Inspection on 02/03/07 for Leybourne House

This inspection was carried out on 2nd March 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Leybourne House 24/01/06

Leybourne House 16/09/05

Leybourne House 19/01/05

Leybourne House 05/08/04

Leybourne House 06/02/04

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

CARE HOMES FOR OLDER PEOPLE Leybourne House Western Avenue Bournemouth Dorset BH10 6HH Lead Inspector Carole Payne Unannounced Inspection 2nd March 2007 09:30 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 Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 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. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leybourne House Address Western Avenue Bournemouth Dorset BH10 6HH 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) 01202 574426 01202 590382 www.care-south.co.uk Care South Mrs Gillian June Blackham Care Home 41 Category(ies) of Dementia - over 65 years of age (41), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (41) Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Four service users in the age range 18-65 years (in the categories DE or MD) may be accommodated to receive personal care. 24th January 2006 Date of last inspection Brief Description of the Service: Leybourne House is part of the Care South (formerly The Dorset Trust) group of homes and is managed by Mrs Gill Blackham. The Dorset Trust was established in 1991 having leased several homes across Dorset from the local authority, the Trust has since expanded and now provides care in Devon and Somerset resulting in the name change to Care South. Care South is a nonprofit making organisation. Leybourne House provides accommodation for up to 41 older people who have dementia or other mental health needs and who require assistance with personal care. The premises were purpose built by the local authority, and provides 39 single rooms, one with an en-suite shower, and one shared room, over two floors. The first floor is reached by a passenger lift and stairways. Residents are able to benefit from the three lounge/dining room areas and conservatory on the ground floor and the mature, accessible gardens. There is off road parking to the front of the home. Current fees are between £545 to £580. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_peop le_choos.aspx Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on the 2nd March 2007 and took a total of 11 hours, including time spent in planning the visit. The inspector was made to feel welcome in the home during the visit. This was a statutory inspection and was carried out to ensure that the thirty nine who are living at Leybourne House are safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit and key standards met at the last inspection were also reviewed. The premises were inspected, records examined and the daily routine observed. Time was spent in discussion with seven residents living in the home and three staff members on duty. Twelve resident survey forms were received by the Commission for Social Care Inspection prior to the visit; three comment cards from health and social care professionals who visit the home; sixteen relative / visitors’ comment cards and two comment cards from General Practitioners. The home also returned a detailed pre-inspection questionnaire prior to the visit. Throughout the inspection and following the visit the management and staff team have demonstrated a positive and proactive commitment to addressing any issues raised and continuously improving the quality of life for people living at Leybourne House. What the service does well: One person returning a resident survey form said ‘The home is well run and organised.’ A care manager / placement officer returning a comment card said that Leybourne House is an ‘extremely well run home.’ A General Practitioner said on a comment card that the care is ‘excellent’ at the service and a health and social care professional said ‘all the staff have a wonderful understanding.’ A relative / visitor to the home said ‘I have no complaints.’ Residents and their families are assured and confident that Leybourne House will meet their needs. The home liaises with specialists in dementia care and ensures that staff are trained and skilled to meet the specific needs of residents accommodated. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 6 Prospective residents and their family members receive a very warm welcome when they visit and assess the quality of the facilities and services provided at Leybourne House. Detailed personal and healthcare plans support the meeting of residents’ needs. Strong links with external healthcare professionals, facilities and effective monitoring promote the meeting of residents’ healthcare needs. Staff members have a sensitive empathy to the needs of residents, treating them with great care and respect and upholding their privacy and dignity. Residents benefit from a stimulating environment and range of activities, which provide people with qualitative experiences, which they can enjoy and share with other residents, their families and staff members. Family members and friends feel part of the life of the home; and this enables residents to continue to enjoy quality time with people who are meaningful to them. Residents are enabled by the home, its environment, but most importantly by the people working in the home, to continue to make choices, wherever possible and to have control over their daily routine. Residents enjoy well-presented meals in the company of other residents, according to their wishes, in homely surroundings. The home has clear and open procedures for complaints, supporting people to feel that they can raise any issues of concerns and can be confident that they will be listened and responded to. The home has good policies and training in place to protect residents from abuse. Residents live in a well-maintained, clean environment, which is arranged to effectively meet the needs of residents, enabling them to feel safe and at home. Residents’ benefit from living in a home that is well run and organised and is therefore person centred. Leybourne House has efficient quality assurance systems in place, to enable the service to be run in the best interests of residents. Good procedures for the safe handling of residents’ monies ensure that people’s financial interests are safeguarded. