed choice about whether they would like to live at the home. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. The Guide was amended at the time of the inspection, to include a summary of the Statement of Purpose and now fully complies with the National Minimum Standards. Since the last inspection two new people have moved into the home. One person said that they were able to visit the home on several occasions before moving in. Full assessment information was provided from the placing authority and other people involved in the care. The person said that staff and other people living in the home are being very supportive and a relationship is already developing with the key worker. Other people living in a lodge with the other new person said that they are enjoying getting to know each other. Some older people living in the home Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 9 said they are happy to share lodges with younger people and would not like to see segregation between age groups. One of the recent admissions to the home has a learning disability. The home is in breach of its conditions of registration. A variation to registration must be completed and the appropriate training for staff provided. (See Standard 35) The Statement of Purpose and Service User Guide must be amended to reflect this. People living in the home have a placement contract between themselves, their placing authority and Leonard Cheshire. Leonard Cheshire also has a statement of terms and conditions in place for people living at the home. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 10 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 standard(s) 6,7 and 8 Care planning systems are in place. Regular review of these records will ensure that the changing needs of people living at the home are met. The systems in place for consultation have significantly improved empowering people living at the home. EVIDENCE: Plans were examined for two people living in the lodges who require nursing support, one new person who had moved into a lodge and two people living in the bungalows. The plan for the new person is being developed from information supplied from family and the placing authority. Other plans had not been reviewed. Parts of these plans had also not been filled in such as the missing person’s record. These must be completed. Care plans must be reviewed at least every six months. It was not evident how people living in the home are involved in the care planning process. People living in the home must sign their care plans wherever possible. Each care plan must also contain a photograph. Permission was being obtained from people living at the home to take photographs. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 11 Care plans for one person who had recently moved from the bungalows into a lodge had not been amended to reflect their changed needs. People spoken to confirmed positive relationships with their key workers and said that they would support them to make choices and decisions about activities of daily living. This was observed during the inspection. People living at the home said that they are consulted about the running of the home. They are involved in recruitment and selection of staff, health and safety, consultation about changes to menus and the range of activities offered at the home. Several said that they help out at reception, answering the telephone and greeting visitors. Some people spoken to felt that there was still room for improvement in particular in relation to the provision of meals (See Standard 17). Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 12 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 standard(s) 11,12,14 and 17. Opportunities for personal development have significantly improved increasing the ways in which people living at the home can effect change. The home has made no progress to improving the provision of a healthy, nutritional and balanced diet, causing concern about the health and wellbeing of people living there. Significant improvements must be made over the next three months or further action will be taken. EVIDENCE: People living at the home have attended training in equal opportunities and are being offered a course on ‘Empowering Service Users’. One person represents the residents at a Health and Safety Meeting with management and spoke with enthusiasm about the positive benefits this has brought to the residents. People living at the home access a variety of educational, leisure and recreational facilities and activities. They say that the biggest problem is that of access to transport. The home employs a driver and has a bank of volunteer drivers but supply in the evenings and at weekends continues to be a Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 13 problem. Some people use taxis and rely on their family. During the inspection staff were trying to find transport for a person wishing to go to church on Sunday. The home employs a volunteer co-ordinator who it is hoped will be able to improve this situation. A vacancy for a twilight shift when filled will also have a positive impact. This situation will continue to be monitored. The home is having a new minibus. Several people living at the home expressed their excitement about a planned holiday to Spain later in the year. A group of staff are accompanying them. Another person had been to Lourdes and someone else was going to France. People living at the home say there has been a significant improvement in their involvement in the daily running of the home. They feel that they are being listened to and that action is being taken as a result. Some people continue to have concerns about the diet they are offered. Meals are provided each day at noon and a selection of ingredients or prepared snacks provided daily to the lodges for tea. On the first day of the inspection there was no evidence of fresh fruit or snacks in the lodges. Although on the second day fresh fruit and biscuits were in evidence in the kitchen of one lodge. Each lodge has a small budget to purchase fruit and snacks. They also have a supply of frozen food given to the home by a local store. Fresh fruit and snacks must be made available to people living at the home. The quality of the food provided for the mid-day meal was also of concern. At the last catering meeting, people asked for fresh vegetables. The menus for the summer period include a mixture of processed and frozen food as well as some freshly prepared meals such as a roast dinner. Alternatives are offered. On the