Inspection on 19/01/05 for Leybourne House

Care Home For Older PeopleLeybourne HouseWestern Avenue Bournemouth Dorset BH10 6HHAnnounced Inspection19th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Leybourne House Address Western Avenue, Bournemouth, Dorset, BH10 6HH Email address Name of registered provider(s)/company (if applicable) The Dorset Trust Name of registered manager (if applicable) Mrs Gillian June Blackham Type of registration Care Home No. of places registered (if applicable) 41 Tel No: 01202 574426 Fax No: 01202 590382Category(ies) of registration, with (number of places) Dementia - over 65 years of age (41), Mental Disorder, excluding learning disability or dementia - over 65 years of age (41) Registration number D550002132 Date first registered Date of latest registration certificate 23rd March 1991 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 11th January 2005 YES NO 5/08/04 If Yes refer to Part CLeybourne HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 319th January 2005 10:30 am Marion HurleyID Code115877Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Gill Blackham ­ Registered ManagerLeybourne HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementLeybourne HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Leybourne House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Leybourne HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Leybourne House is a care home providing personal care and accommodation for 41 older people who have dementia or mental disorder and who need assistance with personal care. It is owned by The Dorset Trust, a not for profit organization. Mrs Gill Blackham is the Registered Manager. The home is located in a residential area of the borough, close to local amenities. Leybourne House is a two-storey building. 40 of 41 bedrooms in the home are single, with one shared room (2 persons). One of the bedrooms has en-suite facilities. There is a passenger lift. The home has large gardens that are well maintained and easily accessible.Leybourne HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSThis inspection visit was announced and started at 09.45 on January 18th, 2005. The inspector was welcomed and the Registered Manager Mrs Gill Blackham and the team of staff had made preparations for this inspection. All documents and records were readily available and the Pre Inspection questionnaire had been comprehensively completed. The inspector was grateful for the time and contributions made throughout the day directly and indirectly by service users, visitors and staff. As part of the inspection process feedback cards were sent to service users, relatives / visitors and community social care and health professionals. The inspector was very pleased to receive 25 cards completed by relatives, friends and visitors, a further 17 completed on behalf of service users and 7 from Health & Social care Professionals. Comments included: - have always found the staff helpful, patients are treated with great respect and dignity, care given is superb, always kind and patient, mother is very well looked after, management and staff deserve praise for the quality of care shown to both patients and visitors, full confidence in staff, kind and efficient and caring. The attitude of the staff, the training they receive and the management of the home is excellent Not all of the National Minimum Standards were assessed at this inspection and standards previously met were not reassessed. The rating of 0 is indicated in the report where the standard was not assessed. Choice of Home (Standards 1-6) 3 standards were assessed and met; the remaining three standards were not assessed at this inspection having been met at previous inspections. Dorset Trust/Leybourne House has produced a very comprehensive and practical Statement of Purpose and Service User Guide. These documents meet the requirements as listed in schedule 1 and regulations 4 & 5. Health and Personal Care (Standards 7-11) 2 standards were assessed and met; the remaining three standards were not assessed at this inspection having been met at previous inspections. Detailed care assessments/plans were available on all service user files inspected. The records were clearly written and provided evidence for the meeting of the standards. Staff promote service users health care needs and access appropriate aids and adaptations to maximize their dignity and privacy. Daily Life and Social Activities (Standards 12-15) 3 standards were assessed and met; the remaining standard was not assessed at this inspection having been met at previous inspections. The inspector noted a full range of activities available to the service users and photographs were displayed of recent events. Leybourne House Page 6 The inspector observed the mid-day meal being served. The mealtime was relaxed and staff gave service users as much help and time as required to enjoy their meal. Visitors book was available and reflected the range and numbers of visitors to the home. Complaints and Protection (Standards 16-18) 2 standards were assessed and met; the remaining standard was not assessed at this inspection having been met at previous inspections. The Statement of Purpose/Service User Guide contains all the relevant information for service users and others regarding the process for raising complaints, full details of the CSCI contact number and address are clearly included. There have been no complaints since the last inspection visit. Environment (Standards 19-26) 1 standard was assessed and met, the remaining 7 standards having been assessed and met at previous inspections were not reassessed at this inspection. Rooms are comfortably furnished and service users are able to personalise them as they wish. A range of aids and adaptations are available throughout the home. On the day of the inspection Leybourne House was found to be clean and hygienic. The premises have been fully assessed by an Occupational therapist