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 7 The health, safety and welfare of residents is protected by the training programmes, the environment and its facilities, which protect people living in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 8 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 Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. By formalising, the individualised assessments carried out before resident move into the home, this will enhance the personalised assessment and planning that takes place, to ensure that the home is able to meet prospective residents’ needs. Residents and their families are assured and confident that Leybourne House will meet their needs. Prospective residents and their family members receive a very warm welcome when they visit and assess the quality of the facilities and services provided at Leybourne House. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 10 EVIDENCE: Twelve people responding in resident survey forms said that they received enough information about the home before they moved in. One relative commenting on a survey form said that ‘we were certain and confident Leybourne was the right one.’ Pre-admission assessments were seen for two people who had recently moved into the home. Both had been completed by the manager and contained individual details regarding people’s specific needs, their wishes and preferences. At present there is not a format for the pre-admission assessment and it was advised that a general form is devised to include all the items listed in the relevant standard as being important in assessing people’s needs. In the present format those items that are not applicable are not included. However it was discussed that it may be important to record that a person does not have any needs in relation to a specific aspect of daily living on admission. Also neither form was signed and dated. It might also be helpful to include the people providing the information as part of the assessment process. Following the inspection the manager has submitted a format that will be used in future to record pre-admission assessments. The manager confirmed that a letter is sent to people planning to move into the home confirming that the service can meet their needs. There was also information from external health and social care professionals on file, which had informed the process of assessment. Appropriate information had been obtained when a person had moved into the home in an emergency, to ensure that the home could meet the person’s needs. One resident had moved from another service in the group and the manager was able to liaise closely with the previous home, so that the person’s needs were fully met on admission. During the visit a family came to look around the home. The deputy manager greeted them and the manager ensured that she made time to meet with the relatives. The family were very impressed with the home, its facilities and the warmth of the welcome that they received. They said that they felt in no doubt that their family member would be happy at Leybourne House. A short term care plan is devised when a resident moves into the home and a key worker system operates to ensure that people feel that there is always someone who will help and support them. One resident had recently moved into the home and throughout the visit staff members were responsive to her needs and there was always someone close by for her. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed personal and healthcare plans support the meeting of residents’ needs. Strong links with external healthcare professionals, facilities and effective monitoring promote the meeting of residents’ healthcare needs. Generally efficient procedures for the safe handling of medicines protect residents. Eye drops with a limited life on opening should be dated when opened so that residents do not receive medicines beyond their use by date. Staff members have a sensitive empathy to the needs of residents, treating them with great care and respect and upholding their privacy and dignity. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans were viewed for four residents. Thorough assessments, including assessments of risk are undertaken, which inform the development of detailed and personal plans of care. The plans include details of residents’ social, personal and healthcare needs so that staff members deliver appropriate care, which responds to the changing needs of residents. Seven people returning resident survey forms said that they usually receive the care and support that they need, five people said that this is always the case. Detailed records are kept of contacts with external health and social care professionals, which allows staff to track the health support needs of residents. When a person had become unwell, it was noted that a corresponding care plan had been produced to inform the delivery of care. One relative responding on a comment card said that a member of staff accompanies them to hospital appointments, and this is very supportive. The manager said that