day of the inspection people were offered Chicken Kiev or Haddock and parsley sauce with new potatoes and salad. The portions provided did not appear to be adequate. One person opted for new potatoes and salad and another fish and potatoes – no other alternatives were provided for them. People indicated that they are buying their own food to supplement the meals provided. One service user who prefers to have their meal in the evening had a meal of fish and potatoes left in the lodge kitchen to be re-heated later. This is a risk to service users health. Again it did not look appetising and no vegetables were included. It is a requirement that re-heating of meals does not take place due to the risks associated with food poisoning. The World Health Organisation recommends 5 portions of fruit and vegetables a day for every person. The home is not meeting this or encouraging healthy living. Due to the medical conditions of some of the service users especially those who have limited mobility or wounds it is recommended they receive a nutritious meal to assist in the healing of the wounds and to prevent complications like constipation. New kitchens are being installed in all lodges within the next 12 weeks. People living at the home have been involved in this process and have chosen the Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 14 kitchen they want to have which will have full cooking facilities. It is hoped that people will then have the opportunity to prepare their own meal whether at lunchtime or in the evening. This will provide people with greater choice and autonomy over their diet and mealtimes. Staff are attending training in Basic Food Hygiene in preparation for this. They must also receive training in nutrition and diet. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 15 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 standard(s) 18, 19 & 20 Service users have access to outside health professionals but in order to ensure the health and welfare of service users, care records must be improved. EVIDENCE: Two service users were case tracked; the care provided for one service user was up to date except that the care plans had not been reviewed. This service user was waiting for delivery of a wheelchair that has been designed to meet their needs. A risk assessment needs to be devised as this service user smokes in their room and it is recommended this be checked with the fire service. The other service user care plans had not been reviewed to reflect the changes in their circumstances (see standard 6). This service user said he is able to have some choice over the staff he has to assist him with his personal hygiene needs. Evidence of health professionals visits was seen. One service user case tracked had wounds that were being monitored by both the home and the Community Nurses. The format used by the home does not allow for sufficient detail of the wounds and their progression. It is recommended that wound mapping or photographs be taken (with the service users permission). This service user’s care plan said he needed an air mattress and hoisting, but there was no air mattress on the bed and he said he is no longer hoisted. These care plans must be updated to reflect the changes. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 16 Since the last inspection the home has reviewed their medication procedure and purchased trolleys. One lodges medication was observed and the care staff took the trolley to the service user with MAR (Medication Administration Record) sheet. Records of medication received and administered and returns were seen. One of the service users case tracked had an assessment for selfmedication. The Qualified nurses said they support the carers in giving medication especially with PEG tubes and are available to give advice. This service user’s homely remedy list had not been reviewed since December 2003 and this must be addressed. This lodge did not have any service users receiving controlled medication. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 17 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 standard(s) 22 The home has a satisfactory complaints system in place with some evidence that people living at the home feel that their views are listened to and acted upon. EVIDENCE: People living at the home said that they are aware of the complaints procedure and would feel confident voicing concerns to their key workers or to the manager. They also said that they have a number of ways in which they can voice concerns either by using the complaints procedure, through their key worker and at reviews, directly to the manager or through one of the committees or residents’ meeting. They also have the opportunity to talk to a representative of Leonard Cheshire at the monthly-unannounced Regulation 26 visit. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 18 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 standard(s) 24,28 and 30. The manager has a clear development plan for environmental improvements within the home reflecting the changing needs of people living there. EVIDENCE: There are significant environment changes taking place to the home at the present time. A new front door is being fitted which will allow controlled access. At present people are accessing the building by a side entrance. There are concerns about the security of this door during times of the day when the offices are not occupied. Risk assessments must be put in place and visitors monitored. On the second day of the inspection, the signing in book had been placed in a more accessible position to the current entrance. The hydrotherapy pool is presently out of use, because it is being re-grouted. Some footpaths and a patio are being laid around the home. A sensory garden is also being developed in memory of a former resident. Within the next three months all lodges will have new kitchens with full cooking facilities. People living at the home said that they had been involved in the choice of kitchen units. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 19 The laundry is also being changed to provide improved access for people living at the home. These improvements comply with requirements issued at previous inspections. A requirement issued at 2 previous inspections for the home to repair damage to the laundry wall has not taken place, however as mentioned above plans are in place to refurbish the laundry. Protective clothing is available for staff to wear in the laundry. In two lodges it was noticed that PEG feeding equipment was placed in the communal sinks in the kitchens. This is an infection control risk as it could lead to cross infection. This was discussed with the care manager and the next day individual washing up bowls have been provided for this equipment to be placed in. New carpets have been fitted to several lodges since the last inspection. The rooms of people moving into the home have also been redecorated. They confirmed their involvement in the choice of colour scheme. A sensory room has also been developed providing a relaxing and quiet area for people living at the home with an array of lights, sound and a water mattress. The manager described environmental improvements scheduled for the home that will have a considerable beneficial impact on the well being of people living there. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 and 35 There are concerns that staffing levels do not reflect the needs of people living at the home reducing the opportunities for people living there to lead fully inclusive lifestyles. Some recruitment and selection procedures need to be improved to ensure the protection of people living at Leonard Cheshire. EVIDENCE: Considerable discussion with people living at the home, staff and the manager centred on the present staff ratios. There are several vacancies for which recruitment is taking place. Volunteers are also being sought to help out with driving and activities within the home. An activities co-ordinator should be appointed within the next few weeks as well as a twilight shift worker. The manager is monitoring how these will affect people’s access to support in the community and recreational activities. People living in the Bungalows said that on occasions the staff supplied to work with them are used to supplement shortages on the lodges. The home must make other arrangements. People living in the bungalows must have access to their support workers. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 21 The staff rota currently in use does not identify when the manager and care supervisor are scheduled to work. Staff are informed verbally when they are not coming into the home due to training or meetings. The schedules for the manager and care supervisor must be available in the home. One of the lodges off duty indicated that a member of staff worked the day shift and then came back to work the night shift. The care manager said this was not the case. To prevent confusion the off duties should work in tandem and contain the same information as this could have resulted in the Commission for Social Care Inspection considering action as the staff member could have put service users at risk due to lack of sleep. There continues to be concern about the availability of staff and drivers at weekends. People living at the home say that this support affects social and recreational activities outside the home. Although they did comment that staff will work overtime on occasions to ensure they can go to concerts or the theatre. The present rota system provides cover from care staff until 8.00 p.m when night staff take over. This indicates that people living at the home do not need support outside these hours. As mentioned staff occasionally volunteer to work beyond these hours to ensure access to social activities. However the assumption is that people living at the home, who require staff support, do not regularly wish to go out for the evening. The manager is in discussion with the staff team about how this dilemma can be resolved. This situation will continue to be monitored. There was an indication during the inspection from staff about a need to clarify the roles and responsibilities of night staff during their shift. The manager said that this would be addressed in the next night staff meeting. Leonard Cheshire has a recruitment and selection procedure in place. The home receives support from the Area Office. The application form does not request a full employment history. This must be amended. People living at the home confirmed that they are involved in the recruitment and selection of new staff. The manager keeps interview records. Staff files examined for new staff did not contain sufficient information. These must contain information as listed under Schedule 4. Photographs of staff have been obtained and are kept on disc. The manager confirmed that Criminal Records Bureau and Protection of Vulnerable Adult checks are being completed and that confirmation is sent to him electronically. Confirmation missing from one file was produced on the second day of the inspection. There were also queries about the employment of a member of staff and whether thorough investigation was completed at the point of selection. The manager said that any discrepancies noted in application forms or references would be looked into in some depth. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 22 Volunteers and other people having regular contact with people at the home have Criminal Records Bureau checks completed. The manager must ensure that he obtains confirmation from an agency that their staff are subject to a thorough recruitment and selection process and information relating to Schedule 2 is obtained by them. A training co-ordinator is employed by the home ensuring that staff have access to mandatory training, refresher courses and any specialist training they should require. The home also has a robust NVQ programme in place. Staff must complete training in the nutritional and dietary needs of people living at the home. Training is also required for staff supporting the person with a learning disability. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,41 and 42. The manager has a good understanding of the areas in which the home needs to improve and the resources required to achieve this. Aspects of health and safety must be improved to ensure the safety and wellbeing of people living at the home. EVIDENCE: People living at the home gave mixed feedback about the accessibility of the manager. Some felt that they are able to talk to him regularly and others said that he was often busy. Overall people spoken with felt that they are being given increased opportunities to raise concerns and be involved in the processes of running the home. Staff also said that they thought standards of care were improving and would continue to do so. People living at the home said that they attended a meeting the day before the inspection with the Responsible Individual for the home, the area manager and manager to talk about the future of the home and of Leonard Cheshire. People Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 24 spoken with were very positive about future plans including greater community presence and access, transport issues and bringing education into the home. Each month an unannounced inspection takes place by a representative of Leonard Cheshire. This took place on the day of the inspection by a person new to the process. The inspectors will monitor the information collated and recorded on the Regulation 26 reports. The visit appeared to be very brief. The registered manager said that this was shortened due to the inspection. Leonard Cheshire also has quality audits that it conducts. A health and safety audit was completed in January 2005 and a catering audit is due. Residents’ meetings take place each month and the chairperson feeds back any concerns or issues to the manager. He said that these are then actioned or a reason is given why they cannot be put in place. Accident and injury records are being kept in an office. These must be stored securely in a locked cabinet. Some records are still in the accident book. Health and safety records confirmed that systems are in place for the monitoring of fridge, freezer, food and water temperatures. Environmental and fire risk assessments are in place and being reviewed. A visitor’s book is in situ. Visitors must sign in. On the day of the inspection a visitor did not sign in and was left to wander around the home. He was unknown to staff. A protocol must be put in place and all staff made aware of this. Fire records are being maintained for drills, training, servicing and checking of fire equipment. Equipment checks must be completed at the intervals indicated in the fire log. A fire drill took place during the inspection and the staff in one of the lodges followed the correct procedure by sending a member of staff to the fire panel and the staff member left in the lodge removed any obstacles from the fire escape route and checked on all the service users. At the meeting afterwards there was some confusion as to the correct procedure to follow and which staff should have collected the off duty. At this time there was no information available to say what staff or service users should have been in the home and if any were out. There are plans to address this. Two staff members carried on working during the fire drill. The home must ensure that all staff are aware of the correct procedure to follow and it is recommended that the home contact the local fire service to assist in devising a protocol suitable to meet the needs of the service users and to protect them if a fire ever occurs. The fire service were contacted during the inspection. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 25 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 2 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 x x 1 Standard No 31 32 33 34 35 36 Score x x 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leonard Cheshire of Gloucestershire Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x 2 2 x D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1,2 Regulation 6, CSA Requirement A variation to registration must be applied for a person with a learning disability. The Statement of Purpose and Service User Guide must be amended to reflect this. Care plans must be completed and kept under review. Care plans must be signed by service users. Care plans must be amended to reflect changes in need of service users. Care plans must include a photograph of the service user. Service users must have access to nutritional and wholesome food in sufficient quantities. Staff must receive training in nutrition and dietary needs of service users. The home must not re-heat service users meals. A risk assessment must be put in place for work being completed by contractors in the home and to minimise security hazards. The duty roster must include the schedules of the manager and care supervisor. The home must ensure that sufficient numbers of staff are Timescale for action 11 June 2005 2. 6 15(1) (2)(b) 11 June 2005 3. 4. 5. 6. 17 17 17 24 16(2)(i) 18(1)(c) 13(3) 13(4) 11 June 2005 11 Sept 2005 11 June 2005 18 May 2005 11 June 2005 7. 33 17(2) 18(1)(a) Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 27 8. 9. 10. 33 34 34 18(2) 19 Sch 2.6 17(2) Sch 4.6. 19(4)(b) 11. 34 12. 35 18(1)(c) 13. 14. 15. 16. 41 42 42 42 17(1) Sch 3.3(j) 13(4) 17(2) Sch 4.17 23(4)(c) (v) 23(4)(d) 17. 18 13(4)(c) 18. 20 13(2) working to support people living in the bungalows. Night staff must have clear guidance about their roles and responsibilities. A full employment history must be obtained for new staff. Information as listed under Schedule 4 must be kept at the home. (Timescale of 25 Nov 2004 not met) Confirmation must be obtained that the agency has obtained information about their staff in line with Sch.2. Staff supporting a person with a learning disability must receive training appropriate to their needs. Accident and injury records must be stored securely. (Timescale of 25 Nov 2004 not met) A record of all visitors must be kept and a protocol for their reception put in place. Fire equipment must be tested at appropriate intervals. The Registered Person must ensure that all staff are aware of the correct procedure to follow in the event of a fire. The Registered Person must complete a risk assessment for any service user that smoke in their room.i The Registered Person must update the homely remedies list with either the service users GP or Pharmacist. 11 June 2005 11 July 2005 11 July 2005 11 June 2005 11 July 2005 11 July 2005 11 July 2005 11 May 2005 11 May 2005 11 July 2005 11 July 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. Refer to Good Practice Recommendations D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 28 Leonard Cheshire of Gloucestershire 1. 2. 3. Standard 14, 33 18 18 There should be sufficient drivers and staff available to enable service users to access social, recreational and leisure pursuits. The registered person should consider using wound mapping and/or photographs to assist in the monitoring of service users wounds. The registered person should ask the fire service to check the risk assessments for service users smoking in their rooms. Leonard Cheshire of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 29 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 of Gloucestershire D51_D03_S16491_LeonardCheshire_V226936_110505_Stage4_U.doc Version 1.30 Page 30 - 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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