who commented on the high standard, safe, comfortable and stimulating environment with secure gardens which provide an interest and stimulation Staffing (Standards 27-30) 3 standards were assessed and met; the remaining standard was not assessed at this inspection having been met at previous inspections. Dorset Trust/Leybourne House is working towards the Department of Health target in respect of NVQ level 2 qualifications for 50 of care staff working at the home to have achieved this qualification or equivalent. Dorset Trust has robust recruitment policies and procedures, which are being fully implemented, at Leybourne House. Management and Administration (Standards 31-38) 4 standards were assessed and met; the remaining 4 standards were not assessed at this inspection having been met at previous inspections. All records relating to health and safety issues and fire training were checked and accurately documented. An independent consultant recently completed a quality assurance survey and commented on the high score achieved by Leybourne House. On the day of the inspection Leybourne House was well organised and the staff clear about their individual and collective responsibilities.Leybourne HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Leybourne HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Leybourne HousePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NA YES YES YES YES YES NA YES YES YES YES YES YES YES YES YES YES NA YES X X X YES YES YES YES 32 X 18/01/05 9.45 5.00Leybourne HousePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Leybourne HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 485.00 To (£) 500.00Any charges for extras If yes, please state what the extras are: Key findings/Evidence This standard is met.YESPERSONAL TOILETERIES, PAPERS, CHIROPODY, DRY CLEANINGStandard met?3Requirements from previous inspections have now been fully met as Dorset Trust /Leybourne House has produced a very comprehensive Statement of Purpose, which incorporates the Service User Guide. These documents meet the requirements as listed in schedule 1 and regulations 4 & 5. The Registered manager has displayed a prominent notice in the main hallway advising visitors that the documents are readily available however, due to the service group it is very unlikely a copy can remain for display purposes only as past experience indicates that service users are prone to walking off with documents /papers etc. All prospective service users and general enquirers receive an Enquiry Pack which contains General information about the services and facilities at Leybourne House, the philosophy of care, copies of the Corporate Home Life Magazine, Annual review, complaints information and general information entitled Thoughts on Dementia and the Care of the sameLeybourne HousePage 12 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met at previous inspections.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? This standard is met The inspector examined the records of recently admitted service users and found the information and assessments to be comprehensive reflecting the service users needs. A pre-admission assessment is generally completed with the service user and significant others and will take place in the service users current environment/situ. From this information a short term (six week) care plan is developed which includes risk assessments. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? This standard is met Leybourne House provides a specialist service for people with varying abilities and disabilities. All services users residing at Leybourne House have some level of dementia. There is a loyal and experienced staff team at Leybourne House that is reflected in the quality and competent services provided to all the service users. As part of the admission process all service users receive a welcome letter which also makes reference to the service users specific needs and how the staff and facilities at Leybourne House can meet their assessed needs.Leybourne HousePage 13 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met at previous inspections. The Registered Manager advised the inspector that for many prospective service users it is not feasible to visit the home prior to admission and a visit for some would clearly cause confusion and potential distress. The inspector accepts this practise is in the best interest of service users. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Leybourne House does not provide an intermediate care service.Leybourne HousePage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met at previous inspectionsStandard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence X 2 Standard met? 0This standard was not assessed having been assessed and met at previous inspections The inspector examined a selection of service user records and noted the quality of the care assessments /plans which were easy to read and gave a comprehensive picture of the individual needs and abilities of the service users. District Nurses are currently treating two service users with pressure areas. The chiropodist and other specialist health related services are arranged according to the service users needsLeybourne HousePage 15 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? This standard is met The inspector observed part of the mid-day medication being administered and noted that this was undertaken competently and accurately. The inspector verified that the requirement made from the last inspection ­ that a controlled drugs register be kept and used as and when required ­ had been acted upon. Action to ensure this requirement was met was taken immediately following the last inspection. The storage for all medication is secure and locked. Two fridges are used solely for the storage of medication when required the temperatures of both are monitored and recorded. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was met at the last inspection and was not assessed at his inspection. The inspector observed service users and staff interacting well together and was pleased to note the care and sensitivity and good humour adopted throughout the day. Staff were working well together as a team. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? This standard is met. The Home has both policies and procedures in the event of a death. The registered Manger described the flexible support provided to a service user and their family /relatives recently. Specialist community nurses when required support staff at Leybourne House in the care of the dying. The wishes and preferences of service users are recorded at the time of their admission to Leybourne House. Records were available for the inspector to verify this information.Leybourne HousePage 16 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met at previous inspections. Leybourne House continues to employ two members of staff specifically to organise activities for and with service users.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? This standard is met. Visitors to Leybourne House are very welcome and within reason may visit at any time. Information with reference to visitors is included in the Statement of Purpose/Service user Guide. The inspector noted the provision of the visitors book. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? This standard is met. The Inspector saw that service users are able to bring their own possessions into the home. The home has information on advocacy services, which is displayed in the main hallway and included in the Statement of Purpose/Service user Guide. Staff encourage service users to maximize choice within a risk assessment framework. The inspector observed staff throughout the inspection visit providing and encouraging service users to form opinions and make choices.Leybourne HousePage 17 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? This standard is met The chef has recently been appointed and is still getting to know the routines and diets of all the service users however, they stated how much they are enjoying the work. All records examined were found to be accurate with details of deliveries and dates all noted. Food temperatures were recorded, as were the temperatures of all appliances. The chef had records of all special diets and meal preparation for individual service users. The menu afforded daily choice and appeared to be nutritional with ample variety.Leybourne HousePage 18 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard is met X X X X X X X 3Standard met?Dorset Trust has comprehensive policies and procedures on the handling and management of complaints and concerns. There have been no complaints raised since the last inspection. Reference was made to a concern however the comment on the feedback card received by the inspector read, immediately dealt with. The Registered Manager has recently established a Relatives Support Group and this will provide opportunities for relatives and other visitors to be involved in the running of the home and raise any ideas and concerns they may have on behalf of the service users. The management and staff team clearly have a positive and open rapport with relatives and visitors in the Home and this was evidenced not only from observations on the day of the inspection but verified by comments on the feedback cards.Leybourne HousePage 19 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? This standard is met. Service users have either family members or solicitors to assist them where needed to represent their wishes. The inspector was told that four service users are on the electoral register but others have shown no interest or comprehension of the process. Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X0 Key findings/Evidence Standard met? This standard was not assessed having been met at previous inspections however; the inspector verified the on going commitment to continually meet this standard by discussing the details of the procedures with the Registered Manager and members of staff. Copies of the procedural flowchart are displayed in the offices and staff room. The service users residing at Leybourne House are particularly vulnerable and if any service user has an accident where staff think bruising is likely to occur the details are fully recorded and a statement bruise might appear. This is good practise and alerts all staff to be especially vigilant.Leybourne HousePage 20 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met as previous inspections. Since the last inspection the communal space downstairs has been reconfigured and now provides three lounge diners. The registered manager stated the smaller groups are working well for the service users who seem to benefit from a quieter smaller group and has seemingly even prompted some to now make their own way to the table for the meal. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met as previous inspections.Leybourne HousePage 21 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met as previous inspections.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? This standard is met An occupational therapist completed an assessment of the premises on 5th August 2004. The certificate is displayed in the front reception. The report stated that Leybourne House provides a high standard, safe, comfortable and stimulating environment with secure gardens which provide an interest and stimulation No recommendations were required following this assessment.Leybourne HousePage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence NO YES NO 39 0 1 0 Standard met? 0 39 00 0 0 1This standard was not assessed having been assessed and met as previous inspections.Leybourne HousePage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met as previous inspections.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met as previous inspections.