should any resident require admission to hospital they are always accompanied by a member of staff and an on call staff member will come in to work in the home. The manager was insightful of the potentially confusing affect that an admission to hospital may have on a resident and is committed to ensuring that the home works in partnership with external agencies to ensure that residents feel secure and comforted. Optical, chiropody and dental services are accessed and residents can retain their own GP if the surgery is able to do so. Clear care plans support residents who need assistance in relation to continence. Throughout the visit staff members provided gentle assistance, supporting residents’ psychological well-being. Residents are also helped to mobilise as independently as possible, whilst maintaining safety, promoting physical well being. Assessments include references to maintaining good skin integrity. From records seen the home liaises with district nursing services should there be any concerns regarding pressure areas. Pressure relieving equipment such as mattresses and cushions are used as necessary. Seven health and social care professionals visiting the home said that they are satisfied with the overall care provided in the home. Two General Practitioners returning comment cards said that the home communicates and works in partnership with them. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 13 Generally efficient procedures were observed for the safe handling of medicines. The home now has a maximum / minimum thermometer to ensure that medicines are stored at the correct temperature. The temperature of the drugs fridge is recorded each day and was within acceptable limits. Two boxes of eye drops with a limited life on opening had not been date labelled. It was also advised that creams and emollients are date labelled on opening. Good systems of receipt and disposal of medicines were seen. Medicines for one resident were checked against medicines held and the amounts corresponded. Throughout the visit staff members showed great empathy for the needs of residents. The principles of privacy, dignity and respect were noted in care planning, which informs the delivery of gentle, enabling care. Staff members took time to sit with residents, listen to them and respond to people in the home needing help with activities of daily living. All health and social care professionals returning comment cards and relatives / visitors to the home said that they are able to see residents in private. One relative / visitor said this was not the case. The home has a conservatory which is sometimes used for relatives / visitors to see residents, if they do not wish to use the resident’s room for privacy. The manager said that she also makes one of the two large offices available for meetings with professionals if needed. A key worker system is used to enable residents to develop special rapports with members of staff. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a stimulating environment and range of activities, which provide people with qualitative experiences, which they can enjoy and share with other residents, their families and staff members. Family members and friends feel part of the lives of their family members and friends; and this enables residents to continue to enjoy quality time with people who are meaningful to them. Residents are enabled by the home, its environment, but most importantly by the people working in the home, to continue to make choices, wherever possible and to have control over their daily routine. Residents enjoy well-presented meals in the company of other residents, according to their wishes in homely surroundings. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 15 EVIDENCE: There are fifty-four hours of dedicated activity time. Staff members also spend a lot of time informally with residents in improving their quality of life. During the day residents in the lounges who were sitting down had items with which they could engage. Residents who were walking around the home were greeted by staff, and took companionable strolls. One resident wanted to go out into the garden and a member of staff accompanied them. The home’s corridors are decorated in suitable colours to distinguish the floors in the home, from grass green to sky. Along the walls there are laminated photographs, which can be removed. There are also different displays such as collages of trees and seasons with different textures to touch. In the main reception area there is a police phone box, and a table with soft toys. One resident was wearing a tabard with useful pockets in which could be placed engaging items. Activities include quizzes, cooking sessions and reminiscence. The home has musical instruments and sing a long sessions are very popular. One resident returning a survey form said that they like the musical activities. Outings are also held to local places of interest. The home has started to take detailed personal histories, so that staff can chat about memories that are important to residents. A record is kept of residents’ participation in events. It is recommended that this is kept as an individual record so that residents’ needs can be easily monitored and ongoing needs identified, which can be reflected in social care plans and enhance the good quality of life experienced by service users. The home has already responded following the inspection indicating that individual activity sheets have been introduced. One relative responding on a comment card said that staff members are always coming in and keeping them informed of their family members’ needs. Three relatives said that they always feel welcome when they come into the home. One family member said that they feel involved in their relative’s care and it is like a home ‘at home.’ Another relative said that they visit the home every day and are always given a cup of tea and a warm reception from all staff members. Sixteen relatives / visitors to the home agreed that they are always made welcome. When relatives came to see the home during the visit, staff members greeted them warmly. Throughout the visit residents made choices about their daily routines. One resident spent the morning in the home’s reception area. They engaged with some of the soft toys on a table, sat on a chair, touching the different textures of the individual toys and then taking time to watch people passing by, staff stopping to talk and the daily comings and goings of the home. Other residents took strolls around the home; they met other residents, exchanged a few words, or linked arms and enjoyed a walk together. Residents with limited Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 16 mobility were sat in the lounge or at tables. One resident was looking at books, another doing careful colouring with a staff member. Photographs are on residents’ doors giving mobile people living in the home the independence to move about the home and find their way back to their rooms. There are also signs on toilet doors for easy recognition. Lunch on the day of the visit look well presented. Small eating areas enable some residents to sit together. Great care is taken to enable people to sit with other residents, with whom they can enjoy the experience of the meal. One resident chatted to their neighbour, and felt secure on sitting with someone familiar, with whom they could share friendship. Some residents needed help with eating. Two staff members were seen standing up to assist residents who required help with eating. This is not appropriate and it was clear that this was not normal practice from the sensitive support generally provided. There is a four weekly menu plan and choices of meals are provided. One relative responding in a comment card said that their family member always eats their meals. One relative said that they are concerned that their family member sometimes eats other people’ food and is concerned because they are a diabetic. The manager had already recognised this and during the visit staff members were seen to promptly intercede when residents showed interest in other people’s food. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear and open procedures for complaints, supporting people to feel that they can raise any issues of concerns and can be confident that they will be listened and responded to. The home has good policies and training in place to protect residents from abuse. EVIDENCE: The home has an effective complaints procedure. No complaints have been received in the past twelve months. Seven people responding in survey forms said that they know how to make a complaint, two people said that this was usually the case, one person said that they did not know how to make a complaint. During the visit people visiting the home came and consulted with members of staff. One relative said that they would have no hesitation in raising any issues of concern with staff members and felt confident that they listen and would address any worries. A quarterly complaints’ analysis form is completed, so that any complaints that have been received can be audited. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 18 The manager of the home has undertaken a manager’s course in adult protection training with the local county council. The home has a flow chart displayed, which informs staff members of the procedure in the event of an allegation of abuse in the home. Adult protection training takes places as part of the organisation’s mandatory programme. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well-maintained, clean environment, which is arranged to effectively meet the needs of residents, enabling them to feel safe and at home. EVIDENCE: The communal areas of the service are arranged in homely areas, where residents felt safe and at home. There is also a conservatory. The home’s corridors are decorated so that they easily orientate residents to where they are in the home. Individual rooms are very personal and contain special possessions and items, which make the environment home to people living at the service. All areas of the home are well maintained. The home benefits from an enclosed garden with pleasant places to sit in the warmer weather. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 20 Pressure mats, which activate the call alarm system are appropriately used to ensure the safety of residents. The home has had a new laundry fitted since the last inspection. Staff members were observed practising good standards of infection control during the visit, washing their hands and wearing gloves as appropriate. The manager confirmed that staff members are booked on update training sessions in infection control as part of the home’s mandatory programme. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are competently and caringly met, both by the numbers of staff working in the home and their skills. The assured, comfortable manner of residents reflects their confidence that they are cared for in safe hands. Review of the hours worked by staff on a long shift will ensure that they are fully competent to carry out their roles. Good practices of recruitment protect residents living in the home. Staff members are well trained and confident to do their jobs. EVIDENCE: The home’s rosters demonstrate that adequate staffing levels are maintained to meet the needs of residents. On the day of the visit there were seven-care staff working and three domestic members of staff. There was also a chef and kitchen assistant. In addition to this both the manager and deputy were on duty. Staff members are allocated according to the needs of residents during the day, with more staff available when residents are most in need of help. Night staffing levels also were adequate to meet the current needs of residents. Most staff work short shifts, however the working of a shift between Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 22 7.15 in the morning and 21.45 in the evening was discussed. Staff members working this shift have chosen to do so and are given frequent breaks. It is however recommended that it is ensured that staff members working such hours; 141/2 hours in the home are safe to do so. Should any incident occur at the end of such a shift, the length of the shift worked may be highlighted as a cause for concern, in terms of the tiredness of the member of staff and competency to carry out their role. Six members of staff have a National Vocational Qualification at level 2 in Care and six at level 3. In addition to this three members of staff are studying for the qualification. There are currently twenty-nine members of care staff working in the home. The service has a detailed induction programme; a completed booklet was seen. Staff records were seen for three members of staff working in the home. Thorough recruitment checks are undertaken prior to a new member of staff starting work in the home. It was advised that explanations for gaps in work history are always recorded. Since the visit the manager has confirmed that any gaps on current records seen have been explored and documented and that all staff now have photographs on their individual files. At the time of the visit the home did not have a summary of training, to enable staff members’ training needs to be monitored and identified. This has been completed since the visit. Training is organised by the organisation as a rolling programme to ensure that all staff members remain up to date in mandatory areas of training. Specialist training is also undertaken, including dementia care and diversity. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home that is well run and organised and is, therefore, person centred. Leybourne House has efficient quality assurance systems in place, to enable the service to be run in the best interests of residents. Good procedures for the safe handling of residents’ monies ensure that people’s financial interests are safeguarded. The health, safety and welfare of residents is protected by the training programmes, the environment and its facilities, which protect people living in the home. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 24 EVIDENCE: Throughout the visit the manager of the home demonstrated a great sensitivity and knowledge of the needs of people living in the home. This is reflected in the satisfaction and confidence that relatives have that the home will meet the needs of their family members. Staff members consult the manager when they need advice and are confident in her leadership. She also enjoys a good working relationship with the deputy manager and together, their leadership, with the support of care team managers, make a difference to the lives of people living at Leybourne House. The manager holds a National Vocational Qualification in Management and a Diploma in Welfare Studies. Throughout the visit she demonstrated competence to carry out her role. She is currently liaising with the college at which she took her diploma to verify if there is equivalency to the NVQ 4 in Care. The service has thorough systems of quality assurance. Satisfaction surveys are sent out yearly and the information from feedback is collated. Other audits are also completed to ensure that all areas of the home are running safely and in line with good standards of practice. One bathroom door had been left open during the visit and because of the risk to residents, who may go in and run a bath unaided, this was promptly locked and the manager has confirmed in writing that this has been followed up to ensure that monitoring ensures that residents are kept safe, but also enjoy the freedom of most of the home. The manager confirmed that the home does not act as appointee for any residents. Some residents’ monies are kept on behalf of residents. Money is individually stored and records for two residents, tallied with amounts held. Two members of staff sign to confirm amounts verified. Hazardous substances are securely stored in the home. Toiletries are also separately stored, but are kept in individual baskets to ensure that the resident to whom they belong only uses them. The home has two mobile hoists and one stand aid. Staff members were observed appropriately using hoisting equipment during the visit. The home’s pre-inspection questionnaire confirmed that all fire equipment and other services and facilities are regularly monitored and serviced. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 25 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 2 3 4 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is recommended that a formal pre-admission form is used, which should include all headings in standard 3.3 and be signed and dated. Following the inspection the home has submitted a form, which will be used in future for the completion of preadmission assessments. 2. OP27 It is recommended that shifts worked between 7.15 am and 21.45 pm with breaks are reviewed to ensure that staff members are safe and competent to carry out their work. Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Leybourne House DS0000003902.V331829.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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