Inspection on 08/12/05 for Leonora

This inspection was carried out on 8th December 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 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

Leonora 09/07/09

Leonora 12/07/07

Leonora 03/05/06

Leonora 08/07/05

Leonora 15/03/05

Leonora 27/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Leonora Wood Lane Chippenham Wiltshire SN15 3DY Lead Inspector Alison Duffy Unannounced Inspection 8th December 2005 10:00 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 Leonora DS0000028393.V272911.R02.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. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leonora Address Wood Lane Chippenham Wiltshire SN15 3DY 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) 01249 651613 Pilgrim Homes Care Home 21 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (21) of places Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated in the home at any one time is 21 No more than 5 service users aged 65 years and over with dementia may be accommodated at any one time When the accommodation identified in the variation application dated 28 June 2004 is no longer required by one or both of the two service users referred to in the same application, occupancy of the home must revert to 20. The Commission must therefore be notified immediately of any changes to occupancy of the identified accommodation. 8th July 2005 Date of last inspection Brief Description of the Service: Leonora is operated by Pilgrim Homes, which is a Protestant Christian organisation. The home is registered to provide care to twenty one older people, five of whom may have dementia. Since the last inspection there has been a change in management. Mrs Mercy Field, the previous manager has left and has been replaced by Mrs Gaie Marshall. Mrs Marshall has been in post for approximately four weeks and is currently undertaking the procedure to become the registered manager. Leonora is situated within a residential area of Chippenham. Residents who are very able may manage the walk into town although a car journey would probably be more appropriate. The home is a spacious detached property, which also contains a sheltered housing scheme. All areas are well maintained, comfortable and furnished to a good standard. Residents’ private accommodation is located on the ground and first floor and a passenger lift gives level access. Residents are encouraged to personalise their room and treat it as their own individual space. There are two pleasant communal lounges and a separate dining room. Staffing levels are maintained at three carers and one senior carer on duty until 2pm and one senior carer and two carers throughout the rest of the afternoon and evening. There are also additional housekeeping and catering staff and an administrator and maintenance officer. At night there is one member of waking staff and a sleep in carer. An on call management system is also available. The home does not provide nursing or intermediate care. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 8th December 2005 between the hours of 9.30am and 2.30pm. Discussion initially took place with the administrator and the new manager. Time was then spent with a number of residents within their private accommodation. A tour of the accommodation was made and discussion took place with various members of staff. The Inspector observed the serving of lunch and then viewed documentation such as health and safety material. Feedback was given at the end of the inspection. Discussion with residents and staff gave a range of positive feedback. There were no suggestions for development, as current provision was deemed more than satisfactory. Residents appeared totally aware of general day-to-day issues within the home and described their choice of preferred routines as standard practice. Many interactions were observed between staff and residents and all appeared totally sincere, respectful and attentive to individual need. What the service does well: What has improved since the last inspection? What they could do better: Management and staff work to high standards and therefore there are no areas that require significant improvement. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 6 Hot water temperature regulators however are required to minimise the risk of injury through higher than recommended hot water temperatures. Staff should also date documentation such as fire instruction and quality assurance questionnaires. 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. Leonora DS0000028393.V272911.R02.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 Leonora DS0000028393.V272911.R02.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 Leonora has an established, well-managed admission procedure. The home does not provide nursing or intermediate care. EVIDENCE: Since the last inspection there have been a number of new admissions. Discussion took place with one resident who had very recently moved into the home. It was reported that Leonora had been selected due to the organisation and its beliefs. The resident had moved to be near family and although early days, no issues of discontentment regarding the home were evident. The resident stated that staff couldn’t have been better and were assisting in their individual ways to promote the feeling of being settled. Discussion regarding moving into the home, took place with one member of staff and a real sense of empathy was evident. Various strategies for giving support were expressed and a clear awareness of need was apparent. Documentation regarding the assessment process was viewed and sufficient information had been gained in order to ensure a suitable placement. This had been used to commence the resident’s individual plan of care. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 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 the following standard(s): 7 and 8 Care planning is of a good standard with all plans containing detailed, comprehensive and up to date information. Health care is well managed with evidence of residents accessing a variety of services as required. EVIDENCE: All residents have an organised, well-maintained plan of care, which is detailed and regularly up dated. All plans follow the same structure, which portrays a holistic view of each resident’s individual needs. There are a number of assessments such as nutrition and pressure care management and each give guidelines when an identified health care professional is required. The documentation clearly evidences all medical intervention and a quick reference section identifies matters such as blood tests and a record of weight. Clear objectives are set as part of the plan and each are reviewed on a monthly basis. Such objectives cover social needs and general interests as well as various health care matters. Documentation demonstrates access to a range of health care services as required. Services include the opticians, the dentist and chiropodist as well as Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 10 services through referral such as occupational therapy. The GP and community nurses visit on a regular basis and excellent support was commented upon. Regulation 37 notifications, which have recently been sent to CSCI, have demonstrated appropriate contact with the emergency services. One resident spoken with reported that staff are very good at recognising problems and quickly get the doctor out for advice. Another resident confirmed that the staff always know ‘when you are under the weather.’ Leonora DS0000028393.V272911.R02.S.doc Version 5.0 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 the following standard(s): 12 and 15 Dedicated input is given to residents’ spiritual needs which complements the aims and objectives of care provision. Residents have the choice of participation within an established, programme of activity. Feedback regarding the food demonstrates a variety of good quality provision that is based on healthy eating and residents’ preferences. EVIDENCE: All residents are encouraged to follow their own routines and choose how they spend their day. A programme of activities is displayed on the notice board and residents can join in if they wish. Such activities include music appreciation and sit and be fit. Committed emphasis is given to residents’ spiritual needs and devotions, services and prayer meetings are held on a daily basis. Residents reported that ‘you can be as busy as you wish.’ Staff also reported that residents could help with housekeeping duties, such as laying and clearing the tables if they wanted to. A number of residents spoke of the benefits of solitary reading and talking books appeared useful. Some residents have developed friendships with others and the home’s visitors were reported to be extremely helpful. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 12 All residents confirmed that the food provided is excellent. There is a choice of two at the lunch and evening meal and in the event of not liking either an additional alternative would be negotiated. Breakfast was described as ‘you can have what you like.’ Another resident described a range of cereals, fruit or porridge with toast and a hot drink or fresh juice. Residents confirmed that there is always a good variety and the food is cooked and presented well. Discussion took place with the cook and it was reported that an emphasis on fresh produce and healthy eating is promoted and therefore items such as salad and fresh fruit are regular components of the menu. Residents are able to eat within the pleasant dining room or in their private accommodation. Leonora DS0000028393.V272911.R02.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 The home has a detailed, well-organised complaints procedure. Residents appeared confident that they would be listened to and their concerns would be satisfactorily addressed. EVIDENCE: Residents expressed total confidence in the handling of complaints. All residents spoken with reported that they would address issues with a member of staff and would presume the matter would be resolved quickly and efficiently. The home has a detailed complaints procedure and clear reporting procedures. Structured documentation is in place to record a complaint. There have not been any reported complaints to the home or to CSCI since the last inspection. Adult protection was not viewed on this occasion as satisfactory procedures were in place at the last inspection. A recent incident was appropriately referred to the Vulnerable Adults Unit. The incident was however deemed an accident and the full procedure was not instigated. Leonora DS0000028393.V272911.R02.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): 20, 24 and 25 Leonora is homely, clean, furnished to a good standard and well maintained. Regulators have not been fitted to all hot water outlets and therefore residents are potentially at risk of scalding. EVIDENCE: Leonora is comfortable, homely and furnished to a good standard. There are two communal lounges and a separate dining room. The main lounge near the entrance area has recently been fitted with domestic lighting giving a more homely feel. Additional lighting for residents with poor sight or those wishing to read has also been purchased. Private accommodation continues to be personalised in response to individual preferences. Residents are encouraged to bring items of furniture with them on admission and make their room as homely as possible. All residents spoken with reported total satisfaction with their environment. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 15 Through discussion it was confirmed that all radiators, except one, within private accommodation have been covered. Mrs Marshall reported that there is no reason why this one could not be undertaken and therefore arrangements would be made to do so. Radiators within corridors and communal areas also remain uncovered, yet these have been assessed as low risk. Mrs Marshall reported however that covers for the corridor radiators would be fitted within the next part of the programme. Hot water temperatures are regularly monitored and documented accordingly. Such records however demonstrated a number of temperatures from hand washbasins above those recommended. Mrs Marshall was informed of the need therefore to fit regulators to all outlets. It was reported that these had been ordered although the installation of such had been postponed due to major work to the boilers. A completion date of the end of January 2006 was however stipulated and therefore a requirement in response to this timescale has been agreed. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 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 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): These standards were not assessed in detail, yet comments and positive interactions between staff and residents highlighted effective staffing provision. EVIDENCE: All key standards were met at the last inspection and therefore were not assessed on this occasion. Through discussion however it was evident that there had been staffing shortages, which had been difficult. The situation, has since improved and the pressure was reported to be less evident. Some staff reported an excellent team with full support and discussion as key factors. All residents gave excellent feedback about the staff by quoting terms such as ‘wonderful’, ‘very kind and considerate’ and ‘they’re just lovely.’ Many attentive, genuine, respectful interactions were observed and hospitality was evident throughout. All staff spoken with were clearly aware of residents’ needs and demonstrated an empathy with conditions and individual circumstances. Leonora DS0000028393.V272911.R02.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, 33 and 38 The home has a new manager, who is experienced and has a sound value base. Residents are regularly consulted with and the home has an established, wellorganised quality auditing system. Health and safety is given high priority yet attention must be given to the installation of hot water regulators, to minimise the risk of scalding. EVIDENCE: As stated earlier in this report, Mrs Marshall has only been in post for approximately four weeks. Mrs Marshall has commenced the process of being registered although at this stage preliminary checks such as references and a CRB disclosure are being gained. Mrs Marshall is a registered nurse and has many years experience of both hospital and residential settings. At this time Mrs Marshall is getting to know residents, staff, relatives and other Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 18 professionals and is hoping to build on existing care provision. Staff and residents spoken with gave positive feedback about the appointment and attributes such as ‘very approachable’ and ‘very kind’ were used. All residents reported that Mrs Marshall had spent time with them and despite being overloaded with paperwork reassurance of a caring nature was given. All residents spoken with appeared to be very aware of events within the home and its day-to-day management. Discussions took place regarding key factors and all confirmed satisfaction with the service received. Communication between residents and staff appeared to be a natural process and residents’ rights appeared central to all interactions. The home has a formal quality assurance system, which is ordered and easy to follow. Mrs Marshall reported that she intends to address such within the New Year, as the subject had not been a priority within her initial days as manager. Staff have undertaken a number of questionnaires with residents and a range of positive feedback was received. In future however, Mrs Marshall was asked to ensure all staff include dates on documentation. The home has a range of health and safety information that is ordered, well written and comprehensive. There are a range of policies and procedures and a number of handbooks for staff reference. Health and safety is included in induction and all staff are up to date with their mandatory training. All fire checks had been satisfactorily undertaken and the fire log book gave order and clarity. At the last inspection it was recommended that staff fire instruction should be documented within the fire log book, as well as individual training records. This has been addressed although dates of such would also be of benefit. The building is well maintained and safety measures were given priority within the recent works to the boiler. Attention however, as stated earlier in this report, must be given to the installation of hot water temperature regulators. Leonora DS0000028393.V272911.R02.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X 3 X X X 3 2 X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 2 Leonora DS0000028393.V272911.R02.S.doc Version 5.0 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 OP25 Regulation 13(4) (a)(c) Requirement The Registered Person must ensure that all hot water outlets are fitted with individual fail-safe devices. Until this time, a wider cross section of outlets must be tested and any risks minimised. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP33 OP38 Good Practice Recommendations The Registered Person should ensure that all documentation such as quality assurance questionnaires is dated accordingly. The Registered Person should ensure that the dates of all staff fire instruction are recorded within the fire log book. Leonora DS0000028393.V272911.R02.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Leonora DS0000028393.V272911.R02.S.doc Version 5.0 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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