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not assessed having been assessed and met as previous inspections. On the day of this inspection the premises were found to be clean and hygienically maintained.Leybourne HousePage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health.Personal Care NursingNo. service users High needs No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence This standard is met.41 X X XNo. staff hours allocated No. staff hours allocated No. staff hours allocated No. of staff hours providedX X X 866.25X X X XX 32 5 Standard met? 3On the day of the inspection there were sufficient staff to meet the needs of this high dependent group of service users. The inspector noted the details of staffing numbers on the rota. The morning shift consistently has 7 care assistants plus two Care Team Managers and the afternoon shift has 4/5care assistants with 1 Care Team Manager. In addition the home has adequate ancillary staffing to cover laundry, domestic and kitchen duties. Leybourne House continues to top up shifts when necessary with Dorset Trust bank staff or agency. Leybourne House Page 25 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed. 6 X Standard met? 0However the inspector is very aware of both the homes and Dorset Trusts continued efforts to reach this standard. Dorset Trust has a commitment to training and more staff have been nominated to complete the NVQ level 2 Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? This standard is met The inspector examined a number of staff files and found that the recruitment policies and procedures had been comprehensively completed and each file contained the required information. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? This standard is met All staff have training files, which contain clear records of training successfully completed, and nomination forms for future training courses. Dorset Trust has a comprehensive training programme, which meets the requirements of this standard. All staff receive initial induction training and after successfully completing the probation period commence the Foundation /Induction training accredited to TOPPS. Additional specialist training completed since the last inspection has included: Funeral awareness, Foot Care, Effective Customer Care, Personal development and supervision skills. It is recommended the Registered manager request details of all training completed by any Agency staff who work at Leybourne House.Leybourne HousePage 26 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? This standard is met. The Registered manager has a management qualification at Level 4 NVQ and throughout the inspection day demonstrated to the inspector their specialist knowledge, and management skills in running Leybourne House. The Registered manager expressed their continued desire to further develop and increase both management skills and their practical understanding of working with people with varying degrees of abilities and dementia. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed. However throughout the day the inspector noted the open and honest style of management and this was verified from comments received on the feedback cards from both Health & Social Care Professionals and relatives and visitors.Leybourne HousePage 27 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? This standard is met. In November 2004 an independent consultant completed a full quality assurance audit and noted there was a high level of overall satisfaction, with very high scores reflecting warmth and friendliness with staff respecting privacy and independence A comment from a feedback card referring to staff attitudes read superb job, helpful and pleasant. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed .Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed. Standard met? 0 X X XLeybourne HousePage 28 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessedStandard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? This standard is met Dorset Trust has a range of policies and procedures that are required by law and these underpin practice at Leybourne House.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? This standard is met Fire records were checked. Fire precautions and training were current and undertaken within the required timescales. Each member of staff has an individual fire training record which is dated and signed off after each session by the member of staff. No hazardous materials were seen inappropriately stored during the visit. All windows have restrictors and these are routinely checked monthly. Individual hoists are regularly checked. The home has four registered first aiders. Evidence for this standard was obtained by the inspector examining records and in discussion with the Registered Manager and staff and in touring the premises.Leybourne HousePage 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager Date Public reportsMarion HurleySignature Signature SignatureIt should be noted that all CSCI inspection reports are public documents. Leybourne House Page 30 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 18th January 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleLeybourne HousePage 31 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 3rd March 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was requiredAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Leybourne HousePage 32 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mrs Gill Blackham of Leybourne House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 ...................................................... am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Roger Charles Fulcher RCFulcher Director 23/02/05Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Leybourne HousePage 33 Leybourne House / 19th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000003902.V196882.R01© This report may only be used in its entirety. 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